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Stewardson AJ, Davis JS, Dunlop AJ, Tong SYC, Matthews GV. How I manage severe bacterial infections in people who inject drugs. Clin Microbiol Infect 2024; 30:877-882. [PMID: 38316359 DOI: 10.1016/j.cmi.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/21/2024] [Accepted: 01/30/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities. OBJECTIVES To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection. SOURCES The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors. CONTENT We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach. IMPLICATIONS We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.
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Affiliation(s)
- Andrew J Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Joshua S Davis
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Adrian J Dunlop
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Gail V Matthews
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; St Vincent's Hospital, Sydney, NSW, Australia
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Lim J, El-Sheikh M, Buckeridge DL, Panagiotoglou D. Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach. Harm Reduct J 2024; 21:126. [PMID: 38943164 PMCID: PMC11212409 DOI: 10.1186/s12954-024-01037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID. METHODS We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks. RESULTS The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI. CONCLUSIONS Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Mariam El-Sheikh
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada.
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Jones JD, Chaple M, Rozen S, DelaCuesta C, Sosa ES, Bryant K. Empirical assessment of wounds among people who use substances. Drug Alcohol Depend 2024; 262:111375. [PMID: 38971028 DOI: 10.1016/j.drugalcdep.2024.111375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Wounds are a significant source of morbidity among people who use substances (PWUS). This project sought to identify the incidence and severity of wounds among PWUS in the South Bronx, a region of New York City with one of the highest morbidities of substance use disorder. METHODS This study recruited PWUS within the past 30 days. Research staff were trained to document the presence and severity of wounds. The primary outcome measure was the incidence of wounds. Acceptability of on-the-street wound care was assessed by the number of participants encountered. The association between participant characteristics and wounds was also evaluated. RESULTS In total, 586 PWUS were assessed (19.4 % female: 69 % Hispanic; 23 % Black; 5 % White). Heroin (65.7 %) and psychostimulants (58.3 %) were the most commonly used drugs. Approximately 23 % of outreach recipients disclosed a wound. Among those with a wound, 60.9 % reported one wound, 27.8 % had two wounds, and 11.3 % had three or more wounds. Small wounds (approximately the size of a cherry) were the most common (78.6 %). Recent use of stimulants or heroin, along with intravenous use of any substance were significantly associated with having a wound. CONCLUSIONS This study found that drug-related wounds were common among PWUS. Toxicology data from other sources indicate that xylazine was present in the NYC market at the time, though its prevalence among the current sample is difficult to determine. The occurrence and severity of substance-related wounds in NYC should continue to be monitored as a function of changes in the xylazine adulteration.
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Affiliation(s)
- Jermaine D Jones
- Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032, United States; New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States.
| | - Michael Chaple
- Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032, United States; New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States
| | - Stephanie Rozen
- Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032, United States
| | - Courtney DelaCuesta
- Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032, United States; New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States
| | - Emely Santiago Sosa
- Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032, United States; New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States
| | - Kellie Bryant
- Columbia University School of Nursing, 560 W 168th St, New York, NY 10032, United States
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Calderón-Villarreal A, Abramovitz D, Avelar Portillo LJ, Goldenberg S, Flanigan S, Quintana PJE, Harvey-Vera A, Vera CF, Rangel G, Strathdee SA, Kayser GL. Water, sanitation and hygiene insecurity predict abscess incidence among people who inject drugs in a binational US-Mexico metropolitan area: A longitudinal cohort study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 129:104485. [PMID: 38901113 DOI: 10.1016/j.drugpo.2024.104485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 06/01/2024] [Accepted: 06/03/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION People who inject drugs (PWID) are at high risk of developing injection-related infections, including abscesses. Access to water, sanitation, and hygiene (WASH) are key human rights and services; yet these services have been underexplored as predictors of abscesses among PWID. METHODS Longitudinal analysis was employed among a cohort of PWID to determine if WASH insecurity (lack of access) was associated with abscess incidence in the Tijuana, Mexico and San Diego, United States metropolitan area during 24-months of follow-up survey data from 2020 to 2023. We calculated abscess prevalence at baseline and tracked the incidence of new abscesses among individuals without an abscess during the previous visit. Time dependent Cox regression modeling was employed with variance clustered by participant to characterize the relationship between WASH insecurity and abscess incidence. RESULTS At baseline, hand hygiene insecurity, bathing insecurity in the previous six months and open defecation in the last week, were reported by 60 %, 54 % and 38 % of participants, respectively; 21 % reported an abscess in the last six months. The incidence of abscesses was 24.4 (95 %CI: 21.1-27.6) per 100 person-years. After adjusting for covariates, the hazard of developing an abscess remained significantly elevated among individuals using non-improved (with risk of contamination) water sources (e.g., surface water) for preparing drugs (adjusted HR [adjHR]: 1.49 [95 %CI: 1.01-2.21], experiencing bathing insecurity (adjHR: 1.59 [95 %CI: 1.12-2.24]) and open defecation (adjHR: 1.65 [95 %CI: 1.16-2.35]). CONCLUSIONS PWID in the Tijuana-San Diego metropolitan area reported facing high rates of insecurity accessing WASH services. Abscess incidence was higher (four to nine times) than observed rate among PWID cohorts in other settings. Access to continuously available toilet facilities, bathing infrastructure, and safe water sources for preparing drugs for injection could prevent abscesses among PWID. Accessible WASH infrastructure should be ensured among PWID communities and promoted as a key component of harm reduction infrastructure.
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Affiliation(s)
- Alhelí Calderón-Villarreal
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego (UCSD), San Diego, CA, USA; School of Public Health, San Diego State University (SDSU), San Diego, CA, USA.
| | - Daniela Abramovitz
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA
| | - Lourdes Johanna Avelar Portillo
- Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, CA, USA
| | - Shira Goldenberg
- School of Public Health, San Diego State University (SDSU), San Diego, CA, USA
| | | | | | - Alicia Harvey-Vera
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA; Universidad Xochicalco, Tijuana, Baja California, Mexico
| | - Carlos F Vera
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA
| | - Gudelia Rangel
- El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico; Border Health Commission, Tijuana, Baja California, Mexico
| | - Steffanie A Strathdee
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA
| | - Georgia L Kayser
- Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, CA, USA
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Calderón-Villarreal A, Avelar Portillo LJ, Abramovitz D, Goldenberg S, Flanigan S, Quintana PJE, Harvey-Vera A, Vera CF, Rangel G, Strathdee SA, Kayser GL. Water, sanitation, and hygiene access among people who inject drugs in Tijuana and San Diego in 2020-2021: a cross-sectional study. Int J Equity Health 2024; 23:79. [PMID: 38644494 PMCID: PMC11034064 DOI: 10.1186/s12939-024-02163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 03/27/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Water, sanitation, and hygiene (WASH) access is critical to public health and human dignity. People who inject drugs (PWID) experience stigma and structural violence that may limit WASH access. Few studies have assessed WASH access, insecurity, and inequities among PWID. We describe WASH access, social and geographic inequalities, and factors associated with WASH insecurity among PWID in the Tijuana-San Diego metropolitan area. METHODS In this cross-sectional binational study, we interviewed PWID (age 18+) in 2020-2021 about WASH access and insecurity. City of residence (Tijuana/San Diego) and housing status were considered as independent variables to describe key WASH access outcomes and to assess as factors associated with WASH insecurity outcomes. Measures of association between outcomes and independent variables were assessed using log modified-Poisson regression models adjusting for covariates. RESULTS Of 586 PWID (202 Tijuana; 384 San Diego), 89% reported basic access to drinking water, 38% had basic hand hygiene, 28% basic sanitation, and 46% access to bathing, and 38% reported recent open defecation. Participants residing in Tijuana reported significantly higher insecurity in accessing basic drinking water (aRR: 1.68, 95%CI: 1.02-2.76), basic hygiene (aRR: 1.45, 95%CI: 1.28-1.64), and bathing (aRR: 1.21, 95%CI: 1.06-1.39) than those living in San Diego. Participants experiencing unsheltered homelessness experienced significantly higher insecurity in accessing basic drinking water (aRR: 2.03, 95%CI: 1.07-3.86), basic sanitation (aRR: 1.68, 95%CI: 1.48, 1.92), bathing (aRR: 1.84, 95%CI: 1.52-2.22), and improved water sources for cleaning wounds (aRR: 3.12, 95%CI: 1.55-6.29) and for preparing drugs (aRR: 2.58, 95%CI: 1.36-4.89) than participants living in permanent housing. CONCLUSION WASH access among PWID in the Tijuana-San Diego metropolitan area was low by international standards and lower than the national averages in both countries. Homelessness was significantly associated with WASH insecurity in this population. Concentrated efforts are needed to guarantee continuously available WASH services for PWID-especially those who are unsheltered.
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Affiliation(s)
- Alhelí Calderón-Villarreal
- Department of Family and Preventive Medicine, University of California San Diego (UCSD), San Diego, California, USA.
- School of Public Health, San Diego State University (SDSU), San Diego, California, USA.
| | - Lourdes Johanna Avelar Portillo
- Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, California, USA
- Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, California, USA
| | - Daniela Abramovitz
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, USA
| | - Shira Goldenberg
- School of Public Health, San Diego State University (SDSU), San Diego, California, USA
| | - Shawn Flanigan
- School of Public Affairs, SDSU, San Diego, California, USA
| | - Penelope J E Quintana
- School of Public Health, San Diego State University (SDSU), San Diego, California, USA
| | - Alicia Harvey-Vera
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, USA
- Universidad de Xochicalco, Tijuana, Baja California, Mexico
| | - Carlos F Vera
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, USA
| | - Gudelia Rangel
- El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico
- Border Health Commission, Tijuana, Baja California, Mexico
| | - Steffanie A Strathdee
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, USA
| | - Georgia L Kayser
- Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, California, USA
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Alexander-Savino CV, Mirowski GW, Culton DA. Mucocutaneous Manifestations of Recreational Drug Use. Am J Clin Dermatol 2024; 25:281-297. [PMID: 38217568 DOI: 10.1007/s40257-023-00835-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Abstract
Recreational drug use is increasingly common in the dermatology patient population and is often associated with both general and specific mucocutaneous manifestations. Signs of substance use disorder may include changes to general appearance, skin, and mucosal findings associated with particular routes of drug administration (injection, insufflation, or inhalation) or findings specific to a particular drug. In this review article, we provide an overview of the mucocutaneous manifestations of illicit drug use including cocaine, methamphetamine, heroin, hallucinogens, marijuana, and common adulterants to facilitate the identification and improved care of these patients with the goal being to connect this patient population with appropriate resources for treatment.
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Affiliation(s)
- Carolina V Alexander-Savino
- State University of New York Upstate Medical University, Syracuse, NY, USA
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA
| | - Ginat W Mirowski
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Oral Pathology, Medicine, Radiology, Indiana University School of Dentistry, Indianapolis, IN, USA
| | - Donna A Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA.
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Smith KR, Shah NK, Adamczyk AL, Weinstein LC, Kelly EL. Harm reduction in undergraduate and graduate medical education: a systematic scoping review. BMC MEDICAL EDUCATION 2023; 23:986. [PMID: 38129846 PMCID: PMC10734177 DOI: 10.1186/s12909-023-04931-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration. METHODS PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation. RESULTS Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles. CONCLUSIONS Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.
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Affiliation(s)
- Kelsey R Smith
- University of California San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
- Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Curtis Building, Philadelphia, PA, 19107, USA.
| | - Nina K Shah
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, #100, Philadelphia, PA, 19107, USA
| | - Abby L Adamczyk
- Scott Memorial Library, Thomas Jefferson University, 1020 Walnut St, Philadelphia, PA, 19107, USA
| | - Lara C Weinstein
- Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Curtis Building, Philadelphia, PA, 19107, USA
| | - Erin L Kelly
- Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Curtis Building, Philadelphia, PA, 19107, USA
- Center for Social Medicine and Humanities, University of California Los Angeles, B7-435, Semel Institute, Los Angeles, CA, 90095-1759, USA
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Goto T, Wang C, Kwiat C, Nguyen C, Saligan LN. Community-Based Wound Care Programs for Unhoused Individuals. J Epidemiol Glob Health 2023; 13:604-614. [PMID: 37847465 PMCID: PMC10686911 DOI: 10.1007/s44197-023-00157-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/21/2023] [Indexed: 10/18/2023] Open
Abstract
Wound care management for unhoused individuals is challenging due to the lack of healthcare infrastructure to handle the unique needs of this population. Therefore, we aimed to obtain insights for best practices and to establish a care clinic that is low threshold, community-based and meets the needs of unhoused people. We employed two approaches: (1) conduct a targeted narrative review of the literature of existing or proposed community-based program models that can address the wound care needs of unhoused individuals, and (2) assess cost-effectiveness and describe the results of a survey administered to unhoused clients and their health care providers at a community-based wound care program in Honolulu, Hawai'i. The literature search and screening yielded 11 articles relevant to the topic. Per the literature, existing community-based healthcare programs were successful when: (1) wound care services were incorporated into a broader social/health program, (2) cost-effective, and (3) comprehensive services were provided. Survey results in Honolulu found that the wound care program matched the needs of the targeted population and was cost-effective. Difficulty in following clients until wound closure and the sustainability of the program, particularly the lack of insurance reimbursement for street-based services, were perceived challenges. Additionally, the lack of insurance reimbursement for street-based wound care services continues to impact sustainability. Community-based programs can be successful in addressing the wound care needs of unhoused individuals if they address complex fundamental issues. This paper highlights existing gaps in logistics and policies that must be addressed to meet the specific medical needs of these vulnerable individuals.
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Affiliation(s)
- Taichi Goto
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Christina Wang
- Hawaii Health & Harm Reduction Center, Honolulu, HI, USA
| | - Catherine Kwiat
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Christopher Nguyen
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Leorey N Saligan
- National Institute of Nursing Research, National Institutes of Health, 3 Center Drive, Building 3, Room 5E14, Bethesda, MD, 20892, USA.
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Curtis SJ, Colledge-Frisby S, Stewardson AJ, Doyle JS, Higgs P, Maher L, Hickman M, Stoové MA, Dietze PM. Prevalence and incidence of emergency department presentations and hospital separations with injecting-related infections in a longitudinal cohort of people who inject drugs. Epidemiol Infect 2023; 151:e192. [PMID: 37953739 PMCID: PMC10728979 DOI: 10.1017/s0950268823001784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/05/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
People who inject drugs are at risk of acute bacterial and fungal injecting-related infections. There is evidence that incidence of hospitalizations for injecting-related infections are increasing in several countries, but little is known at an individual level. We aimed to examine injecting-related infections in a linked longitudinal cohort of people who inject drugs in Melbourne, Australia. A retrospective descriptive analysis was conducted to estimate the prevalence and incidence of injecting-related infections using administrative emergency department and hospital separation datasets linked to the SuperMIX cohort, from 2008 to 2018. Over the study period, 33% (95%CI: 31-36%) of participants presented to emergency department with any injecting-related infections and 27% (95%CI: 25-30%) were admitted to hospital. Of 1,044 emergency department presentations and 740 hospital separations, skin and soft tissue infections were most common, 88% and 76%, respectively. From 2008 to 2018, there was a substantial increase in emergency department presentations and hospital separations with any injecting-related infections, 48 to 135 per 1,000 person-years, and 18 to 102 per 1,000 person-years, respectively. The results emphasize that injecting-related infections are increasing, and that new models of care are needed to help prevent and facilitate early detection of superficial infection to avoid potentially life-threatening severe infections.
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Affiliation(s)
- Stephanie J. Curtis
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Samantha Colledge-Frisby
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Lisa Maher
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Kirby Institute, Faculty of Medicine, UNSW, Wallace Wurth Building, Kensington, NSW, Australia
| | - Matthew Hickman
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mark A. Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Kirby Institute, Faculty of Medicine, UNSW, Wallace Wurth Building, Kensington, NSW, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul M. Dietze
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Harvey LH, Green TC, Park JN, Rich JD. Xylazine in the drug supply: A research agenda. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104190. [PMID: 37708584 PMCID: PMC10664799 DOI: 10.1016/j.drugpo.2023.104190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Leah H Harvey
- Alpert Medical School at Brown University, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906, United States
| | - Traci C Green
- Alpert Medical School at Brown University, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906, United States
| | - Ju Nyeong Park
- Alpert Medical School at Brown University, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906, United States
| | - Josiah D Rich
- Alpert Medical School at Brown University, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906, United States.
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Quijano T, Crowell J, Eggert K, Clark K, Alexander M, Grau L, Heimer R. Xylazine in the drug supply: Emerging threats and lessons learned in areas with high levels of adulteration. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104154. [PMID: 37574646 DOI: 10.1016/j.drugpo.2023.104154] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/22/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Xylazine, a sedative analgesic drug approved as an animal tranquilizer but not for human use, has become an adulterant in the illicit opioid marketplace in North America. Recently declared an emerging health threat in the U.S., the prevalence of xylazine in overdose deaths increased 5.5-fold between 2019 and 2021. More information is needed about the impact of xylazine on opioid users and harm reduction service providers. METHODS The impact of xylazine adulteration was triangulated through examination of (1) opioid overdose fatalities in Connecticut between 2017 and 2021 reported by the Office of the Chief Medical Examiner data, (2) a convenience survey of people in Connecticut who use drugs (PWUD) regarding their knowledge of and attitude about the local illicit drug supply, and (3) semi-structured interviews of harm reduction service providers in Connecticut and Philadelphia in response to prompts on the impacts of and responses to xylazine adulteration. RESULTS The presence of fentanyl or its analogues in fatal opioid overdoses was a statistically significant predictor of xylazine presence [OR = 25.0, 95%CI (10.7,81.1)] as was being Hispanic [OR = 1.36, 95%CI (1.03,1.77)]. A survey of people who used drugs revealed that 43% (n = 286) were concerned that the drug supply was always unpredictable. Three-quarters of respondents were aware of xylazine and two-thirds would use a xylazine test strip if one was available. Respondents who identified as White, Hispanic were most likely to be aware of xylazine, to have used a fentanyl test strip, and to be interested in a xylazine test strip. Respondents who injected drugs were 3.6-fold more likely than those who did not inject to endorse an interest in a xylazine test strip. Harm reduction service providers were cognizant of a range of problems surrounding the use and injection of xylazine. Although they reported implementing practices to better respond to xylazine harms, they recognized the absence of solutions to many of the problems encountered. CONCLUSION The prevalence of xylazine has expanded, especially in combination with fentanyl. Harm reduction education efforts with fidelity to best practices have emerged, but the harms persist and community prevention needs are largely unmet.
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Affiliation(s)
- Thomas Quijano
- Yale School of Public Health, New Haven, CT, United States.
| | - Jason Crowell
- Sex Workers and Allies Network, New Haven, CT, United States
| | - Kathryn Eggert
- APT Foundation, New Haven, CT, United States; Antioch University Graduate School of Leadership and Change, Yellow Springs, OH, United States
| | - Katie Clark
- Clark Health Education and Research Solutions, Branford, CT, United States
| | - Marcus Alexander
- Yale Institute for Network Science, New Haven, CT, United States
| | - Lauretta Grau
- Yale School of Public Health, New Haven, CT, United States
| | - Robert Heimer
- Yale School of Public Health, New Haven, CT, United States
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Zagorski CM, Hosey RA, Moraff C, Ferguson A, Figgatt M, Aronowitz S, Stahl NE, Hill LG, McElligott Z, Dasgupta N. Reducing the harms of xylazine: clinical approaches, research deficits, and public health context. Harm Reduct J 2023; 20:141. [PMID: 37777769 PMCID: PMC10544173 DOI: 10.1186/s12954-023-00879-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023] Open
Abstract
OBJECTIVES Xylazine has emerged as a consistent part of the unregulated drug supply in recent months. We discuss major domains of xylazine's harm, current knowledge deficits, clinical and harm reduction strategies for minimizing harm, and xylazine's public health and policy context. As an interdisciplinary team from across the USA, we have pooled our knowledge to provide an overview of xylazine's current and emerging contexts. METHODS To inform this essay, the pertinent literature was reviewed, clinical knowledge and protocols were shared by multiple clinicians with direct expertise, and policy and public health context were added by expert authors. RESULTS We describe xylazine's major harm domains-acute poisoning, extended sedation, and wounds, along with anemia and hyperglycemia, which have been reported anecdotally but lack as clear of a connection to xylazine. Current successful practices for xylazine wound care are detailed. Understanding xylazine's epidemiology will also require greater investment in drug checking and surveillance. Finally, approaches to community-based wound care are discussed, along with an orientation to the larger policy and public health context. CONCLUSIONS Addressing the harms of xylazine requires interdisciplinary participation, investment in community-based harm reduction strategies, and improved drug supply surveillance. The relatively unique context of xylazine demands buy-in from public health professionals, harm reduction professionals, clinicians, basic science researchers, policymakers and more.
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Affiliation(s)
- Claire M Zagorski
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 3.208J, Austin, TX, 78712, USA.
| | - Rebecca A Hosey
- HIV Prevention Research Division, Department of Psychiatry, School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4000, Philadelphia, PA, 19104, USA
| | | | - Aaron Ferguson
- National Survivors Union, 1116 Grove St, Greensboro, NC, 27403, USA
| | - Mary Figgatt
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Shoshana Aronowitz
- University of Pennsylvania School of Nursing, Fagin Hall, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Natalie E Stahl
- Greater Lawrence Family Health Center, 34 Haverhill Street, Lawrence, MA, 01841, USA
| | - Lucas G Hill
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 3.208J, Austin, TX, 78712, USA
| | - Zoe McElligott
- Department of Pharmacology, Bowles Center for Alcohol Studies, University of North Carolina, CB#7178, 104 Manning Road, Chapel Hill, NC, 2759, USA
| | - Nabarun Dasgupta
- University of North Carolina, 725 MLK Jr. Blvd., CB 7505, Chapel Hill, NC, 27599, USA
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Rehman S, Arif S, Ushakumari LG, Amreen J, Nagelli A, Moonnumackel SJ, Nair A. Assessment of Bacterial Infections and Antibiotic Regimens in Intravenous Drug Users. Cureus 2023; 15:e45716. [PMID: 37868523 PMCID: PMC10590200 DOI: 10.7759/cureus.45716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Bacterial infections in people who inject drugs (PWID) are a significant cause of hospitalizations and increased morbidity in this group. In this review, we evaluated bacterial trends in the most common infections and appropriate empiric antibiotic coverage. Articles from PubMed and Google Scholar were curated in a Google document with shared access. Discussion and development of the paper were achieved over Zoom meetings. The common infections in PWID were skin and soft tissue infections (SSTIs), infective endocarditis, septic arthritis, osteomyelitis, and bloodstream infections (BSIs). The presence of comorbidities increased susceptibility to bacterial infections. Staphylococcus aureus was the predominant species in all the infections and included methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA). The current standard of antibiotic use for Staphylococcus species was found to be sufficient. The gram-negative bacillus Serratia marcescens was prevalent in PWID as a causative agent of septic arthritis, osteomyelitis, and infective endocarditis. Its treatment required a combination of β-lactam and either a fluoroquinolone or an aminoglycoside for a prolonged duration. Streptococci were commonly implicated in SSTIs and BSIs. The appropriate response was seen with β-lactam antibiotics. In PWID, Enterococcus and Pseudomonas were implicated in infective endocarditis of native and prosthetic valves. The former being difficult to treat, a new strategy of using dual β-lactam antibiotics was found to be supported by clinical data. Anti-pseudomonal antibiotics can be avoided in other infections seen in this group, as their prevalence was low. PWID, especially those with comorbidities, have an increased risk of acquiring infections with difficult-to-treat microbes. Therefore, empiric antibiotic treatment should be relevant to the infection, for which bacterial trends and antibiotic susceptibility must be reassessed periodically.
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Affiliation(s)
- Sana Rehman
- Medicine, Fatima Memorial Hospital (FMH) College of Medicine and Dentistry, Lahore, PAK
| | - Sehrish Arif
- Medicine, Fatima Memorial Hospital (FMH) College of Medicine and Dentistry, Lahore, PAK
| | - Lekshmi G Ushakumari
- Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davanagere, IND
| | - Jasiya Amreen
- Medicine, Dr. Vizarath Rasool Khan (VRK) Women's Medical College, Hyderabad, IND
| | | | | | - Arun Nair
- Pediatrics, Saint Peter's University Hospital, Somerset, USA
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Benrubi LM, Silcox J, Hughto J, Stopka TJ, Palacios WR, Shrestha S, Case P, Green TC. Trends and correlates of abscess history among people who inject drugs in Massachusetts: A mixed methods exploration of experiences amidst a rapidly evolving drug supply. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 8:100176. [PMID: 37753348 PMCID: PMC10518505 DOI: 10.1016/j.dadr.2023.100176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 09/28/2023]
Abstract
Background Injection drug use poses significant risk for skin and soft tissue infections, such as abscesses. In places with endemic fentanyl and an increasingly contaminated drug supply, injecting and injection-related harms may be increasing, yet are understudied. We aimed to explore abscess prevalence, experiences, and themes among people who inject drugs (PWID) in the context of an evolving drug supply. Methods Between 2019 and 2022, we surveyed and interviewed Massachusetts- based PWID about current drug use behaviors and abscess experiences. Chi-square tests explored correlates of abscess history and trends for past-year abscess percentages over time. Transcribed interview data were analyzed to identify themes related to abscess risk and opportunities for intervention. Results Of the 297 PWID surveyed, 65.3% reported having an abscess at the injection site in their lifetime; 67.5% of these instances occurred within the last year. Reported past-year abscesses increased from 36.7% to 75.6% between 2019 and 2022. Correlates of past-year abscesses included frequent injection; methamphetamine, crack, or fentanyl use; and injection into the neck or calf. Methadone treatment was associated with significantly fewer recent abscesses. Interview data (n=151) confirmed the identified abscess risks, including syringe sharing and lack of hygienic supplies. Qualitative interviews provided additional data regarding healthcare provider stigma contributing to healthcare avoidance and the self-treatment of abscesses with adverse results. Conclusions Abscesses are an increasing concern among PWID residing in areas of high fentanyl prevalence and a contaminated drug supply. Community drug checking, overdose prevention sites, injection hygiene interventions, and improved access to care are indicated.
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Affiliation(s)
- Leah M. Benrubi
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Joseph Silcox
- Brandeis University Opioid Policy Research Collaborative, 415 South Street, Waltham, MA 02453, USA
- University of Massachusetts - Boston, 100 Morrissey Boulevard, Boston, MA 02125, USA
| | - Jaclyn Hughto
- Brown University School of Public Health, 121 South Main Street, Providence, RI 02912, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Wilson R. Palacios
- University of Massachusetts, School of Criminology & Justice Studies, 113 Wilder Street, Lowell, MA 01854, USA
| | - Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Patricia Case
- Bouve College of Health Sciences, Northeastern University, 360 Huntington Avenue, Boston, MA 02115, USA
| | - Traci C. Green
- Brandeis University Opioid Policy Research Collaborative, 415 South Street, Waltham, MA 02453, USA
- COBRE on Opioids and Overdose at Rhode Island Hospital, 1125 North Main St., Providence, RI 02902, USA
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Bennett TE, Rizzo J, Yang S, Rosfjord E. Assessing Reuse of Hypodermic Needles in Mice by means of Digital Imaging, Photomicrography, Bacterial Culture, Analysis of Nest Building, and Animal Vocalization. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2023; 62:205-211. [PMID: 36990673 PMCID: PMC10230537 DOI: 10.30802/aalas-jaalas-22-000094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/02/2022] [Accepted: 01/23/2023] [Indexed: 03/31/2023]
Abstract
Hypodermic needles are sometimes reused in animal research settings to preserve the viability of and to conserve limited quantities of injected material. However, the reuse of needles is strongly discouraged in human medicine to prevent inju- ries and the spread of infectious disease. No official guidelines prohibit needle reuse in veterinary medicine, although the practice may be discouraged. We hypothesized that reused needles would be significantly more blunt than unused needles and that reuse for additional injections would cause more animal stress. To test these ideas, we evaluated mice that were injected subcutaneously in the flank or mammary fat pad to generate cell line xenograft and mouse allograft models. Needles were reused up to 20 times, based on an IACUC-approved protocol. A subset of reused needles was digitally imaged to determine needle dullness based on the area of deformation from the secondary bevel angle; this parameter was not different between new needles and needles that had been reused 20 times. In addition, the number of times a needle was reused was not significantly related to audible mouse vocalization during injection. Finally, nest building scores for mice that were injected with a needle used 0 through 5 times were similar to those of mice injected with a needle had been used 16 through 20 times. Among the 37 reused needles that were tested, 4 were positive for bacterial growth; the only organisms cultured were Staphylococcus spp. Contrary to our hypothesis, reusing needles for subcutaneous injections did not increase animal stress based on analysis of vocalization or nest building.
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Affiliation(s)
- Terese E Bennett
- Previously affiliated with Comparative Medicine, Worldwide Research, Development and Medical, Pfizer, Pearl River, New York
| | - Jason Rizzo
- Pharmaceutical Sciences Small Molecule Analytical Research and Development, Pfizer, Groton, Connecticut; and
| | - Sharon Yang
- Previously affiliated with Oncology Research and Development, Pfizer, Pearl River, New York
| | - Edward Rosfjord
- Previously affiliated with Oncology Research and Development, Pfizer, Pearl River, New York
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Allaw F, Zakhour J, Kanj SS. Community-acquired skin and soft-tissue infections in people who inject drugs. Curr Opin Infect Dis 2023; 36:67-73. [PMID: 36718912 DOI: 10.1097/qco.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the latest evidence of the epidemiology, microbiology, risk factors, diagnosis and management of community-acquired skin and soft tissue infections (SSTIs) in people who inject drug (PWID). RECENT FINDINGS SSTIs are common complications in PWID and a major cause of morbidity and mortality. Infections can range from uncomplicated cellulitis, to abscesses, deep tissue necrosis and necrotizing fasciitis. They are predominantly caused by Gram-positive pathogens in particular Staphylococcus aureus and Streptococcus species; however, toxin-producing organisms such as Clostridium botulism or Clostridium tetani should be considered. The pathogenesis of SSTI in the setting of intravenous drug use (IDU) is different from non-IDU related SSTI, and management often requires surgical interventions in addition to adjunctive antibiotics. Harm reduction strategies and education about safe practices should be implemented to prevent morbidity and mortality as well as healthcare burden of SSTI in PWID. SUMMARY Prompt diagnosis and proper medical and surgical management of SSTI will improve outcomes in PWID.
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Affiliation(s)
- Fatima Allaw
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
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17
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Rich KM, Solomon DA. Medical Complications of Injection Drug Use - Part I. NEJM EVIDENCE 2023; 2:EVIDra2200292. [PMID: 38320040 DOI: 10.1056/evidra2200292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Medical Complications of Injection Drug Use - Part IDuring the past 2 decades, the risk of death and the prevalence of hospitalizations in the United States have increased substantially among people who inject drugs, in large part because of the opioid epidemic. This article reviews the complications observed in people who inject drugs as well as strategies to reduce harm.
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Affiliation(s)
| | - Daniel A Solomon
- Harvard Medical School, Boston
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston
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18
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Britton TR, Clague MR, Zagorski CM, Hill LG, Loera LJ. A wound care and immunization needs assessment for participants of a mobile syringe services program in Austin, TX. J Am Pharm Assoc (2003) 2023; 63:361-365.e1. [PMID: 36549930 DOI: 10.1016/j.japh.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/03/2022] [Accepted: 10/16/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND People who inject drugs (PWID) are subject to injection-related harm, including skin and soft tissue infections. Syringe services programs (SSPs) provide sterile syringes, disposal of used syringes, and other supportive services. Given their contact and credibility with PWID, SSPs could facilitate triage and treatment of wounds and access to immunizations for communicable diseases. OBJECTIVE This work aimed to assess wound care and immunization needs among participants accessing mobile SSP services in Austin, TX. METHODS A 21-item mixed-methods survey was created to assess frequency and severity of wounds, wound care approaches, and vaccination status. Participants were included if they reported injection drug use and experienced a related wound in the previous 6 months. Interview sections included screening, demographics, wound care, and immunization status. RESULTS A total of 21 participants completed the semistructured interview. A majority identified as male (n = 13, 61.9%), white (n = 12, 57.1%), and were unhoused (n = 12, 57.1%). The primary drug of injection was heroin alone (n = 14, 66.7%). Many avoided seeking wound care from health care providers (n = 16, 76.2%) owing to stigmatization (n = 13, 61.9%) and previous negative experiences (n = 7, 33.3%). Self-treatment of wounds included over-the-counter medications (n = 10, 47.6%), over-the-counter supplies (n = 10, 47.6%), and antibiotics (n = 9, 42.8%). In the past 5 years, few had received vaccination for hepatitis A and B (n = 3, 14.3%) or tetanus (n = 7, 33.3%), and many expressed interest in receiving vaccinations through the SSP. Interest for other expanded services included access to antibiotics, an on-site provider, wound care supplies, and education. CONCLUSIONS PWID may avoid professional health care for wound care or immunizations owing to perceived stigma. Expanding availability of wound care services and immunizations directly through mobile SSPs is desired by participants and could positively affect public health.
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Abstract
Although many of the tenets of harm reduction have been around for centuries and more traditional harm reduction services such as syringe services programs have been in existence for decades, there has been a recent increase in interest and acceptance of harm reduction as an essential component of a public health approach to substance use. This article provides an overview of harm reduction and its application to alcohol, tobacco, and drug use. It discusses the importance of integrating harm reduction principles and services with traditional psychiatric, medical, and addiction treatment programs.
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Affiliation(s)
- Avinash Ramprashad
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 701 W Pratt St, 2nd Floor Suite 289, Baltimore, MD 21201, USA
| | - Gregory Malik Burnett
- Center for Addiction Medicine, University of Maryland Midtown Campus, 827 Linden Avenue 4th Floor, Suite 405, Baltimore MD 21201 USA; Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 22 S. Greene Street S-1-D-04, Baltimore, MD 21201, USA.
| | - Christopher Welsh
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 22 S. Greene Street S-1-D-04, Baltimore, MD 21201, USA
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Colledge-Frisby S, Jones N, Larney S, Peacock A, Lewer D, Brothers TD, Hickman M, Farrell M, Degenhardt L. The impact of opioid agonist treatment on hospitalisations for injecting-related diseases among an opioid dependent population: A retrospective data linkage study. Drug Alcohol Depend 2022; 236:109494. [PMID: 35605532 DOI: 10.1016/j.drugalcdep.2022.109494] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/05/2022] [Accepted: 05/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Injecting-related bacterial and fungal infections cause substantial illness and disability among people who use illicit drugs. Opioid agonist treatment (OAT) reduces injecting frequency and the transmission of blood borne viruses. We estimated the impact of OAT on hospitalisations for non-viral infections and examine trends in incidence over time. METHODS We conducted a retrospective cohort study using linked administrative data. The cohort included 47 163 individuals starting OAT between August 2001 and December 2017 in New South Wales, Australia, with 454 951 person-years of follow-up. The primary outcome was hospitalisation for an injecting-related disease. The primary exposure was OAT status (out of OAT, first four weeks of OAT, and OAT retention [i.e., more than four weeks in treatment]). Covariates included demographic characteristics, year of hospitalisation, and recent clinical treatment. RESULTS 9122 participants (19.3%) had at least one hospitalisation for any injecting-related disease. Compared to time out of treatment, retention on OAT was associated with a reduced rate of injecting-related diseases (adjusted rate ratio[ARR]=0.92; 95%CI 0.87-0.97). The first four weeks of treatment was associated with an increased rate (ARR 1.53, 95%CI 1.38-1.70), which we believe is explained by referral pathways between hospital and community OAT services. The age-adjusted incidence rates of hospitalisations for any injecting-related disease increased from 34.8 (95% CI =30.2-40.0) per 1000 person-years in 2001 to 54.9 (95%CI=51.3-58.8) in 2017. INTERPRETATION Stable OAT is associated with reduced hospitalisations for injecting-related bacterial infections; however, OAT appears insufficient to prevent these harms as the rate of these infections is increasing in Australia.
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Affiliation(s)
- Samantha Colledge-Frisby
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; Burnet Institute, Melbourne, Australia.
| | - Nicola Jones
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Sarah Larney
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; School of Psychology, University of Tasmania, Hobart, Australia
| | - Dan Lewer
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Thomas D Brothers
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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