Educational Section

Protean manifestations of intravenous drug use

R.M. Warner, J.R. Srinivasan
Department of Plastic and Reconstructive Surgery, Northern General Hospital, Herries Road, Sheffield, S5 7AU

Correspondence to: R.M. Warner, 20 Manor Park, Dewsbury, WF12 7ST Email: rmwarner@hotmail.com                 

Introduction Case reports Discussion

Conclusion References

Intravenous drug use is an increasing social problem. Repeated venepunctures, injection of insoluble substances and needle sharing habits in intravenous drug users result in complications leading to admissions under various medical specialities. Many of these patients, however, manifest soft tissue wounds requiring specialised care from plastic surgeons. Typical presentations include injection site related abscess, cellulitis, necrotising fasciitis and non-healing wounds. We present a series of 11 consecutive cases treated in our unit over a six-month period, to highlight the varied clinical presentations and potential difficulties in their management

INTRODUCTION
Drug use in the United Kingdom (UK) appears to be rising in all age groups. In the year 2000 the UK Drug report showed that 34% of adults aged 16-59 admitted to use of an illicit drug, in their lifetime, compared with 28% in 1994.¹ In England, nearly half of the users were in their twenties, a further 13% were under twenty years of age, with the ratio of males to females being 3:1.² Most of the affected individuals are young males in the prime of their lives, highlighting the social and economic implications of intravenous drug use (IVDU). The number of drug users presenting for treatment as well as drugrelated deaths are increasing steadily in the UK.² Heroin is the most common drug of use among those presenting for treatment, followed by methadone, cannabis, cocaine and amphetamines, although cannabis is the most common substance to be used.²

CASE REPORTS
The patients in our study are summarised in Table 1, detailing their presenting features, medical speciality to which they presented, overall management and outcome. Two cases are presented in detail to further illustrate the varied clinical presentations and management options of these patients with wounds related to IVDU.

Case 1
A 29-year old man was referred by his General Practitioner with two non-healing wounds to the right middle and little fingers, following heroin injection (Figure 1). Following adequate debridement of the middle finger wound, a 1cm segment of flexor digitorum profundus (FDP) was exposed between the proximal and distal interphalangeal joints. A cross finger flap from the right ring finger was fashioned to reconstruct the soft tissue defect (Figure 2). Exploration of the little finger wound revealed that the FDP, volar plate and distal interphalangeal joint (DIPJ) capsule were necrotic and non-salvageable. As the patient had declined terminalisation, the wound was debrided conservatively and treated with dressings. The ring to middle cross finger flap was divided at two weeks.

Figure 1: IVDU related wounds of the right middle finger 

Figure 2: Right ring to middle cross finger flap 

At two months follow-up, the cross finger flap was settling well with limited but functional movement of the digit. Not surprisingly, the little finger wound was still present. A formal terminalisation was recommended but the patient declined the advice. This patient failed to attend the subsequent outpatient appointment.

Case 2
A 30 year old man presented to general surgeons at a District General Hospital with a large groin abscess, as a result of recent heroin injection, and subsequent necrotising fasciitis. Following drainage of the abscess and extensive debridement, the patient was referred to our unit for definitive wound management. With further surgical debridement and vacuum assisted dressings a granulating wound was achieved (Figure 3). Meshed split skin grafts were applied at a subsequent procedure.

On discharge, the wound was healing well despite small areas of graft loss, requiring further wound management in the community. This patient failed to attend any follow-up clinics.

Figure 3: IVDU related wound of the left medial thigh; post debridement of necrotising fasciitis in patient two

DISCUSSION
The increased incidence of intravenous drug use has led to more patients presenting with complications, both acute and chronic. This is a result of repeated venepuncture, injecting insoluble or impure substances and needle sharing habits. The variety of clinical presentations is listed in Table 2. It is evident that such protean manifestations may come under the initial care of various surgical and medical specialities. Makower et al. (1992) found that over a third of IVDU-related admissions required surgery.³ However, most of the soft tissue wound complications would require the expertise of a plastic surgeon at some stage in their management.

Of the IVDUs presenting to an inner city Accident and Emergency department, nearly 60% were directly related to the act of injection. Almost a third of them, presented with infective conditions - ranging from superficial cellulitis, abscess, pseudoaneurysm to extensive necrotising fasciitis.³ Unusual organisms, such as clostridium botulinum, have been isolated from wounds related to IVDU.⁴ In our series staphylococci and streptococci were commonly isolated, with occasional reports of mixed coliforms and anaerobes. These conditions demand aggressive management with appropriate antibiotics and often, multiple surgical interventions. Extensively thrombosed veins from multiple venepunctures, compromised nutritional status and poor compliance of these patients usually impedes such interventions.

Intravenous drug users carry a high risk of contracting blood borne infections such as HIV, Hepatitis B and C. Over a third of intravenous drug users attending specialist services have evidence of Hepatitis C infection.⁵ Disease transmission from these patients to their treating healthcare professionals is a small but real risk. Because of the potential for disease transmission, all IVDU patients are presumed to be ‘high risk’ and treated accordingly - with double gloves and/or ‘space suits’ (Figure 4).

Figure 4: Protective ‘space suits’ used when performing surgery on high risk patients

Such practices complicate and prolong even simple procedures, adding further strain to already stretched operating theatre availability.

In our series, five patients presented with abscesses, which required incision and drainage. Three patients were referred with chronic, non-healing wounds and a further three patients presented with a flexor sheath infection, pseudoaneurysm and necrotising fasciitis, respectively. Management ranged from conservative treatment with regular dressings, to vacuum assisted (VAC) dressings, to surgical intervention, which included abscess drainage, wound debridement, split skin grafting and flap cover (a bi-pedicle flap and a cross finger flap).

An issue that is certainly not unique, but appears to be common amongst injection drug users is a sub-optimal nutritional status and lack of compliance with medical intervention. We observed that this group of patients often missed ward rounds, medication rounds and physiotherapy sessions. Over half the patients, in our series, took their own discharge against medical advice and nearly two thirds failed to attend dressing clinic or outpatient appointments. Two patients, on separate occasions, were found to be actively injecting heroin within the hospital building. In addition, a study by one of our nursing staff has shown that people within the medical profession harbour negative attitudes and prejudices towards illicit drug users.⁶ Such attitudes alienate the drug users and health professionals. Drug users themselves have characterised medical staff as lacking in knowledge, understanding and sympathy.⁶ This climate of mistrust between these patients and health professionals further complicates the effective delivery of care and follow-up.

From our experience we can recommend management strategies for patients presenting with wounds resulting from intravenous drug use. A proportion of these patients can be managed conservatively, but, where indicated, aggressive and proactive surgical management to obtain wound cover, prior to discharge, is advisable. Occasionally, this may lead to a longer hospital stay but the time can be used to implement appropriate psychological, nutritional and social support for the patients.

In addition, healthcare professionals should be educated not only about the potential risks associated with managing these patients but also with regards the wider issues of drug dependence and the need for a better understanding of these patients and their unique circumstances. Such efforts would improve the trust between the drug users and medical staff and may lead to improved compliance with treatment and followup care.

CONCLUSION
We have attempted to increase awareness to the particular difficulties in the management of wounds resulting from IVDU. The majority of acute wounds involve a soft tissue component and may benefit from early referral to a plastic surgery unit. We have highlighted the varied clinical presentations, the specific challenges and precautions required in their management and suggested possible solutions when dealing with this unique group of patients.

REFERENCES
1. UK Drug Report 2001. The Drug Situation in the United Kingdom. www.drugscope.org.uk.
2. Department of Health. Statistics from the regional misuse databases for six months ending March 2001. Statistical Bulletin 2002/07; 2002.
3. Makower RM, Pennycook AG, Moulton C. Intravenous drug abusers attending an inner city accident and emergency department. Arch Emerg Med 1992; 9: 32-39.
4. Merrison AFA, Chidley KE, Dunnett J, Sieradzan KA. Wound botulism associated with subcutaneous drug use. BMJ 2002; 325: 1020-21.
5. Department of Health. Hepatitis C - Guidance for those working with drug users. 2001.
6. Dyer SJ. Health Care Professionals Attitudes to Illicit Drug Users. BMedSci Thesis. University of Sheffield; 2002.
7. Department of Health. Categorisation of pathogens according to hazard and categories of containment. The Advisory Committee on Dangerous Pathogens. HMSO, 1984.

Copyright: 31 March 2004