What is the management approach for an intravenous (IV) drug user?

Management of Intravenous Drug Users

The management of IV drug users should prioritize medication-assisted treatment with methadone or buprenorphine combined with behavioral interventions, alongside comprehensive infectious disease screening, vaccination, and harm reduction services. 1

Immediate Substance Use Disorder Treatment

Medication-Assisted Therapy (First-Line)

• Initiate long-term medication-assisted therapy with methadone or buprenorphine as the primary treatment approach, as short detoxification programs have limited success in achieving sustained abstinence 1
• Methadone maintenance programs are the most effective intervention for opioid use disorder, with the strongest evidence for effectiveness 2, 3
• Buprenorphine serves as an alternative partial agonist option that can be prescribed in office-based settings 1, 2
• Naltrexone (an opioid antagonist) may be considered for patients who have completed detoxification, though methadone and buprenorphine have superior evidence 2
• Combine pharmacologic therapy with behavioral interventions (cognitive and behavioral therapies) for optimal outcomes 1

Treatment Duration and Monitoring

• Longer duration of treatment allows restoration of social connections and is associated with better outcomes 2
• Medication-assisted treatment reduces needle-sharing, exchange of sex for money or drugs, and other high-risk behaviors 1
• Treatment serves as an entry point to medical care and improves adherence to medical treatment regimens for infectious diseases 1

Infectious Disease Screening and Prevention

Mandatory Testing

• Test for HIV, hepatitis B, and hepatitis C at initial presentation 1
• If HIV and hepatitis C antibody tests are negative, repeat HIV testing annually 1

Vaccination Requirements

• Vaccinate against hepatitis A and hepatitis B 1
• Ensure vaccination is completed regardless of current drug use status 1

Treatment of Identified Infections

• Initiate treatment for hepatitis C using the same direct-acting antiviral regimens as non-IV drug users, without requiring specific methadone or buprenorphine dose adjustments 1
• Monitor for signs of opioid toxicity or withdrawal when treating hepatitis C in patients on opioid substitution therapy 1
• A history of IV drug use and recent drug use at treatment initiation are not associated with reduced sustained virologic response for hepatitis C treatment 1

Harm Reduction Services

Syringe Access and Safe Injection Practices

• Provide clean drug injecting equipment through syringe exchange programs or pharmacy access 1
• Syringe exchange programs reduce transmission and mortality from infectious diseases like HIV and connect individuals to health and social services 1
• Instruct patients to never reuse or share syringes or drug-preparation equipment 1
• Advise use of sterile water to prepare drugs, or clean water from fresh tap water if sterile water unavailable 1
• Recommend new containers (cookers) and new filters (cotton) for drug preparation 1
• Instruct to clean injection sites with new alcohol swabs before injection 1
• Ensure safe disposal of syringes after use 1

Overdose Prevention

• Prescribe take-home naloxone to prevent fatal overdose 2
• Naloxone can be administered intravenously, intramuscularly, or subcutaneously, with intravenous administration providing the most rapid onset 4
• Educate patients that repeated doses of naloxone may be necessary since the duration of action of some opioids exceeds that of naloxone 4, 5

Multidisciplinary Support Structure

Pre-Treatment Assessment

• Evaluate housing, education, cultural issues, social functioning and support, finances, and nutrition 1
• Assess current drug and alcohol use patterns 1
• Link patients to social support services and peer support programs 1

Ongoing Monitoring

• Patients with ongoing social issues, history of psychiatric disease, or more frequent drug use during therapy require closer monitoring and more intensive multidisciplinary support due to risk of lower adherence 1
• Deliver treatment within a multidisciplinary team setting 1

Counseling Components

• Discuss HCV transmission, risk factors for fibrosis progression, treatment options, reinfection risk, and harm reduction strategies 1
• Counsel to moderate or abstain from alcohol, especially with evidence of advanced liver disease 1
• Counsel to moderate or abstain from cannabis use if advanced liver disease is present 1

Critical Pitfalls to Avoid

• Do not withhold medication-assisted treatment based solely on active drug use, as decisions must be made case-by-case and active use is not associated with reduced treatment success 1
• Do not require psychosocial services or abstinence as prerequisites for initiating medication-assisted treatment 6
• Do not discontinue medication-assisted treatment for any reason other than harm to the patient 6
• Avoid short detoxification programs as the sole intervention, given their limited success 1
• Do not advise patients on opioid substitution therapy to reduce or stop therapy, as it is not a contraindication for advanced medical interventions including liver transplantation 1