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Wound care in patients with a history of intravenous drug use

Leanne Cook RGN MHSc
Lecturer/Practitioner
School of Human and Health Sciences University of Huddersfield

Management of leg ulcers is often challenging, but in patients who have a history of intravenous drug use, it can be even more problematic due to the multifactorial nature of the disease and the patient's lifestyle

Leg ulceration is a chronic condition affecting approximately one to three per 1,000 of the UK population (3-5%), most commonly in people aged over 65.1-5 However, there is a group of younger sufferers who are known to have a history of intravenous (IV) drug abuse. Most drug users in the UK are young people aged 15-44 years.6

The UK has one of the highest rates of recorded illegal drug use in the western world; in particular, the misuse of heroin and cocaine.7 Heroin and cocaine can either be smoked or injected, but most users prefer to inject, as a smaller amount of the substance is required to result in the same effect.

Intravenous drug users increase their risk of lower limb ulceration due to damage caused to the superficial veins through repeated trauma and thrombophlebitis. Deep venous damage can also occur due to deep vein thrombosis (DVT).8 This results in chronic venous hypertension, which is known to be the causative factor for the development of venous leg ulceration.5,9,10 

Injection techniques such as ‘skin popping', when the user cannot find venous access, result in the substance being deposited under the skin to be absorbed by the subcutaneous tissues. This approach can lead to abscess formation, and possibly ulceration. Recurrent abscesses from IV drug use result in coin-shaped scarring on large areas of the limbs. 

Around one third of users report an injection-related abscess, sore or open wound within a one-year period.11 This comes as no surprise as heroin is not a sterile drug, but is often mixed with citric acid, which, if over-used, can contribute to acid burns either within the vessels or the subcutaneous tissues, leading to cell death and necrosis.6

Patient profile
Caring for patients with a history of IV drug use can be challenging for the healthcare practitioner as often the dependency to a substance dominates the patient's life, resulting in a chaotic lifestyle and frequent failure to attend appointments. Patients can find accessing healthcare very difficult, as many live extremely transient lives, moving homes and towns on a regular basis. Many IV drug users are homeless, so registration with a GP is difficult. 

Lack of access to healthcare frequently results in patients presenting late with longstanding, significant lower limb ulceration. They have often been self-caring for a number of weeks or months with many having already tried methods to control the exudate from the wounds, such as talcum powder, sanitary towels, babies nappies and hand towels to ‘dry out' the ulceration.8 The need to self-care is often a direct result of the difficulties patients with a history of substance misuse face in accessing appropriate, timely healthcare, with many experiencing prejudice and discrimination from health professionals.12 

Role of the primary care nurse
The role of the primary care nurse is to carry out accurate diagnosis of the cause of the ulceration and recommend appropriate treatment pathways, ensuring that equitable care is provided to IV drug-using patients. Assessment should be performed in line with the Royal College of Nursing (RCN) guidelines for the management of patients with leg ulceration.13 This recommends a full clinical history and physical examination is undertaken, including assessment of:

  • Venous disease risk factors.
  • Skin.
  • Ulceration (location, duration, size, wound bed assessment).
  • Pain.
  • Circulation, including ankle brachial pressure index (ABPI) measurement. 

Accurate assessment is essential to ensure appropriate treatment is commenced. The majority of IV drug users will have ulceration due to venous insufficiency/damage of the veins and this group of patients is often relatively young, with little risk of developing arterial disease, such as hypertension, diabetes and cardiovascular disease. If assessment indicates venous ulceration the most effective way to promote healing of the ulceration is the application of graduated compression therapy.10 

Graduated compression is often provided through the application of four-layer compression bandaging renewed on a weekly basis. However, with IV drug abusers, attendance to clinic can often be sporadic, with many patients preferring the freedom of self-care; therefore, practitioners must consider other ways of providing graduated compression.

The use of compression hosiery kits can provide an alternative to multilayer compression bandaging. These are designed to provide therapeutic levels of compression equal to that of a multilayer elastic bandage. A number of compression hosiery systems are available, all of which aim to provide 40 mmHg pressure at the ankle.

Concordance
Concordance with compression therapy is acknowledged as an important determinant to the healing of venous ulceration, with many factors given for issues with concordance, including pain, problems with footwear, odour and stigma. Enabling patients to take control of their care by being able to apply and remove their hosiery themselves encourages ownership and, ultimately, aids concordance.14 IV drug users are known to seek treatment late, have poor compliance and are challenging to treat.15

The practitioner can face frustrations with poor concordance to the treatment plan, as it is not uncommon for patients to go ‘off radar' for a few weeks at a time, leaving the practitioner concerned about who, if anyone, is changing the dressings and feeling frustrated at the obvious setback in healing times. 

To ensure effective outcomes the patient needs to feel protected from criticism and believe that their relationship with the practitioner is a trusting and empathic one, where education and support will be provided.

Pain
Pain is often a factor in lower limb ulceration, both of the non-user and the user of illicit drugs. However, unlike non-drug users who often are very stoic about their pain, and who try to cope with little analgesia, IV drug users often report a high intensity of pain that they often control by increasing their use of illicit drugs.16 

Prescription of opioid-based medication for this client group should be avoided as it can feed their dependency and there is a risk of patients selling on their medication to purchase the drug of their choice. Prescribed analgesia should be non-opioid based and, ideally, only be prescribed in combination with local drug services.

Many drug users may be on methadone programmes to try to detach themselves from chaotic and expensive drug habits. Methadone is a synthetic heroin substitute and its effects are active for 24 hours, which provides the user with greater stability and the opportunity to reduce the injection behaviours.

Contrary to popular belief, methadone does not provide a high; rather, it simply allows the user to reduce their injection behaviours and lead a normal life. If a methadone replacement programme is chosen it is important that practitioners realise that, although clients are experiencing significant pain, prescription medication should not be given. Instead, the patient should be referred back to the local drug service to ensure that a true record of total prescribed opioid intake is maintained.

Challenges
When treating this specific client group it is vital that the healthcare practitioner works in liaison with the multidisciplinary team, including close communication with local drug services. Treatment programmes for those clients who are known IV drug abusers should be individualised to treat not only the venous leg ulcer, but also the general and mental health needs of the patient, thus improving long-term outcomes for the individual and their family.

Hunt and Derricott suggest that many community practitioners hold a negative and prejudicial attitude towards patients who misuse substances.17 Peckover and Childlaw support this view and go on to say that nurses' work with drug abusers is often task-orientated and focused on getting the job done, rather than caring and focusing on good communication.18 This is thought to be due to professionals' beliefs that drug users are seen as ‘risky', which results in the clients receiving inadequate contact and a poor-quality service. Practitioners involved in the management of drug users with ulceration need to ensure that this is not the case and that they provide good physical and psychological care.

Conclusion
Leg ulceration is a common problem associated with IV drug abuse, and drug users are often stigmatised and perceived to be on the margins of society. This is compounded by leg ulceration, often resulting in isolation.19  

Practitioners need to provide flexible services and have an understanding of the difficulties faced by this client group to ensure that healthcare is equitable, building up relationships to ensure consistent and prolonged application of compression therapy to successfully treat the ulceration and prevent recurrence.

References
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