Skin and Soft Tissue Infections in Injection Drug Users

Mucocutaneous alterations and complications in amphetamine abusers: a narrative review

Amphetamines are the second most commonly used illicit drug worldwide. Amphetamine use can result in significant cutaneous morbidity. This review highlights the dermatological manifestations of amphetamine abuse.

Skin Popping for the Hand Surgeon: A Case Report and Review

INTRODUCTION

Subcutaneous injection of illicit drugs, colloquially known as skin popping, is associated with skin and soft tissue infections of the upper extremity. Sequelae of these infections often present to hand surgeons in the late stages of disease, are associated with challenging clinical scenarios, and are a significant burden to both patients and providers. The authors present an illustrative case and review the literature regarding this growing phenomenon in upper extremity surgery.

METHODS

A case report detailing the surgical reconstruction of a large forearm wound in the setting of intravenous heroin use and skin popping is presented. Search terms related to upper extremity subcutaneous drug injection were used to find relevant articles in PubMed and EMBASE. A total of 488 articles were found, with 22 studies meeting the inclusion criteria.

RESULTS

In this case report, the patient had a long history of skin popping to the forearm and presented with a chronic wound with exposed bone. The patient was treated with serial debridement, bony fixation, intravenous antibiotics, and soft tissue coverage using an arteriovenous loop and a muscle-only latissimus flap. Literature review yielded 22 studies comprising 38 patients with 55% (11/20) women and age range of 23 to 58 years. Heroin was the most commonly used drug (50.0%). The most common presentation was soft tissue infection (6/20 patients), manifestations of noninfected wounds (5/20), and wound botulism (4/20 of patients). Seventy percent of patients presented with multiple injection sites. Surgical management was described in 18% of cases, with all but one case describing drainage and debridement techniques. Only one case of formal reconstruction using a dermal template was described.

CONCLUSIONS

Skin popping infections have unique pathogenesis, presentation, and management patterns that hand surgeons must be aware of when treating these patients. A literature review revealed a relative paucity of reports regarding risk factors and surgical management of "skin popping" sequelae. If patients are reconstructive candidates, complex reconstruction requiring free tissue transfer may be warranted.

Wounds and Skin and Soft Tissue Infections in People Who Inject Drugs and the Utility of Syringe Service Programs in Their Management

Significance: Opioid use disorder and transition to injection drug use (IDU) are an urgent, nationwide public health crisis. Wounds and skin and soft tissue infections (SSTIs) are common complications of IDU that disproportionately affect people who inject drugs (PWID) and are a major source of morbidity and mortality for this population. Critical Issues: Injections in a nonsterile environment and reusing or sharing needles facilitates bacterial inoculation, with subsequent risk of serious complications such as sepsis, gangrene, amputation, and death. PWID are susceptible to infections with a wide spectrum of organisms beyond common culprits of SSTI, including Clostridium and Bacillus spp., as well as Candida. Recent Advances: Syringe services programs (SSPs) are cost-effective and successful in reducing harms associated with IDU. SSPs provide new equipment to PWID and aid in discarding used equipment. SSPs aim to reduce the risks of unhygienic injecting practices, which are associated with transmission of infections and blood-borne pathogens. Future Directions: Concurrently run SSPs and wound care clinics are uniquely positioned to facilitate care to PWID. Providing new, sterile equipment as well as early wound care intervention can reduce morbidity and mortality as well as health care expenditures by reducing the number of SSTI and injection-related wounds that require hospital admission. Establishment of wound care clinics as part of an SSP represents an untapped potential to reduce harm.

Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

BACKGROUND

Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).

METHODS

Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017-18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).

RESULTS

Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48-8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61-5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69-3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93-5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13-3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01-2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27-2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17-1.73, p<0.001).

CONCLUSIONS

These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.

Considerations in the Diagnosis and Management of Lower-Extremity Infections in Injection Heroin Users: A Case Series

BACKGROUND

On a national level, heroin-related hospital admissions have reached an all-time high. With the foot being the fourth most common injection site, heroin-related lower-extremity infections have become more prevalent owing to many factors, including drug preparation, injection practices, and unknown additives.

METHODS

We present a 16-month case series in which eight patients with lower-extremity infections secondary to heroin abuse presented to The Jewish Hospital in Cincinnati, Ohio.

RESULTS

Three cases of osteomyelitis were seen. All of the infections were cultured and yielded a wide array of microbes, including Staphyloccoccus, Streptococcus, Bacillus, Serratia, Prevotella, and Eikenella. All of the patients were treated with intravenous antibiotic agents, with nearly all receiving combination therapy. Seven of the eight patients underwent surgery during their hospital stay, with two undergoing amputation. Only half of the patients followed up after discharge.

CONCLUSIONS

This case series brings to light many considerations in the diagnosis and management of the heroin user, including multivariable attenuation of immunity, existing predisposition to infection backed by unsterile drug preparation and injection practices, innocuous presentation of deep infections, microbial spectrum, and recommendations on antimicrobial intervention, noncompliance, and poor follow-up. By having greater knowledge in unique considerations of diagnosis and treatment, more efficient care can be provided to this unique patient population.

Compliance to antibiotic guidelines leads to more appropriate use of antibiotics in skin and soft tissue infections in injecting drug users

Background: Knowledge about the treatment of skin and soft tissue infections in injecting drug users in countries with a low prevalence of antibiotic resistance is limited. We investigated bacterial antibiotic resistance and treatment of skin and soft tissue infections in Norwegian drug users. Methods: We performed a two year clinical cross-sectional observational study in a Norwegian hospital. Data were collected retrospectively from hospital records. We examined bacteriological findings and antibiotic resistance, and evaluated compliance to treatment guidelines and appropriateness of empirical antibiotic therapy relative to results of cultures and susceptibility testing. Descriptive and univariate analyses were performed. Results: Hundred and thirty-five injecting drug users were admitted with skin and soft tissue infection in the study period. Cultures were obtained from 103 (77%) abscesses and eight (24%) erysipelas and cellulitis, with bacterial growth in 80 (78%) and five (63%), respectively. Streptococci and staphylococci were the most prevalent bacteria, but methicillin-resistant Staphylococcus aureus was found in only one patient. Compliance to hospital antibiotic guidelines was 70%. Ninety-one per cent of patients in the compliant and 79% in the non-compliant group were given effective empirical antibiotics (p = .334). In the non-compliant group, significantly more patients received broad-spectrum empirical antibiotics (p < .001). In 30 cases where adjustment of antibiotic therapy was possible according to susceptibility testing, this was performed in only 14 cases. Conclusions: Bacteria and resistance patterns did not differ significantly from the skin and soft tissue infections in the general population in Norway. Compliance to antibiotic guidelines led to significantly less use of broad-spectrum antibiotics and to good bacterial coverage. General guidelines for treatment should be applied to injecting drug users with skin and soft tissue infections.

The Heroin Epidemic in America: A Surgeon's Perspective

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

Experiences with skin and soft tissue infections among people who inject drugs in Philadelphia: A qualitative study

OBJECTIVES

To understand how people who inject drugs (PWID) experience skin and soft tissue infections (SSTI) and make decisions to seek or delay medical treatment.

METHODS

We conducted semi-structured, in-depth interviews in 2015 with 19 PWID at a syringe exchange program in Philadelphia. We analyzed the data using standard qualitative techniques.

RESULTS

PWID described adequate knowledge about SSTI, although they could not always implement knowledge about SSTI prevention due to environmental constraints. Participants reported different experiences with incident SSTI. Some sought immediate medical care at initial presentation. Most, however, waited to seek care. Previous positive and negative healthcare experiences, both in general -including stigma and withdrawal- and specific to SSTI, influenced this decision. Among those who delayed medical care, some reported self-treatment, including increased drug use for pain control, and lancing and draining their own wounds.

CONCLUSION

Reducing the incidence of SSTI and promoting earlier treatment are important public health priorities. Both require ongoing attention and improvements to the environments in which PWID inject and receive care.

Measuring individual-level needle and syringe coverage among people who inject drugs in Myanmar

BACKGROUND

Myanmar has prioritised people who inject drugs (PWID) as a key population for HIV mitigation efforts, with targets for needle and syringe distribution set at a population level. However, individual-level coverage, defined as the percentage of an individual's injecting episodes covered by a sterile syringe, is a more sensitive measure of intervention coverage. We sought to examine individual-level coverage in a sample of PWID in Myanmar.

METHODS

We recruited 512 PWID through urban drop-in-centres in Yangon, Mandalay and Pyin Oo Lwin. Participants were administered a quantitative questionnaire covering five domains: demographics, drug use, treatment and coverage, and injecting risk behaviour. We calculated past fortnight individual-level syringe coverage, estimating levels of sufficient (≥100% of injecting episodes covered by a sterile syringe) and insufficient (<100%) coverage, and examined associations between key variables and insufficient coverage via logistic regression.

RESULTS

Our sample was predominately male (97%), employed (76%), and living in stable accommodation (96%), with a median age of 27. All participants reported heroin as the drug most frequently injected, and injected a median of 27 times in the past two weeks. Nineteen per cent of participants had insufficient coverage in the two weeks before interview. Insufficient coverage was positively associated with syringe re-use (AOR: 5.19, 95% CIs: 2.57, 10.48) and acquiring sterile syringes from a location other than a formal drop-in-centre (AOR: 2.04, 95% CIs: 1.08, 3.82). Participants recruited in Mandalay (AOR: 0.30, 95% CIs: 0.11, 0.80) and Pyin Oo Lwin (AOR: 0.39, 95% CIs: 0.18, 0.87) had lower odds of insufficient coverage than those recruited in Yangon.

CONCLUSION

Our study shows coverage in selected areas of Myanmar was comparable with studies in other countries. Our results inform the delivery of harm reduction services for PWID, specifically by encouraging the use of formal drop-in-centres, over other sources of syringe distribution, such as pharmacies.

View from the front lines: an emergency medicine perspective on clostridial infections in injection drug users

Injection drug use (IDU), specifically non-intravenous "skin-popping" of heroin, seems to provide optimal conditions for Clostridial infection and toxin production. IDU is therefore a major risk factor for wound botulism and Clostridial necrotizing soft tissue infections (NSTI) and continues to be linked to cases of tetanus. Case clusters of all 3 diseases have occurred among IDUs in Western U.S. and Europe. Medical personnel who care for the IDU population must be thoroughly familiar with the clinical presentation and management of these diseases. Wound botulism presents with bulbar symptoms and signs that are easily overlooked; rapid acquisition and administration of antitoxin can prevent neuromuscular respiratory failure. In addition to Clostridium perfringens, IDU-related NSTIs can be caused by Clostridium sordellii and Clostridium novyi, which may share a distinct clinical presentation. Early definitive NSTI management, which decreases mortality, requires a low index of suspicion on the part of emergency physicians and low threshold for surgical exploration and debridement on the part of the surgeon. Tetanus should be preventable in the IDU population through careful attention to vaccination status.

Two psychiatric presentations linked with ‘head shop’ products

We report two cases of acute onset and rapid resolution of psychotic symptoms, the first following oral ingestion and the second following intravenous injection of some head shop products (HSPs). Both were associated with autonomic instability and negative results on urine toxicology screening using standard techniques. They highlight the potential dangers of managing such cases in acute stand-alone psychiatric units. Recent advance in characterising some HSPs by toxicology screening is also discussed.

Demographic description of the presentation and treatment of lower extremity skin and soft tissue infections secondary to skin popping in intravenous drug abusers

Skin popping refers to the act of subcutaneous injection of intravenous drugs, a practice that often results in the development of cellulitis and the formation of soft tissue abscesses. Although the foot and ankle represent common injection sites, few data have described the presentation and natural history of this pathologic entity. The objective of the present study was to retrospectively assess the descriptive demographic data of a patient cohort admitted for lower extremity skin and soft tissue infection caused by intravenous drug abuse. Fifty skin popping lesions in 49 patients were identified during a 733-day data collection period (August 1, 2010 to August 31, 2012) that had been treated by the in-patient podiatric surgical service for lower extremity infection caused by intravenous drug abuse at an urban, level-one trauma center. With respect to patient race, our hospital has a typical in-patient census of 55% black patients and 25% white patients. The present patient cohort consisted of 12% black patients and 65% white patients. The mean length of stay was 5.71 ± 3.56 days, and 42 patients (85.71%) underwent some form of surgical debridement, with 31 (63.27%) having undergone a formal procedure in the operating room. Six patients (12.24%) left the hospital against medical advice or refused intervention at some definitive point of care, and 36 (73.47%) did not return for scheduled outpatient follow-up visits. Three cases (6%) resulted in minor amputation. The microbiologic culture data and common antibiotic prescriptions used in the diagnosis and treatment, respectively, of these patients have been summarized. We hope these original descriptive data can be used by other physicians treating patients at similar urban practices to improve the care of these sometimes difficult-to-treat patients and better serve this population as a whole.

Parenteral organophosphorus poisoning in a rural emergency department: a case report

BACKGROUND

Poisoning is a common presentation in the emergency department. Oral exposures to organophosphorus compounds are especially frequent in rural and agricultural regions of South Asia and throughout the developing world.

CASE PRESENTATION

Here we report a case of deliberate self-harm with an organophosphorus pesticide via the relatively uncommon parenteral route. A young woman injected herself with chlorpyriphos. Although the cholinergic effects were mild, cellulitis and abscess development were noted as a result.

CONCLUSION

Resource limited agricultural countries like Nepal present health care workers with numerous challenges in poisoning management. This case represents a rare but potentially morbid method of agrochemical poison exposure.

Physical illness in psychiatric inpatients: comparison of patients with and without substance use disorders

BACKGROUND

Physical comorbidities and substance use are commonly reported in patients with mental disorders.

AIM

To examine somatic comorbidity in patients with substance use disorders (SUD) compared to patients with mental disorders but no SUD.

METHODS

Lifetime prevalence data on mental and physical health status were collected from inpatients in 12 mental health care facilities in five different countries. Differences in somatic comorbidity were examined by means of logistic regression analysis controlling for age and gender.

RESULTS

Of 2,338 patients, 447 (19%) had a primary or secondary SUD diagnosis. In comparison to patients with other mental disorders, patients with SUD had a higher prevalence of infectious and digestive diseases but a lower prevalence of endocrine, nutritional and metabolic disorders. Patterns of physical comorbidities differed according to type of substance used (alcohol use - cardiovascular; tobacco use - respiratory, neoplasms; cannabinoid use - injuries; opioid use - infectious, digestive; benzodiazepine use - endocrine, nutritional, metabolic; stimulants - urogenital).

CONCLUSIONS

SUD are related to specific somatic health risks while some of our findings point to potentially protective effects. The widespread prescription of benzodiazepines requires research on physical health effects. Early detection of SUD and their integration into programmes targeting physical comorbidity should be a priority in organizing mental health care.

Skin popping scars – a telltale sign of past and present subcutaneous drug abuse

Background: Identifying women with past and present drug abuse is an essential aspect of prenatal care.

Case: Despite having typical telltale physical signs of prior subcutaneous drug injections, a 33-year-old pregnant woman who had regular prenatal care visits with multiple obstetric care providers was only identified as a drug abuser after a cesarean section, when her skin scars were identified by one provider as the result of “skin popping” related to injections of illicit drugs before this pregnancy.

Conclusion: This case demonstrates that obstetricians must become aware of the telltale signs of drug abuse, such as subcutaneous injections (skin popping) with illicit drugs leading to scaring of the arms and other parts of the body.

Community-associated methicillin-resistant Staphylococcus aureus is prevalent in wounds of community-based injection drug users

Injection drug users (IDUs) have an elevated risk for carriage of Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA). Cutaneous injection-related infections are common in IDUs but detailed studies are few. Based on a subsample of 218 individuals from a community-recruited cohort of IDUs at a supervised injection facility, we investigated the microbiology and related antibiotic susceptibility profiles of isolates from 59 wounds. Twenty-seven percent of subjects had at least one wound and 25 (43%) were culture positive for S. aureus alone [14 MRSA and 11 (19%) methicillin-susceptible (MSSA) isolates]. Sixteen of 18 MRSA isolates were classified as community associated (CA) by the presence of genes encoding for PVL. MRSA and MSSA occurred in mixed infection with other organisms on three and six occasions, respectively. All CA-MRSA isolates were susceptible to tetracycline, vancomycin and linezolid but only 13% were susceptible to clindamycin compared to 63% of MSSA isolates. The frequency of CA-MRSA is a cause for concern in wound infection in the IDU setting.

Evaluation of morphological changes of the liver caused by heroin abuse in forensic practice

Background/Aim. A study of morphological lesions in the liver of heroin addicts enables a precise overview of the type and degree of the liver damages caused by intravenous (iv) heroin abuse, additive effects of viral infections and alcohol consumption, as well as whether the expressiveness of these lesions depends on the duration of the time period of heroin application. The aim of the study was to investigate histopathological, ultrastructural and morphometric features of the liver of heroin addicts in forensic samples of the liver. Methods. The study involved the autopsy conducted on 40 bodies of iv heroin addicts and 10 control autopsies. The investigated group consisted of liver samples of 36 male subjects and 4 female subjects aged 35-40 years and the control group of 8 male and 2 female cadaveric bodies aged 15-35 years. The liver tissue samples were prepared for light microscopy. Sections of the tissue paraffin blocks 5 ? thick were stained using classical Hematoxylin and Eosin method (H&E), as well as PAS Van Gieson, Gomori, and Congo Red techniques. For investigation purposes of ultrastructural changes, liver tissue was fixed in glutaraldehyde and molded with epon. The analysis was performed using the method of transmission electron microscopy. Morphometric investigation of the liver sinusoidal macrophages was performed by using the M42 test system. Results. In the investigated group of iv heroin addicts, the liver autopsy samples showed degenerative vesicular and fat changes, chronic hepatitis, cirrhosis, sedimentation of pathologic protein amyloidosis, dysplastic changes, reduction in the amount of glycogen in hepatocytes, as well as the change in the number of Kupfer and endothelial cells. The established changes correlated with the duration of iv heroin abuse, whereas sinusoidal macrophages were activated in cases with active hepatitis, and no significant change in their number was found in hepatocytes with alcohol-related fatty changes. Conclusion. The study showed that the most present change in the hepatocytes of drug addicts was vesicular degeneration, and it is the only direct consequence of the effect of heroin. Other morphological changes were present due to viral infections and they correlated with the duration of narcotic abuse. The finding of dysplastic changes in this susceptible population of young people is particularly significant. The forensic significance of the established changes in the liver tissue is in the possibility of their practical application for determination of the immediate cause of death of iv heroin addicts, as well as the differential diagnosis of not only heroin, but also alcohol, sedative and other substances abuse, and all that on the basis of morphological damages of the liver.

HIV seropositivity predicts longer duration of stay and rehospitalization among nonbacteremic febrile injection drug users with skin and soft tissue infections

BACKGROUND

Skin/soft tissue infections (SSTIs) are the leading cause of hospital admissions among injection drug users (IDUs).

METHODS

We performed a retrospective investigation to determine the epidemiology of SSTIs (ie, cellulitis and/or abscesses) in febrile IDUs, with a focus on bacteriology and potential predictors of increased health care utilization measured by longer length of stay and rehospitalization. Subjects were drawn from a cohort of febrile IDUs presenting to an inner-city emergency department from 1998 to 2004.

RESULTS

Of the 295 febrile IDUs with SSTIs, specific discharge diagnoses were cellulitis only (n = 143, 48.5%), abscesses only (n = 113, 38.3%), and both (n = 39, 13.2%). Documented HIV infection rate was 28%. Of note, 10 subjects were newly diagnosed with HIV infection during their visits. Staphylococcus aureus was the leading pathogen, and increasing rates of methicillin-resistant S. aureus emerged over time (before 2001: 4%, 2001-2004: 56%, P < 0.01). HIV seropositivity predicted rehospitalization within 90 days [adjusted hazard ratios and 95% confidence intervals: 2.90 (1.20 to 7.02)]. HIV seropositivity also predicted increased length of stay in those who were nonbacteremic [adjusted hazard ratios and 95% confidence intervals: 1.49 (1.11 to 2.01)].

CONCLUSIONS

Among febrile IDUs with SSTIs, a strong association between HIV seropositivity and health care resource utilization was found. Accordingly, attention to HIV serostatus should be considered in clinical disposition decisions for this vulnerable high-risk population.

Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: an evaluation

Background

The report presents evaluation results from an intervention using specially produced foil packs to promote a transition from heroin injecting to inhalation (chasing) with injecting drug users (IDUs) attending four needle and syringe programmes (NSPs) in south west England.

Methods

Service activity/uptake measures, brief structured interviews.

Results

Out of 320 attenders, 54% took the foil packs when they became available. Over the period of the evaluation, NSP transactions increased by 32.5% from 1,672 to 2,216. Additionally, 32 new clients (non-injecting heroin users) started attending the service to obtain the foil packs. This group would not otherwise have been in contact with the treatment service. More detailed data from one site are reported for 48 recent injectors who took foil within the NSP where the piloting first commenced. Prior to the introduction of the foil packs, 46% of this sub-group reported chasing heroin in the previous four weeks. At follow up, 85% reported using the foil to chase heroin on occasions when they would otherwise have injected. Among the people who took it, client satisfaction with the quality and size of the foil packs was good and respondents viewed its availability as a valuable extension to the NSP's services.

Conclusion

These findings suggest that distributing foil packs can be a useful means of engaging NSP attenders in discussions about ways of reducing injecting risks and can reduce injecting in settings where there is a pre-existing culture of heroin chasing. Further research should see whether these findings can be reproduced in other cultural contexts and evaluate whether the observed behavioural changes are sustained and lead to reductions in harm including blood-borne infections and overdose.

Somatic health among heroin addicts before and during opioid maintenance treatment: a retrospective cohort study

Background

The long-term impact of opioid maintenance treatment (OMT) on morbidity and health care utilization among heroin addicts has been insufficiently studied. The objective of this study was to investigate whether health care utilization due to somatic disease decreased during OMT, and if so, whether the reduction included all kinds of diseases and whether a reduction was related to abstinence from drug use.

Methods

Cohort study with retrospective registration of somatic disease incidents (health problems, acute or sub-acute, or acute problems related to chronic disease, resulting in a health care contact). Medical record data were collected from hospitals, Outpatients' Departments, emergency wards and from general practitioners (GPs) and prospective data on substance use during OMT were available from 2001 onwards. The observation period was five years before and up to five years during OMT. The cohort consisted of 35 out of 40 patients who received OMT between April 1999 and January 2005 in a Norwegian district town. Statistical significance concerning changes in number of incidents and inpatient and outpatient days during OMT compared with the pre OMT period was calculated according to Wilcoxon signed rank test. Significance concerning pre/during OMT changes in disease incidents by relation to the type of health service contacts, as well as the impact of ongoing substance use during OMT on the volume of contacts, was calculated according to Pearson chi-square and Fisher's exact tests.

Results

278 disease incidents were registered. There was a reduction in all incidents by 35% (p = 0.004), in substance-related incidents by 62% (p < 0.001) and in injection-related incidents by 70% (p < 0.001). There was an insignificant reduction in non-fatal overdose incidents by 44% (p = 0.127) and an insignificant increase in non-substance-related incidents by 13% (p = 0.741). Inpatient and outpatient days were reduced by 76% (p = 0.003) and 46% (p = 0.060), respectively. The disease incidents were less often drug-related during OMT (p < 0.001). Patients experienced a reduction in substance-related disease incidents regardless of ongoing substance use, however there was a trend towards greater reductions in those without ongoing abuse.

Conclusion

Although as few as 35 patients were included, this study demonstrates a significant reduction in health care utilization due to somatic disease incidents during OMT. The reduction was most pronounced for incidents related to substance use and injection. Inpatient and outpatient days were reduced. Most probably these findings reflect somatic health improvement among heroin addicts during OMT.

Prevalence and correlates of abscesses among a cohort of injection drug users

Recent studies have indicated that injection-related infections such as abscesses and cellulitis account for the majority of emergency room visits and acute hospitalizations accrued by local injection drug users. The objective of this analysis was to examine the prevalence and correlates of developing an abscess among a cohort of injection drug users in Vancouver and to identify socio-demographic and drug use variables associated with abscesses at baseline. We examined abscesses among participants enrolled in a prospective cohort of injection drug users. Categorical variables were analyzed using the Pearson's chi-square test and continuous variables were analyzed using the Wilcoxon signed rank test. Among 1 585 baseline participants, 341 (21.5%) reported having an abscess in the last six months. In a logistic regression model that adjusted for all variables that were associated with having an abscess at p < 0.1 in univariate analyses, female gender [odds ratio (OR) = 1.7, [95%CI: 1.2 – 2.4]; p = 0.002), recent incarceration (OR = 1.7, [95%CI: 1.3 – 2.2]; p < 0.001), sex trade involvement (OR = 1.4 [95% CI: 1.0 – 2.0]; p = 0.03), frequent cocaine use (OR = 1.5 [95%CI: 1.2 – 2.0]; p = 0.002) and HIV serostatus (OR = 1.5, [95%CI: 1.2 – 2.0]; p = 0.003) were positively associated with having an abscess. Explanations for these associations require further study, and interventions are needed to address this highly prevalent concern.