Prevalence and factors associated with chronic venous insufficiency, leg ulceration and deep-vein thrombosis among people who inject drugs in London, UK

Wound care in hard-to-reach populations: rough sleepers

People sleeping rough commonly develop wounds and other skin disorders. Wounds vary and develop for multiple reasons. They include acute wounds such as burns, infected injection sites, abscesses and cellulitis, as well as chronic wounds such as pressure ulcers; rough sleepers have a high prevalence of lower limb wounds. Skin and soft tissue infections are common, especially in people who inject drugs via subcutaneous or intramuscular routes. Emergency departments are often the pathways into healthcare for homeless people as traditional health and care systems often fail to meet their needs. Across England, initiatives have been developed to improve access to wound care for those who sleep rough. A case study illustrates the care of a homeless man presenting with a lower limb wound.

Septic pulmonary emboli: a case discussion

A septic pulmonary embolus occurs from the embolisation of an infected thrombus - typically from an infected source such as an abscess - that enters the venous circulation, implanting in the lungs, which in turn causes a parenchymal infection. This case discussion gives a candid reflection on the treatment and management of a patient who was a known intravenous drug user, with a past history of a deep vein thrombosis and new presentation of a groin abscess. He was initially reviewed by a trainee advanced clinical practitioner, working out of hours in a hospital setting. This article will reflect on the patient presentation, the clinical examinations and investigations undertaken, which finally led to the diagnosis of septic pulmonary emboli. Although this condition is rare, having a high index of suspicion in patients with known risk factors may lead to early diagnosis and successful treatment.

Prevalence and factors associated with neck injection among people who inject drugs in San Francisco, California

BACKGROUND

Groin and neck injections are generally a last resort for people who inject drugs (PWID) who do not have easy access to functioning veins. These alternative injection practices can lead to an increased likelihood of adverse health outcomes. There is still much we do not know about groin and neck injections among PWID in the US, as the literature to-date comes from studies primarily focused on groin injections outside the US. We assessed prevalence, predictors, and associated behaviors of neck injection through a survey fielded in San Francisco, California, US.

METHODS

The sample comes from a longitudinal observational study that used targeted sampling to recruit PWID in San Francisco. The current study sample includes 239 PWID who completed their 12-month survey between June 2019 and June 2020.

RESULTS

About a third of the sample reported injecting in their neck in the past 30 days, with the most common reason being lack of available veins. Age, past 6-month abscess / soft tissue infection, and past 30-day use of opioids mixed with cocaine were significantly associated with past 30-day neck injection in the final multivariate model. Past 30-day neck injection was also significantly associated with being injected by another person in the past 30 days.

CONCLUSIONS

PWID at higher risk for vein deterioration were more likely to inject into their neck. Harm reduction strategies such as safer injection counseling, safe smoking supplies, use of "street doctors," and safe consumption sites may reduce instances of neck injection and/or associated health risks.

Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence

BACKGROUND

People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England.

METHODS

We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research.

RESULTS

Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with 'drugs used in substance dependence' collectively categorised as posing low risk if delayed and moderate risk if omitted.

CONCLUSIONS

Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the 'low-risk' categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.