Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

146 III. SUBSTANCES OF ABUSEgroups in the United States, black or Hispanic poor persons are overrepresented.True iatrogenic opioid dependence rarely persists to become chronic,although the risk exists for those with chronic, painful medical or surgical problems.Although men and women seek treatment in roughly equal numbers,women who are mothers of dependent children may benefit from a more favorableprognosis.Opioid addiction follows a relapsing and remitting course until middle age,when its relentless grip on the individual seems to abate slowly and spontaneously.Some experts have estimated 9 years as the average duration of activeopioid addiction (Jaffe, 1989). Criminal activity, usually in support of addiction,is very common during periods of active use. In periods of remission, criminalactivity drops off significantly. The overall death rate in opioid abusers isestimated to be as much as 20 times that of the general population. The proximatecause of death is usually overdose, use-related infections, suicide, homicide,or accidental death.Significant psychiatric comorbidity has been observed; depression and personalitydisorder are the most frequent diagnoses. Polysubstance abuse is commonin opioid addicts. Many are nicotine addicted, and many have seriousalcohol-related problems as well. Benzodiazepine use is common and probablyunderestimated, because it may not be specifically assayed in urine specimens.Sporadic use of cocaine and other stimulants is common, as is the use of marijuana.A few opioid addicts also use hallucinogens or inhalants.The medical complications of opioid abuse are many and diverse. Theystem most commonly from (1) the failure to use aseptic techniques duringinjection, (2) the presence of particulate contaminants in the injected solution,and (3) the direct pharmacological actions of the drug. The consequences ofinfection are the most frequently encountered medical complications of opioidabuse. Skin abscesses, lymphadenopathy, osteomyelitis, septic emboli in thelungs, endocarditis, septicemia, glomerulonephritis, meningitis, and brain abscessesare encountered with regularity when “dirty needles” are used. A lowlevelimmunodeficiency may exist in chronic opioid addicts, causing them to bemore susceptible to infectious processes such as tuberculosis, syphilis, malaria,tetanus, and hepatitis (Senay, 1983). HIV infection may result from sharingneedles with an infected individual. Risk of this complication is highest in thenortheastern United States, where a survey of opioid addicts in methadonetreatment programs showed seropositivity in 60% of those who reported sharingneedles (Jaffe, 1989). Fortunately, the percentage drops dramatically in mostother parts of the country, and aggressive efforts at education of both addictsand those who treat them in clinics and elsewhere have helped slow the spreadof this deadly virus.Addicts frequently inject opioid solutions contaminated with adulterantssuch as talc and starch; these substances are used to increase the bulk of theillicit powder, thus increasing profits for the drug dealer. Addicts mix the pow-