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TB: A Rising Risk for Drug Treatment Patients and Staff

Screening, prevention, and control of infectious diseases is a particularly critical function in methadone treatment programs—both for the patients and for protecting the staff who work with these patients. Intravenous drug users are at high risk for a range of infectious diseases, such as syphilis and other sexually transmitted diseases, hepatitis, and the human immunodeficiency virus (HIV), which causes AIDS. Patients infected with HIV, because of their impaired immune systems, are particularly vulnerable to infectious diseases.

Experts at the Centers for Disease Control (CDC) are concerned about the rising U.S. incidence of tuberculosis (TB), particularly among those with HIV, and strongly recommend that drug treatment programs regularly screen their staffs, as well as patients, for TB infection. The 30-year decline in U.S. cases ended in 1984, and the number of cases reported each year has now risen to almost 26,000. About 90 percent of new TB cases occur in persons who have been infected in the past. Extremely effective drug regimens are available for treating patients who have the disease, as well as for preventing the disease in infected individuals (those currently without symptoms or clinical findings).

Increases in drug-resistant strains of TB

In recent months, particularly dangerous forms of TB have struck in 13 States, according to CDC experts. Strains of the bacterium that are resistant to the standard anti-tuberculosis drugs have been identified throughout the country, including New York, California, and Georgia. These outbreaks chiefly afflict people already infected with HIV, but the disease can be a threat to anyone in close contact with a person who has TB. TB is spread through droplets dispersed through the air by coughing, sneezing, or speaking, which can remain airborne indoors for long periods. Many patients with drug-resistant strains of the disease can be cured, but treatment needs to be given promptly.

Federal regulations presently require that all patients in methadone programs receive a tuberculin skin test on entry and annual repeat tests for those who continue in the program. TB is commonly found in this population. Studies show that more than 20 percent of innercity black and Hispanic intravenous drug users in some areas have tuberculous infection.

Actions methadone programs can take

Methadone treatment programs are in a position to take significant additional measures, beyond screening, to protect their patients, staff, and the general public (see sidebar). These measures include:

• Work with public health authorities to arrange for quality laboratory services, essential for proper identification of the organism and for drug sensitivity testing
• Explore the possibility of providing direct observed preventive therapy for patients with inactive tuberculous infection (this means that the anti-TB medication is swallowed in the presence of another person)
• Assure that all patients with chronic cough, fever, and other symptoms are rapidly evaluated for active TB and treated quickly

Methadone programs can play a key role in delivering preventive care to vulnerable patients—intravenous drug users, those with HIV, the homeless—in ways that assure continuity of treatment and completion of the required chemotherapy regimen. Most infectious patients become non-infectious very rapidly—within a few days to weeks after starting chemotherapy, and more than 95 percent of first-time patients can be treated successfully if they complete the prescribed regimen. Irregularity or interruption of self-medication cause most treatment failures. In some large urban centers, up to 60 percent of patients fail to complete the suggested duration of treatment. Experience suggests that the patient most likely to be noncompliant is the single, unemployed, innercity, male alcoholic.

Methadone programs can get assistance in setting up a screening and prevention program for TB and other infectious diseases from their local or State health departments (see insert for listing of State contacts). Staff will need training and information on issues particularly important for drug treatment patients, such as:

• Awareness of anergy—a condition affecting many patients who have HIV or take medications affecting the immune system—in which patients do not show a significant positive reaction to the tuberculin skin test even though they have TB infection or active TB
• Awareness of possible interactions between methadone and anti-TB medication (for example, patients receiving rifampin—a common TB medication—may need to have their methadone dosage increased to prevent withdrawal symptoms that can result from interaction of the two drugs)
• Awareness of the need for monthly checkups of persons on preventive therapy to check for toxicity (especially liver toxicity) resulting from the medication

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