Infect Dis Clin N Am 16 (2002) 535551

Injection drug use in North America

Eugene P. Schoener, PhDa,*, John A. Hopper, MDb,
James D. Pierre, MDc
a

Departments of Pharmacology, Psychiatry, and Community Medicine,

Wayne State University School of Medicine, 2761 East Jeerson Avenue,
Detroit, MI 48207, USA
b
Departments of Internal Medicine, Pediatrics, and Psychiatry,
Wayne State University School of Medicine, 2761 East Jeerson Avenue,
Detroit, MI 48207, USA
c
Wayne State University School of Medicine, 2761 East Jeerson Avenue,
Detroit, MI 48207, USA

Parenteral self-administration of psychotropic agents (and the potential

for resulting sepsis) has been part of the American landscape for more than
a century. Indeed, soldiers left in chronic pain and distress after the Civil
War self medicated with injections of morphine that was available for purchase at local pharmacies. The introduction of heroin (diacetylmorphine)
early in the twentieth century brought with it a heightened concern regarding
the potential for misuse. This concern led to legal constraints that reduced
but did not eliminate injection drug use and its consequences. Specic drug
preference has uctuated over the years depending upon drug availability,
cost, and cultural attitudes. Opiates (heroin) and stimulants (cocaine and
amphetamine) have been most widely used. During the past 15 years, the
escalation of human immunodeciency virus (HIV), hepatitis C virus
(HCV), and other chronic infectious diseases associated with injection drug
use has raised the level of concern profoundly. Indeed, the proportion of
HIV disease attributable to injection drug use grew from about 17% in
1987 to more than 50% in 1994, with even higher rates in some communities.
Persons who use psychotropic (mood- and mind-altering) substances for
nontherapeutic purposes employ almost every possible route of administration, depending upon the nature of the substance, their experience with
it, and their specic intent with any given administration. Although they
have not studied pharmacokinetics, drug users know that for many of these

* Corresponding author.
E-mail address: eschoen@med.wayne.edu
0891-5520/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 8 9 1 - 5 5 2 0 ( 0 2 ) 0 0 0 1 0 - 7

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drugs far more rapid eects are achieved with inhalation and intravenous
administration than with oral or intranasal dosing. Although rst drug
experiences are often noninvasive, use frequently progresses to parenteral
administration for economic, social, and pharmacologic reasons. That is,
users ultimately inject these agents (intravenously, subcutaneously, or intramuscularly) to maximize cost-eectiveness, to engage in sanctioned rituals of
the drug-using subculture, and to produce the desired eects as rapidly as
possible.
Terminology
Terminology was stable for many years, but the manner of reference to
injection drug use has changed during the past decade to become less pejorative and more inclusive. The most prevalent clinical term for such behavior before 1990 was intravenous drug abuse (IVDA). This language
evolved, rst to intravenous drug use (IVDU) and then to injection drug
use (IDU). The current usage reects greater sensitivity toward substanceusing patients as well as the obvious point that nonintravenous parenteral
administration also can produce severe medical consequences.
Natural history of injection drug use
To understand the pathogenic mechanisms that drive injection drug use,
it has been suggested that injection drug use per se be conceptualized as a
behaviorally infectious and socially contagious disease, distinct from its
medical sequelae. This concept extends the traditional idea of infection as
an invasion of body tissues by microorganisms to include a behavioral
incursion that coopts and entrains brain chemistry. Although the toxin in
this case may not produce physical injury, the insult is tangible, with profound eects on early and persistent gene expression. In most instances,
there is no apparent organic lesion, but functionally there is progressive
amplication of the primary behavioral manifestations that lead ultimately
to secondary physical damage from trauma, emboli, or bacterial and viral
infection.
The idea that injection drug use is transmitted through a process of social
contagion derives from a growing body of literature describing the interpersonal dynamics that enable initiation, provide support, and promote continuation of injection drug use. Although many commonly held beliefs confuse
the issue, it is now understood that drug users (not pushers) initiate
others, most often those people closest to them, and that they form self-sustaining networks based on economic need. Conceptualizing injection drug
use per se as a contagious or infectious disease has great utility beyond the
insight it can provide for clinicians who want to understand its etiology and
dissemination. This concept enables the astute physician to develop specic
tools for screening and intervention of the behavioral disorder as well as for

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537

the medical consequences. Furthermore, it oers tangible means to prevent

the spread of injection drug use.
Predisposing factors for injection drug use
An early epidemiologic attempt [1] to characterize the predisposition of
certain people for injection drug use examined relationships between early
childhood misbehavior, demographics, and later drug use, comparing a population of injection drug users with other residents of the same Baltimore
community. Misbehavior was construed from a complex of events that
occurred before the age of 16 years: running away from home, ghting, damaging property, causing trouble at school, truancy, stealing, and being
arrested. Both male and female injection drug users reported profoundly
higher levels of these childhood problems than did nondrug users. Although
there were no signicant dierences in gender distribution or educational
attainment between the groups, the IDU group had disproportionately
more minority individuals than the community sample. Consistent with
these ndings, Dinwiddie [2] reported that injection drug users were likely
to manifest a variety of behavior problems in early adolescence and to meet
diagnostic criteria for antisocial personality disorder in adulthood. Taking
another approach, Crofts, Louie, Rosenthal, et al [3] interviewed a large
number of young persons who had recently started using injection drugs.
Most of their respondents told of family disruption, homelessness, school
dropout, unemployment, and incarceration, with use of injection drugs
beginning at about the age of 16 years. Almost all these youngsters knew and
understood the potential of injection drug use to transmit life-threatening
viruses, but this knowledge did not impede their behavior.
Initiation of injection drug use
In spite of the obvious threats posed by infection resulting from injection
drug use, little attention has been paid to the reasons for starting to use
injection drugs. Through interviews with 300 Australian users of injection
drugs aged 14 to 22 years, Crofts, Louie, Rosenthal, et al [3] provide a penetrating picture of the process of initiation. Virtually all their respondents,
like those in other studies, had a history of intranasal, oral, or inhalation
drug use before injecting. The most common substances injected at the
beginning were amphetamines, but drug preference was variable and highly
subject to local availability, cost, and culture. Almost half the sample said
that it was their own idea to inject, but two thirds indicated that it just happened. Only 12% actually injected themselves the rst time; the injector
usually was a friend or acquaintance, sometimes a family member, and the
new user paid for the drug in only about half of the cases. In this Australian
study, women were more likely than men to be injected by a sexual partner,
but more recently Doherty, Garfein, Monterroso, et al [4] found no such

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gender dierence in a Baltimore sample. A more experienced injection drug

user often provided training on the skills needed for preparation of the drug
and self-injection. When asked why they wanted to inject, the new users gave
a variety of reasons, including the rapidity of eect (rush) and curiosity
about the dierent eects they could experience. Only one in ve implied
that they felt some peer pressure to inject. About half the new injectors used
their own needles and syringes; others borrowed them. Fewer used their own
cookers or spoons to prepare the drugs. Half of these injectors reported
that they helped at least one other person to start injecting.
Patterns of social support among injection drug users
Injection drug use is essentially a social behavior. Injection of psychotropic agents occurs in group settings more often than individual ones, and
recent research investigating the social dynamic has focused on networks [5].
Some of the initial ndings are quite revealing and clinically relevant. For
example, the frequency of injecting in a drug-using network is directly
related to the number of people in the network. Even the nature of their
interaction can inuence the behavior, with closer personal relationships
(especially sexual ones) leading to more frequent injection. Both these variables also seem to predict risky behaviors, particularly sharing of injection
paraphernalia (needles, syringes, cookers, cotton, and rinse water) and unprotected sex. Networks can be dynamic; members join and leave. The
rate of movement denes group stability (with an inverse relationship), and
instability leads to increased risk-taking behavior. Networks exist to sustain
injection drug use and so have essential economic value. Relationships are
often based on barter for goods and services, frequently drugs and sex. Not
unexpectedly, users with greater economic resources usually belong to more
stable, exclusive groups. Networks provide the vehicle for exchange of many
things other than drugs, paraphernalia, and sex, including concrete needs
such as housing, food, and transportation. Networks also serve to transmit
knowledge, skills, and infectious disease.

Risk-taking behaviors associated with injection drug use

Many detrimental health outcomes are associated with injection drug use,
but the most challenging today are chronic infectious diseases including
viral hepatitis B (HBV), HCV, human T-lymphotropic virus (HTLV-II) and
HIV. Because of its dire consequences, HIV has attracted the greatest attention from clinicians and researchers, but behaviors linked to HIV transmission certainly apply to other infections. One of the most profound changes
in risk factors for HIV in the United States over the past 2 decades is the
declining inuence of sexual transmission and the increasing impact of injection drug use [6]. According to Battjes, Pickens, Haverkos, et al [7], about

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539

half of all new HIV infections in major metropolitan areas are attributable
to injection drug use. However, the risk-taking behaviors associated with sex
and drug use are by no means independent, [8]. Indeed, they should
be viewed as culturally, psychologically, and pharmacologically entwined.
Psychotropic substances alter both cognitive and emotional states and
incline people toward risky behavior. In fact, the quantity and frequency
of alcohol consumption is highly correlated with needle sharing [9] and with
unprotected sex [10,11].
Injection-related behaviors that place users at risk for HIV and other
infections fall into three categories: injection practices, sharing of material,
and venue of injection. Injection practices include frequency of injection,
physical site of injection, equipment, paraphernalia, sterilization practices,
and even the type of drug used. It should be readily apparent that more
frequent exposure (injection) leads to greater likelihood of disease transmission, but few understand that the site of injection preferred by an
injection drug user provides information about the users past experience.
Darke, Pickens, Haverkos-Ross, et al [12] report that one in ve injection
drug users experiences infections or abscesses from injecting and that most
of them progress from initially injecting in the antecubital fossa to the forearm, then the upper arm, hand, and possibly neck. Some may go on to inject
at sites in the lower extremities and groin. All injection drug users acknowledge that the drugs they obtain are likely to contain toxic microorganisms
and particulate matter; they go to great lengths in cooking (sterilizing)
and ltering the solution. But, surprisingly, they seldom extend this concern
to the sharing of their paraphernalia. Material frequently shared includes
needles, syringes, spoons, cotton, and rinse water, with no eort made to
clean them between users. They even share drug solution through the practice of backloading or backllingloading one syringe from another in
which the drug was prepared. One recent study in Chicago [13] found that
about half the injection drug users questioned shared syringes, but 70% of
them shared cotton, cookers, and rinse water. A large survey by Hunter,
Stimson, Judd, et al [14] in England and another in Denver [15] made similar
observations. The data are clear: sharing of injection paraphernalia is the
rule, not the exception. The injection venue is not inherently problematic but
may be crucially important in that it can promote sharing and shortcuts in
the injection process along with increased frequency of use. The venue of
greatest concern is the so-called shooting gallery where users often borrow or even rent paraphernalia and trade sex for drugs.
Epidemiologic studies have shown that demographic proles have some
predictive value for risk-taking behavior by injection drug users. For example, age seems to be an important determinant of risky behavior. A recent
analysis of dierences between injection drug users under and over 30 years
of age in San Francisco by Kral, Lorvick, Edlin, et al [16] revealed that
younger users of injection drugs are signicantly more likely than older
users to share syringes, have unprotected intercourse, and experience

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overdose. Although gender dierences in injection drug users seem to be

diminishing over the last few years, women still seem to exchange sex for
drugs more frequently than do men. Given the likelihood of risky sexual
practice under these conditions, women may experience greater potential for
infection than men. Of course, prostitution itself increases the opportunity
for sexual transmission of disease simply because of the frequency of intercourse and the number of dierent partners. Issues of sexual orientation
make the dynamic of sexual activity more complex than a simple male/
female gender dierence, however. For example, needle sharing seems to
be greater among homosexual and bisexual men than among men who are
strictly heterosexual.
An examination of dierences between urban and suburban injection
drug users in Chicago [13] found that suburban users are signicantly more
likely to share syringes than those living in the city. One implication that
may be drawn from this study is that sharing is not simply an economic
issue; that is, people may use the same syringe and needle as their partner
out of intimacy and trust, not simply nancial need. Of course, economic
factors are often important, as demonstrated by the high degree of association between the rate of needle sharing and lower economic status shown in
a large survey of injection drug users in Baltimore [17].
A wide array of sexual behavior carries a risk of infection. The most central risk-taking behavior is sexual intercourse without a condom (unprotected), whether vaginal, anal, or oral. Other activities correlated with
high rates of infection include frequent intercourse with multiple sex partners, sexual intercourse with injection drug users, and exchanging sex for
drugs or money. Substance use per se, whether parenteral or not, contributes to sex-mediated transmission of HIV because it impairs judgment, leading to unprotected intercourse. This correspondence of substance use and
unprotected intercourse has been demonstrated clearly for the use of alcohol
[18,19] and crack cocaine [20]. Indeed, Seidman, Lorvick, Edlin, et al [21]
reported that crack smokers are particularly likely to choose partners with
sexually transmitted diseases. Unfortunately, people who smoke crack
cocaine are inclined to increase their use over time, ultimately turning to
injection of cocaine, heroin, or a mixture of the two [22].
There is a growing awareness that substance use is highly associated with
mental illness. In fact, the co-occurrence is commonly referred to as dual
diagnosis. Thirty percent to 50% of those who abuse alcohol, cocaine, or
opiates meet criteria for a psychiatric disorder. Injection drug users frequently exhibit symptoms of mood and anxiety disorder [23] but more commonly (35%69%) manifest antisocial personality disorder [24,25]. Studies
of injection drug users in treatment have noted that injection drug users with
antisocial personality disorder exhibit higher rates of risk-taking behavior
(eg, unprotected sex, excessive alcohol use, sharing of syringes or needles),
more frequently and with a larger number of people, than injection drug
users without mental illness [26,27].

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541

Scope of injection drug use in the United States

Two approaches are commonly employed to determine the incidence and
prevalence of injection drug use in the United States today. The rst method
broadly surveys representative samples of the general population or selected
subgroups, such as youth. The second involves the focal analysis of a particular type of drug use. Both approaches have limitations. Information from
the rst approach is limited because the rate of use for a given drug is often
small in the general population, and large samples are required for analysis.
Furthermore, illegal activities such as injection drug use are likely to be underreported. The second approach might include interviews of injection drug
users, surveys of high-risk populations, or indirect indicators such as treatment program census, police arrests with positive drug screen, or drug-related
deaths. In general, targeted methods provide more valid estimates of injection
drug use but underestimate experimental or intermittent use [28].
Data on injection drug use in the United States come from a variety of
sources. Pulse Check, a series of interviews with treatment and law enforcement professionals conducted by ethnographers, provides a subjective
picture of drug abuse across the country. The Drug Abuse Warning
Network (DAWN), sponsored by the Substance Abuse and Mental Health
Services Administration (SAMHSA), tracks drug-related emergency department visits and deaths. The DAWN data are obtained from hospitals in
selected metropolitan areas; they do not represent the national prevalence
of drug-related incidents. The Treatment Episode Data Set (TEDS), also
compiled by SAMHSA, reports data from publicly funded treatment facilities in participating states. This dataset accounts for about half of all (public
and private) admissions to United States treatment facilities. The annual
National Household Survey on Drug Abuse (NHSDA), conducted for the
National Institute on Drug Abuse (NIDA), is a probability study of tobacco, alcohol, and illicit drug use in the civilian noninstitutionalized population, 12 years of age or older. The National Institute on Drug Abuse also
funds the annual Monitoring the Future (MTF) survey that samples students in the eighth, tenth, and twelfth grades attending public and private
high schools in the coterminous United States [29].
Use of injection drugs, including heroin, cocaine, amphetamines, and
benzodiazepines, accounts for 12% of all illicit drug use in the United States
today. The rate of injection drug use by drug type changes over time and is
geographically variable, reecting both cultural and market forces. Table 1
shows overall estimates for the main drugs used by injection [30]. The most
commonly injected drug now is heroin, so it is the focus of this discussion.
Injection of psychomotor stimulants (cocaine, amphetamine, and methamphetamine) has become popular in some areas, and the epidemiology
of these drugs also is reviewed briey.
The prevalence of heroin use in the United States has increased during
the past decade, most likely because of greater availability, higher purity,

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Table 1
Injection drug use by class of drug
Drug class

% injection drug users

Heroin
Other opiates
Stimulants
Sedatives or hypnotics

67
15
29
4

and lower cost. In 1999, the NHSDA estimated that 3.0 million Americans
over the age of 12 years had used heroin at least once in their lifetime and
that 403,000 people had used it at least once in the past year. Lifetime prevalence of heroin use overall was 1.4%, but among persons aged 18 to 25
years, it was 1.8% [31]. The incidence of new use during the past year for
persons at least 12 years old was 0.2%. Among the 149,000 new users, it was
estimated that 37% injected heroin. According to MTF surveys, lifetime heroin use among high school seniors in 2000 increased signicantly to 1.5%.
On the other hand, lifetime heroin use decreased among eighth graders from
1.4% in 1999 to 1.1% in 2000. This reduction represents the rst decline
among eighth graders since 1997. Forty-six percent of high school seniors
who had used heroin had rst done so before tenth grade [32].
The transition from noninjecting to injecting use of heroin is only partially understood. Neaigus, Miller, Friedman, et al [33] investigated the process by following noninjecting heroin users over a period of time. Follow-up
interviews showed that more than 15% of the participants switched from
inhaling to injection over a little more than a year. During that time, they
increased the amount and number of drugs used, indicating that they may
have turned to injection as a matter of cost-eectiveness [34]. Initiation of
injection drug use occurs at about the same age (19.5 years) for both men
and women. Men generally introduce men to injection drug use, and women
initiate women [4]. Comparing frequent injectors (those who have injected
10 or more times) with those who have injected nine times or fewer, the
frequent injectors are more likely to be younger at rst use, unemployed,
homeless, long-time users, unafraid of needles, snort heroin with former
injection drug users, and to have sex partners who are injection drug users
[33]. In general, injection drug users engage in more frequent drug use, are
more drug-dependent, are polydrug users, have poorer general health and
psychosocial functioning, and exhibit more criminal behavior [35].
Demographics of injected heroin use
Injection is the most common route of heroin administration in most major
cities across the United States [36]. According to recent TEDS data, 67% of
heroin users presenting for treatment are men, and 33% are women [30]. Epidemiologists, ethnographers, and treatment professionals report that most

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543

heroin users are over the age of 30 today. Patients aged 35 years and older
account for a majority (55%) of heroin and morphine mentions in the 2000
DAWN study. Between 1999 and 2000, opiate-related DAWN mentions in
this group increased 11%; indeed, they have more than tripled since 1990
[37]. Over the same time, however, such mentions increased 22% among 18to 25-year-old patients [37]. Young adults (aged 1830 years) account for the
largest group of new heroin-using patients in treatment programs in the
Northeast and Southern United States. Consistent with these observations,
heroin-using youth now have the highest rate of injection drug use [38].
In 2000 the racial and ethnic distribution of heroin and morphine DAWN
mentions across the country was 42% white, 32% black, and 15% Hispanic.
Between 1999 and 2000, emergency department mentions for whites
increased by 20% but remained stable for the other racial and ethnic groups
[37]. According to the TEDS database, 50% of heroin users presenting for
treatment are white, 22% are black, and 25% are Hispanic [30].
Although injection drug users who prefer heroin can be found at all socioeconomic levels, the largest group of such users is in the lower socioeconomic
class [36]. Low educational attainment also is a statistical predictor of those
most likely to use heroin. In the treatment population, about one half of the
people admitted for heroin dependence do not have a high school diploma
[36]. Among the general population, the NHSDA reveals that about 1 in
100 college students now uses heroin. Heroin use overall varies by education:
0.4% of adults with less than a high school education, 0.1% of high school
graduates, 0.2% of persons with some college, and 0.1% of college graduates
use heroin [29]. People who are employed full time are less likely to use heroin than those who work part time or are unemployed. About 0.1% of full
time employed adults use heroin, compared with 0.3% of those who work
part time and 0.6% who are unemployed. Those who describe themselves
as retirees report 0.2% heroin use; 0.1% of disabled adults indicate that they
use heroin; and 0.03% of homemakers report heroin use [29].
Most heroin users reside in urban areas. The cities of Chicago, New
York, and Baltimore led the DAWN list for emergency department mentions of heroin and morphine in 2000 [37]. Use has grown in the suburbs
during the past few years, however. Leading suburban areas included those
around Boston, New York City, Chicago, Detroit, Billings, Denver, Honolulu, and El Paso. A typical case in point comes from a New Jersey report,
where the rate of injected heroin use among suburban and rural patients in
treatment for substance abuse increased from 34% in 1993 to 51% in 1999.
During the same period the percentage grew from 18% to 38% for urban
residents [39].
Demographics of injected methamphetamine use
A majority (62%) of methamphetamine injectors are men, representing
about 11% of all male injection drug users [35]. Approximately 5% of female

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injection drug users are current methamphetamine injectors [40]. Young

adults are the most frequent methamphetamine injectors across the United
States, except in Miami, Florida, and Los Angeles, California, where methamphetamine use is more common among adolescents. Although injected
methamphetamine is used in all racial and ethnic groups, this use is most
common among suburban whites. Middle and lower socioeconomic groups
are most likely to use inject methamphetamine, except in New Orleans,
where such use is now common among upper socioeconomic groups [36].
Polysubstance use
Although drug users typically express a preference for one particular
drug, they seldom limit their use to that drug alone. Polysubstance use is the
rule today, not the exception. The drug taken most often in combination
with heroin is cocaine, and alcohol is most commonly used with methamphetamine. The heroin/cocaine speedball is generally injected; other drug
combinations may be consumed by mouth or both routes. Benzodiazepines,
such as alprazolam and clonazepam, are sometimes taken orally with heroin
[36] whereas diazepam and temazepam may be injected along with heroin
[41]. Other prescription drugs, such as the antidepressant amitriptyline and
the antihypertensive clonidine, are used to moderate the eects of the primary drug (enhancing or reducing arousal as desired.) Younger heroin
users today are taking a range of other substances with heroin, including
methylenedroxymethamphetamine (MDMA) (ecstasy), marijuana, ketamine,
and phencyclidine hydrochloride (PCP) [36]. Heroin-injecting youth engage
in signicantly more polysubstance use than do youth who use substances
other than heroin [38].
Impact of injection drug use on human immunodeciency
virus and hepatitis C
The medical impact of heroin and other drug use has escalated during the
past decade in communities nationwide. Especially challenging are the
chronic viral infections such as HIV and hepatitis C transmitted through
injection drug use and associated risk-taking behaviors. The increased prevalence of HIV and AIDS cases seems to mirror the popularity and availability
of heroin in such places as Portland, Maine. Cases of HIV and AIDS have
risen dramatically subsequent to increased rates of injection drug use from
Seattle, Washington, to Miami. Hepatitis C cases have skyrocketed in Billings, Montana, Columbus, Georgia, Los Angeles, and Portland, Maine [36].
Infections related to injection drug use
Injection drug use may result in acute and chronic infections and may
predispose the patient to future infections long after injection drug use has
stopped. The agents of disease include bacterial, viral, and fungal organisms,

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545

and mixed infections are common. Infections are the most frequent cause of
emergency department visits and hospitalization among injection drug users
[4244].
Most infections related to injection drug use result from nonsterile injection practices. Contamination can take place at several levels. The injection
drug itself may have adulterants and may be contaminated. Infectious
agents may be introduced in preparing the drug for injection, usually accomplished by heating it on a spoon and ltering it through cotton into the
syringe. In the process, the injection drug user may touch the needle to
mouth, hands, or other surfaces, a known source of contamination. The
drug user also may fail to clean the skin properly before injecting. Shared
or reused injection equipment can result in contamination and crosscontamination.
Additional drug-related factors may contribute to infections. The risk of
abscess seems to be higher with subcutaneous and intramuscular injection
techniques than with intravenous injection [45,46]. Soft tissue ischemia may
result from injection of heroin mixed with cocaine [46]. For reasons that are
as yet unclear, intravenous use of cocaine seems to be a greater independent
risk factor for the development of endocarditis than that of other injection
drugs [47].
Numerous comorbid medical and psychiatric conditions are likely to contribute to acute infections. Malnutrition, vascular disease, and HIV are common medical comorbidities that predispose injection drug users to infection.
Smoking, which is highly prevalent among injection drug users, leads to
chronic vascular disease and increased risk of ischemia and infection. The
concomitant use of alcohol and other drugs also contributes to infectious
risk through trauma and impaired immune function.
Acute and subacute infectious complications
Because of nonsterile injection practices, any organ or organ system can
be subject to acute infectious complications of injection drug use. The agents
of disease are generally bacteria and fungi, although other agents such as
malaria-associated plasmodia [42,48] have been described.
Chronic infections
Chronic disease also results from nonsterile injection practices. These
infections are predominantly viral and may also result from the lifestyle factors associated with injection drug use already discussed. Second to needle
sharing, the foremost risk is introduced by unprotected sexual intercourse.
Years of injection drug use and the comorbidities associated with drug use
render the host vulnerable to future acute and chronic infections.
Three chronic viral infections HCV, HIV, and HBVare common and
important sources of endemic infection among injection drug users.

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Hepatitis C virus infection

Hepatitis C virus infection has emerged as the most common chronic
viral infection among injection drug users worldwide. Its sheer magnitude
has been understood only since 1990 when a specic antibody test for HCV
was developed. In 1998, the Centers for Disease Control estimated that the
prevalence of HCV infection among current injection drug users is between
72% and 86% [49]. Similarly high levels of HCV prevalence have been noted
in studies of injection drug users from around the world. Injection drug use
is now responsible for at least 60% of all HCV infections in the United
States.
Human immunodeciency virus
Unlike HCV, HIV shows enormous regional and worldwide variability in
prevalence. The availability of clean injection equipment is a primary factor
in variability. The sharing of needles, syringes, and other paraphernalia
between injection drug users varies greatly from region to region and from
one group to another. Injection drug use and consequent sexual transmission of HIV is a leading source of AIDS in women and children in the
United States [50].
Hepatitis B virus
As with HIV, the prevalence of HBV shows considerable geographic variability. Rates of chronic HBV among injection drug users are much lower
than rates of HCV, in part because of the higher rates of HBV clearance
after acute infection. The development of an eective vaccine for HBV has
made screening for the virus among injection drug users particularly valuable. Unfortunately, substance abuse treatment programs often do not have
the resources to screen and immunize injection drug users for HBV. The
vaccination schedule is a potential barrier to providing adequate immunization for out-of-treatment injection drug users.
A number of chronic nonviral infections have greater prevalence among
injection drug users than in the general population. Infections such as syphilis and tuberculosis are more common and often more severe among injection drug users than among nondrug users. These infections are associated
with lifestyle factors including homelessness, incarceration, and trading sex
for drugs.
As noted earlier, longstanding injection drug use has medical consequences that subsequently predispose the individual to acute and chronic
infectious complications. Chief among these is venous stasis, with the
ensuing problems of repeated lower-extremity cellulitis and nonhealing
venous ulcers [51]. Repeated injections in the groin area can lead to progressive venous stasis. The circulatory defects from venous stasis create an
environment that increases infectious risk and complicates antibiotic treatment. Bone and joint infections, particularly in cases of joint replacement,

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547

predispose the individual to future chronic infections associated with orthopedic hardware. Nonnative cardiac valves, which may be implanted after
an episode of endocarditis, are also susceptible to future infections.
Prevention of infections
Reducing the prevalence and severity of infections among injection drug
users will require attention to public health measures and practices at the
level of individual patients and providers. Success in reducing infectious
complications necessitates a greater level of cooperation between providers
and policy makers than currently exists. The stigma of drug use as a moral
or social problem prevents rational intervention with appropriate prevention and treatment strategies. Until chemical dependence is recognized universally as a chronic, relapsing medical condition, the schism between policy
and practice will endure.
Mechanisms of preventing and reducing infectious
complications of injection drug use
Mechanisms for reducing the risk of infection among injection drug users
include increasing treatment access and quality of care, reducing the sharing
of needles and other paraphernalia, vaccination, screening and testing for
infection, and enabling the use of sterile injecting practices through evidence-based approaches of harm reduction. Within each of these areas, a
number of clinical and public health strategies can reduce rates of infection
among injection drug users. When working with active injection drug users,
clinicians should consider each of these areas as a potential opportunity for
prevention or intervention.
Drug abuse treatment, with consequent reduction or termination of injection drug use, is clearly the single most eective means of preventing infection. By improving both the quality and availability of treatment services,
use of injection drugs can be signicantly reduced. Increased access to care
can be achieved by providing more treatment opportunities and by lowering
barriers, providing what is known as treatment on demand. Treatment
quality can be enhanced in a number of ways. For example, length of treatment is directly correlated with reduced drug use and other positive outcomes. In general, the longer patients remain in treatment, the greater
their improvement. Enhancing the quality of treatment with counseling and
case management services has been shown to reduce drug use dramatically
[52]. For most addictive disorders, the use of multiple treatment modalities
is associated with better outcomes. Pharmacologic and behavioral therapies
can operate synergistically to yield far greater benet than either alone.
Reduction of needle and syringe sharing by injection drug users can be
accomplished through various means. Burris, Lurie, Abrahamson, et al
[53] have outlined policies and procedures for prescribing and dispensing

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sterile injection equipment. Needle and syringe exchange programs that

replace used apparatus with new and the legal prescribing and dispensing
of sterile injection equipment are two proven methods to reduce needle sharing. In the absence of exchange programs, injection drug users can learn how
to improve their injecting practices to prevent infection. In fact, epidemiologic
studies report that simple skin cleaning before injection decreases the probability of soft-tissue infection, abscess, and endocarditis [46,54]. When sterile
needles and syringes are not available, used ones can be cleaned eectively
with full-strength bleach (5.25% sodium hypochlorite) to reduce the risk
of infection. The apparatus may be dicult to disinfect fully, however, and
injection drug users often do not devote sucient time to the process [55].
Immunization of injection drug users can prevent the contraction of several infectious diseases. Available vaccinations provide eective immunity
for infections of hepatitis A and B, inuenza, pneumococcal pneumonia,
and tetanus toxoid. Although tetanus is a relatively uncommon infection
in the United States, cases still occur among injection drug users [56]. Pneumonia occurs with increased frequency in HIV-positive injection drug users,
and its frequency may be elevated in HIV-negative injection drug users as
well [57,58]. When injection drug users are oered vaccination, studies have
shown high acceptance rates for inuenza [59], pneumococcal [59], and HBV
vaccine [60]. Fulminant hepatitis A has been described in injection drug
users, especially in the setting of underlying chronic liver disease such as
alcoholic hepatitis [61].
Screening and testing for infections such as HIV, viral hepatitis, and sexually transmitted diseases may benet both infected and noninfected injection drug users. Patients who are found to be infected through screening
have the opportunity for early and eective treatment. Individuals who test
negative for diseases such as HIV, hepatitis, or syphilis may realize the
opportunity to modify their behavior and prevent future illness.

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