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Public Health England
Public Health England, 2021
People who inject drugs are at risk of serious and potentially life-threatening wounds. In new guidance, Public Health England describes how drug services can be ‘wound aware’ by adopting three key characteristics.
Summary People who inject drugs are at risk of serious and potentially life-threatening wounds (skin lesions and infections) and other tissue and blood vessel damage, because of what they inject and how they inject it. The featured resource published by Public Health England is intended to be a guide for commissioners and providers on how drug services can be ‘wound aware’. As the following summary describes, wound aware services follow three principles: (1) they prevent infections; (2) they identify worsening injection sites; and (3) they provide advocacy and access to treatment.
People who inject drugs are at risk of serious and potentially life-threatening wounds and other tissue and blood vessel damage, because of what they inject and how they inject it.
Local services can be ‘wound aware’ by:
• helping people who inject drugs prevent injection-related wounds;
• identifying wounds and other problems early and getting them treated;
• helping people who inject drugs access wound care and harm reduction support;
• promoting wound awareness with guidance and information;
• offering general health assessments that include checking wound status and referring to relevant services (including tissue viability nurses or inpatient hospital care).
Wounds and other health problems can result from injecting drug use. They can occur because of the injection mixture, technique and site, or from years of repeated injecting; they can also occur when people who inject drugs do not have access to adequate supplies of clean water and clean injecting equipment, and they re-use damaged equipment that has not been cleaned properly.
Untreated bacterial infections can lead to serious complications, such as blood poisoning or infection of the inner lining of the heart (endocarditis), that carry a high risk of death. People who inject drugs often do not go to hospital until late on in their infection, at which time they might need to be admitted to intensive care (a specialist hospital ward for patients who are seriously ill and require intensive treatment and close monitoring).
Drug services can help prevent hospital admissions and deaths by providing early and rapid access to treatment for infections. People who inject drugs commonly reuse injecting equipment, which can increase the risk of infection.
People who inject drugs with injecting-related wounds often experience complex health and social barriers that prevent them from accessing care, such as homelessness, mental health diagnoses or chronic diseases. These can make it more difficult for people who inject drugs to get appropriate treatment.
Healthcare professionals need to consider the following barriers to accessing care or treatment when they are identifying patients’ wounds or providing support and options to someone who needs care:
• The person may be sleeping rough or in unsatisfactory living conditions, where there is no access to water or other facilities for personal and environmental hygiene and safe injecting behaviour.
• They may be unwilling or unable to access prevention or early intervention services due to previous bad experiences of healthcare, lack of transport, or if available services were not being promoted to them in the right way.
• Diagnoses and treatment of wound and skin problems can be late if the person is not able or willing to report early signs to professionals. People who are used to self-managing their wounds may have large and severe infections by the time they seek care.
• They may be reluctant to wait in the Accident and Emergency department or for admission to hospital. They might be concerned that their opioid substitution treatment will be interrupted or feel the need to take drugs to ease drug withdrawal.
• Wounds can heal more slowly if the person finds it difficult to access appropriate nutrition and hydration. The negative effects of smoking, alcohol and illicit drug use can also affect healing.
• As a person gets older, their ability to heal slows down, and they may have other health problems and weakened immune systems.
• Wound-related care needs might not be easily identified or prioritised if the person has multiple health problems they need care for, such as hepatitis C, HIV infection, diabetes, hypertension, mental health problems and chronic pain.
A drug service that is wound aware focuses on preventing infections and will have the following features:
• The service provides an initial health assessment which discusses injecting behaviour, and past and current wounds and infections with the service user.
• Safer injecting advice and wound care are part of the care plan and are regularly reviewed.
• Staff are aware of the risks carried by different injecting practices and have confidence in trying to prevent these by offering advice on safer injecting, discussing safer ways of drug use than injecting, and promoting self-care.
• Staff discuss the wider risks of drug use as well as the risks of alternatives to injecting (such as smoking, snorting and rectal use of drugs), and support service users to make informed decisions.
• Written and oral information and advice are easily available for service users and prominently displayed throughout the service.
• Peer-led programmes promoting safer injecting are developed.
• Service users are provided with or signposted to supplies of clean injecting equipment and wound care packs.
• Service users are made aware of community services where they can get clean clothes and food, and shower, and intensive efforts are made to resolve homelessness or poor accommodation problems.
A drug service that is wound aware will be alert and able to identify infections or infection sites that are getting worse and have the potential to become infected. It will have the following features:
• Keyworkers will have regular check-ins with service users about their injecting experiences.
All staff will keep an eye on their service users’ health and know who to tell or what to do if they spot a problem.
• All staff, including reception and business support staff, will keep an eye on their service users’ health and know who to tell or what to do if they spot a problem.
• Other services involved in infection control and wound care (eg, GPs and community wound services) will be part of staff induction programmes, health promotion and staff training events.
• Trained, wound-aware peer champions and staff will be able to identify likely infections and provide information and reassurance to service users.
A drug service that is wound aware provides advocacy and access routes to specialist treatment and support for wound infections. It will have the following features:
• Staff know the contact details of local services, including GPs, wound care specialists, tissue viability nurses, and the Accident and Emergency department.
• Staff are confident about referring people to NHS primary care for early interventions and to specialist services where these exist.
• There is a clear protocol for dealing with wound-related emergencies, such as bleeding or signs of severe infection.
• Arrangements are in place to support and continue opioid substitution treatment for people with wound-related issues who are admitted to hospital.
• Staff are aware of infection prevention issues and the service has a link with its local NHS infection prevention and control team.
• The service records and monitors cases of serious infection, including details of referrals they make.
commentary People who inject drugs are at risk of serious and potentially life-threatening wounds (skin lesions and infections) and other tissue and blood vessel damage. By helping to prevent infections, identify worsening injection sites, and facilitate access to treatment, the featured document indicated that drug and alcohol services can share the burden of injecting-related harm as well as reduce the level of harm and suffering people who inject drugs are exposed to. This is particularly salient for service users whose position of deep marginalisation and disadvantage means they struggle or are unable to practise hygienic injecting (eg, due to sleeping rough and injecting in public places).
Surveys of people who inject drugs suggest a high prevalence of injecting-related skin and soft tissue infections among people who inject drugs in the UK: 52% of 2,874 respondents from a national survey reported having such an infection in the past 12 months, and 65% of 455 respondents in London reported a lifetime history of injecting-related infections. The factors associated with injecting-related infections in both surveys were similar, including older age, number of years injecting, number of attempts required to inject into the vein, injecting into the hands, feet, groin or neck, and re-using or sharing needles/syringes.
Ensuring that people who have injecting-related infections can access timely treatment is vital in order to prevent suffering and the serious consequences that come with invasive infections such as sepsisSepsis is a life-threatening reaction to an infection.
It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs.
You cannot catch sepsis from another person.
Sepsis is sometimes called septicaemia or blood poisoning.
https://www.nhs.uk/conditions/sepsis/, necrotising fasciitisNecrotising fasciitis is a rare but serious bacterial infection that affects the tissue beneath the skin and surrounding muscles and organs (fascia).
It’s sometimes called the ‘flesh-eating disease’, although the bacteria that cause it do not ‘eat’ flesh, but release toxins that damage nearby tissue.
Necrotising fasciitis can start from a relatively minor injury, such as a small cut, but gets worse very quickly and can be life threatening if it’s not recognised and treated early on.
https://www.nhs.uk/conditions/necrotising-fasciitis/ and death. However, the barriers to timely healthcare are numerous and well-documented, and include feeling marginalised, judged, or criminalised in relation to drug use, being stigmatised due to wound odour or appearance of homelessness, struggling to navigate unfamiliar environments, unequal power relations with medical professionals, prior negative experiences of care (eg, pejorative treatment by staff and intense discomfort due to withdrawal or pain), restrictive opening hours, and competing priorities. This can have far-reaching consequences for people who use drugs. For example, a study following 6,683 people who use heroin in London found major disparities in cancer management and cancer outcomes: they were twice as likely to die from cancer; and they were half as likely to have a hospital admission for cancer treatment.
A study analysed in the Effectiveness Bank examined whether SKIN, an injecting hygiene education programme, could have an impact on injecting-related infections, using as its measure, the rate of attendance at the emergency department and admission to hospital in the subsequent year. The intervention significantly reduced injecting-related emergency department visits compared with usual care. However, because injecting-related emergency department visits constitute only a small percentage of total visits among this frequently-returning population, the improvement did not produce a significant reduction in total emergency department visits or total hospital admissions. Furthermore, while an intervention may be able to change individual behaviour (eg, SKIN targeted three areas of injecting-related risk behaviours: hand washing, injection site skin cleaning, and needle cleaning), there are many factors outside of an individual’s behaviour that impact injecting hygiene. Appreciable risk of harm also comes from the physical environment people inject drugs in.
Last revised 20 January 2021. First uploaded 14 January 2021
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