Barbara Pieper, PhD, CNS-BC, CWOCN, FAAN, WOCNF shared that drug abuse or addiction affects millions of individuals each year in the United States. In 2019, 20.4 million people met the criteria for a substance use disorder, and in 2021, 1.1 million Medicare beneficiaries were diagnosed with opioid use disorder.¹ Of the 6.5 million Americans who have injected illicit drugs, the most common demographic used to be individuals born between 1940-1960, but now a much younger population is emerging.^2,3

There are several injectable illicit drugs that Dr. Pieper noted clinicians should be aware of, firstly, heroin. Heroin overdose deaths more than tripled between 2010 and 2021.⁴ It is an opioid drug made from the seed pod of select opium poppy plants. It is highly addictive, causing a euphoric surge after injection, sniffing, snorting, or smoking. Naloxone can treat an overdose if administered right away.⁴

Fentanyl is a synthetic opioid, originally developed for cancer pain management, and is 50-times stronger than heroin and 100-times stronger than morphine.⁵ It is commonly mixed with other drugs, and is also reversible by naloxone. The user experiences a quick, short, but intense rush.⁵

Cocaine is a stimulant with no targeted reversal option, said Dr. Pieper. Users may inject, dissolve, smoke, or snort it, and it may also be mixed with other drugs or fillers such as cornstarch or talcum powder. Adverse effects of cocaine can include vascular constriction, dilated pupils, nausea, elevated temperature and blood pressure, tachycardia, tremors, and restlessness.

Another substance of particular interest to the wound care community, Xylazine, or “Tranq” is a non-opioid veterinary tranquilizer not approved for human use. It is often added to illicit opioids and is a central nervous system depressant. Naloxone is recommended for overdose, but does not reverse xylazine itself, rather it reverses any included opioids. Xylazine does have an association with skin ulcers and abscesses, likely due to local vasoconstriction and decreased local perfusion.⁶

In addition to Xylazine, she pointed out that there are other substances, called adulterants, that may also be mixed with other illicit drugs, including caffeine, quinine, and mannitol, each with its adverse potential effects.⁷

Injectable Drugs and Wounds

Persons who inject drugs (PWID) often experience skin problems, with one study Dr. Pieper presented citing 60%, primarily abscesses, lumps, track marks, leg ulcers, acid burns, and other chronic ulcers.⁸ Contributing factors include the injection composition and technique, the equipment used, site selection, length of use, and underlying medical history.⁸

However, skin problems in PWID are not always clear. Wounds do not indicate patient drug use. Ulcers or wounds unrelated to drug use may present similarly to drug-related wounds, including in sickle cell anemia, cancer, pyoderma gangrenous, or factitious conditions. In these cases, patient history and physical are vital to the differential diagnosis. Alternately, PWID with skin issues may not present for treatment due to self-diagnosis and attempts at self-care, she said.⁹

Track Marks

Track marks are scars from chronic injectable drug use at the same site of injection. Old needles, repeat injection sites, and drug impurities contribute to their formation. Many PWID will try to hide these marks under clothes or in tattoos, said Dr. Pieper.

Skin Popping

Skin popping may occur when the user misses a vein or injects the drug into a tented, pinched area of skin, she explained. This injection may result in less of a rush, but a longer high. It may also bring prolonged inflammation, ischemia, necrosis, ulceration, abscess, fibrosis, or dangerous infections. Treatment may involve surgical debridement, with one study identifying primarily Staphylococcus involvement, treatable by trimethoprim/sulfamethoxazole.¹⁰ Lack of patient follow up is a significant concern. Another study looked at more extreme results of skin popping in their series, including polymicrobial infection necessitating multidisciplinary care.¹¹

Skin and Soft Tissue Infection

As a common complication, skin and soft tissue infection can arise from multiple risk factors, including the user's injection practices and frequency. These infections also have nonclinical risk factors, including inadequate access to care, unstable housing, and stigma regarding drug use.¹² Abscesses may also occur. Treatment of abscesses that stem from injectable drug use includes incision and drainage, possible packing, antibiotics, local wound care, and harm reduction education.¹²

Vascular Consequences

For persons who inject drugs, clinicians must consider the potential impact on the vascular system. Dr. Pieper shared that vasospasm, vasoconstriction, thrombosis, and decreased oxygenation may all occur depending on the individual, the substance, and the technique of injection. Of specific note, she highlighted that Xylazine specifically can contribute to necrotic wounds with local dysvascular findings. It is also possible for PWID to experience chronic venous insufficiency related to their drug use. She stressed the importance of evaluating circulation and referring to a vascular specialist when indicated.

Neuropathic Consequences

Presenting similarly to other etiologies of peripheral neuropathy, one must be aware that injectable drug use has a risk of nerve damage. Evaluation of sensation and neurological status is wise, she added, along with recruiting a multidisciplinary approach in these cases.

Concluding Thoughts

Dr. Pieper encouraged the audience to consider psychosocial factors that impact these patients, along with the fluid nature of the community’s habits. Patient education and communication are critical, she stressed, and that a comprehensive team, including drug treatment, is vital for these patients.

References

1. Kacha-Ochana A, Jones CM, Green JL, et al. Characteristics of Adults Aged ≥ 18 Years Evaluated for Substance Use and Treatment Planning – United States, 2019. MMWR Morb Mortal Wkly Rep. 2022;71:749-756
2. Visconti AJ. Primary Care for Persons Who Inject Drugs. Am Fam Physician. 2019;99(2):109-116.
3. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. Accessed October 16, 2023. www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHFFRRe…
4. Centers for Disease Control and Prevention. Heroin. Accessed October 16, 2023. www.cdc.gov/opioids/basics/heroin.html
5. Centers for Disease Control and Prevention. Fentanyl. Accessed October 16, 2023. www.cdc.gov/opioids/basics/fentanyl.html
6. United States Drug Enforcement Administration. DEA reports widespread threat of fentanyl mixed with xylazine. Accessed October 16, 2023. www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine
7. Di Trana A., Berardinelli D, Montanari E, et al. Molecular insights and clinical outcomes of drugs of abuse: adulteration: new trends and new psychoactive substances. Int J Mol Sci. 2022;23(23):14619.
8. Coull AF, Atherton I, Taylor A, Watterson AE. Prevalence of skin problems and leg ulceration in a sample of young injecting drug users. Harm Reduct J. 2014;11:22. doi:10.1186/1477-7517-11-22
9. Roose RJ, Hayashi AS, Cunningham CO. Self-management of injection-related wounds among injecting drug users. J Addict Dis. 2009;28(1):74-80.
10. Pirozzi K, Van JC, Pontious J, Meyr AJ. Demographic description of the presentation and treatment of lower extremity skin and soft tissue infections secondary to skin popping in intravenous drug abusers. J Foot Ankle Surg. 2014;53(2):156–159.
11. Michet CJ, Whitelock C, Siparsky N. It takes a village: the management of extreme sequelae of skin popping. Wounds. 2021;33(1):9-19.
12. Monteiro MG, Rehm J, Duennbier M. Alcohol Policy and Coronavirus: An Open Research Agenda. J Stud Alcohol Drugs. 2020 May;81(3):297-299.