The new epidemic in wound care: wound care for persons who inject drugs (PWID)

Purpose: An estimated 2.6 percent of Americans over the age of thirteen have injected illicit drugs.  Chronic drug use is associated with endovascular infections, endocarditis, abscesses, limb ischemia, cellulitis, and compromise to the immune system.  Our 3 case studies demonstrate certain characteristics associated with chronic injection drug abuse that presents challenges to wound management/healing in this patient population.There are no current guidelines on the recognition and treatment for wounds caused from chronic injection drug abuse; WOCNs routinely manage these wounds through trial and error.In our academic, urban hospital, patients are admitted with fevers and wounds are diagnosed with cellulitis/abscess resulting in a wound care consult to the WOCN.  When obtaining a past medical history, patients seldom admit to injecting. PWID begin injecting in the arms, eventually move to the lower legs.  Women opt to inject in the groin and legs to hide any visual evidence of injecting drugs. 

Clinical approach:  Wounds are atypical in appearance.  Our examples are larger areas on the extremity with well demarcated wounds, full thickness with pitting, irregular tissue, covered with some slough, areas of eschar with creamy, purulent drainage from infection.  The patients are medically managed with systemic antibiotics for osteomyelitis/endocarditis for minimum of 6 weeks. Ankle Brachial index studies are necessary to evaluate patient’s tolerance of multi-layer compression therapy.  Meticulous wound care includes debridement, contact layers to manage tissue damage and protect ligaments, nerves, and bone.  Initially, we focus on achieving a clean wound bed and designing a dressing that prevents continued injecting in the wound.  Hydroconductive dressings manage bioburden and exudate.  Full wound closure and limb preservation is possible and can encourage the patient to seek abstinence. Care for PWID can be long-term and requires multidisciplinary approach.