Intravenous drug use can result in leg ulceration, causing pain and distress. Healthcare services need to respond to this frequently unrecognised problem
Timothy Devey, PGCert, BA, DipN, is team leader, harm reduction team, substance misuse service, Sheffield Health and Social Care Foundation Trust.
Devey T (2010) Using an outreach service to meet the needs of users of intravenous drugs with leg ulceration. Nursing Times; 106: 20, early online publication.
Leg ulceration is an often unrecognised problem associated with intravenous drug use. This article describes why ulceration occurs and how an outreach team developed skills to reach users of IV drugs and manage these complex wounds.
Keywords Intravenous drug use, Leg ulceration, Outreach nurses
- This article has been double-blind peer reviewed
- Services should be provided in settings that are already frequented by IV drug using clients.
- Clinics should be a mix of drop in and booked appointments to prevent resources being wasted on missed appointments.
- Nurses should have a wide range of skills and knowledge to ensure positive outcomes for clients (word of mouth is everything in this client group).
It is estimated that 88% of intravenous drug users have signs of vascular damage to their legs and 55% of these have signs of severe venous disease (Pieper and Templin, 2001). Despite this, Department of Health (2007) guidelines on drug misuse and dependence do not mention venous disease or leg ulceration.
Studies consistently show that the UK has one of the highest rates of recorded illegal drug use in the western world (DH, 2007). In particular the UK has high rates of heroin and crack cocaine misuse. Although both these can be smoked, most clients inject – this is considered a cheaper option because a smaller quantity of the drug is required to achieve the same effect. Any vein can be used for injecting but once surface veins become damaged deeper ones such as the femoral vein or jugular vein are often used. The femoral vein is often used repeatedly for years (Fig 1), which results in scar tissue leading to stenosis (narrowing), which obstructs venous blood flow. Clients in their early twenties often have signs of hypertrophic skin changes and ankle flare which are common signs of venous disease.
Street heroin needs to be mixed with an acid in order to make it into an injectable substance. Common acids used for this purpose include citric and vitamin C which can be purchased in powder forms or are given out in needle exchanges. There is little research into the effects of using such acids on the lumens of veins. Street heroin is also often mixed with filler materials by dealers in order to make their product go further; this may be done in unhygienic environments.
Using crack cocaine can accelerate the rate at which venous damage occurs because the drug has a short term action, giving a short lived feeling of euphoria and wellbeing. As the effects of the drug wear off, users often become tense and paranoid and this leads to repeated use to try to recapture those initial feelings. Such behaviour can result in a crack binge, where a user may inject into the femoral vein up to 20 times in one day. There is also a trend among new drug users to use the femoral vein rather than superficial veins because the injection sites are not visible and the vein is easy to access.
Further damage to veins can occur when clients develop deep vein thrombosis (DVT). The link between IV drug use and DVT is well established (Cooke and Fletcher, 2006; McColl et al, 2001) but is often overlooked as a risk factor for venous disease in this client group.
Accessing wound care services
Accessing healthcare can be difficult for IV drug using clients. Many have extremely transient lives, moving from city to city as well as within a city. This makes registration with a GP difficult and making and keeping appointments is also an issue. In my experience, most clients are worried about their health but are more concerned about the prospect of withdrawal, so making money to fund drug use is generally a client’s first priority.
Failure to access leg ulcer care means wounds may deteriorate and ultimately require a lengthy hospital stay. Once patients are discharged they may again fail to attend clinic appointments and a cycle of crisis management develops.
Meeting the need for leg ulcer care
Providing healthcare for IV drug using clients is challenging. Our client group tend not to use statutory services and are frequent non attenders for clinic appointments so it was decided that outreach drop in clinics were the most likely way to engage this group.
Clinics were set up in venues across Sheffield, including the main needle exchange project run by Turning Point and a project run by the cathedral to give homeless people breakfast.
All our clinics are run on a drop in basis with appointments available for those clients who may have jobs or are recovering and may not wish to have contact with current drug users. When the service was established it was anticipated that most staff time would be taken up with treating minor illness. However, it soon became apparent that wound care, and in particular leg ulcer care, is a huge and unrecognised problem for this client group. We liaised with the community tissue viability service for the city and were soon regularly dressing clients’ wounds.
Within three months of starting a clinic at the needle exchange service, we were regularly seeing over 60 clients a month for leg ulcer care. We now provide 12 clinics a week across seven different venues and had more than 1,300 wound care consultations last year.
Providing effective wound care can have a profound effect on patients’ lives but also presents challenges. Many clients do not re-attend when asked; this often leads to nursing staff worrying about clients who have the same set of bandages on for three weeks. Clients often refuse to wait for ankle brachial pressure index measurements, which can mean applying compression on the basis of their history and symptoms.
These problems have been overcome as the client group we serve have gradually come to know and trust the service. Clients now usually come back when asked and usually allow the time required to provide a comprehensive assessment. This is illustrated in the case study in Box 1.
[note to subs/art – pls use box or side panel for case study]
Box 1. Case study
Steven* is a white working class man from a deprived area. He rarely attended school and left with no qualifications. He grew up in an area where many of his peer group used either drugs or alcohol to excess. His father died when he was six and his mother had problems with alcohol for as long as he can remember. He is the third of six children and has two older brothers who have had problems with heroin.
His first experience with this drug was when he was 16 and he has been injecting in his femoral vein since the age of 19; he is now 31.
By the time Steven was 27 he had developed leg ulcers. At this time he was homeless and lived in a violent, dangerous and uncomfortable world. He had no real friends and spent much of his time feeling ill as a result of the beginnings of withdrawal and pain from his leg ulcers. These were infected and smelt offensive. When Steven injected heroin his problems were forgotten and he described it as the only reliable thing in his life. He knew it was the cause of many of his problems but it gave him a break from his own reality.
I began treating this client two years ago and first met him at a clinic run from a pick up point for vendors of The Big Issue. At first Steven was reluctant to accept care and was obviously ashamed of the condition of his legs. He dressed them with toilet paper from the public toilets in the town centre and it took time to remove this and reach his wound. Steven was in a rush during this first visit as he was beginning to withdraw and had to sell his copies of The Big Issue so he could afford to buy more drugs. This is a common problem and we often face the dilemma of whether to apply compression bandaging, which is recommended for venous leg ulceration but contraindicated for ulcers associated with arterial problems.
Steven had a history of injecting into his femoral vein and DVT. On examination he had ankle flare, oedema, varicose veins, hypertrophic skin changes and varicose eczema. These suggested the leg ulcers were venous in aetiology. The client was unwilling to wait for an ankle brachial pressure index to be measured to confirm the diagnosis. We decided to apply three layer compression to Steven’s legs and he was advised to return the next day.
The next morning the client was able to pick up his copies of The Big Issue to sell. He was delighted with the results of the bandages, which he said greatly reduced the pain and the odour from his ulcers. He attended the clinic regularly and the ulcers healed six months later. If we had not used compression at this first meeting he would have been unlikely to re-engage with the service.
Steven explained that a large barrier to engaging with drug services was embarrassment about the odour from his wounds. As a result of regular contact for wound care he started on methadone and now has his own flat and has not used drugs for a year.
*The client’s name has been changed.
While leg ulceration is a common problem associated with IV drug use, it is often unrecognised. The outreach service aimed to meet the health needs of IV drug using clients and identified problems with wound care among this group. The service responded to this need by offering flexible wound care to clients. Developing a model that is based on outreach has meant many clients have had hospital admissions drastically reduced. This model of outreach nurse led health services is effective and provides nurses with real opportunities to develop advanced practice.
Cooke VA, Fletcher AK (2006) Deep vein thrombosis among injecting drug users in Sheffield. Journal of Emergency Medicine; 23: 777-779.
Department of Health (2007) Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: DH.
McColl MD et al (2001) Injecting drug use is a risk factor for deep vein thrombosis in women in Glasgow. British Journal of Haemotology; 112: 3, 641-643
Pieper B, Templin T (2001) Chronic venous insufficiency in persons with a history of injection drug use. Research in Nursing and Health; 24: 423-432.