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Illicit drug use is a major health issue worldwide. Annually, approximately 250 million individuals are involved in drug use, with up to 21 million using injection drugs.1 In 2008, an estimated 20.1 million Americans ≥12 years of age used an illicit drug within the previous month, and of these, 213,000 used heroin, nearly twice the prevalence rate of 2005.2 Between 1996 and 2006, heroin-related ED visits more than doubled (from 73,846 to 189,780), with the majority of visits made by men (69%) and patients aged 35 to 44 years.2

The practice of injection drug use, and the lifestyle and culture of the injection drug user, place the individual at risk for a wide variety of infectious and noninfectious medical complications. In addition to carrying an increased risk of human immunodeficiency virus (HIV) infection, hepatitis, tetanus, and sexually transmitted diseases, the injection drug user’s lifestyle is also associated with an increased risk of trauma and intimate partner violence.3 The high incidence of migration, incarceration, homelessness, nutritional deficiencies, coincident smoking and alcohol use, and mental illness further compromise this population’s health.4

The sale of drugs and participation in commercial street sex work to generate illegal income, and the exchange of sex for drugs further complicates the lives of these individuals and produces medical complications that lead them to seek care. Many enter the industry to maintain expensive drug habits. Drugs may be supplied to a sex worker by the handler (pimp) in exchange for earnings. Sex workers are more likely to be exposed to high levels of violence and abuse, including beatings, stabbing, rape, robbery, and death, perpetrated by both clients and handlers. Many of these crimes go unreported, and information about them may not be volunteered to health care workers by the victim due to fear of reprisal. Pressure from clients, depressed judgment when intoxicated, increased likelihood of exposure to social networks with a high prevalence of sexually transmitted infection, and competition from other sex workers may lead these workers to offer, or be coerced into accepting, unprotected vaginal or anal sex for more money. This behavior places them at increased risk of acquiring bacterial infections (syphilis, gonorrhea, chlamydial infections, and mycoplasma infections) and viral infections (HIV infection; hepatitis A, B, and C; herpes simplex; and human papillomavirus infection) and their associated long-term sequelae. Vaccination against hepatitis virus, human papillomavirus, and, when it becomes available, HIV should be provided to these individuals.5

In addition to placing patients at greater risk for immunomodulating infections such as HIV infection and hepatitis, injection drug use itself, including immunomodulation by opiates, has been associated with immune dysregulation. Exaggerated and atypical lymphocytosis, diminished lymphocyte responsiveness to mitogenic stimulation and depressed chemotaxis, hypergammaglobulinemia, increased opsonin production, decreased T-cell and natural killer cell activity, high levels of circulating immune complexes, and reticuloendothelial abnormalities have been found in injection drug users. Because of this immune stimulation, false positive ...

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