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The Challenge of Managing Wounds in the Injecting Drug- Dependent Patient

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The Challenge of Managing Wounds in the Injecting Drug- Dependent Patient Clinical PRACTICEClinical DEVELOPMENT REVIEW The challenge of managing wounds in the injecting drug- dependent patient Managing wounds in the patient who injects drugs is complex for healthcare professionals. As with the non- drug taking population, the problems of mobility, odour from the wound, social limitation and pain still occur, but fears of discrimination may lead to reluctance to seek medical intervention, potentially leading to slower recovery and chronicity. This article focuses on the problems encountered by injecting drug users, a group that can suffer significant wound care issues, including infection, wound abscess and fistula formation, along with other management problems, such as a reciprocal mistrust of healthcare professionals. Andy Roden Irrespective of the route of doses of opioid are given to patients KEY WORDS administration, once heroin is taken with chronic pain.’ Heroin users report a feeling of well-being, Drug addiction relaxation and safety, which Finnie and It is quite possible that a patient Nicolson (2002; p. s18) describe as ‘like may have a tolerance/addiction to Analgesics being wrapped up in a warm blanket’. opioids, which requires analgesia, as Wound care management It is these properties, along with the well as pain from a chronic wound, Healthcare professionals euphoria associated with taking heroin, which also needs managing. This can which makes it such a potentially be a difficult task for the healthcare powerfully addictive drug. professional and is one where specialist help from a drug and alcohol specialist eroin (diacetylmorphine or team will be required. By administering diamorphine) is a powerful There is no therapeutic opioids, practitioners may also be seen Hanalgesic synthesised from discovery that has been so as condoning or reinforcing the drug- the group of mixed alkaloids present great a blessing and so great taking behaviour. in cultivated and processed opium a curse to mankind as the poppies. The drug was initially hypodermic injection of Tolerance Opioid dependence is a complex developed around 1900 by what is morphia (Kane, 1881). now the Bayer Company as a non- health condition that often requires addictive morphine substitute and long-term treatment and care (World cough suppressant while doctors at All strong opioids can produce Health Organization [WHO], 2009). the company were trying to isolate adverse effects such as respiratory McQuay (1999, p. 2230) describes codeine. Any GP can prescribe heroin depression, nausea and vomiting, but tolerance as ‘the need for a higher dose for pain relief in terminal illness, but McQuay (1999, p. 2229) noted that (or increased plasma concentration) they require a Home Office licence although healthcare professionals to achieve the same pharmacological if the drug is to be prescribed for need to be mindful of the effect of effect’. Clinicians treating patients in drug addiction. opioids, they should not fear them: the non-drug taking population will ‘What happens when opioids are given automatically assume that any increased to someone in pain is different from need for analgesia is due to a worsening what happens when they are given to of the patient’s condition. However, in someone not in pain. The respiratory patients with a known drug habit, any depression that results from the acute increased request for strong analgesics use of opioids is seen in studies of may be seen as drug-seeking behaviour. volunteers who are not in pain. But WHO (2009) have stated that no single Andy Roden is Lecturer, Faculty of Health, respiratory depression is kept to a treatment is effective for all individuals University of Wales, Bangor minimum when appropriate regular with opioid dependence — diverse Wounds UK, 2009, Vol 5, No 4 95 Roden, final.indd 31 26/10/2009 07:24 Clinical REVIEW treatment options are needed, including (1992) found huge differences in the skin and underlying tissue/muscle. psychosocial approaches (i.e. counselling method of administration across the UK, This practice is called ‘skin-popping’ and cognitive behavioural therapy for example, in South London, 50% of and can lead to the development [CBT]) and pharmacological treatment. new patients on treatment programmes of ‘shooter’s patches’ (non-healing smoked heroin, whereas in the Wirral, ulcers which the patient will use Dependence/addiction this figure was 95% — at the same as a means of administering their Early definitions of dependence or time it was estimated that 95% of users drugs when no vascular access can addiction focused on the mechanics of in Edinburgh were injecting the drug, be found) (Williams and Southern, taking a drug, for example, WHO (1979) possibly because this method reduces 2005). described dependence as ‘a compulsion the cost, as less heroin is needed to to take a drug on a periodic or continual produce the same effect (Finnie and Barriers to effective treatment basis’. However, this view does not Nicolson, 2002). Individuals with substance use disorders consider the holistic view of patients in are less likely than others to receive this category. Heather (1998) suggested This article will focus on the effective pain treatment (Rupp and that a more complete definition problems encountered by injecting drug Delaney, 2004). This is due to four should include reference to a person’s users, as this is a group that can suffer main factors: behaviour and not purely his or her drug significant wound care issues, including 8 Fear of addiction at the outset taking, and that Edwards et al’s (1982, infection, wound abscess and fistula of treatment p. 4) definition of ‘repeated use of a formation, along with other management 8 Patients seeking opioids for reasons substance despite awareness of resultant problems, such as a reciprocal mistrust other than pain relief harm’ is a more satisfactory one. of healthcare professionals (Butcher, 8 Difficulty in knowing where pain 2000; Merrison et al 2002; Palfreyman et ends and craving starts The scale of intravenous (IV) drug al, 2007; Roose et al, 2009). 8 Distrust of healthcare professionals. use in the UK Due to the secretive nature of heroin Why are patients who inject at risk of Fear of addiction at the outset of treatment use, exact numbers are difficult to developing skin and vascular problems? Bennett and Carr (2002) described this accurately gauge, but Frisher et al (2006) In people that use drugs there are as ‘opiophobia’, an irrational fear of the estimate UK IV drug use at 48.8 per several prominent issues with regards drug for both drug-users and non-drug 100,000, although there will be areas the development of skin and vascular users, which impedes its appropriate use, of higher use. As long ago as 2001, the problems, including: fearing that patients will become addicts. Home Office Research Study suggested 8 The drug is adulterated or ‘cut’ with that 2% of men and 1% of women had other substances, e.g. chalk, talcum Bennett and Carr (2002) suggest used heroin on at least one occasion powder or gravy browning (up to that opioids may be withheld due (Ramsay et al, 2001). Stimson and 99%) in an effort to produce more to their inherent side-effects, or the Metrebian (2003) estimated the total profit. This cutting is likely to be done fear that the patient will become a number of problematic heroin users in in unhygienic conditions, potentially management problem. There is limited the UK at around 200,000, while also introducing bacteria and spores information relating to the risk of acknowledging the difficulty in estimating (Finnie and Nicolson, 2002) the patient becoming addicted to its use. 8 Heroin needs to be dissolved in the opioids while being treated for a an acidic medium before being painful condition, although Lema (1998) How is the drug taken? injected, which often means mixing suggested the incidence to be less than Depending on its source and purity, it with lemon juice or citrate — any 1:20,000. However, Passik et al (2006) heroin varies from white to brown in substance which is acidic or alkaline found that 47% (51/109) of people colour with a crystalline appearance. is irritant to veins presenting for addiction to oxycodone It can be smoked, snorted or injected 8 Before injection, the heroin may be (a strong synthetic opioid) received subcutaneously/intramuscularly or filtered in an attempt to remove their first exposure to opioids through a intravenously. Initially, heroin is usually impurities. This may be done through legitimate prescription. inhaled by users using a technique a clean cigarette filter or through known as ‘chasing the dragon’. cotton wool, but even this practice Patients seeking opioids for non-pain purposes When this fails to deliver a ‘high’, the may introduce particulate matter Savage et al (2008) described the individual’s next step may be to inject into the veins difficulties associated with the use of intravenously in order to reach the 8 Injecting against the blood flow — opioids in individuals with a history desired euphoric state. once the veins thrombose, injecting of substance abuse, stating that such against the flow may lead to the their patients raise complex clinical and ethical However, it may be too simplistic bursting under the pressure issues. Healthcare professionals have a to suggest that users automatically 8 Once the veins of the body have duty to alleviate suffering, which is the gravitate to intravenous injection having been exhausted, the patient may purpose of opioid drugs, however, their previously smoked heroin. Strang et al be forced to inject directly into the administration may ultimately lead to 96 Wounds UK, 2009, Vol 5, No 4 Roden, final.indd 32 26/10/2009 07:24 Clinical REVIEW harm, i.e. through the subsequent misuse intravascular route. Vascular problems aneurysms, Georgiadis et al (2005) of the drug. may arise when the user seeks to noted that the presenting signs and use deeper blood vessels due to the symptoms included a pulsatile mass Difficulty knowing where the pain ends prolonged use of more superficial (69%), ischaemic pain (23%), active and the craving begins veins, which allow easier access but bleeding (38.5%), signs of inflammation The issue for healthcare professionals become damaged over time.
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