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Chapter 7 of TAP 11: Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination

Chapter 7–Substance Abuse-Related Infectious Diseases

Persons who abuse alcohol and other drugs are at greater risk of health consequences. These include problems such as malnutrition, damage to various systems of the body, risks of accidental deaths and suicide, brain impairments, and infectious diseases. In this chapter, several illnesses related to substance abuse will be discussed. Implications for management and prevention also will be presented.

Why There Is Concern for Substance Abuse-Related Diseases

The medical needs of alcohol-and drug-involved persons can be highly complex and usually require a multidisciplinary approach. The medical complications, as well as underlying substance abuse and related psychosocial problems, must be carefully assessed and treated. Substances abusers, like all patients, are entitled to the highest standards of medical care (Novick, 1992). It is not possible to examine adequately substance abuse treatment without exploring the issue of related health effects. There are both individual and societal consequences that must be considered.

Concerns for Individuals

Substance abusers are more prone to a variety of diseases and medical complications than similar persons in the general population. They experience health problems more frequently than others, and their illnesses are often more severe.

Treatment goals and interventions that emphasize correcting medical problems are important to the prognosis of patients. Improved health, in tandem with substance abuse recovery, has the potential of returning individuals to productive functioning.

Societal Concerns

A variety of diseases is dramatically linked to substance abuse. With the advent of Acquired Immune Deficiency Syndrome (AIDS), this correlation has been underscored. The transmission of the human immunodeficiency virus (HIV), the causative agent of AIDS, is related to substance abuse in three ways. First, there is direct transmission when needles are shared between infected and non-infected individuals allowing blood-to-blood contact to occur. Second, persons who have acquired HIV through needle sharing may further transmit the disease to their sexual partners. Third, women who become infected through using injected drugs or having sex with infected drug users may infect their infants in utero, during delivery, or through breast milk.

HIV is a highly infectious organism when coupled with certain risk behaviors. There is not yet a preventive vaccine or cure for those who become infected. Once HIV disease progresses to AIDS it appears to be universally fatal.

The spread of other infectious diseases, such as tuberculosis, has been associated with HIV disease and substance abuse. In addition to threatening the health and recovery of substance abusing persons, such diseases impact general community health, as well. Some infectious diseases, like tuberculosis and syphilis, which will be discussed later in the chapter, had been very effectively controlled with modern medical practices. However, they are again on the rise and are reaching epidemic proportions in some areas.

HIV disease, other infectious diseases, and a variety of illnesses, often exacerbated by alcohol or other drug use, have dramatically affected this country's health care system. Especially in areas where there is a high incidence of injection drug use, the spread of infectious diseases is rampant. This is stretching the capacity of health care programs. Medical costs, already at phenomenally high levels, threaten to be pushed even higher by the incidence of these infectious diseases.

Effective treatment of substance abuse disorders is viewed as essential in controlling both the spread and the associated costs of substance abuse-related diseases. Alcohol and drug abuse treatment does reduce chemical dependency. Considering both the human and the financial burden of substance abuse-related diseases, treatment for addictive disorders and other medical illnesses can be very cost-effective.

Substance Abuse and Medical Illnesses

Rates of Substance Abuse-Related Illnesses

The incidence of health-related problems is always higher among substance abusers than among similar persons in the general population. Lifestyle is one predisposing factor, frequently including malnutrition, crowded and substandard living conditions, and general personal neglect. Alcohol and other drugs are also responsible for compromising the immune system, making users more susceptible to a variety of infectious diseases and other health complications. Many drugs, especially injected drugs, may be mixed with contaminated substances when they are sold on the street, thus increasing the likelihood of infections (Crane, 1991).

There was a dramatic decline in deaths from infection among addicts in New York City between the 1950s and the mid-1970s. In approximately 20 years, the rate of drug-related deaths due to infections declined from 27.1 percent in the 1950s to 5 percent in 1974. However, AIDS in New York City was responsible for a 124 percent increase in drug-related deaths between 1980 and 1984, while the purported number of addicts in the city remained more or less constant. This substantial increase in deaths included those directly caused by AIDS-related illnesses, as well as other infections in which suppression of the immune system by HIV makes persons more susceptible to infectious organisms (Crane, 1991).

The incidence and types of infectious diseases affecting substance abusers varies according to several factors. The types of drugs used and the way they are ingested varies by geographic areas. Thus, in areas where drugs are frequently injected, rates of infections are likely to be higher. The duration of addiction also may influence the types of related infectious diseases. There also are some reported gender differences, probably related to the preferred routes of drug administration. Female injection drug users more often inject drugs subcutaneously (under the skin) which is related to a higher incidence of fatal tetanus and infections at the site of the injection. On the other hand, male addicts more frequently inject drugs intravenously (into a vein), with which other infections are associated (Crane, 1991).

Substance Abuse-Related Health Consequences

There are many physical and medical consequences of alcohol and drug abuse. These are often interrelated and complex. However, three principal types of health problems will be reviewed briefly. The remainder of the chapter will focus on the last of these- infectious diseases.

The Physical Effects of Alcohol and Other Drugs

Malnutrition is a common occurrence among substance abusers. The first priority for addicted individuals is to obtain and use alcohol or other drugs. Thus, money needed for food may be diverted for drug use. Appetite may be decreased by substance abuse, particularly when certain drugs are used, such as stimulants. Alcohol and other drugs may interfere with the absorption of food from the digestive system to the rest of the body, resulting in vitamin deficiencies.

One of the functions of the liver is the removal of toxic substances from the blood. In the liver, alcohol and some other drugs, are transformed into water soluble substances. These are then eliminated from the body through urine and feces. Alcohol, cocaine and inhalants are frequently associated with damage to the liver and various liver diseases.

Many other body systems may be damaged by alcohol or specific drugs. Excessive use of alcohol, central nervous system (CNS) stimulant drugs, marijuana, and inhalants may cause brain damage. The heart may be affected by cocaine or opiate drugs. Alcohol affects the digestive system, and smoked drugs (e.g., tobacco, marijuana, cocaine) injure the lungs. Alcohol, marijuana, and cocaine are known to affect hormones and reproductive health in both men and women.

Accidental Injuries and Death

Traffic accidents caused by alcohol- or drug-impaired drivers are a significant concern because of their human and economic impact. Use of alcohol and other drugs by public transportation workers jeopardizes public safety. News accounts have heightened awareness of substance abuse by truck drivers, train engineers, bus drivers, and airplane pilots. Many deaths and serious injuries have resulted from such incidents.

Other types of accidents also may be related to substance abuse, including falls and other injuries sustained by persons who are inebriated. Hallucinogens and PCP sometimes cause panic reactions or violent behaviors resulting in injuries or death.

While many addicted persons assert their ability to control their alcohol and other drug use, they also may realize the potential for overdose and death. Opiate overdoses may result in death. Alcohol poisoning is sometimes fatal, particularly for youth whose bodies have less water content to dilute the alcohol. Cocaine has resulted in cardiac arrest for some users. Inhalants pose a risk of death from suffocation because they often are ingested from air-tight bags placed over the head.

Suicide risk is increased with drug use. Emotional problems that might result in suicide attempts or completions include depression, psychoses, and panic reactions. There is also a correlation between substance abuse and homicides. Certain drugs, such as alcohol, amphetamines, and PCP, may lead to assaultive behaviors in some users. Drug trafficking and gang-related activities also are frequently violent, posing risks of impairment or death to both users and bystanders.

Infectious Diseases

Substance abuse-related infectious diseases are frequently associated with injection drug use. However, they are not limited to those administering drugs in this manner. The sources of microorganisms that cause infectious illnesses include the environment, other drug users, and the addicted person's lifestyle (Crane, 1991).

Practices may differ according to the type of drug being used and customs among particular groups of injection drug users. However, typically, when heroin is used, it is mixed with water in a spoon or bottle cap (called a "cooker") and heated over a flame. Heating helps dissolve the powdered form of heroin in water so it can be injected. As a source of clean water is not always available, toilet water, saliva, or other sources of contaminated water might be used. A lighter, matches, or candle flame often are used to heat the mixture; this may not generate enough heat to kill toxic substances in the drug solution. Cocaine and some oral medications are mixed with water if they are to be injected. However, unlike heroin, they do not necessarily have to be heated to dissolve them. The drug mixture is then drawn into the syringe. When injected into a vein, some blood is first drawn from the vein into the syringe. Then the drug is injected. Small amounts of the user's blood may remain in the needle or syringe (Crane, 1991; Karan, Haller & Schnoll, 1991).

These practices place the needle user at increased risk of infections. The water used to mix the drug may be contaminated; injection drug users rarely cleanse the skin around the area of the puncture; and the particular drug used also may have been mixed by the seller with non-sterile substances. In addition, injection drug users frequently share the same drug paraphernalia. It is estimated that 68 to 80 percent of addicts engage in needle sharing (Crane, 1991).

Sharing injection equipment is sometimes attributed to friendship bonds among users. They may share needles (and the small amounts of blood left in them by previous users) as a bonding ritual. However, needles and other equipment are often shared by anonymous users, as well. New needles and syringes cannot be sold without a prescription in many States. Thus, they are usually scarce for those wanting them to inject illegal drugs. Sometimes syringes are hidden in public rest rooms or other places. Addicted persons are able to find and use these "public works" without knowing the previous users. "Shooting galleries," usually vacant apartments or buildings in which dealers sell drugs, also rent the equipment to drug users. After needles are used, they are returned to the dealer and rented to subsequent users (Crane, 1991). Bloodborne pathogens are easily transmitted from one injection drug user to another through shared equipment.

Although injection drug use is most commonly associated with heroin, it can occur with several other substances of abuse. With recent widespread cocaine use in some areas, high rates of infections have also been noted. The euphoria associated with cocaine use is of very short duration. Cocaine is often used in binges during which the person will administer it frequently until the supply is exhausted. If it is being injected, this may result in multiple needle administrations in a very short period, increasing the likelihood of infection. Cocaine also can be ingested nasally. It is a caustic substance that can damage mucous membranes in the nose. Parts of the nasal passage that filter out foreign substances may be destroyed, leading to a higher probability of infection (Crane, 1991).

Lifestyle factors contributing to infectious diseases among addicted persons include crowded and unhealthy living conditions and unsafe sexual activities. Airborne diseases, such as tuberculosis, can be transmitted from infected to non-infected persons in poorly ventilated living environments. Unprotected sex is a common route of transmission of bloodborne pathogens such as HIV, hepatitis, and other sexually transmitted diseases. Malnutrition, tobacco use, and dental neglect, while not the direct cause of infectious disease transmission, often contribute to susceptibility to and severity of infections. Similarly, the effect of alcohol and other drugs on the body's immune system may increase the likelihood that, once an infectious organism enters the body, illness will develop.

Infectious Diseases Associated With Substance Abuse

The prevention and treatment of substance abuse-related infectious diseases is critical for the benefit of chemically dependent persons, as well as society. The personal toll of such diseases as AIDS, tuberculosis and hepatitis is devastating. Recent epidemics also have critically affected the nation's health care system and threaten its future. The burden of these infectious diseases is manifested in higher health care costs, personnel shortages, and other demands on scarce resources. Significant resources have been channeled toward research and treatment of these illnesses, stretching the capacity of the system to meet other needs effectively. Four infectious diseases most commonly associated with substance abuse will be described in greater detail. A brief explanation of several other infectious diseases also will be provided in this section.

HIV/AIDS

The AIDS epidemic has highlighted the relationship between injection drug use and infectious diseases. Injection drug use is the second most common risk behavior associated with HIV transmission, and the proportion of AIDS cases that are attributed to this route of transmission is increasing steadily. Among women with AIDS, the majority of cases are linked to injection drug use. Women also may become infected because of their own drug-use behaviors or through sexual contact with male injection drug users. Women who engage in prostitution to support their drug use are potential vectors for heterosexual transmission, as well. Infected women, in turn, may infect their infants because of the exchange of body fluids in utero, during delivery, or by breast feeding. Injection drug use is also the most pivotal factor in AIDS cases reported among ethnic/racial minorities (Brown, 1991; Des Jarlais, Friedman, Woods & Milliken, 1992; Selwyn, 1992). The numbers of cases attributed to injection drug use as of December 1992 are listed in Table 7-A.

Table 7-A.-Cases of AIDS Related to Injection Drug Use

Exposure Category	White	Black	Hispanic	Other	Total	% of Total
Men who inject drugs	8,895	21,100	13,613	92	43,700	7.2%
Women who inject drugs	2,901	7,860	2,784	54	13,599	5.4%
Men who have sex with men and inject drugs	9,044	4,407	2,334	97	15,882	6.3%
Men who have sex with women who inject drugs	616	1,522	438	9	2,585	1.0%
Women who have sex with men who inject drugs	1,139	2,979	1,735	28	5,881	2.3%
Children under 13 whose mothers injected drugs	257	1,001	429	8	1,695	0.7%
Children under 13 whose mothers had sex with men who inject drugs	106	331	280	3	720	0.3%
TOTALS	22,958	39,200	21,613	291	84,062	33.2%

Explanations:

1. The numbers of cases reported in this table include only those who have met the case definition for AIDS. Those infected with HIV but not having one of the AIDS defining illnesses are not included.
2. The categories of men and women include all adolescents aged 13 and over and adults with AIDS.
3. The percentage of total cases is based on 253,448 total adolescent, adult and pediatric cases reported through December 1992.

Source: Centers for Disease Control. HIV/AIDS Surveillance Report. February 1993.

The natural course of HIV disease begins when the virus is transmitted from an infected person. Casual transmission, through typical daily activities, is not a method of infection. The virus does not appear to be viable outside the body. However, exposure to body fluids through unprotected sex, sharing of unsterile injection equipment, and infection of an unborn baby by an infected mother are the most common routes of transmission. Only a few documented cases have occurred through job-related exposures, such as a health care worker accidentally being exposed to the blood of an infected patient. Soon after the virus has infected the body, some people experience a brief illness, similar to the flu. Others have no early symptoms, and some people continue in good health for several years. The average time from infection to development of AIDS is between 7 and 10 years (Selwyn, 1992). The virus attacks the cells of the body's immune system and gradually destroys them. This makes infected persons susceptible to many disease organisms that a healthy, functioning immune system would easily combat. Some people experience symptoms related to HIV disease that are not considered diagnostic symptoms of AIDS. These include diarrhea, fevers, fatigue, and many other complications that can be very distressing, and, in some cases, incapacitating.

AIDS is diagnosed only when specific illnesses are manifested. These include certain cancers and opportunistic infections that occur with the presence of HIV. The specific illnesses used to define AIDS were changed as of January 1, 1993. Table 7-B lists these AIDS-defining illnesses.

The case definition of AIDS has changed over the course of the epidemic because more has been learned about the natural progression of the disease. It does not affect all persons in the same way. For example, injection drug users are less likely to develop Kaposi's sarcoma which is often seen among homosexual/bisexual men with AIDS. On the other hand, injection drug users have frequently developed a variety of infectious diseases other than the specific opportunistic illnesses that formerly limited the diagnosis of AIDS. Bacterial infections, such as pneumonia, endocarditis (an infection of the heart valves), and others, occur more commonly in HIV-infected drug users, and they also may be more severe among this population. Tuberculosis also is frequently associated with HIV disease in injection drug users (Selwyn, 1992). More information about this disease will be provided in the next section of this chapter. Thus, with the new definition of AIDS, a significant increase in diagnosed cases of AIDS was noted. This more inclusive definition will be helpful in the treatment of persons with HIV disease, as they will qualify for medical and other benefits that previously were limited to those meeting a more restricted case definition.

* Added in the 1993 expansion of the AIDS surveillance case definition.

Source: Centers for Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992; 41 (No. RR-17), p. 15.

Injection of drugs presents a risk of HIV exposure because of the sharing of unsterile injection equipment. Small amounts of blood left in the equipment may contain the virus and transmit it to the next user. The risk of infection can be virtually eliminated if the equipment is cleaned with bleach and rinsed between uses. However, this precaution often is not practiced regularly. The frequency of injection also increases the risk of exposure. Thus, cocaine injection may be more likely to result in HIV exposure than heroin use. Cocaine users tend to binge, using the drug almost continuously while the supply lasts. Because the euphoria experienced from cocaine is short, there may be multiple injections in a very short span of time. The frequency of injection may increase the number of times the equipment is shared and it may decrease the likelihood that it will be cleaned between injections (Des Jarlais et al., 1992).

HIV-infected drug users are prone to a variety of psychosocial stresses. Common emotional reactions include (Crowe, 1990):

• denial;
• anxiety;
• fear;
• anger;
• depression; and
• grief.

The risk of suicide attempts or completions among persons with AIDS is substantially higher than for the general population.

Prejudice and stigma are often experienced by persons with HIV disease, including injection drug users. Coupled with this, many experience other social problems related to the following (Crowe, 1990):

• inadequate housing;
• lack of social support systems;
• need for financial assistance;
• legal problems;
• termination of or inability to find employment; and
• problems and concerns for child care and child custody, especially among infected women.

Obtaining medical care is another difficulty for many HIV-infected drug users. Both the availability and funding of appropriate health care may be significant issues.

Treatment Recommendations

Drug abuse treatment is effective in preventing HIV infection among many individuals using injected drugs. Outpatient methadone maintenance programs that are effective in reducing injection drug use are one important form of treatment. However, the escalation of the HIV/AIDS epidemic among injection drug users may not be stopped soon given the realities of the present drug treatment system. The present system is capable of providing treatment to approximately 15 to 20 percent of those using drugs. Considerable time and expense is required to expand treatment resources to more adequately meet the current need. Concomitantly, many injection drug users are not motivated to enter treatment. As addiction is a chronic, relapsing disorder, periodic return to drug use for some recovering individuals is a reality. Thus, improvements in the treatment system would likely help in reducing HIV transmission. However, such change includes many practical issues related to funding, locating HIV-infected persons, recruiting and retaining them in treatment programs, and maintaining confidentiality (Des Jarlais et al., 1992).

Effective programs need to include ways of convincing injection drug users in a local area that AIDS is a threat to them. Ways of changing behaviors, including drug abuse treatment, must be available. Education about safer injection practices (i.e., sterilizing injection equipment) is also recommended. Some States are considering needle exchange programs in which addicts may receive sterile needles and syringes in addition to education. Finally, new behaviors must be effectively reinforced through peer approval and new social norms regarding injection drug use (Des Jarlais et al., 1992; Schleifer, Delaney, Tross & Keller, 1991).

Batki and London (1991) recommend that HIV-infected drug users, especially those with psychiatric problems, be provided with multidisciplinary interventions involving drug abuse counselors, social workers, psychotherapists and physicians. Six levels of intervention are suggested:

Level 1:		Provision of concrete forms of practical, material assistance and support
Level 2:		Provision of helpful information to reduce patients' feelings of helplessness (this may include information about HIV disease, drug use, prevention practices, services and resources and a variety of other areas)
Level 3:		Self-help groups to reduce isolation
Level 4:		Supportive psychotherapy
Level 5:		Psychiatric medications if psychotherapy alone is not adequate
Level 6:		Residential treatment, if needed to protect patients from hurting themselves or others or to support patients who cannot provide for basic self-care needs

Programs must be cognizant of and effectively address staff concerns when treating HIV-infected persons. Fear of infection, confidentiality dilemmas and the emotional stress of treating patients with poor prognoses, are some of the issues to be confronted. Programs should develop clear guidelines, apply infection control policies, provide training, and institute staff support groups to alleviate some of the problems experienced by staff working with HIV-infected persons (Sorensen & Batki, 1992).

Program challenges include compliance with both State and federal regulations for program operation, which occasionally are contradictory. Maintaining sufficient levels of program funding is another obstacle programs often face. Community opposition to programs and staff retention and continuing competency are also administrative challenges (Brown, 1991).

In summary, the continuing spread of HIV disease and AIDS is a growing concern for society. Injection drug use and related factors are increasingly recognized as a causal factor in disease transmission. Both the human suffering and societal costs of HIV disease are devastating. Drug abuse treatment can be effective in preventing the continuing escalation of cases of infection. However, many issues and problems must be addressed to provide the level of services needed. Services must be comprehensive and matched to patient needs. Relapse prevention programming is essential. With these elements, treatment can be a cost-effective response to the problem of HIV infection.

Tuberculosis

Tuberculosis (TB) is reemerging as a serious infectious disease in the United States. Until the mid-1980s, the incidence of TB had declined dramatically and was no longer considered a major health threat. However, since 1985, case rates have climbed steadily, with an increase of 16 percent between 1985 and 1990. In some of the poorest areas of the nation, TB rates surpass those of the poorest countries in the world (Cowley, Leonard & Hager, 1992; Department of Health and Human Services [DHHS], 1992).

Mycobacterium tuberculosis (MTb) is the infectious organism that causes TB. It is transmitted when an infected person coughs up droplets of respiratory secretions containing MTb. These are inhaled by non-infected persons in the same environment. The organisms multiply in the lungs and then are transferred into the bloodstream. This circulation may lead to infection in any organ of the body; however, the lungs are the most common site of TB infections. Most people experience few, if any, symptoms with initial infection. The disease then becomes dormant, and most people may continue to be infected but asymptomatic. However, in some persons the disease may be reactivated, often because the immune system is weakened by HIV disease and/or substance abuse. Symptoms of acute, active infection include (Barthwell & Gilbert, 1993; Novick, 1992):

• fatigue;
• fever;
• weight loss;
• cough;
• pleuritic chest pains (pleurisy is inflammation of the membranes enclosing the lungs); and
• hemoptysis (spitting up blood from the lungs or bronchial tubes).

TB is indisputably linked with both substance abuse and HIV infection. Alcoholism and injection drug use are associated with TB because of malnutrition, damage to the immune system, poor compliance with treatment regimens, and poor socioeconomic situations often accompanying chemical dependency. TB often precedes other opportunistic diseases associated with HIV infection. This suggests that TB may be reactivated in HIV-infected persons with less damage to the immune system than is the case with other infections. Indeed, in some cases, a diagnosis with TB is the first indicator that a person may also be HIV infected. Thus, anyone with TB who has not received HIV testing should be encouraged to do so. Homeless persons are also at high risk for exposure to MTb because of crowded shelter conditions, malnutrition and alcoholism. Many Black and Hispanic individuals also are at increased risk of exposure because of socioeconomic factors. In 1989, 67 percent of reported TB cases were in racial and ethnic minorities; more than 80 percent of childhood cases of TB are in minority populations. Persons in correctional facilities and nursing homes are also at increased risk for contracting TB. Crowded conditions in jails and prisons are partially linked to mandatory minimum sentences for possessing and selling drugs (Barthwell & Gilbert, 1993; Boodman, 1992; DHHS, 1992; Novick, 1992).

TB infection can be detected by an easily administered skin test. If there is a positive result, more extensive, confirmatory x-ray and microbiological tests should be conducted. TB is a very treatable infection, but it requires taking multiple anti-TB drugs for a minimum of six to nine months. For those who are infected, preventive treatment may avert reactivation of the disease (Barthwell & Gilbert, 1993).

Unfortunately, a strain of TB that is resistant to the therapies presently available for treatment is becoming more prevalent. Called multidrug-resistant tuberculosis (MDR TB), it is very difficult to treat, and the cost of treatment may be greater than 10 times the cost of traditional therapy (DHHS, 1992). MDR TB is also much more dangerous. Even with intensive treatment, it is 50 to 80 percent fatal (Cowley, Leonard & Hager, 1992). In a nationwide survey conducted by the Centers for Disease Control and Prevention in 1991, 14.9 percent of cases tested had organisms resistant to at least one anti-tuberculosis drug. An additional 3.3 percent of cases were resistant to both of the major drugs currently used to treat TB (National MDR-TB Task Force, 1992).

Treatment Recommendations

The Center for Substance Abuse Treatment (CSAT-formerly Office of Treatment Improvement) developed a Treatment Improvement Protocol in 1991 specifically related to TB and other infectious diseases. Entitled Screening for Infectious Diseases Among Substance Abusers, it outlines specific procedures that should be undertaken by substance abuse treatment programs. Treatment program personnel and decision makers should review the entire document. The following summarizes the major recommendations of this protocol (Barthwell & Gilbert, 1993):

• All persons entering substance abuse treatment programs should be screened for TB by a tuberculin skin test and a medical history.
• Drug treatment patients with negative TB tests should be retested at least yearly or more often.
• Persons with positive indicators of TB infections should receive a chest x-ray.
• A confirmatory microbiological test should be performed on anyone with a positive skin test and chest x-ray.
• Those who are infected but do not have active TB should receive preventive treatment for 6 to 12 months; HIV-positive persons may need preventive treatment for a longer period.
• Persons with active TB must receive treatment and close medical follow-up.
• It is recommended that the administration of drug therapy for TB be directly observed to increase compliance.
• All new cases of active TB must be reported to local or State health departments.
• To minimize the possibility of disease transmission, program facilities should provide adequate ventilation in areas where persons with possible or proven TB congregate.
• Health care personnel are at risk of TB infection and should be tested every 6 to 12 months, or more often if they have been exposed to active TB.
• Informed consent of patients and staff should be obtained before screening and treatment are administered.
• Programs must comply with confidentiality requirements.
• Health education should be provided when possible.

In addition, Novick (1992) suggests that program staff should maintain supportive, interested, and nonjudgmental attitudes. Flexible schedules also are helpful in assuring compliance with treatment. Again, comprehensive services are needed, including drug and alcohol treatment, medical care, and social services.

Sexually Transmitted Diseases

Sexually Transmitted Diseases (STDs) also had declined in the United States but have begun to increase again. Drug abuse, particularly injection drug use and crack cocaine, have been associated with STDs. Use of crack may result in high levels of sexual activity, infrequent use of condoms, and the exchange of sexual favors for the drug. Prostitution is a common denominator in both drug use and STD transmission (Novick, 1992).

HIV, which has already been reviewed, can be transmitted through sexual activities. Other STDs include the following.

• Syphilis. Caused by a spirochete that enters the body through a mucous membrane, syphilis can be very serious if not treated. The first stage of the disease is characterized by a sore at the point of contact. After several months, if untreated, the person may develop a rash and flu-like symptoms. The third stage of untreated syphilis may cause extensive damage to the body or death. Syphilis can be diagnosed with a blood test and treated with antibiotics. If untreated, syphilis can be transmitted from a pregnant woman to her fetus (Family Health and Medical Guide, 1989).
• Gonorrhea. A bacterium transmitted from an infected person to another is the cause of gonorrhea. Eighty percent of infected women and 10 to 20 percent of infected men will be asymptomatic. For those with symptoms, women may experience vaginal discharge, painful urination and low abdominal pain. Men may have painful urination with an intermittent or continuous discharge from the penis. If infection has occurred in the throat or anus, a sore throat or anal discharge may be noted. Gonorrhea can be treated with antibiotics. If untreated, it can result in damage to the reproductive system. Infected women may transmit the infection to the baby's eyes, which can result in blindness if not treated (Family Health and Medical Guide, 1989).
• Chlamydia. Chlamydia is caused by a virus-like organism that is transmitted through sexual contact. After an incubation period, a blister forms on the genital area. The infection then spreads to the lymph nodes. The rectum may become inflamed and fistulas may form. Joint pain, skin eruptions and conjunctivitis also may be caused by chlamydia. It can be treated effectively with antibiotics (Family Health and Medical Guide, 1989).
• Herpes. Herpes Type II is an infectious virus found in the genital area and transmitted by sexual contact. Painful blisters occur at the point of contact. The sores may recur periodically and may be precipitated by stress, emotional upset, fatigue, illness, and other factors. Transmission takes place through direct contact with a herpes sore. Once infected, herpes is a lifelong condition, as there is no cure for it, although there is a drug that helps control it. Thus, prevention by avoiding contact with persons who have active lesions is important (Family Health and Medical Guide, 1989).
• Venereal warts. Venereal warts are caused by a virus and produce bumps in the genital area. Treatment may include an ointment to kill the virus, freezing and removing the warts, or surgical removal. If untreated, they will spread and become larger (Family Health and Medical Guide, 1989).
• Chancroid. Caused by a bacterium, chancroid is highly contagious. A small pimple first appears on the skin of the external genital organs. It will enlarge and finally break, leaving a painful pus-filled ulcer. A skin test can diagnose the illness and antibiotics are used in its treatment (Family Health and Medical Guide, 1989).

STDs that cause genital ulcerations make the sexual transmission of HIV infection highly efficient. Substance abusing pregnant women risk transmitting certain STDs to their infants if untreated. Lack of prenatal care is an important factor. The proper use of condoms and application of spermicides can prevent transmission of STDs (Novick, 1992). Treatment programs should include education about STDs and their prevention.

Hepatitis

Hepatitis, and resulting liver damage, are common among injection drug users. There are four different, but similar, hepatitis viruses.

• Hepatitis A (HAV). HAV is spread through the fecal-oral route and is linked with poor sanitation, overcrowding, and fecal contamination of food or water. Among substance abusers, possible explanations for the transmission of HAV include tasting the drug to assess its quality; direct contamination with fecal material during cultivation or smuggling of the drug; and poor personal hygiene and living conditions of some drug-involved persons (Novick, 1992).
• Hepatitis B (HBV). Transmission of HBV occurs through exposure to the blood of an infected person. Many injection drug users contract HBV in the same way that HIV infection occurs through sharing of unsterilized injection equipment. An infected person also may transmit the disease through sexual contact. HBV can cause liver damage and may even result in death (Novick, 1992).
• Hepatitis C (HCV). The major agent, HCV has been identified just recently; thus, more research on it is needed. It is estimated that 70 to 92 percent of injection drug users have the HCV virus (Novick, 1992).
• Hepatitis D (HDV). This strain of the virus has been endemic in the Mediterranean and parts of Asia, Africa, and South America. However, it has now spread to the United States. It can be transmitted with HBV (Novick, 1992).

There is a vaccine for HBV which also will prevent HDV. It is given over a period of several months, and for that reason, some drug users do not comply with receiving the entire amount of the vaccine. Staff members of drug treatment programs should be informed about hepatitis and offered the vaccine (Novick, 1992).

Other Infectious Diseases

There are several other infectious diseases that are commonly associated with substance abuse. The following brief descriptions are provided.

Infective Endocarditis

Infective endocarditis is a microbial infection of the heart valves. As there is a high incidence of serious complications and mortality with the disease, persons with symptoms should be assessed carefully. High fevers, chills, pleuritic chest pain and shortness of breath are common symptoms. It can be treated with antibiotics administered intravenously for four to six weeks (Novick, 1992).

Pneumonia

Pneumonia is a common complication among substance abusers. Many contributing factors include cigarette smoking, which impairs lung functioning, and malnutrition and trauma, which may interfere with breathing and cough mechanisms. Seizures and depressed gag reflexes resulting from alcohol or drug use may allow fluids to enter the lungs. Symptoms include fever, cough, chest pain, and shortness of breath (Novick, 1992).

Skin and Soft Tissue Infections

Skin and soft tissue infections are very common among injection drug users. Pain and swelling are initial symptoms that may progress to gangrene if untreated. Treatment ranges from localized medication to antibiotics and surgical interventions, depending upon the seriousness of the infection (Novick, 1992).

Infected False Aneurysms

Infected aneurysms may result from damage to peripheral arteries during unsuccessful attempts to inject drugs. Infected aneurysms can cause the involved artery to rupture, possibly leading to death. A false aneurysm is a swollen, infected area within the vessel wall, as contrasted with other aneurysms caused by swelling at a weak point in the artery wall. Swelling and pain in the groin area, accompanied by fever and chills, may be associated with attempts to inject drugs in the thigh (Novick, 1992).

Substance Abuse Treatment Consideration

There is a high incidence of infectious diseases and other medical illnesses associated with substance abuse. These add to the distress of persons who are chemically dependent. Concomitantly, they present formidable challenges to the health care delivery system. Treatment programs are in a pivotal position to impact both the problem of substance abuse and associated infectious diseases. One of the five critical areas of substance abuse treatment is comprehensive services. Appropriate screening and management of health complications is a vital part of these services. A multidisciplinary approach is important. Substance abuse treatment programs may provide a health care component or manage this part of patients' care through referral to other providers. In either case, there should be continuity of care across the spectrum of each individual's needs.

Screening and Diagnosis

Infectious disease screening is imperative. If the treatment program has a health care component or is linked with a medical facility, it should be less difficult to coordinate such screenings and monitor individuals who need to be assessed. If these are not a part of, or an adjunct to the program, effective and efficient referral mechanisms should be in place.

During a program's comprehensive assessment process, health history should be explored with each person. In addition to personal health experience and symptoms, current knowledge of the seriousness of a disease and its prevalence in specific localities should be the basis for considering screening (Barthwell & Gilbert, 1993). Diseases that should be considered for priority in health screening include (Barthwell & Gilbert, 1993):

• human immunodeficiency virus (HIV);
• tuberculosis (TB);
• sexually transmitted diseases (STDs); and
• hepatitis viruses.

For each of these, as well as other diseases, there are established medical protocols that should be followed. Programs should develop policies and procedures for providing appropriate health screening services for each patient. Decision makers at the local and State levels may need to consider the incidence of various diseases and recommend or mandate that health screening for these disorders be included for persons entering substance abuse treatment.

Medical Care and Management of Infected Persons

There are two considerations in providing care to persons with infectious diseases:

1. prevention and
2. treatment.

A person with an infectious disease not only has potentially severe medical problems, but also is capable of infecting others.

Prevention

Programs must focus on preventing the spread of various infectious diseases and take appropriate steps to minimize that possibility. Patient education about particular diseases and how they are acquired is imperative, but not sufficient, to allay further transmission. Changing behaviors also requires convincing individuals the disease is a real threat, providing the means for changing the behavior, and reinforcing new behaviors (Des Jarlais et al., 1992).

Many people deny their own vulnerability to a particular illness, though there is strong evidence to the contrary. Not only must the potential danger to the individual in treatment be stressed, but the possibility of infection of significant others is also an essential message to convey. Behaviors that place individuals at risk of disease transmission include sharing injection equipment, unprotected sex, pregnancy, and in the case of tuberculosis, inhaling disease organisms. Thus, the means for changing behaviors will vary according to the particular illness being considered. However, there is a definite link between these diseases and substance abuse, particularly injection drug use. Therefore, entering and remaining in treatment to stop chemical dependency is crucial. Providing and teaching people to use condoms during sex is another important element for behavior change. With tuberculosis, having an infected person cover the mouth and nose when coughing and sneezing, and providing adequate ventilation of living and work areas, are important (Barthwell & Gilbert, 1993). Peer approval and development of new social norms for a behavior are important in maintaining new behaviors to diminish risks (Des Jarlais et al., 1992).

Treatment

Treatment protocols for different infectious diseases will vary. Attention to health issues should be included in the treatment plan for all persons entering substance abuse treatment. Lack of attention to these problems may trigger relapse, as good emotional and physical health are important for long-term recovery (Barthwell & Gilbert, 1993).

Compliance with treatment regimens may be a problem with some patients. Programs may need to consider directly observed therapy (i.e., administration of medications), when possible. Some medications will interact with others the individual is taking and may reduce their effectiveness or cause unpleasant side effects (Barthwell & Gilbert, 1993). These problems should be followed closely by medical personnel, and adjustment should be made when necessary. Advising patients in advance of the effects that are commonly experienced can help them tolerate these changes. Special attention should be given to pregnant women who are chemically addicted and have infectious diseases. Both the woman's health and that of the fetus must be considered. Effective treatment, in some cases, can reduce the risk to the fetus. Thus, appropriate medical intervention with this group of persons is especially important.

Effective case management, communication, and coordination among providers of substance abuse and other medical treatment is critical. As the needs of patients in substance abuse treatment are often complex, providing a range of services is often very important. Many need material resources, medical and psychiatric care, and legal assistance, in addition to substance abuse treatment. Ideally, the availability of these services in one place can help patients access needed services and follow through on the resolution of various problems. This is not possible for many treatment programs, but at the very least, there should be working agreements with other community agencies to provide needed services. Substance abuse treatment program case managers should monitor the individual and the assorted service providers to make sure needs are being met. Often, basic services, such as transportation, may be a critical element determining whether or not an individual will keep medical and other appointments and comply with various treatment regimens.

Legal and Ethical Issues

Discrimination

The Americans with Disabilities Act (ADA) prohibits discrimination in public accommodations against persons with handicapping conditions (Barthwell & Gilbert, 1993). Persons with AIDS, as well as those with impaired mobility, vision, and hearing and other disabilities, are covered under this Act. Many persons with AIDS, substance abuse problems, and other disabilities have experienced significant discrimination in the areas of housing, employment, and even medical treatment and other services. Staff of substance abuse treatment programs need to position themselves to advocate for patients who are experiencing such discrimination. Decision makers at local and State levels may need to reinforce the intent of the ADA through planning and oversight efforts within their areas.

Patients' Rights

Informed consent is an important right of patients receiving screening and treatment for any purpose. Patients also have the right to refuse to be tested and treated for infectious diseases. They should not be denied services solely because of that refusal. Informed consent and respect for patients' rights is an inherent part of the therapeutic process. If a helping relationship is to be developed, there must be open communication and a clear delineation of mutual expectations (Barthwell & Gilbert, 1993).

Confidentiality

Confidentiality is essential in substance abuse and other medical treatment. Both federal and State confidentiality laws must be considered by programs. The issue of contact tracing and partner notification interfaces with confidentiality concerns. In some cases there is a duty to warn others that they may have been exposed to an infectious disease. Chapter 11 will address issues of confidentiality and other legal/ethical concerns in greater detail.

Program Staff Considerations

Program staff working in substance abuse treatment programs with patients with infectious diseases will have some special needs. There is often fear, or an actual risk, of transmission of some diseases. Tuberculosis, an airborne disease, is highly contagious in crowded, poorly ventilated areas. On the other hand, contracting HIV from patients is only a risk if body fluids are exchanged. Efforts should be made to make working conditions as positive and healthful for staff as possible, to reduce fears about infection. Clear procedures for infection control, training, and support groups are recommended for addressing staff concerns (Sorensen & Batki, 1992). These must be recognized as essential program components by administrators and local and State decision makers. Often funding cuts are proposed in areas such as training and other staff services and benefits. While financial issues are paramount, ultimately excessive turnover of staff whose needs go unmet may be more costly.

Administrative Considerations

Federal and State regulations affect program policies and procedures. On occasion, these regulations may counter each other, leaving administrators in a dilemma about complying with each (Brown, 1991). Effective coordination and communication among the program, State, and federal levels with responsibilities in these areas are essential. Local and State decision makers should assess such problems and attempt to reconcile differences for the benefit of programs and, ultimately, the persons they serve.

Funding issues are of paramount concern to program administrators. Levels of funding, as well as many other factors, directly impact the quality of care that can be provided to patients. Funding considerations often influence the number and types of services provided, the number of individuals that can be served, and the staffing patterns of a program. At the decision-making level, funding patterns should be examined and equitable allocation of resources should be ensured for all programs. Ultimately, the patients are the persons most affected by such decisions.

Adequate facilities for substance abuse and other medical treatment programs are vital. However, there is often community resistance to developing substance abuse treatment programs. Lack of appropriate facilities in suitable locations may limit a program's ability to provide or link with comprehensive medical, social, and legal services for patients. Where opposition to program development is high, local and State decision makers may have to use appropriate measures to overcome it (Primm, 1992).

Staff shortages are another area of administrative concern. Staff turnover in treatment programs is high because of burnout, lower pay scales, and lack of respect for their work from the public. Staff shortages and turnover interfere with effective service delivery (Brown, 1991; Primm, 1992). The need to recruit and retain well-trained staff is a continual issue for program administrators and local and State decision makers.

Treatment in Criminal Justice Settings

Crowded correctional facilities are the norm today, and this condition exacerbates the problem of infectious diseases. Not only is there greater likelihood of disease transmission, but prisoners tend to be sicker and have more complex medical and social problems. If these needs are not adequately addressed, public health may be jeopardized when these persons are released and return to their homes and communities (Boodman, 1992).

Future Directions for Research and Treatment

It will be increasingly important that substance abuse treatment programs incorporate program components and integrate services to deal with the problems presented by infectious diseases. Comprehensive on-site services, including medical screening and treatment may be a valuable direction for many programs to take. Many will need to implement prevention and treatment of health care problems in the treatment plan for individuals. Multi-disciplinary approaches are an important part of program design (Batki & London, 1991).

Another area for examination for future programs is the modification of various treatment approaches to make them more accessible and appropriate for infected persons, particularly those with HIV. Self-help groups and therapeutic communities, among others, may be able to play greater roles in reducing drug abuse and preventing the spread of infectious diseases (Batki & London, 1991).

Because of the recent cocaine epidemic, more effort is needed to develop effective treatments for these substance abusers. The interface of cocaine abuse and infectious diseases merits further study and specific attention to the substance abuse and medical treatment of these individuals (Batki & London, 1991).

Conclusion

Infectious diseases and their relationship to substance abuse have added an urgency to the field of substance abuse treatment. It is essential for the health of persons with chemical dependency problems, as well as public health, that infectious diseases be diagnosed and treated at the earliest possible juncture. Therefore, substance abuse treatment programs must provide or refer patients for screening and treatment of these diseases. Comprehensive services, including material resources, medical treatment, social services, and legal assistance must be a part of the thorough assessment and treatment plan provided for all persons in substance abuse treatment.

Local and State decision makers should recognize the critical connection between substance abuse and infectious diseases. This makes the development, coordination and funding of effective substance abuse treatment programs even more vital. When considering the cost of medical care and the lost productivity of those who are victims of infectious diseases, the cost-effectiveness of substance abuse treatment is further underscored.

References

Barthwell, A., & Gilbert, C.L. (1993). Screening for infectious diseases among substance abusers (Treatment Improvement Protocol Series 6). Rockville, MD: Center for Substance Abuse Treatment.

Batki, S.L., & London, J. (1991). Drug abuse treatment for HIV-infected patients. In J.L. Sorensen, L.A. Wermuth, D.R. Gibson, K.H. Choi, J.R. Guydish & S.L. Batki (Eds.), Preventing AIDS in drug users and their sexual partners. New York: The Guilford Press.

Boodman, S.G. (1992, July 7). Prison medical crisis. Washington Post.

Brown, L.S. (1991). The impact of AIDS on drug abuse treatment. In R.W. Pickens, C.G. Leukefeld & C.R. Schuster (Eds.), Improving drug abuse treatment (Research Monograph 106). Rockville, MD: National Institute on Drug Abuse.

Centers for Disease Control (1993, February). HIV/AIDS surveillance report. Atlanta, GA: Author.

Centers for Disease Control (1992, December 18). 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report (MMWR), 41(No. RR-17).

Cowley, G., Leonard, E.A., & Hager, M. (1992, March 16). A deadly return. Newsweek.

Crane, L.R. (1991). Epidemiology of infections in intravenous drug abusers. In D.P. Levine & J.D. Sobel (Eds.), Infections in intravenous drug abusers. New York: Oxford University Press.

Crowe, A.H. (1990). A core curriculum on AIDS and HIV disease: Psychosocial aspects (Module 3). Lexington, KY: University of Kentucky.

Department of Health and Human Services (1992, February 14). Tuberculosis: An update. HHS Issue Profile. Author.

Des Jarlais, D.C., Friedman, S.R., Woods, J., & Milliken, J. (1992). HIV infection among intravenous drug users: Epidemiology and emerging public health perspectives. In J.H. Lowinson, P. Ruiz, R.B. Millman & J.G. Langrod (Eds.), Substance Abuse: A comprehensive textbook (Second Edition). Baltimore, MD: Williams & Wilkins.

Karan, L.D., Haller, D.L., & Schnoll, S.H. (1991). Cocaine. In R.J. Frances & S.I. Miller (Eds.), Clinical textbook of addictive disorders. New York: The Guilford Press.

National MDR-TB Task Force (1992, April). National action plan to combat multidrug-resistant tuberculosis. Rockville, MD: Department of Health and Human Services, Public Health Service.

Novick, D. M. (1992). The medically ill substance abuser. In J.H. Lowinson, P. Ruiz, R.B. Millman & J.G. Langrod (Eds.), Substance Abuse: A comprehensive textbook (Second Edition). Baltimore, MD: Williams & Wilkins.

Primm, B.J. (1992). Future outlook: Treatment improvement. In J.H. Lowinson, P. Ruiz, R.B. Millman & J.G. Langrod (Eds.), Substance Abuse: A comprehensive textbook (Second Edition). Baltimore, MD: Williams & Wilkins.

Schleifer, S.J., Delaney, B.R., Tross, S., & Keller, S.E. (1991). AIDS and addictions. In R.J. Frances & S.I. Miller (Eds.), Clinical textbook of addictive disorders. New York: The Guilford Press.

Selwyn, P.A. (1992). Medical aspects of human immunodeficiency virus infection and its treatment in injecting drug users. In J.H. Lowinson, P. Ruiz, R.B. Millman & J.G. Langrod (Eds.), Substance abuse: A comprehensive textbook (Second Edition). Baltimore, MD: Williams & Wilkins.

Sorensen, J.L., & Batki, S.L. (1992). Management of the psychosocial sequelae of HIV infection among drug abusers. In J.H. Lowinson, P. Ruiz, R. B. Millman & J.G. Langrod (Eds.), Substance abuse: A comprehensive textbook (Second Edition). Baltimore, MD: Williams & Wilkins.

Woodson, D.W., et al. (Eds.) (1989). The new Good Housekeeping family health and medical guide. New York: Hearst Books.

Last Updated 11-7-02