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Promoting Safety: Tuberculosis and Drug Abuse

Posted By HealthcareOnTime Team Posted on 2022-05-06 Promoting Safety: Tuberculosis and Drug Abuse

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).

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.

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.


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