Can We Talk?: Be Alert: Skin and Wound Problems in Persons Who Inject Drugs are on the Rise

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Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN Professor, Interim Associate Dean Faculty Affairs, College of Nursing, Wayne State University, Detroit, MI

The United States is experiencing an epidemic of prescription opioid misuse that cannot be ignored. An estimated 2 million individuals have an opioid use disorder associated with prescription opioids.1 Not surprising, oral opioid misuse has led to a resurgence in the number of persons who inject drugs (PWID), especially among young people.2 The lifetime number of PWID comprise 2.6% of the US population age 13 years and older or about 6.6 million people in 2011.3 

There are many reasons for skin and wound problems in PWID, including the injection mixture, technique, site, and years of injecting. The most common skin and wound problems are abscesses, lumps, track marks, and leg ulcers.4,5 Elana Gordon,6 a reporter/producer for public television, interviewed nurses, physicians, and PWID about wounds and their care in the community. Ms. Gordon highlighted critical issues that clinicians need to consider.

What implications does this resurgence in injecting have for clinicians (eg, nurses, physicians, and podiatrists)? Practitioners need to be alert to find and diagnosis skin and wound problems. PWID often hide wound and skin problems; thus, diagnosis and treatment can come at a late stage. Most (94%) PWID have a history of self-management of their wounds.7 When they do seek care, the wound can be large and infections pronounced. 

What are issues wound clinicians should consider? Practitioners are encouraged to examine their feelings and beliefs about caring for PWID. PWID perceive negativity when they seek care; they state they are talked down to and not shown respect. They do not trust the care they will receive. PWID may require hospitalization. The most common reasons for hospitalization are bacterial skin and soft tissue infections (SSTIs). Prevalence estimates of SSTI among PWID range from 10% in a supervised program of injecting to 34% of a street sample.2 US hospitalization rates for heroin-related SSTI doubled between 2000 and 2010 and were concentrated in individuals ages 20 to 40 years.2 PWID may fight hospitalization because they are concerned about going through withdrawal.

Wound care can be long-term and necessitates a rigorous appointment schedule. Pirozzi et al8 reported as many as 36 of 49 patients (73%) did not return for their scheduled outpatient follow-up visit. Flexibility in appointment scheduling or offering a walk-in service may help. Teaching home care wound strategies may be the best option. Some organizations offer wound care in vans and community outreach sites so the service is provided in an environment in which these individuals are comfortable. 

 Wound care should be a partnership with PWID. Teaching must be a creative, critical component of care. Engaging the person in clinical and harm-reduction practices for injecting, such as washing the skin, injecting techniques, and handling contaminated equipment, may prevent infections and wounds. PWID may have multiple health care problems such as hepatitis C, HIV infection, diabetes, hypertension, depression, and chronic pain that need care. Helping PWID with services such as drug treatment programs, primary health care, food, or shelters shows sensitivity and helps develop a positive outlook patients appreciate. 

Unfortunately, the number of wounds from injecting drugs is on the rise. Wound care provided in a sensitive, caring, knowledgeable manner is a cornerstone of good practice… something all of us want when we face a health/illness situation. 

References

1. Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017;318(5):425–426. doi: 10.1001/jama.2017.8913.

2. Ciccarone D, Unick GJ, Cohen JK, Mars SG. Nationwide increase in hospitalizations for heroin-related soft tissue infections: associations with structural market conditions. Drug
Alcohol
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. 2016;163:126-133. doi: 10.1016/j.drugalcdep.2016.04.009. 

3. Lansky A, Finlayson T, Johnson C, et al. Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections. PLoS
One
. 2014;9(5):e97596. doi: 10.1371/journal.pone.0097596.

4. Coull AF, Atherton I, Taylor A, Watterson AE. Prevalence of skin problems and leg ulceration in a sample of young injecting drug users. Harm Reduct J. 2014;11:22. doi: 10.1186/1477-7517-11-22. 

5. Smith ME, Robinowitz N, Chaulk P, Johnson KE. High rates of abscesses and chronic wounds in community-recruited injection drug users and associated risk factors. J Addict Med. 2015;9(2):87–93. doi: 10.1097/ADM.0000000000000093.

6. Healing the wounds from injecting drugs. Available at: https://whyy.org/segments/healing-wounds-injecting-drugs/. Accessed March 26, 2018.

7. Roose RJ, Hayashi AS, Cunningham CO. Self-management of injection-related wounds among injecting drug users. J Addict Dis. 2009;28(1):74–80. doi: 10.1080/10550880802545200

8. Pirozzi K, Van JC, Pontious J, Meyr AJ. Demographic description of the presentation and treatment of lower extremity skin and soft tissue infections secondary to skin popping in intravenous drug abusers. J Foot Ankle Surg. 2014;53(2):156–159. doi: 10.1053/j.jfas.2013.12.017.

 

This article was not subject to the Ostomy Wound Management peer-review process.