Heroin Use and Infections

3 Common Modes of Transmission

Man holding needle in a park with his head down

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Rates of heroin use have been climbing in the United States over the last decade. Heroin overdose deaths have increased by almost 400%. Over 8,000 people die in the United States from overdoses each year. Rates of abuse have doubled among women and have risen by 50% among men in the United States. Infections account for much of the harm.

Beyond deaths directly from overdoses, heroin use is also associated with infections which may directly or indirectly affect people long after the drug has cleared the system. Treatment for addiction may reduce the risk of overdose, but some infections may remain while others have created scars of a sort.

The fact that heroin is often injected is the reason why it causes infections to spread. Some may start by abusing prescription drugs before moving to less expensive heroin. This move may be between drugs that are not injected and a drug that is.

Prescription drug use alone is dangerous. Forty-four people die in the United States per day as a result of a prescription drug overdose. Roughly, 10 people a day die from a heroin overdose.

There are three main ways in which heroin can lead to these infections:

  • Shared needles and other injecting equipment, leading to infections spreading by blood
  • Non-sterile injection practices, leading to infections from bacteria on the skin
  • Contaminated heroin, leading to some uncommon infections

Shared Injecting Equipment

Shared injecting equipment is a primary mode of transmission for many communicable diseases.

Hepatitis C

Hepatitis C is a virus that causes liver damage. It can occur with the appearance of acute symptoms, but most people do not even know they have the disease until decades later when the liver disease has progressed. Hepatitis C is most often spread by shared injecting equipment.

It is thought that roughly 90% of all hepatitis C infections worldwide are related to injecting drug use, while more than half of all cases in the United States are attributed to shared needles.

There are approximately 2.7 million cases of chronic Hepatitis C in the United States. Most infections occurred in the 1970s and 1980s before blood supplies were routinely tested for the virus. It is thought that one in three injecting drug users (IDUs) in the United States 18 to 30 are infected, while 70% to 90% of older IDUs are infected.

Hepatitis B

Hepatitis B is a virus unrelated to hepatitis C, but it is also transmitted by sharing needles and also causes liver damage. Hepatitis B (HBV) infection in IDUs was reported to be as high as 20% in the United States.


HIV can be spread through a variety of ways, including sex, mother-to-child transmission, and shared needles. Worldwide, it is thought about 30% of HIV infections outside of sub-Saharan Africa are from shared needles and injection equipment.

In fact, in countries like Russia, injecting drug use is today the primary mode of HIV transmission, unlike the United States where the sexual transmission of HIV predominates.

Lack of Sterile Technique

There are a number of infections that spread because the needles, though not shared, are used without sterile technique. The use of needles requires practice and protocols to avoid spreading infections. The needles pierce through skin that is normally covered in bacteria, taking the bacteria under the skin and into the bloodstream.

One of the most common bacteria spread by shared needles is methicillin-resistant Staphylococcus aureus (MRSA), a highly resistant infection seen in alarming numbers in both heroin and crystal methamphetamine users.

There are other infections caused by bacteria, like Group A streptococcus that can lead to invasive infections. These infections can spread through skin-popping, leading to abscesses, boils, and cellulitis. Some types of cellulitis can be mild, while others can lead to severe complications like necrotizing fasciitis.

Intravenous drug use can send the bacteria directly into the bloodstream. This can cause an infection in the blood, leading to sepsis. The bacteria can affect other parts of the body including heart valves (endocarditis), bones (osteomyelitis), and joints (septic arthritis).

Contaminated Drugs

Drugs injected are not usually "pure" but are generally mixed with other substances, some of which may include other harmful microorganisms. Some IDUs mix their drugs with unsterile tap water, leading to infections from microbes like Pseudomonas and Corynebacterium diphtheriae).


Botulism is a rare bacterial infection that is potentially fatal but is now uncommon in the United States because of safety measures in food canning and preparation. The same cannot be said for injecting drug use.

The bacterium Clostridium botulinum regularly contaminates heroin, especially "black tar heroin." It can be spread by skin popping or intravenous drug use, causing weakness, drooping eyelids, blurred vision, and difficulty swallowing.

Because botulism is a rare infection, diagnoses may be delayed. However, because the bacterial toxins can contaminate entire batches of heroin, there will often be a localized outbreak recognized by public health officials.


Tetanus spores can contaminate heroin injection, either during production and the injection itself. Clostridium tetani are found naturally in the environment such as in dirt or on rusty equipment. In the United States, about 15% of cases of tetanus occur each year among IDUs, mainly as a result of heroin. In the United Kingdom, a tetanus outbreak was directly linked to heroin injections in 2003 to 2004.


Although anthrax conjures images of bioterrorism, the spores causing anthrax can be found naturally in some environments. There were, in fact, 82 cases of anthrax (Bacillus anthracis) in Scotland from 2009 to 2010 among injecting heroin users. Most had soft tissue infections but some had serious systemic infections.

Other Causes

Other spores infections caused by spores have also been reported, including Bacillus cereus (a relative of Bacillus anthracis) and Clostridium sordellii (a relative of Clostridium botulinum and Clostridium tetani).

For help with dealing with drug addiction, call the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-HELP.

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