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

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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

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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. This may (61.5%) and positive blood culture is being able to differentiate between be due to phlebitis, which is caused (31%). Bleeding complications developed the symptoms of pain and the signs by repeated injections in a single area, in two patients, who subsequently of craving or withdrawal from opioid a process further complicated by the underwent extra-anatomic bypass. In medication. Typically, a patient in severe unhygienic conditions of preparation this study, the pseudo-aneurysms most acute pain will exhibit signs such as and the injection of particulate matter commonly involved the femoral and increased blood pressure and heart brachial arteries. rate, sweating and hyperventilation. In chronic pain, patients may also show The issue for healthcare Woodburn and Murie (1996) psychological signs such as distress, professionals is being able warned about the need for careful restlessness and depression (Savage to differentiate between examination for pseudo-aneurysms. Up et al, 2008). All these symptoms may the symptoms of pain and to 23% are non-pulsatile and attempts at be difficult to distinguish from acute the signs of craving or incision and drainage should be avoided, withdrawal from opioid medication withdrawal from opioid as what might appear to be an abscess (NHS Clinical Knowledge Summaries, could in fact be a pseudo-aneurysm. available online at: www.cks.nhs.uk/ medication. opioid_dependence/management/ Ting and Chen (1997) found similar detailed_answers/managing_acute_ (Finnie and Nicolson, 2002). This is results in a study of 34 patients with withdrawal_syndrome/recognizing_ often associated with the injection of infected pseudo-aneurysms, with all of acute_withdrawal_syndrome). temazepam tablets (which have been the patients presenting with pain and crushed) or gels (Woodburn and Murie, swelling — interestingly, 70% were also Healthcare professionals’ mistrust of the 1996). Coughlin and Mavor (2006; p. found to be anaemic. degree of pain and suffering 391) warn about the specific dangers The anecdotal attitudes of ward-based of cocaine due to its effects upon both Chronic venous insufficiency (CVI) staff towards patients who misuse the myocardium and the arterial tree and venous hypertension as a result substances reveal a deep-seated mistrust in general, and suggest that ‘arterial of injecting drugs may also lead to the and an assumption that requests for problems must always be considered in formation of chronic ulcers (Sudhindran, analgesia are made to feed addiction. cocaine users who present acutely’. 1997). Similarly, Pieper et al (2006) Ford et al (2008) supported this found that in a subject group of 46 observation in a large (n=1,600) As peripheral vascular access drug users, CVI, leg function and drug questionnaire examining nurses’ becomes more difficult to achieve injection were all interrelated. perceptions of patients who use illicit over time, the user runs the risk of drugs. The conclusion was that nurses an inadvertent intra-arterial injection, Georgiadis et al (2005) stated struggle to provide care to this patient a potentially lethal complication, and that limb salvage with immediate group and that access to appropriate the formation of pseudo-aneurysms. revascularisation is safe and achieves skilled support staff (drug and alcohol Inadvertent intra-arterial injection functionality; therefore, its use is teams) was very important. predisposes users to distal limb justified in the treatment of pseudo- ischaemia and arterial puncture leading aneurysm. Ligation and excision of the Problems associated with patients to the formation of infected pseudo- pseudo-aneurysm with debridement who inject drugs aneurysms (sometimes referred to as and drainage of the infection appears The problems associated with patients an ‘aneurismal abscess’). Mosby’s Medical to be standard treatment, but Ting and who inject drugs regularly can be divided Dictionary (2009) defined these as: Chen (1997) warned that the timing into three distinct areas: 8 Dilation of an artery caused by and method of re-vascularisation 8 Vascular complications damage to one or more of its layers is still controversial. Immediate re- 8 Infective complications as a result of arterial trauma or vascularisation had the advantage of 8 Management issues. rupture of a true aneurysm minimising limb loss. However, putting 8 A tortuosity of a blood vessel or a graft into potentially infected tissue Vascular complications cavity resulting from a herniated could lead to haemorrhage and The injection of illicit drugs is a infarction — also called pulsatile secondary infection. significant problem in Western society haematoma. and many different substances, such as Infective complications heroin, cocaine, oxycodone, pethidine In a study of 26 injecting drug It has already been noted that drugs are and methadone are taken via the users who were treated for pseudo- often prepared in unhygienic conditions

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and mixed with a variety of unsterile associated with subcutaneous heroin (1999, p. 2229) noted, ‘concern about components. The risk of infection is made injection. Although rare, early detection respiratory depression should not greater by the re-use of syringes and of such infection is vital for improving inhibit the appropriate use of opioids, needles, potentially passing infection from outcomes. i.e. to provide analgesia when the pain one user to the next (McCreddie, 2001). is deemed to be opioid-sensitive’ and Management issues ‘that the medical use of opioids does not Sutton et al (2006) highlighted Managing patients who have a drug create drug addicts, and restrictions on the problem of serious blood-borne habit is an emotive topic and the this medical use hurts patients’ (McQuay, infections such as hepatitis B (HBV) and author has found that anecdotal 1999, p. 2230). In the hospital setting, the hepatitis C (HCV) from a large sample evidence gathered from working with failure of patients to disclose true drug of injecting drug users (n=20,000). They the acute and chronic pain team in a usage for fear of prosecution should also found that rates of 38% of HBV and large district hospital highlighted many be considered (Morrison et al, 1997). 95% of HCV were attributable to drug areas of conflict. users who make up less than 1% of the The use of an ‘opioid contract’, a overall population. formal written agreement between Williams and Southern clinician and patient may be beneficial. One way to prevent spread of (2005) noted the trend Many are available and include issues infection is through the use of needle- among heroin addicts to use such as seeking or selling medication, exchange programmes (NEPs). Such wound/ulcer granulation misuse of resources, e.g. not attending programmes are now commonplace tissue as a route of drug clinics, random drug screening, and but are seen by some as condoning illicit administration once side-effect education. However, Fishman drug use, thus their role is contentious et al (1999) cautioned that although (Bates, 2002). The National Institute for vascular access became their use is widespread, efficacy has Health and Clinical Excellence (NICE) impossible. This may result not been proven. Fishman et al (1999; (Cole, 2009) supports the use of NEP, in the patient wanting the p. 37) concluded that: ‘The contract estimating that 200,000 people in Wales wound not to heal as it may be an appealing tool for clarifying and England inject illegal opiates and allows easy access to the terms, addressing potential pitfalls, stimulants and that around 25% share vascular bed. acquiring informed consent, and helping their needles, which greatly increased to establish a therapeutic relationship. their risk of contracting hepatitis B and Its efficacy in improving compliance, C or human immunodeficiency virus Healthcare professionals were enhancing the treatment process, or (HIV). However, Strathdee et al (1997) reluctant to prescribe/administer protecting the rights of patients or questioned the role of NEPs, stating analgesia as they viewed the pain- clinicians is far from certain.’ that despite having the largest NEP in behaviour as drug-seeking behaviour and North America, Vancouver has been providing strong (opioid) medication Conclusion experiencing an ongoing HIV epidemic. as compounding the issue. Other The nature of managing wounds in the They concluded that although NEPs commonly encountered problems patient who injects drugs is a complex are crucial for sterile syringe provision, included non-compliance with treatment one for the healthcare professional. As they should only be considered as regimens. This was illustrated by with the non-drug taking population, one component of a comprehensive Williams and Southern (2005) who the problems of mobility, odour from programme, including counselling, noted the trend among heroin addicts the wound, social limitation and pain support and education. to use wound/ulcer granulation tissue still occur, but fears of discrimination as a route of drug administration once may lead to reluctance to seek medical A range of infections has been vascular access became impossible. intervention, potentially leading to reported in this group of patients. This may result in the patient wanting slower recovery and chronicity. The Brett et al (2005) noted spore-forming the wound not to heal as it allows easy advice of specialised drug and alcohol bacteria were responsible for Clostridium access to the vascular bed. Roose et al services should be sought in an effort to novyi in 63 patients in 2000 and 71 (2009) also noted that mistrust led to rationalise treatment and avoid conflict patients in 2001, as well as 20 cases of self-management techniques, such as between the many teams, including tetanus between late 2003 and early drug users treating themselves with illicit GPs, consultants, nurses, pain teams, and 2004 in the UK and Ireland. Brett et al antibiotics, or purposely disrupting the tissue viability and leg ulcer specialists, (2005) also noted an increase in wound wound so that the non-healing wound all of whom may be responsible for the botulism. Botulism is usually contracted bed was a port for the drugs to be patient’s management. Wuk through the ingestion of contaminated administered through. food, but Mulleague et al (2001) identified two cases that developed as a The failure to administer opioids References result of injecting heroin. Merrison et al for fear of overdose is another issue in Bates P (2002) Are needle exchange schemes (2002) also described a case of botulism clinical practice, however, as McQuay ethical? Pharm J 269: 214

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