There are few sights as sad as the loss of a strong brilliant youth to the needle.
Most of the time, it is a case of a bad situation leading to bad decisions.
Whether due to trauma beyond that which can be emotionally borne, ease of access,
or poor choice of company one keeps, narcotic abuse often starts changing life in
small ways before these inflate into catastrophes laying waste to so much promise
and potential. These catastrophes can either shock the user into realizing their
mistakes and making amends, or change them in irredeemable ways. Like other problems,
the fight against drug abuse is also marred by lack of complete information in the minds of the public.
One thing that everyone seems to know is that narcotics are addictive, but what most
people do not realize is that one use, or even several uses may not lead to development
of the addiction the dose required changes from person to person. When a first time user
does not crave the drug as they are expected to, they feel immune to its effects and return
to the thrill time and again, before finally the substance traps the victim in its malicious
maw without them even realizing it until it is too late.
It is not only the socio-economic condition that is affected by drug abuse.
In the body of the user, the immune system is not exempted from being damaged
by substance abuse. Drug usage makes these individuals more prone to contracting
diseases, one among which is Tuberculosis (TB).
Tuberculosis
TB is a lung infection caused by the bacteria Mycobacterium tuberculosis. It can also
infect other parts of the body like kidney, spine or brain, in this case it is known as
Extrapulmonary Tuberculosis (EPTB), TB infection can be either active or latent (LTBI);
active infection shows symptoms and is infectious whereas latent infection remains
hidden without showing symptoms for a long time. Latent infections can revert back
into active ones. Some of the symptoms of TB include cough (sometimes with blood),
weight loss, fever, chills and night sweats. TB is often associated with HIV infection,
which is rampant among drug users
Tuberculosis and Drug Use
The incidence of both active and latent TB has been recorded to be higher among
drug users. These users are also more likely to suffer from reversion of latent TB to
active disease. Multidrug resistant variants of TB have been found to be more common
in drug users. In addition, coinfection with HIV, as well as Hepatitis B and are commonly
seen in intravenous drug users. In a study conducted at the YR Gaitonde Centre for Substance
Abuse-related Research, Chennai, 33.9% of injection drug users were found
to be suffering from TB and HIV comorbidity.
There are several factors that make drug users more susceptible to TB,
which can be divided into epidemiological or behavioral causes,
and physiological causes. Among the former are the following:
The duration of use and higher age of the individual; both of these are
risk factors for latent tuberculosis in case of drug users.
Increased susceptibility to TB due to their tendency for high-risk behavior and the environment shared by
these users. Drug users show higher rates of transmission due to exposure to close,
poor ventilation, high-risk environments and sharing of drug equipment, such as pipes.
Homelessness, addicted to tobacco and alcohol.
High rates of incarceration; prisons are also high-risk locations for TB and HIV infections.
Physiological causes that may contribute to higher prevalence of TB
in illicit drug users include:
- Lung damage due to habitual use of drugs like cocaine.
- Direct impact of illicit drugs on cell mediated immunity. This includes the impairment of
alveolar macrophages and monocytes which are critical for resistance against TB infection
Suppressing the expression of cytokines; some examples of which include interferon
gamma and tumor necrosis factor alpha, both of which are involved in the formation of
granulomas that restrict tuberculosis bacteria. Other cytokines like interleukins are
responsible for recruiting monocytes, T cells and neutrophils are also suppressed by opiates.
- Downregulation of pro-inflammatory responses that are necessary for host microbial control,
such as caused by heroin.
Hurdles in diagnosis and treatment of TB in drug addicts
The first among the many problems
faced by drug users who suffer from TB is delay in going for treatment. The major reason for
this is stigma associated with their habit. Despite being at high risk, these patients are often
overlooked when it comes to diagnosis, management and treatment of TB. Drug users should
have access to the full range of TB and HIV prevention, and treatment facilities, regardless of
the age, sex, race or preference of the affected individual, and without worrying about the
risk of being harassed. This indirectly also benefits their families and the community as a whole.
Drug users tend to have difficulty completing medical evaluations and with treatment adherence.
Lack of education among illicit drug users can cause them to remain unaware about certain key
details regarding tuberculosis, such as the fact that it spreads through coughing, or that it can
become resistant to certain drugs. One theory suggest that the suppressive action of opioid on
coughing may cause a contracted TB infection to go unnoticed for longer than it would have in non-user.
Socio-economic factors such as alcohol use, unstable lifestyle, poverty and fear of hospitalization tend
to keep drug addicts from seeking treatment.
Even after beginning treatment for TB, injection drug use, forbidden use of marijuana and
sedatives, being HIV seropositive, alcoholism as well as homelessness are the risk factors
for failure of the treatment.
Diagnosis and Treatment
Diagnosis of tuberculosis is also more complicated in high
risk patients. The most common method for latent TB testing, is Tuberculin Skin Tests
(TST) and Interferon Gamma Release Assay (IGRA). IGRA is also utilized for testing
the prevalence of LTBI among drug users. The Xpert MTB is yet another technique which
helps overcome difficulties in diagnosing active TB cases, particularly those who suffer from
HIV coinfection, and/or MDR TB.
Certain care has to be taken when administering the standard TB treatments to drug users.
One such consideration is the treatment of these patients with drug regimens that may be
toxic to the liver. Since most drug users already have liver damage (due to either hepatitis
B or C infection, or alcohol), they are at greater risk for drug-induced hepatitis.
Management
With respect to healthcare, effective models to integrate the treatment delivery of HIV,
TB and hepatitis are required. Infection control measures and treatment clinics should
be readily available for management of more complicated cases. They should have
increased accessibility such as by reducing unnecessary crossreferrals while undergoing
treatment. As per WHO recommendations, a one-stop solution is more amenable for drug
addicts, which would provide opioid substitution therapy, diagnosis and treatment of HIV, and
TB as well as vaccinations for hepatitis B and C, all in the same place.
Proper epidemiological studies to quantify the burden of TB among drug users is essential
so as to allow the monitoring of effectiveness of TB treatment services and its coverage.
There is also a crucial need for clinical research with respect to unlawful drug use,
which includes the development of rapid diagnostic tools for TB and development of tailor
made drug regimens for narcotic users. Co-treatment measures for TB, HIV and hepatitis
should also be developed with existing and new drugs against these diseases.
Certain other policies can be implemented to reduce the adverse effects of narcotics on
drug users as well as those around them:
- Better education and access to information, especially regarding reducing
the risk of contracting TB
- Drug rehabilitation programs
- Confidential testing facilities for HIV
- Better access to vaccines for hepatitis B and C
Both drug abuse, as well as the higher incidence of highly communicable diseases in
drug users, are public health issues. It is in the best interest of the community to ensure
that they receive the best care against tuberculosis, not only out of common decency for
a fellow human being but also to reduce national and global prevalence of a deadly disease.
