Opioid Use Disorder 545
in cellulitis, abscesses, and circ ular-appearing scars from healed skin lesions. Tetanus and
Clostridium botulinum  infections are relatively rare bu t extremely serious consequences of
injecting opioids, especially with contaminated  needles. Infections may also occur in other
organs and include bacterial endocarditis, hepa titis, and HIV infection. Hepatitis C infec-
tions, for example, may occur in up to 90% of  persons who inject opioids. In addition, the
prevalence of HIV infection ca n be high among individuals who inject drugs, a large pro-
portion of whom are individuals with opioid  use disorder. HIV infection rates have been
reported to be as high as 60% among heroin users with opioid use disorder in some areas
of the United States or the Russian Federati on. However, the incidence may also be 10% or
less in other areas, especially those where a ccess to clean injection material and parapher-
nalia is facilitated.
Tuberculosis is a particularly serious problem among individuals who use drugs in-
travenously, especially those who are dependen t on heroin; infection is usually asymptom-
atic and evident only by the presence of a posi tive tuberculin skin test. However, many cases
of active tuberculosis have been found, espe cially among those who are infected with HIV.
These individuals often have a newly acquired infection but also are likely to experience
reactivation of a prior infection be cause of impaired immune function. 
Individuals who sniff heroin or other opioid s into the nose (“snorting”) often develop
irritation of the nasal mucosa, sometimes acco mpanied by perforation of the nasal septum.
Difficulties in sexual functioning are common. Males often experience erectile dysfunction