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A 23-year-old woman is seen for her intake physical in a residential treatment program for women recovering from substance abuse. She has not injected heroin for 2 days now, but her tracks are still visible (Figure 252-1). Her parents were both addicted to heroin, and she admits to having been born addicted to heroin herself. She began using heroin on her own in her early teens and has been on and off heroin since that time. She acknowledges a history of physical and sexual abuse as a child. She has had many suicide attempts and has cut herself with a knife across her arm many times. She has traded sex for money to buy heroin. Her 2 children are in foster care after having been removed by Child Protective Services. She is a young woman looking for help and is thankful to have been admitted to this program. She does not know whether she has acquired hepatitis B, hepatitis C, or HIV, but wants to be tested.

FIGURE 252-1

A 23-year-old woman with visible tracks on her arms from intravenous heroin use. She also has visible scars from self-mutilation with a knife. (Reproduced with permission from Richard P. Usatine, MD.)


Injection-drug use of psychoactive drugs affects millions of people across the world. Combinations of genetic, environmental, and behavioral factors influence risk of drug use and addiction. People who inject drugs often have other medical and psychiatric diagnoses, as well as social, legal, and vocational problems. Comprehensive management includes acute treatment and continuing care. Relapse is common, but involvement in a treatment program improves outcomes. While the injection use of heroin has been on the rise for years, the rise in illicitly manufactured fentanyl (IMF) injection use has fueled the overdose problem in the United States.1


  • An estimated 16 million people inject drugs worldwide, based on data from 148 countries. The largest numbers of injection drug users are in China, the United States, and Russia.2

  • In the United States in 2016, there were 63,632 drug overdose deaths (many from injection drug use). From 2015 to 2016, deaths increased across all drug categories examined. The largest overall rate increases occurred among deaths involving cocaine (52.4%) and synthetic opioids (100%), likely driven by IMF.1

  • Synthetic opioid–involved deaths in 2016 accounted for 30.5% of all drug overdose deaths and 45.9% of all opioid-involved deaths. As of 2017, an average of 115 Americans die every day from opioid overdose.3 Synthetic opioids propelled increases with 19,413 deaths (more than any drug examined) fueled by the contribution of fentanyl. In addition, IMF is now being mixed into counterfeit opioid and benzodiazepine pills, heroin, and cocaine, likely contributing to increases in overdose death rates involving other substances.1,...

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