Workup for Past IV Heroin Use
All patients with a history of intravenous heroin use should be tested for hepatitis C (HCV), hepatitis B (HBV), and HIV, as these bloodborne infections represent the most significant morbidity and mortality risks in this population.
Essential Screening Tests
Bloodborne Viral Infections (Priority Testing)
Hepatitis C: Anti-HCV antibody followed by HCV RNA if positive 1, 2
- HCV accounts for approximately 50% of new hepatitis C cases from injection drug use 3
- Even past users remain at risk and require screening
Hepatitis B: HBsAg and anti-HBc 2
- If either is positive, test for HBV DNA
- If all markers negative, administer hepatitis B vaccine series
HIV: HIV antibody testing 2, 4
- Approximately 9-12% of new HIV cases are associated with injection drug use 3
- If positive, obtain CD4 count and viral load
Additional Recommended Testing
- Hepatitis A: Consider testing and vaccinate if non-immune 2
- Complete blood count: Assess for cytopenias that may indicate chronic liver disease
- Hepatic panel: ALT, AST, bilirubin, albumin, INR to evaluate liver function 2
- Renal function: Creatinine and eGFR (important for potential HCV treatment planning)
Clinical Assessment Specifics
History Elements to Elicit
- Duration and recency of injection drug use - impacts reinfection risk and treatment timing 5, 6
- Sharing of needles or drug preparation equipment - highest transmission risk 1
- Current substance use status - active use vs. recovery vs. opioid substitution therapy 7, 8
- Sexual history and partners' risk factors - additional transmission routes 4
- Prior overdoses or complications - may indicate rhabdomyolysis, compartment syndrome, or other sequelae 9
- Vaccination history - hepatitis A and B status 2
Physical Examination Focus
- Skin examination: Track marks, abscesses, cellulitis
- Cardiovascular: Murmurs suggesting endocarditis (Bacillus species and other organisms) 10
- Hepatomegaly or stigmata of chronic liver disease: Spider angiomata, palmar erythema, ascites
- Neurological assessment: If history of overdose, assess for delayed complications 11
Risk Stratification and Follow-Up
If HCV Positive
- Obtain HCV genotype and quantitative HCV RNA 2
- Assess liver disease severity with non-invasive methods (FIB-4, transient elastography) or consider liver biopsy 1
- Former users can be treated with standard DAA regimens with excellent cure rates 8
- Those on stable opioid substitution therapy (methadone/buprenorphine) can be safely treated without dose adjustments 7, 8
If HIV Positive
- Obtain baseline CD4 count and HIV viral load 4
- Screen for HBV coinfection (higher rates of severe liver disease) 2
- Initiate antiretroviral therapy per HIV guidelines
If HBV Positive
- Test for HDV (hepatitis D) antibody - particularly important in injection drug users 2
- Assess for HCV and HIV coinfection
- Evaluate need for antiviral therapy based on HBV DNA levels and liver disease stage
Common Pitfalls to Avoid
- Don't assume "past use" means low risk - many former users have undiagnosed chronic infections acquired years ago
- Don't delay HCV treatment - even patients on opioid substitution therapy achieve SVR rates of 96% with modern DAAs 8
- Don't forget HDV testing in HBV-positive patients with injection drug use history 2
- Don't overlook the need for regular screening - if patient returns to active use, annual HCV testing is indicated 8
Counseling Points
- They should not donate blood, organs, tissues, or semen
- Risk of sexual transmission is low in monogamous relationships but condoms recommended for multiple partners
- Should not share toothbrushes, razors, nail clippers, or any skin-penetrating instruments
- If they return to drug use, must use clean needles and equipment every time
The cornerstone of workup is bloodborne pathogen screening (HCV, HBV, HIV), as these infections drive long-term morbidity and mortality in this population, and highly effective treatments now exist for all three conditions.