Many people who abuse drugs use injectable drugs. The reason to inject drugs, despite all the attendant harms and risks, is invariably to intensify the resulting high. Unfortunately, those who inject drugs may feel they are subjected to a triple stigma – for the drug use in general, for the injectable drug use in particular, and if they have contracted an infectious disease. However, it is important to understand that numerous medical, mental health, and addiction professionals have dedicated their careers to the compassionate and effective care of those who are seeking recovery services for their substance abuse and treatment for viruses at all different stages of development.
Education is key in the area of IV drug use and the communication of bloodborne diseases. There are at least three ways in which people inject drugs: into a vein (this practice has numerous slang names including shooting and slamming), under the skin (skin popping), and directly into a muscle (muscling). Typically, a person who uses injectable drugs will do so into a vein; however, over time, veins can collapse or become infected, which causes a person to seek alternate points of entry – hence under the skin or into a muscle. From the perspective of a concerned person, the practice of injecting drugs may be difficult to understand. However, the prevalence of injectable drug use is a testament to how powerfully drugs can hijack the brain, causing people to engage in dangerous activities solely to service the addiction.
Facts on IV Drug Use
The following facts and statistics, provided by the American Civil Liberties Union, provides insight into some of the perils of injectable drug use:
- In the US, there are an estimated 350,000 persons who regularly use injectable drugs.
- Compared to the general population, individuals who use injectable drugs are at a heightened risk of communicating or contracting an infectious disease, such as HIV and hepatitis.
- Greater than 25 percent of all incidents of AIDS among Americans 13 years of age or older are directly connected to injection drug use.
- Approximately 35 percent of all cases in which a mother communicates HIV to a fetus involve injectable drug use.
- Among females who have an HIV diagnosis, approximately 60 percent either used injectable drugs or had sexual relations with someone who used injectable drugs.
Although this information highlights the health risks associated with intravenous drug use for women, men are also at risk, especially certain subgroups. For instance, men who have sex with men and abuse methamphetamine face an increased likelihood of contracting HIV; however, this statistical finding does not differentiate between the types of methamphetamine use, such as snorting versus injecting or whether the transmission owes to unprotected sex or syringe sharing. At present, men who have sex with men continue to be at an increased risk of HIV transmission in general. Although sharing syringes may not directly be involved in each incidence of transmission, being high after intravenous drug use is a contributing factor in at least a portion of these cases.
Many drugs can be injected. According to CASA Columbia, a research-based organization dedicated to advisement on the best practices for treatment and prevention of diseases, the following illicit drugs are the most commonly injected:
- PCP and analogs
- Anabolic steroids
In addition to illicit drugs, lawfully manufactured opioid pain relievers and stimulants (e.g., branded amphetamines such as Adderall) can be crushed and then mixed with liquid and injected. The following is a partial list of opioid generic pills and their branded drugs that are known to be crushed and injected:
- Oxycodone (branded drugs includes OxyContin)
- Hydrocodone (Vicodin)
- Fentanyl (Duragesic)
- Hydromorphone (Dilaudid)
- Morphine (MS Contin)
- Propoxyphene (Darvocet)
In view of the abuse potential of opioid pills, one drug manufacturer has reformulated a top-selling opioid pain reliever in an effort to curb its abuse. The U.S. Food and Drug Administration (FDA) has approved a new formulation of OxyContin that includes an abuse-deterrent factor.5 The reformulated OxyContin, which is already in distribution, is comparatively more difficult to cut, break, chew, crush, and dissolve.
An FDA advisory panel has already voted to similarly change the formulation of hydrocodone-based pain relievers, such as Vicodin and Percocet. These efforts at the pharmaceutical manufacturing level are a step in the right direction – one that may help to curb the prescription opioids abuse epidemic.
IV Drug Use and Disease
According to the Centers for Disease Control and Prevention, the use of injectable drugs is associated most closely with the transmission of HIV, hepatitis B, and hepatitis C. While media reports of disease communication by intravenous drug use invariably focus on unhygienic syringes, it is important to be aware of additional causes of transmission. The use of injectable drugs is both a direct and an indirect cause of the transmission of bloodborne diseases. As the National Institute on Drug Abuse notes, infectious diseases can be directly transmitted through needle-sharing. However, diseases can also be communicated indirectly due to the greater likelihood that a person on drugs will engage in risky behaviors such as unprotected sex (includes sex work and drug/sex exchanges as well as romantic relationships).
In addition, injectable drug use paraphernalia, other than syringes, can be contaminated. For instance, waters, spoons, filter, cotton, and other unhygienic equipment can lead to disease transmission. Pregnant women can pass infections onto their fetuses, with the result that children are born daily in America who are positive for infectious diseases.
Research shows that an estimated 12.2 million persons around the globe use injectable drugs, and 1.65 million people in this group (13 percent of this population) are likely to be living with HIV. When HIV is spread, the use of injectable drugs often plays a significant role. Surveys demonstrate that approximately 30 percent of all HIV infections in the world outside of Sub-Saharan Africa arise from injectable drug use. Residents of certain countries face an exceptionally high risk of HIV infection (particularly China and Eastern Europe). For example, 57 percent of all new HIV infections in Russia in 2013 were caused by intravenous drug use. Although drug use generally presents a risk of HIV infection, of all drug users, injectable drug users face the highest risk.
The HIV infection rate in the US remains a formidable public health concern. According to the National Institute on Drug Abuse, in 2010, there were 47,000 Americans who were newly diagnosed with HIV. Per the CDC, 8 percent of this group were people who use injectable drugs. Despite the prevalence of government campaigns, and other efforts, to spread awareness of the risk
of HIV infection, an estimated 1.2 million Americans are infected with HIV and unaware of their status (translated to one in five of all infected people). Not knowing one’s HIV status presents a risk of transmission. The CDC officially recommends that those who inject drugs be tested for HIV at least once a year.
At present there is no cure for HIV. However, a combination of medications, called antiretroviral therapy (ART), help those who have contracted this virus to live longer and healthier lives. ART also helps to reduce the risk of transmitting HIV to others.
HIV medications target the mechanisms of the virus that are responsible for copying HIV and therefore reduces the amount of HIV in the body. Less HIV in the body means that a person’s immune system can more easily recover from infections and stave off cancers. Dual treatment for substance abuse and HIV infection is available, and each therapy complements the other by improving the person’s health status overall.
Hepatitis B is a virus that effects the healthy functioning of the liver by causing acute inflammation. The virus is graded as acute (a short-term infection that clears over time) or chronic (a long-term infection that leads to liver damage). The risk that hepatitis B will become chronic relates directly to an infected person’s age. In general, 2-6 percent of adults with the hepatitis B virus will progress to the chronic stage. However, infants born with hepatitis typically develop chronic hepatitis B (90 percent of cases). The impact of hepatitis on infants is one unintended but real downstream consequence of injectable drug use among pregnant women.
Among injectable drug users, sharing a syringe is a main cause of transmission; however, those who are infected with hepatitis B can also communicate the virus through personal items like razors and toothbrushes. For this reason, being forthright about one’s injectable drug use, and consequent risk of being infected with hepatitis B or other diseases, can alert people in the environment to exercise heightened caution.
The best practice is to be tested for hepatitis B so as to be aware of the risk of transmission. Note that it takes 4-6 weeks for the hepatitis B virus to be detected in one’s blood, hence the need to advise others of one’s injectable use status.
The National Institute on Drug Abuse provides the following insightful statistics regarding hepatitis B:
- An estimated 800,000 to 1.4 million Americans are living with this disease (even more are living with hepatitis C).
- If not properly diagnosed and treated, hepatitis B can cause cirrhosis of the liver.
- Hepatitis B is a major risk factor for liver cancer; approximately 22,000 Americans were expected to die due to hepatitis B-involved liver cancer in 2013.
- From a public health standpoint, there is particular concern about those who use injectable drugs because the compulsive nature of drug abuse results in repeat syringe and paraphernalia use and, therefore, repeat exposures to hepatitis B and other viruses.
- Research shows that those who use injectable opioids who are in treatment and receiving targeted medications (e.g. methadone, buprenorphine, naltrexone) can be safely treated with antiviral medications for their hepatitis infections.
Receiving treatment for injectable drug abuse never compromises treatment for hepatitis B or any other infectious diseases. In fact, undergoing simultaneous treatment for the substance abuse and hepatitis is a way to improve recovery for each issue. As rehab centers conduct an intake interview and any necessary medical examinations of incoming clients, hepatitis B can be treated (potentially offsite but as part of a coordinated care plan), whether it is known or detected for the first time upon admission to rehab.
Medications are available to treat hepatitis B. For those who have chronic hepatitis B, several antiviral drugs are available (including interferon alfa-2b, entecavir, telbivudine, and adefovir dipivoxil). Medical monitoring can help to ensure that hepatitis B does not progress to liver damage or cancer, though treatment is available if these severe conditions do result. The key is not to let hepatitis B go untreated, as this virus can lead to death.
The hepatitis C virus (HCV) is responsible for hepatitis C, a liver infection. Most cases of hepatitis C today stem from injectable drug use (via syringes or drug use-related paraphernalia). According to the CDC, approximately 70-80 percent of people who contract HCV will face a chronic infection.
Hepatitis C is considered a severe condition that can cause a host of health problems and lead to fatality. At present, there is no vaccine for hepatitis C. The best prevention tool is to avoid high-risk behaviors, such as sharing syringes and other drug paraphernalia.
As injectable drug use remains prevalent, it is advisable from a personal and public health standpoint for people to be tested for this virus. In cases where a person is positive and continues to use injectable drugs, the best practice is to incorporate personal safety strategies into the injectable drug use to reduce the risk of spreading hepatitis C.
The potential health consequences of untreated hepatitis B discussed above apply with equal force to hepatitis C. As the National Institute on Drug Abuse notes, the following statistics demonstrate the prevalence of hepatitis C and the need for appropriate treatment responses:
- In the US, there are an estimated 2.7-3.9 million individuals living with hepatitis C (more than hepatitis B).
- It is expected that in the next 40-50 years, 1 million Americans with untreated chronic hepatitis C will meet with a fatal outcome as a result of their infection.
- One recent study found that each person who is infected with hepatitis C is likely to infect approximately 20 other people (typically within the first three years of exposure to the virus).
- Some individuals infected with hepatitis C naturally clear this virus from their bodies.
- Antiviral medications are available for the treatment of hepatitis C, but research findings show that not everyone benefits from these medications.
There are older and newer generation medications for hepatitis C. The older generation antiviral medications are pegylated interferon and ribavirin. These treatments are, however, associated with severe side effects, such as depression and suicidal thoughts. Fortunately, the newer generation antiviral medications, boceprevir and telaprevir, are safer.
These medications are delivered intravenously with pegylated interferon and lasts 12-48 weeks, depending on the individual’s responsiveness. Studies show that these treatments can cure hepatitis C. As discussed with reference to hepatitis B earlier, a person who engages treatment in a substance abuse recovery program can simultaneously receive care for hepatitis C or any other known or newly detected virus or disease.
Safer Use of Injectable Drugs: Harm-Reduction Strategies
In the context of the War on Drugs national approach, the concept of harm reduction seems to be a poor and unwelcome fit. Harm-reduction strategies assume, unlike the War on Drugs, that drug abuse cannot be entirely stamped out and seek to provide those who use drugs with education and improved drug use conditions.
The term harm reduction is intended to be distinguished from abuse prevention; rather than focus exclusively on preventing drug abuse and punishing it when it occurs, harm reduction aims to make drug use as safe as possible. This approach addresses an unfortunate research finding: Drug prevention efforts can actually increase the harm associated with drug use, including intravenous drug use. The harm-reduction approach can also be folded into the criticism that there are strong societal causes of drug use, such as the criminalization of drug abuse rather than a policy focusing on
drug treatment (although US policy is continuing to move in this direction, however slowly). Needle exchange programs are some of the clearest and most salient examples of harm-reduction efforts.
Regarding needle exchange programs (i.e., persons who use injectable drugs qualify for free syringes to ensure greater safety in their drug use), the Obama administration attempted to lift the ban on federal funding for such programs. On December 16, 2009, President Obama signed a new law that allows federal funds to be used to support needle exchange programs in the US. The main policy goal of this new law was to stop the communication of infectious diseases among those who use injectable drugs as well as those affected collaterally, such as infants who contract viruses in-utero. Congress, however, reinstated the ban. Despite this, the American Civil Liberties Union reports that there are 138 needle exchanges operating in 38 states.
One Canadian locale has adopted the harm-reduction approach, in a more generous way than even the Obama administration contemplated. To reduce the incidence of new HIV cases, a government-run program in Vancouver provides persons with a safe facility in which to use injectable drugs. It appears that the clinic exists in a legal gray area; however, the Supreme Court of Canada has made a ruling in favor of its operation. Clinic clients receive clean equipment, such as syringes, tourniquets, and filters, and use injectable drugs under the supervision of medical personnel. All services are free and funded by the government. As of 2010, the clinic reported that more than 12,000 people used the clinic over a total of 312,000 visits.
Canada is not alone in its harm-reduction efforts. It is estimated that there are 90 safe injection sites in Europe and Australia. The governments of Germany, Norway, and Spain have affirmatively granted full legal approval to safe injection sites. Although the US has not followed suit, as more statistical data is compiled on the positive outcomes of these programs, it will be more difficult for American policymakers to challenge the harm-reduction approach.
A discussion of injectable drug use necessarily touches on matters of personal and public health. As noted, injectable drug use does not occur in a vacuum. In addition to the infected person, infants, and a host of other people can be exposed. For this reason, prevention efforts are not enough. In order to contain the spread of infectious diseases, many believe that harm reduction is necessary.
As there is no federally back harm-reduction program in the US, harm reduction must occur largely on a personal, family, and community level. Although drug abuse challenges the ability of people to take care of their health, let alone others, it is of paramount importance that those who are infected with bloodborne viruses be regularly tested for HIV, hepatitis B, hepatitis C, and a host of other potential viruses.
Personal harm-reduction strategies can take numerous forms. The following are some of the most advisable ways to ensure greater safety during injectable drug use and to minimize the risk of communicating diseases:
- Use sterile, clean equipment (e.g. syringes, cotton, spoons, and filters).
- Obtain syringes from reliable sources, such as a local exchange program, pharmacy, clinic, or nonprofit agency that provides free needles service.
- Make a personal commitment not to share injectable drug use equipment, including preparatory paraphernalia.
- Clean the area where the injectable drugs are prepared.
- Wash one’s hands.
- Inject slowly.
- Place a used syringe in a hard container and dispose of it safely (or take it to a needle exchange facility; if one is not available, a local pharmacy or clinic may accept it).
Better than Harm Reduction
While harm-reduction strategies can mitigate some potential damage, the best option is for those struggling with injection drug use to get comprehensive addiction care in a professional setting. As mentioned, dual treatment can be provided for injection drug abuse and any infections that have developed as a result of drug use. Rehab centers will typically make referrals to trusted medical facilities that can provide the appropriate treatment for any viruses, infections, or diseases for which a client tests positive. The key is to engage rehab and medical services as early as possible. That being said, it’s never too late to get help; recovery is always an option.
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