Substance Use & Infectious Disease

1. Substance Use & Infectious Disease Presented by: Dave Pulliam Ann White Mary Hanson Kim Orahood Joyce Hall

2. Substance Abuse and Infectious Diseases • HIV/AIDS • Sexually Transmitted Diseases • CLAYMIDIA • GONORRHEA • SYPHILIS • Hepatitis B and C • Tuberculosis • Other Infectious Complications

3. HIV • “Behavior associated with drug abuse is now the single largest factor in the spread of HIV infection in the U.S.” • ~National Institute on Drug Abuse

4. Substance Abuse and HIV • Affected behavior while under the effects of the substance. • Affected behavior stemming from the need for more of the drug • Equipment used to take the drug.

6. Huge Sale! Buy Crystal, Get HIV Free! • Biochemical effects: • Reduce inhibitions • increases sexual desire and • feelings of invincibility • Powerful drug in terms of initiating, enhancing and prolonging sexual activity (Horn, 2005)

7. Crystal Meth and Sex • Largest at risk group MSM (men who have sex with men) • Condoms are more likely to be abandoned • Numerous sex partners are likely to be had • Trauma to the lining of the anus more likely (greatly increasing the risk of HIV) (Horn, 2005)

8. METH • Users are motivated by feelings of invincibility, and energy (especially men with AIDS because it negates both emotional and physical pain) • Sex occurs without guilt and mental distractions of shame and embarrassment • Inhibitions are lowered resulting in more anonymous sex • Users report more “hard core” sex • Meth users average more incidents of unsafe sex compared to cocaine users (Huff, 2005)

9. What Meth Can Do For You: • Permanently damage nerve cells • Meth + Viagra+ Poppers = high risk of Heart Attack • Suppress the immune system • Cause long term “crystal dick” (limp) • Increase the risk of contracting HIV • Contribute to psychotic episodes • Rapidly increase the progression of HIV (Cascade AIDS Project)

10. What is the Link between STDs and HIV infection? • Testing and treating STDs can be an effective tool in preventing the spread of HIV • Individuals with STDs are at least two to five times more likely than uninfected individuals to acquire HIV if exposed through sexual contact. • HIV-infected person with an STD is more likely to transmit HIV through sexual contact than other HIV infected persons

11. Alcohol & Marijuana use and STDs • Alcohol or drug use inhibits the use of condoms->increasing risks • Higher taxes on beer have shown reduced rate in STD infections

12. Adolescents • Adolescents (i.e. persons aged <15 yrs) who are sexually active are high risk for STDs because: • They frequently have unprotected intercourse • are biologically more susceptible to infection • Engage in partnerships of limited duration • Face obstacles to utilization of health care • Providers frequently fail to address sensitive areas (e.g. sex and drug use behaviors) (CDC/MMWR, 2002)

13. Prostituted Children (under 18 years old) • Based on substance abuse by sex workers of nearly 100% in some locations, a high % of child prostitutes use tobacco, alcohol, inhalants and opiates. • Incurring health risks such as overdose; permanent kidney, liver, and brain damage; infection with HIV, HBV, HVC, other blood borne diseases; and cancer • Risks based on local prevalence of HIV infection in sex workers, access to condoms and attitudes of sex workers (Willis, Levy,2002)

14. Estimated Yearly Occurrence of Adverse Health Effects of Child Prostitution • Infectious Disease • STD 2,000,000 • HIV infection 300,000 • HPV infection 4,500,000 • Substance Abuse • All substances 9,000,000 • Mental Illness • PTSD 6,700,000 • Attempted suicide 1,640,000 (Willis, Levy, 2002)

15. HIV Infection Rates • Vietnam 5%, Thailand 17% • 50-90% of children “rescued” from brothels in parts of SE Asia are infected • Adolescent girls have a 1% risk of acquiring HIV during one act of unprotected sex with an infected partner • Combined with other STD’s risk increases four fold • Children with HIV are a very high risk for developing active TB

16. Chlamydia • 2.8 million Americans infected/per year • Silent disease, ¾ of the women and ½ the men never have symptoms • Symptoms in female: abnormal vaginal discharge, burning sensation when urinating, lower abdominal pain, low back pain, nausea, fever • Symptoms in male: discharge from penis or burning sensation when urinating • Can also infect rectum or throat • Treated with antibiotics, all partners need to be treated, abstain from until partners have completed treatment (CDC)

17. Gonorrhea • Affects more than 700,000 Americans/per year • Can occur in the female reproductive tract and urethra in both men and women or in the mouth, throat, eyes and anus. • Many have no symptoms • Symptoms may appear 2-5 days after infection or up to 30 days. • Men may have burning sensation, white, yellow or green discharge, painful or swollen testicles • Female may have burning/pain when urinating, increased vaginal discharge or vaginal bleeding between periods. (CDC)

18. Gonorrhea (con.) • Female @ risk of developing Pelvic Inflammatory Disease, PID (about 1 million women/yr) • Causes internal abscesses that are difficult to cure • May cause infertility • Increases the risk of an ectopic pregnancy • Males can suffer from epididymitus that effects the testicles and can cause infertility • If gonorrhea spreads to the blood or joints, it can be life threatening • Treatment: Antibiotics, many strains have become drug resistant making it difficult to treat (CDC)

19. Gonorrhea • Persons with gonorrhea are more susceptible to HIV • Persons with HIV and gonorrhea are more likely to transmit HIV to others (CDC)

20. Syphilis • Rates in Portland are up 400% in the last 3 years • Known as the great imitator because symptoms are indistinguishable from other diseases • Only laboratory tests can confirm DX • Can cause: blindness, hair loss, eye damage, brain damage, kidney problems, spinal cord damage and heart problems (Cascade AIDS Project, CDC)

21. Syphilis (con) • Three Stages • Sore or chancre appears (10-90 days after infection) usually small round and painless • Typically starts with a rash (not itchy), may present as rough, red or reddish brown spots on palms or bottom of feet, fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss. • Latent stage, symptoms disappear (CDC)

22. Syphilis (con) • What is the link between HIV and syphilis? • Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection sexually. • Estimated 2-5 fold increased risk of acquiring HIV when syphilis is present. (CDC)

23. WARNING • Ulcerated STDs that cause sore, ulcers, or breaks in the skin or mucous membranes, disrupt barriers that provide protection against infections.

24. STD Prevention • Abstinence • Be in long-term mutually monogamous relationships • Get educated (learn the risks) • Be tested (if more than one partner- test every 6 months) • Get vaccinated (Hepatitis) • Communicate with partners (ask about history, infections) • Use latex or polyurethane condoms consistently • Avoid using drugs with sex • Use lots of water based lubricant (CDC)

25. Funding for STD Prevention • Has shown STD rates are responsive to increased alcohol taxes and in drinking age • Estimated cost of alcohol-attributed STDs exceeds $556 million annually

26. What is Hepatitis • A gastroenterological disease featuring inflammation of the liver • Many types of hepatitis with causes including viral infection, excessive drinking, toxins, certain medications, bile duct obstruction, and immune system deficiencies

27. Viral Hepatitis • The only infectious form of hepatitis • Currently 6 different forms (A,B,C,D,E, &G) • 4 forms (B,C,D, and G) are blood borne while 2 (A & E) forms are oral-fecal • Hepatitis D is typically a co-infection with Hepatitis B and Hepatitis G is typically a co-infection with Hepatitis C

28. Viral Hepatitis cont’d • All forms of viral hepatitis have the similar signs and symptoms: jaundice, fatigue, abdominal pain, loss of appetite, nausea,& vomiting • Signs and symptoms of hep B & C also include joint pain and dark urine • IDU’s are at high risk for contacting either Hepatitis B or C • It is estimated that 50%-90% of IDUs with HIV also have Hep C

29. Transmission • For both Hep B & C transmission occurs when infected blood enters the body of a person who is not infected • Hep B is most frequently transmitted through unprotected sex, shared needles and works, and from mother to child during birth • Hep C is most frequently transmitted through sharing needles and works, and from mother to child during birth. Hep C has a lowest risk of sexual transmission among the hep viruses • Hep B & C are acquired rapidly among IDU’s. Within 5 years of beginning injection drub use 50%-70% of IDUs become infected with Hep B and 50%-80% become infected with Hep C • Blood exposure is most efficient method of transmission • Large number of individuals with the disease equally large numbers of potential transmission • High rate of sharing among IDUs: drugs, solutions, works, needles, syringes, etc.

30. Risk Factors Associated with Reported Hepatitis B, 1990-2000, United States *Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous injury Source: NNDSS/VHSP

31. Sources of Infection for Persons with Hepatitis C

32. Hep B Prevention • The hepatitis B vaccine has been available since 1982 • It requires 3 shots over the course of 6 months • The vaccine is most highly recommended for IDUs because of the rapid rate of transmission • The CDC still emphasizes education and counseling but is focusing on the vaccine

33. Hep C Prevention • In 2001 the CDC outlined a prevention and control program for Hep C, consisting of identifying persons at risk, providing education, counseling, testing and appropriate medical services including substance abuse treatment • This program includes the controversial element of increased funding for needle/syringe exchange program and using these programs to help facilitate the education and counseling for high risk individuals

34. Treatment • Hep B becomes chronic in 90% of infected infants, 30% of infected children age 1-5, and 2-6% of those infected after age 5 • Hep C becomes chronic in 75-85% of those infected • Treatment for both consists of regular blood tests, counseling for avoiding alcohol and IV drug use, and the Hep A vaccine. If/when it becomes necessary, antiviral therapy will be employed • IDUs can be treated successfully while on methadone maintenance and in a setting that addresses the special needs of the population

35. Perspective on Tuberculosis • TB is one of the world’s deadliest diseases. • One-third of the world’s population is infected with TB. • Each year, 9 million people around the world become sick with TB. • Each year, there are over 2 million TB-related deaths worldwide. • TB is the leading killer of people who are HIV infected. • TB causes more deaths among women worldwide than all causes of maternal mortality combined.

36. What is TB? • TB is caused by a bacteria called Mycobacterium tuberculosis. • Bacteria usually attack the lungs, but can attack any part of the body such as kidney, spine, and brain. • If not treated can be fatal

37. How is TB Spread • Through the air by coughing or sneezing. • When a person breathes in TB bacteria, it can settle in the lungs and grow. From there it can move through the blood to other parts of the body (kidney, spine, and brain). • TB in the lungs and throat can be infectious, TB in other parts of the body is usually not. • People with active TB are most likely to spread it to people they spend time with every day. Includes family, friends, and coworkers.

38. Two TB related conditions exist • Latent TB: Body is able to fight off bacteria and stop them from growing. Bacteria becomes inactive, but remain alive and can become active later (especially in people with weakened immune systems e.g. IVD and HIV) • Active TB: Weakened immune systems can’t stop bacteria from growing. The active bacteria begin to multiply in the body and cause active TB disease.

40. Threat of Multidrug-Resistant TB • Multi-drug resistant TB (MDR TB) is active TB caused by bacteria that is resistant to drugs commonly used for treatment. • Forty seven states and the District of Columbia have reported diagnosing and caring for persons with MDR TB. • MDR TB is extremely difficult and costly to treat; it has been estimated that ONE case can cost up to $1.3 million to treat.

41. Other infectious complications in intravenous drug users: • Skin and soft-tissue infections • Common in the intravenous drug user (IDU) • Frequent injections, nonsterile technique, sharing equipment and skin popping all predispose the addict to soft-tissue infection. • Cellulitis, skin abscesses, thrombophlebitis (vein inflammation due to blood clot), necrotizing fasciitis (flesh-eating bacteria), pyomyocisitis (abscess found in a muscle), gangrene • Besides causing abscesses at an infected injection site, needle use can also inject bits of foreign matter into the bloodstream that can lodge in the spine, brain, heart, lungs, or eyes and cause an embolism or other problems.

42. Other infectious complications: • MRSA (methicillin-resistant staphylococcus aureus) • IDUs have higher carriage rates of staphylococcal and streptococcal organisms than general population. • As many as 60% of intravenous drug users may be taking antibiotics sold on the street, often supplied by the intravenous drug supplier. • One result is the emergence of MRSA, methicillin-resistant staphylococcus aureus. • Endocarditis • A common, but potentially fatal condition caused by bacteria that lodge and grow in the valves of the heart. • IV cocaine users have a higher rate of endocarditis, perhaps because the ups and downs of cocaine require more injections than heroin or methamphetamines.

43. Other infectious complications: • Tetanus • There have been many reports of increased incidence of tetanus among IDUs. • An acute, sometimes fatal disease caused by exotoxin produced by Clostridium tetani (C. tetani). Potential sources of tetanus in IDUs include contamination of drugs, adulterants, paraphernalia and skin. • Heroin is frequently cut with quinine, which causes favorable conditions for C. tetani growth. • Skin popping increases superficial skin infections and growth potential for C. tetani. • Cotton fever • The symptoms are similar to those of a very bad case of the flu. • A very common disease, caused by bits of cotton used to filter a drug or by infections carried into the body by cotton fibers injected into the blood.

44. Other infectious complications: • Malaria • Malaria in IDUs was first reported in 1929. Over next decade it was reported with increasing frequency in large cities in the U.S. Then it dropped off in the following decades. • In the 1960’s and 1970’s, the incidence of malaria increased as servicemen returning from Vietnam with intravenous drug habits spread malaria. • Once again the incidence has declined, and malaria is now an uncommon complication of IDU; however, needle transmission remains the primary way in which new cases of malaria are spread in U.S. • Pulmonary infections • The lungs are at considerable risk from the use of injected or inhaled drugs, including an increased incidence of pneumonia and pulmonary disease. • Regular marijuana smoking is associated with significant airway inflammation. One study showed that THC suppressed immune reactivity against lung cancer.

45. Other infectious complications: • Skeletal infections • Septic arthritis (infection of a joint which leads to destruction if untreated) and osteomyelitis (acute infection of the bone) may occur as a result of a blood spread from a distant site, most commonly endocarditis • These infections are generally confined to immunocompromised patients or those with chronic debilitating illnesses. However, in the IDU, skeletal infections are often in a young, otherwise healthy individual. • Most frequent site of osteomyelitis infection is the vertebral column, especially the lumbar spine; and, infectious arthritis usually involves the knee or hip • Nervous system infections • Most common nervous system infections in IDUs include meningitis, epidural abscess, and brain abscess • Extensions of bone infections (osteomyelitis) and embolic complications of endocarditis may be the source of nervous system infections.

46. Other infectious complications: • Alcohol • Infectious disease also linked to excessive drinking because it can disrupt white blood cells and in other ways weaken the immune system, thus resulting in greater susceptibility to infections.

47. Other infectious complications: • Remember…. • It is impossible to overemphasize the danger of using infected needles because IV use of a drug bypasses all the body’s natural defenses such as body hairs, mucous membranes, body acids, and enzymes. • Many of the same illnesses transmitted sexually can also be transmitted through contaminated hypodermic needles when drugs are taken intravenously, subcutaneously, and intramuscularly. Besides putting a large amount of a drug into the bloodstream in a short period of time, needles also inject other substances like powdered milk or even Ajax, used to cut or dilute drugs. They can also inject dangerous bacteria and viruses.

48. Resource Links • http://www.cdc.gov/page.do • http://www.nida.nih.gov/ • http://www.beingalivela.org/specialprojects.html • http://www.crystalneon.org/ • http://www.gmhc.org/ • http://www.tweaker.org/html/crystalsex/crystalsex.html • http://www.cascadeaids.org/ • http://www.mchealth.org/std/ • http://www.lifeormeth.org/