Using Drugs Or Using Germs ?

Using Drugs Or Using Germs?

_{Rihab FELLAH}

Using drugs has become a burden that human societies bare daily. Persons Who Use Drugs (PWUD) are mostly young. Once they have entered the cycle of transition from craving euphoria to suffering from hellish withdrawal, they become captive of the substances they use. Not only does acquiring drugs causes their financial and social ruin, it represents an imminent danger on their lives. That risk is primarily dominated by the ever-looming risk of overdose. It also adds to the many hazards on their well being in the long term. Infection is one of these hazards and is often encountered in this population. It accounts for devastating consequences and is generally overlooked by health- care personnel as well as the general public. Thus, we thought we might put it under your radar.  

Opioid use disorder isdefined in the DSM V* a “problematic pattern of opioid use leading to clinically significant impairment” and is diag- nosed if 2 of 11 criteria were met in a period of 12 months. (cf. Mechanisms of addiction: p13)

            Opioids are every substance, natural or syn- thetic, that can act on our brain’s opioid receptors causing analgesia which accounts for their medical use, as well as euphoria explaining their “recreational” one and their popularity among youngsters^{1, 2}.

            However, delivering the occasional (and in most cases frequent) dose of happiness doesn’t come without a cost and the cost is quite a filthy. Whether from the hosts commensal flora, the bacteria contam- inating the drug, the drug adulterants (which are all substances added to the drug intentionally - facilitat- ing its delivery or boosting volume for sale -or acci- dentally during the process of its making) or in the paraphernalia (tools such as syringes or pipes that permit drug use), consuming drugs whether by inhala- tion or injection is a gateway to inoculating germs³.

Indeed, drug users have higher rates of Staphy- loccocus aureus colonization in the nares and skin. It is thought that the damage ensued by drug consump- tion to the nasal septum and skin through inhalation and injection respectively is responsible of this por- tage. Poor hygiene is also an important risk factor^6,7.

             This increases the chances of Staphyloccocus aureus skin infection and abscesses and even of bac- teremia^6,7. Eventually, bacteremia would cause septic shock and fatal multiorgan failure⁶.

             Such a bacteremia could also cause the infec- tion of sterile sites such as bone and joints. A condition known as hematogenous osteomyelitis. Its most common site is the vertebrae. Thus the presence of bacteria in the vertebral body (spondylitis) can cause inflammation, bone fragility and even fractures. The contiguous involvement of the intervertebral disc, or discitis, is quite common (note that the disc is avas- cular and couldn’t be contaminated from the blood stream) and in the case of S. aureus spondylodiscitis, perivertebral abscesses are frequent too³.

          The gravity of this condition lies in the con- sequences of such inflammation or even compression (by the mass of the abscess or the mechanical compli- cation of the infection itself) on the adjacent spinal cord which results in a radiculopathy (motor weakness and sensory changes) and ultimately paralysis. Surgi- cal management is indicated in these cases⁴.

           Another “fun” fact! It is reported that illicit drug syringes contain up to 10⁸ organisms per mL⁵, that some drug adulterants such as talc can directly damage valvular endothelium and that, as mentioned previously, drug users have poor hygiene and import- ant nasal and skin S. aureus colonization and bactere- mia⁶. All of this put together predisposes to a particu- lar form of disease and quite a grave one: INFECTIVE ENDOCARDITIS. This fancy term often confuses people and hides the gravity of the issue. When explaining to patients that they are suffering from an infection in their heart, you can only imagine the terror they must feel⁸.

          This heart infection is actually a cluster of fi- brin, platelet and leucocytes that appendages itself to an already injured endocardium (the valves are the most involved). This cluster is secondarily colonized by important numbers of a pathogen which is generally a bacteria but could sometimes be a fungus that hap- pened to be circulating in the blood stream. Therefore a vegetation is formed and can hitherto damage the neighboring endocardial tissue or valves⁸.

          As we all know, valves are what maintains blood‘s one-way flow through the heart and circulato- ry system. Once the function of these valves is jeopar- dized by a large vegetation for example, important he- modynamic consequences may occur: from pulmonary oedema and hypertension to cardiac failure and shock. Extension of germ colonization to endocardial tissue could also cause mechanical complication such as perivalvular abscess, or cordage rupture. Nodal tissue involvement can occur and conduction blocks could also result^8,9.

         The vegetation could be source of septic em- boli which is the migration of its detached parts and thereof the occlusion of any artery in the pulmonary or systemic circulation. This could cause a widespread of manifestation from pulmonary embolism and pneu- mopathy to stroke or paralysis, consequences of a brain injury⁸.

          Anatomically speaking, a vegetation located in the right-heart’s valves would embolize to the lungs, while a left-heart vegetation would mostly embolize to the systemic arteries (brain, legs, spleen, kidneys...)⁸.

          The most common form of infective endocar- ditis in drug users involves the tricuspid valve (This is explained by the fact that injecting drugs is done in veins which blood is drained to the right heart) and is due to S. aureus⁶ (No surprise there!). It manifests clinically by a fever, pleuritic chest pain and cough⁷. The classic heart murmur can be absent. Although the mortality of this form is quite low (5%), a large vegeta- tion size > 2cm or a fungal etiology might make things worse (25% and 65% mortality rates respectively)¹⁰. In all cases, isolating the responsible germ (staph or other) in blood-cultures and visualizing the vegeta- tion through imaging methods (mainly transthoracic echocardiography and sometimes trans-esophageal one) are the two major criteria in diagnosing an in- fective endocarditis. They belong to an ensemble of criteria known as Duke’s⁹.

            Last but not least, let us speak of blood-borne viruses, mainly HIV and HCV. The use of non-sterile sy- ringes is the main source of contamination. Addition- ally, the existence of blood on drug sniffing straws is thought to vehicle HCV between users who share this paraphernalia¹¹.

Remember when we said that tricuspid valve endocarditis has a low death tow of 5%? That rate be- comes higher in HIV-infected users with a low CD4 count⁷. In fact, the highest mortality tolls in drug users are due to drug overdose and HIV-related illnesses¹¹.

It is estimated that 13% of PWID have an HIV infection (an approximate 1,7 million people world- wide)^1,10. In fact, drug use is one of HIV major risk fac- tors. Not only does it disseminate the virus among drug users by sharing syringes. It sustains the infec- tion in the general population through transmission to sexual partners. This situation is aggravated by the fact that drug users are a subgroup who is criminal- ized and socially stigmatized. They do not benefit from adequate prevention services such as needle and sy- ringe programs (elevating availability of new syringes and needles for IDUs) and opioid substitution treat- ment. Government policies concerning drug use focus on limiting the supplication and use of licit and illicit substances. Subsequently, fear of getting caught or frequent incarcerations and imprisonments prevent them from getting HIV testing, and adequate antiret- roviral treatment¹¹.

             HIV infection particularity lies in the virus’s capacity to specifically replicate in CD4 positive T Lymphocytes. These lymphocytes are responsible for orchestrating both the humoral and cellular specific immune response. Therefore, their fall when viral rep- lication is active results in an immunocompromised state and elevates the organism’s susceptibility to be harmed by microbes. Since drugs users are already germ carriers, opportunistic infections and a high risk of neoplasia associated with AIDS multiplies their burdensome health problems.

          Additionally, injecting drugs is mostly associated with HCV infection. Actually, Injection Drug Us- ers (IDUs) “are the largest group of infected persons, the group in which most new infections occur, and the group that has been the most severely affected by the epidemic.”¹³

Emphasis should fall upon the fact that most HCV infections evolve to chronicity in 50 to 80% of cases. Chronic hepatitis C (CHC) would lead in 20% of cases to cirrhosis and to hepatocellular carcinoma (HCC) at an incidence of 4-5% per year in cirrhotic pa- tients¹⁴. _{The list still goes, and our intention was far} from being exhaustive of all the infections a drug user might suffer from during their lifetime. It was none- theless intended, to bring to mind that in the face of the ever-escalating problem that is drug addiction, the probability that any healthcare professional no mat- ter their subspecialty will eventually deal with similar patients is high. Therefore we must be armed with a basic knowledge of addiction medicine, but also with patience and tolerance towards the persons we’ll en- counter. Because after all addiction is a disease and like all diseases, we must fight IT and not the patient bearing it!

*DSM V: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

 Is a manuscript assembled by the American Psychiatric Association in which all Mental disorders had been classified and characterized by a number of criteria in order to help clinicians retain or revoke diagnoses more easily.

References:

1-   United Nations Office on Drugs and Crime. World Drug Report 2018. United Nations publication, Sales No. E.18.XI.9. Available from: https://www.unodc.org/wdr2018.

2-    Strain E.Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis. Uptodate 2018.

3-   Schmitt S. Osteomyelitis. Infectious Disease Clinics of North America. 2017;31(2):325-338.

4-   Berbari E, Kanj S, Kowalski T, Darouiche R, Widmer A, Schmitt S et al. 2015 Infectious Diseases Society of Ameri- ca (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clini- cal Infectious Diseases. 2015;61(6):e26-e46.

5-    Sande MA, Lee BL, Mills J, et al. Endocarditis in intrave- nous drug users. In: Infective Endocarditis, Kaye D (Ed), Ra- ven Press, New York City 1992. p.345.

6-    Quagliarello B, Cespedes C, Miller M, Toro A, Vavagiakis P, Klein R et al. Strains of Staphylococcus aureus Obtained from Drug-Use Networks Are Closely Linked. Clinical Infec- tious Diseases. 2002;35(6):671-677.

7-    Gordon RJ, Lowy FD. Bacterial Infections in Drug Users. N Engl J Med 2005;353:1945-54. 

8-    Ryznar E, O’Gara PT, Lilly LS. Valvular Heart Disease. In: Pathophysiology of heart disease (Lilly), 6th edition, 2016. p.212.

9-    Habib G, Lancellotti P, Antunes M, Bongiorni M, Casalta J, Del Zotti F et al. 2015 ESC Guidelines for the manage- ment of infective endocarditis. European Heart Journal. 2015;36(44):3075-3128.

10-         Martı ́n-Da ́vila et al. Analysis of mortality and risk factors associated with native valve endocarditis in drug users: The importance of vegetation size. American Heart Journal.2015 ; 150(5) :1099-1106.

11-         Joint United Nations Programme on HIV/AIDS. The GAP report. UNAIDS Information Production Unit. September 2014.  Available from: http://www.unaids.org/sites/default/ files/media_asset/UNAIDS_Gap_report_en.pdf.

12-         Tortu S, McMahon JM, Pouget ER, Hamid R. Sharing of noninjection drug-use implements as a risk factor for hepa- titis C Subst Use Misuse. 2004;39(2):211.

13-          Edlin BR, Carden MR, FerrandoSJ. Managing Hepatitis C in Users of Illicit Drugs. Curr Hepat Rep. 2007 ; 6(2): 60–67.

14-         Li H-C, Lo S-Y. Hepatitis C virus: Virology, diagnosis and treatment. World J Hepatol 2015 June 8; 7(10): 1377-1389.