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Illicit Drug Use Revisited: What a Long, Strange Trip It's Been
- Peter A. Selwyn, MD, MPH
- Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut. Reprint Requests to: Peter A. Selwyn, MD, MPH, AIDS Program, Yale-New Haven Hospital, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510.
The first apparent reference to a medical complication of illicit drug injection was an article in the 1876 Lancet entitled Tetanus after hypodermic injection of morphia [1]. This brief report describes a woman who had been taught the use of the hypodermic syringe some years before for the relief of the vomiting of pregnancy, and there was some reason to believe that she had practiced the injection surreptitiously where no actual occasion for it existed. Since this description of an apparent medical curiosity, the medical literature has burgeoned with reports on the adverse sequelae of illicit drug injection, involving every major organ system and various infectious agents. (Although previously denoted as intravenous drug abuse, the practice of parenteral injection of nonprescribed pharmaceuticals or illicit drugs is now more precisely and less pejoratively referred to as injection drug use.) An estimated 1.1 to 1.8 million illicit drug injectors exist in the United States; recent household survey data from the National Institute on Drug Abuse indicated that approximately 2.5 million people had ever used illicit drugs by injection [2]. Thus, nonprescribed injection drug use must be considered not a bizarre or aberrant behavior but rather an important social phenomenon with major clinical and public health consequences.
To help understand injection drug use in its current context, two observers who first called attention in the 1960s to the health effects of illicit drug use [3, 4] provide, in this issue of Annals, a comprehensive and well-referenced update on the medical consequences of drug injection [5]. As they note, the major changes that have occurred during the intervening years have been the advent of AIDS and the emergence (or re-emergence) of cocaine as a major drug of abuse. It would have been difficult to predict even 15 years ago that a lethal blood-borne infection such as HIV would soon spread with such grim efficiency through large groups of injection drug users throughout the world, with secondary heterosexual and perinatal transmission. Seroprevalence studies of HIV in diverse groups of injection drug users have shown levels of HIV infection exceeding 30% to 40% in many cities, not only in North America and Europe but also in parts of South America and Southeast Asia [6]. Mortality rates among drug injectors (already 10 times that of their age-matched peers) increased three to four times in the 1980s because of HIV [7].
The 1980s also showed evidence of increased morbidity and mortality from cocaine among drug users [8]. Aside from the observed increased frequency of cocaine overdoses and the social morbidity caused by cocaine-related crime and violence, specific medical complications of cocaine abuse have also been identified. These include cardiac arrhythmias and ischemia; pulmonary complications such as bronchospasm, barotrauma, and airway disease; and central nervous system disease including intracerebral hemorrhage and other stroke syndromes [9-11].
As a group, drug users with HIV infection have an increased risk for bacterial pneumonia and tuberculosis compared with other HIV-infected groups [7, 12, 13]. Recently an association has been reported between smoked cocaine or crack use and an increased risk for bacterial pneumonia among HIV-seropositive drug users in Baltimore [14]. Shared marijuana use [14] and crack use have been linked to transmission of tuberculosis in local outbreaks [16], a particularly ominous finding in view of the known association between crack use and HIV risk [17] and the crowded, close conditions that often characterize crack smoking. These observations suggest the continuing important connections between substance abuse, social and behavioral factors, and certain infectious diseases.
Although an appreciation of the full range of medical complications of illicit drug use is important, attention to drug abuse treatment and prevention as key elements in the medical care of injection drug users is equally important. Unfortunately, the availability of adequate drug treatment services is limited in many areas, including those regions heavily affected by AIDS [2, 18]. Current estimates suggest that 80% to 90% of injection drug users are not in treatment programs at any given time [2]. Long waiting lists for treatment are the norm, and treatment on demand is rarely available. Whereas it would be almost unthinkable to discharge a patient from the hospital after a myocardial infarction without a planned cardiac rehabilitation program, active injection drug users (with or without HIV infection) are frequently discharged after a 6-week antibiotic course for endocarditis without even a referral for drug rehabilitation. This disparity seems rooted in a medical care system attuned to treating only the complications of drug-using behavior, within an essentially punitive rather than clinical approach to the problems of drug addiction.
From the vantage point of 1993, it appears that the law enforcement orientation of the past decade's War on Drugs has failed as a strategy to decrease the level of drug use in the United States. Indeed, some experts have claimed that criminal justice-driven approaches have served indirectly to promote the spread of unsafe illicit behaviors and the transmission of HIV in many regions of the world [6]. As an alternative to punitive and proscriptive approaches for controlling drug use, there is recent interest in new strategies for drug abuse treatment and prevention. Among these is the concept of harm reduction, articulated most clearly in Europe, which states that if illicit drug use cannot be eliminated, then we must at least ensure that drug users minimize harm to themselves and others [19-23]. This approach has included interventions such as needle and syringe exchange programs, bleach distribution, street-based education on safer injection practices for drug users (such as preinjection skin cleaning, associated in two studies with reduced risk for endocarditis and skin infections [24, 25]), drug treatment on demand, and alternatives to prison sentencing for minor drug-related offenses.
Although some indirect evidence exists [26], no study has yet shown that syringe exchange and other harm-reduction approaches have directly resulted in decreased transmission of HIV. However, such programs have been associated with decreased transmission of hepatitis B, have not been found to result in increased levels of drug injection, and in fact have often served as a bridge to treatment for drug users previously not in contact with the health care system [19, 21-23, 27]. Public health concerns and principles of harm minimization were also articulated by some advocates in drug policy debates in the 1960s and 1970s, in response to the perceived epidemic of heroin use then affecting Europe and North America [28]. Although AIDS thus may not be unique in raising these issues, it provides compelling current reasons to pursue a comprehensive public health approach to address both illicit drug use and the related behaviors that result in HIV transmission.
One trend that has been stimulated by the AIDS epidemic has been the attempt to link primary care, mental health, and drug treatment services, which have received federal support through joint funding initiatives by the National Institute on Drug Abuse, the Health Resources and Services Administration, and, most recently, the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration. Several programs have successfully provided ongoing primary care to injection drug users infected with HIV, both in drug-abuse treatment programs and in hospital-based clinics [29-32]. These demonstration projects offer encouraging evidence that comprehensive medical care for injection drug users can be effectively delivered.
Unfortunately, however, medical education and training remain seriously inadequate in preparing physicians to identify and to treat substance abuse. Although the past two decades have seen an increase in elective offerings on substance abuse in medical school curricula, a 1987 report concluded that the percentage of required (medical school) teaching hours on alcoholism and drug abuse remained well under 1%, a level far out of proportion to the extent of the public health problem [33]. If medical school curriculums on substance abuse are not broadened, both to impart the basic principles of treatment and to address physicians' own prejudices and fears about drug addiction, it is difficult to envision how the medical care system can respond effectively to the challenges posed by the current AIDS epidemic among injection drug users.
It is necessary to promote more widespread awareness and sensitivity about illicit drug use among physicians who provide care for illicit drug users, whether by intention or default. Even though we cannot predict what new epidemics may emerge among injection drug users during the next 25 years, we can expect, as long as attention to substance abuse is not fully incorporated into mainstream medical education and practice, that we will be inadequately prepared to confront them.
- Copyright 2004 by the American College of Physicians
