Open Access

Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study

  • Maria Elisa Smith1,
  • Natanya Robinowitz2,
  • Patrick Chaulk2 and
  • Kristine E Johnson1Email author
Harm Reduction Journal201411:28

https://doi.org/10.1186/1477-7517-11-28

Received: 4 June 2014

Accepted: 22 September 2014

Published: 19 October 2014

Abstract

Background

We surveyed a population of injection drug users (IDUs) frequenting the mobile Baltimore City Needle Exchange Program (BNEP) to investigate self-care factors associated with chronic wounds, a significant cause of morbidity especially among older IDUs.

Methods

Participants ≥18 years old completed a survey regarding chronic wounds (duration ≥8 weeks), injection and hygiene practices. Study staff visually verified the presence of wounds. Participants were categorized into four groups by age and wound status. Factors associated with the presence of chronic wounds in participants ≥45 years were analyzed using logistic regression.

Results

Of the 152 participants, 19.7% had a chronic wound. Of those with chronic wounds, 18 were ≥45 years old (60.0%). Individuals ≥45 years old with chronic wounds were more likely to be enrolled in a drug treatment program (Odds ratio (OR) 3.4, 95% Confidence interval (CI) 1.0–10.8) and less likely to use cigarette filters when drawing up prepared drug (OR 0.2, 95% CI 0.03–0.7) compared to the same age group without chronic wounds. Compared to individuals <45 years old without chronic wounds, individuals ≥45 with a chronic wound were more likely to report cleaning reused needles with bleach (OR 10.7, 95% CI 1.2–93.9) and to use the clinic, rather than an emergency room, as a primary source of medical care (OR 3.4, 95% CI 1.1–10.4).

Conclusions

Older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene behaviors than their peers and younger IDUs without wounds in Baltimore City. Because of these differences, older IDUs with wounds may be more receptive to community-based healthcare and substance abuse treatment messages.

Keywords

Chronic wounds Injection drug use Aging Harm reduction

Background

Older injection drug users (IDUs) are a growing subgroup of active IDUs and IDUs seeking treatment[15]. It is estimated that the number of adults 50 years or older with substance use problems will double from an annual average of 2.8 million (2002–06) to 5.7 million by 2020[6]. Age-associated health complications and ongoing chronic drug use may further intensify the social marginalization of older IDUs, which may diminish quality of life, access to health care and social productivity[7, 8]. Furthermore, injection drug use has been associated with accelerated biologic aging[9, 10] and the premature onset of health conditions normally associated with aging[3, 11, 12]. Due to these life course differences and evidence that IDUs have higher overall mortality rates, older IDUs are of growing interest to public health researchers and are typically defined as individuals older than 40–50 years[13, 14].

Overall, older IDUs report impaired mental and physical health and functioning compared to age- and gender-matched population standards[15, 16]. Older IDUs often self-reported health conditions such as deep vein thrombosis, skin ulcers, respiratory problems, diabetes, hypertension, hepatitis, and liver cirrhosis[8, 15]. Studies on venous damage and chronic venous insufficiency (CVI) in IDUs revealed that CVI develops prematurely in IDUs[11, 12].

Certain risky injection drug use behaviors such as sharing needles, subcutaneous injection (skin-popping), injecting a mixture of heroin and cocaine (speedballing), using cigarette filters to draw up prepared drug, and injection under unhygienic conditions, have been linked to adverse outcomes such as abscesses, skin and soft tissue infections, injection site ulcers, and endocarditis[1725]. Local and national public health authorities have implemented harm reduction measures to raise awareness and to educate IDUs regarding these risky behaviors. However, efforts have not been focused on raising awareness of the long-term consequences of injection-related venous damage among IDUs, which can lead to CVI and lower extremity ulcers. The effectiveness of these programs may also be attenuated by an individual’s severity of addiction, socio-cultural environment and prior exposure to harm reduction messages[5].

Some studies have determined that older IDUs who started injecting at a young age, as opposed to later in adulthood, were more likely to have high-risk injection practices including sharing of injection equipment and more frequent injection[26, 27]. In addition, the existing literature regarding the aging IDU population focuses on general physical and mental health conditions or injection-related behaviors[13, 15, 16, 2629]. The injection behaviors and socio-demographic characteristics of IDUs living with chronic wounds have not been well explored, even though chronic wounds are a significant health concern among older active or former IDUs.

We examined the prevalence of chronic wounds and associated injection-related behaviors among an IDU population accessing needle exchange services from the Baltimore City mobile Needle Exchange Program (BNEP), which has been in operation since 1994[30]. We were interested specifically in determining whether there were distinctions between the demographics and behaviors of older IDUs living with chronic wounds as compared to their peers and younger IDUs. An improved understanding of the behaviors of older IDUs may help inform prevention strategies and both skin- and drug-related treatment efforts for individuals living with chronic wounds.

Methods

We conducted a cross-sectional study among active IDU participants of the BNEP, age ≥18 years, regardless of wound status. Data collection occurred between May 2012 and November 2013 and was conducted at five different exchange sites, though most participants were from Site A and Site B, which were 1.9 miles apart and demographically distinct. Site A is frequented primarily by African Americans and Site B is frequented primarily by Caucasians. Site C was near several local exotic dance clubs and was geographically separate from Sites A and B.

All participants provided written, informed consent and completed a paper-administered survey including questions addressing demographics, injection behaviors, pre-injection skin care, wound history, wound care, and general medical history. Surveys required approximately 20 minutes and upon completion, participants were given a $10 gift card for local businesses. Chronic wounds were defined as open areas on the skin that had been present and non-healing for ≥8 weeks. Study team members visually verified the presence of chronic wounds at the time of the survey. This study was approved by the Johns Hopkins Medicine Institutional Review Board.

Participants were stratified into four groups by reported age (<45 years or ≥45 years) and wound status (presenting with a current chronic wound or without a current chronic wound). The primary outcome was considered the presence of a chronic wound among participants ≥45 years. This outcome was independently compared to three distinct reference groups: 1) participants < 45 years without chronic wounds; 2) participants ≥45 years without chronic wounds; 3) participants < 45 years with chronic wounds.

All variables were categorical except for age and number of times a needle was used, which were continuous variables. Predictor variables associated with the primary outcome group were analyzed using univariate and multivariate logistic regression. Odds ratios predicting risk of outcomes of interest with 95% confidence intervals were assessed. T-tests were used to compare means and/or proportions. P values ≤ 0.05 were considered statistically significant. Statistical analysis was performed using Stata 12 (StataCorp, College Station, TX).

Results

A total of 152 individuals were surveyed. The overall prevalence of chronic wounds was 19.7% (n/N = 30/152). Of the 152 individuals, 73 were younger than 45 years (48.0%) and 79 were aged 45 years or older (52.0%). Of those with chronic wounds, 12 were in individuals younger than 45 years (40.0%) and 18 were in individual aged 45 years or older (60.0%) (p = 0.121). We focused our analysis on the latter subgroup of participants: IDUs who were 45 years of age or older with at least one current chronic wound. This group accounted for 11.8% of all study participants (18/152).

Within the particular subgroup of interest (IDUs age ≥45 years with chronic wound(s)), the median age was 55 years with an interquartile range (IQR) of 46–58. The participants were primarily male (61.1%), African American (72.2%), reported having stable housing (94.4%), and had a self-reported HIV prevalence rate of 27.8% (5/18). They reported long histories with injection drug use, most having injected for greater than 15 years (94.4%). The most frequently reported injection behaviors included daily heroin injection (72.2%), daily speedball injection (55.6%), leg injection (61.1%) and cleaning the injection site with alcohol before injecting (72.2%). Of the nine participants who reported reusing their needles (9/18, 50.0%), seven of eight reported cleaning their needles with bleach prior to reuse (87.5%). Older IDUs with chronic wounds also reused their needles less frequently compared to their peers without wounds (p = 0.021) and compared to younger IDUs without wounds (p < 0.001). See Table 1 for additional information on demographics, injection practices and medical history for all participants, participants in the outcome group (IDUs age ≥45 years with chronic wound(s)), and participants in the three reference groups.
Table 1

Socio-demographic, medical and injection behaviors by age and chronic wound status †

 

All participants

Outcome group ≥45 years, with chronic wound

Reference group #1 <45 years, no chronic wound

Reference group #2 ≥45 years, no chronic wound

Reference group #3 < 45 years, with chronic wound

Description

No. (%)

No. (%)

No. (%)

p a

No. (%)

p a

No. (%)

p a

N = 152

N = 18

N = 61

N = 61

N = 12

All participants (N = 152)

152 (100.0)

18 (11.8)

61 (40.1)

61 (40.1)

12 (7.9)

Ageb,c

45; (35–52)

55; (46–58)

33; (28–39)

<0.001*

52; (49–57)

0.579

40; (35–42)

<0.001*

Gender

        

 Male

96 (63.2)

11 (61.1)

31 (50.8)

0.442

48 (78.7)

0.131

6 (50.0)

0.548

 Female

56 (36.8)

7 (38.9)

30 (49.2)

0.442

13 (21.3)

0.131

6 (50.0)

0.548

Race

        

 Caucasian

75 (49.3)

4 (22.2)

47 (77.1)

<0.001*

16 (26.2)

0.701

8 (66.7)

0.015*

 African American

68 (44.7)

13 (72.2)

9 (14.8)

<0.001*

44 (72.1)

0.926

2 (16.7)

0.003*

 Native American

4 (2.6)

1 (5.6)

1 (1.6)

0.379

0 (0.0)

0.063

2 (16.7)

0.322

 Other or Multipled

5 (3.3)

0 (0.0)

4 (6.6)

0.263

1 (1.6)

0.589

0 (0.0)

Housinge

        

 Stable

113 (74.3)

17 (94.4)

41 (67.2)

0.022*

47 (77.1)

0.100

8 (66.7)

0.046*

 Unstable

39 (25.7)

1 (5.6)

20 (32.8)

0.022*

14 (23.0)

0.100

4 (33.3)

0.046*

Exchange site

        

 Site A

54 (35.5)

9 (50.0)

10 (16.4)

0.003*

34 (55.7)

0.670

1 (8.3)

0.018*

 Site B

72 (47.4)

5 (27.8)

40 (65.6)

0.004*

18 (29.5)

0.889

9 (75.0)

0.011*

 Site C

5 (3.3)

0 (0.0)

4 (6.6)

0.263

0 (0.0)

1 (8.3)

0.214

 Other

21 (13.8)

4 (22.2)

7 (11.5)

0.249

9 (14.8)

0.457

1 (8.3)

0.316

Jail/prison - past 6 months

45 (29.6)

1 (5.6)

28 (45.9)

0.002*

12 (19.7)

0.157

4 (33.3)

0.046*

Years injecting drugs

        

 ≤2

15 (9.9)

0 (0.0)

12 (19.7)

0.041*

2 (3.3)

0.435

1 (8.3)

0.214

 3 – 8

25 (16.4)

0 (0.0)

18 (29.5)

0.009*

5 (8.2)

0.209

2 (16.7)

0.073

 9 – 14

20 (13.2)

1 (5.6)

12 (19.7)

0.157

5 (8.2)

0.715

2 (16.7)

0.322

 ≥15

92 (60.5)

17 (94.4)

19 (31.2)

<0.001*

49 (80.3)

0.157

7 (58.3)

0.016*

Injection site location

        

 Arm

92 (60.5)

7 (38.9)

38 (62.3)

0.078

39 (63.9)

0.059

8 (66.7)

0.136

 Leg

37 (24.3)

11 (61.1)

8 (13.1)

<0.001*

16 (26.2)

0.006*

2 (16.7)

0.016*

 Neck

17 (11.2)

4 (22.2)

10 (16.4)

0.571

2 (3.3)

0.008*

1 (8.3)

0.317

Drug treatment programf

36 (23.7)

8 (53.3)

12 (20.7)

0.012*

15 (25.4)

0.037*

1 (11.1)

0.039*

Using cigarette filterg

65 (42.8)

2 (11.8)

31 (51.7)

0.003*

28 (46.7)

0.009*

4 (40.0)

0.089

Using needles (# of times)h

3; 1 – 4

1; 1 – 3

3; 2 – 7

<0.001*

2; 1 – 3

0.021*

3; 2 – 3

0.112

Clean needles upon reusei

        

 Water

56 (50.5)

1 (12.5)

29 (60.4)

0.012*

23 (51.1)

0.043*

3 (30.0)

0.375

 Bleach

55 (49.5)

7 (87.5)

19 (39.6)

0.012*

22 (48.9)

0.043*

7 (70.0)

0.375

Cleaning injection sitej

        

 Do not clean

35 (23.0)

4 (22.2)

13 (21.3)

0.935

12 (19.7)

0.817

6 (50.0)

0.114

 Water

12 (7.9)

0 (0.0)

4 (6.6)

0.263

7 (11.5)

0.132

1 (8.3)

0.214

 Soap/water

14 (9.2)

0 (0.0)

9 (14.8)

0.083

4 (6.6)

0.263

1 (8.3)

0.214

 Alcohol

83 (54.6)

13 (72.2)

33 (54.1)

0.171

34 (55.7)

0.210

3 (25.0)

0.011*

 Multiple or other

8 (5.3)

1 (5.6)

2 (3.3)

0.655

4 (6.6)

0.879

1 (8.3)

0.772

Medical care provider

        

 Clinic

48 (31.6)

9 (50.0)

14 (23.0)

0.027*

23 (37.7)

0.350

2 (16.7)

0.064

 Private doctor

14 (9.2)

1 (5.6)

5 (8.2)

0.715

6 (9.8)

0.581

2 (16.7)

0.322

 Emergency room

85 (55.9)

8 (44.4)

42 (68.9)

0.058

28 (45.9)

0.911

7 (58.3)

0.456

 Other

5 (3.3)

0 (0.0)

0 (0.0)

4 (6.6)

0.263

1 (8.3)

0.214

† All numbers have been rounded to nearest decimal place.

ap values refer to the comparison between the Reference group and the Outcome Group. p value for "Age" was obtained using two-group mean comparison t-test. All other p values were obtained using two-group proportion t-test.

bContinuous variable.

cMedian; (Interquartile range).

dHispanic, Asian, multiple.

eUnstable includes living in a shelter, on the streets, in an abandoned unit, no set place, or multiple. Stable housing includes living in an owned/rented house, subsidized housing, with a friend, other (e.g. transitional house).

fParticipant in a drug treatment program; Denominator changes where responses were missing: All: N = 152; Outcome group: N = 15; Reference group #1: N = 58; Reference group #2: 59; Reference group #3: N = 9.

gUsing cigarette filters to draw up prepared drug; Denominator changes where responses were missing: All: N = 152; Outcome group: N = 17; Reference group #1: N = 60; Reference group #2: 60; Reference group #3: N = 10.

hDenominator changes where responses were missing: All: N = 150; Outcome group: N = 17; Reference group #1: N = 61; Reference group #2: 60; Reference group #3: N = 12.

iIncludes only participants who reported reusing needles. All: N = 111; Outcome group: N = 8; Reference group #1: N = 48; Reference group #2: 45; Reference group #3: N = 10.

jMost frequent method of cleaning injection site before injection; "Other" includes bleach, saliva, baby wipe, multiple agents.

*p ≤ 0.05.

Older IDUs with chronic wounds compared to younger IDUs without wounds

Compared to individuals younger than 45 years who did not have chronic wounds, the univariate analysis indicated that participants older than 45 years old with chronic wounds were more likely to be African American compared to Caucasian (Odds ratio (OR) 17.0, 95% Confidence interval (CI) 4.5 – 64.1, p < 0.001), to have stable housing (OR 8.3, 95% CI 1.0–66.8, p = 0.047), to visit a clinic as their primary source of medical care rather than an emergency room (OR 3.4, 95% CI 1.1–10.4, p = 0.035), and to frequent BNEP site A versus Site B (OR 7.2, 2.0–26.3, p = 0.003) (Table 2A). They were also more likely to have injected drugs for 15 or more years (OR 10.7, 95% CI 1.3–91.5, p = 0.030), to be participating in a drug treatment program (OR 4.4, 95% CI 1.3–14.5, p = 0.016), to inject speedball everyday (OR 4.2, 95% CI 1.1–15.7, p = 0.035), to inject into the leg (OR 10.4, 95% CI 3.1–34.7, p = <0.001) and to clean needles with bleach upon reuse (OR 10.7, 95% CI 1.2–93.9, p = 0.033). Additionally, they were less likely to have been in jail or prison for more than 24 hours during the past 6 months (OR 0.07, 95% CI 0.009–0.6, p = 0.012), and also less likely to use cigarette filters to draw up prepared drug (OR 0.1, 95% CI 0.03–0.6, p = 0.009).
Table 2

Group #1: Older IDUs with chronic wounds compared to younger IDUs without wounds

 

A. univariate (N = 79)

B. multivariatea(N = 71)

OR

95% CI

p

OR

95% CI

p

Race

      

 Caucasian

Ref

  

Ref

  

 African American

17.0

4.5 – 64.1

<0.001*

16.3

1.4 – 190.3

0.026*

 Native American

11.8

0.6 – 225.4

0.102

9.3

0.2 – 475.3

0.268

 Other

b

     

Housingc

      

 Unstable

Ref

     

 Stable

8.3

1.0 – 66.8

0.047*

d

  

Medical Care

      

 Emergency room

Ref

     

 Clinic

3.4

1.1 – 10.4

0.035*

d

  

 Private doctor

1.1

0.1 – 10.2

0.996

   

 Other

b

     

Exchange site (N = 29)

      

 Site A

Ref

  

Ref

  

 Site B

7.2

2.0 – 26.3

0.003*

1.5

0.2 – 12.0

0.719

 Site C

4.6

1.0 – 21.3

0.053*

17.8

1.2 – 254.5

0.034*

Time injecting drugs (years)

      

 9 – 14

Ref

     

 ≥15

10.7

1.3 – 91.5

0.030*

d

  

Participating in drug treatment program

      

 No

Ref

     

 Yes

4.4

1.3 – 14.5

0.016*

d

  

Speedball

      

 Never

Ref

     

 Occasionally

1.2

0.3 – 5.3

0.820

d

  

 Everyday

4.2

1.1 – 15.7

0.035*

   

Injecting into leg

      

 No

Ref

  

Ref

  

 Yes

10.4

3.1 – 34.7

<0.001*

9.9

1.3 – 73.1

0.024*

Skin-popping

      

 No

Ref

     

 Yes

4.4

1.0 – 19.9

0.055

d

  

Cleaning needle with bleach upon reuse

      

 Water

Ref

     

 Bleach

10.7

1.2 – 93.9

0.033*

d

  

Jail/Prison during last 6 months

      

 No

Ref

     

 Yes

0.07

0.009 – 0.6

0.012*

d

  

Cigarette filters to draw up drug

      

 No

Ref

  

Ref

  

 Yes

0.1

0.03 – 0.6

0.009*

0.06

0.004 – 0.9

0.039*

Abbreviations: IDUs injection drug users, OR odds ratio, CI confidence interval.

aVariables with at least one category with p ≤ 0.010 at the univariate level were included in the multivariate model.

bInsufficient observations for both univariate and multivariate logistic regression.

cUnstable includes living in a shelter, on the streets, in an abandoned unit, no set place, or multiple. Stable housing includes living in an owned/rented house, subsidized housing, with a friend, other (e.g. transitional house).

dNot included in multivariate model.

*p ≤ 0.05.

In the multivariate model, older individuals with wounds were more likely to be African American (Adjusted odds ratio (AOR) 16.3, 95% CI 1.4–190.3, p = 0.026) and inject into the leg (AOR 9.9, 95% CI 1.3–73.1, p = 0.024), and they were less likely to use cigarette filters (AOR 0.06, 95% CI 0.004–0.9, p = 0.039) (Table 2B).

Older IDUs with chronic wounds compared to similar-aged peers without wounds

Among participants 45 years or older, those with a chronic wound were more likely to be in a drug treatment program (OR 3.4, 95% CI 1.0–10.8, p = 0.043), and to inject into the leg (OR 4.4, 95% CI 1.5–13.4, p = 0.008) or neck (OR 8.4, 95% CI 1.4–50.7, p = 0.020), compared to the same age group without chronic wounds (Table 3A). In the multivariable model, older individuals with chronic wounds remained less likely to use cigarette filters when drawing up prepared drug into the syringe (AOR 0.1, 95% CI 0.01–0.9, p = 0.044) (Table 3B).
Table 3

Group #2: Older IDUs with chronic wounds compared to older IDUs without wounds

 

A. univariate (N = 79)

B. multivariatea(N = 72)

OR

95% CI

p

OR

95% CI

p

Trading sex for money

      

 No

Ref

  

Ref

  

 Yes

3.3

1.1 – 10.0

0.039*

2.3

0.4 – 13.9

0.346

Participating in drug treatment program

      

 No

Ref

  

Ref

  

 Yes

3.4

1.0 – 10.8

0.043*

3.2

0.8 – 12.9

0.098

Injecting into leg

      

 No

Ref

  

Ref

  

 Yes

4.4

1.5 – 13.4

0.008*

3.2

0.7 – 13.4

0.120

Injecting into neck

      

 No

Ref

  

Ref

  

 Yes

8.4

1.4 – 50.7

0.020*

4.9

0.4 – 58.3

0.212

Using cigarette filters to draw up drug

      

 No

Ref

  

Ref

  

 Yes

0.2

0.03 – 0.7

0.018*

0.1

0.01 – 0.9

0.044*

Abbreviations: IDUs injection drug users, OR odds ratio, CI confidence interval.

aVariables with at least one category with p ≤ 0.050 at the univariate level were included in the multivariate model.

*p ≤ 0.05.

Older IDUs with chronic wounds compared to younger IDUs with wounds

Among participants with chronic wounds, those 45 years or older were more likely to be African American (OR 13.0, 95% CI 1.9–88.0, p = 0.009), to exchange needles at Site A compared to Site B (OR 16.2, 95% CI 1.6–167.7, p = 0.020), to inject into the leg (OR 7.9, 95% CI 1.3–47.0, p = 0.024), and to clean the injection site with alcohol before injection (OR 6.5, 95% CI 1.1–38.6, p = 0.040) when compared to younger IDUs with chronic wounds (Table 4A). In the multivariate model, leg injection was more common among older individuals with chronic wounds (AOR 31.3, 95% CI 1.1–873.6, p = 0.043) (Table 4B).
Table 4

Group #3: Older IDUs with chronic wounds compared to younger IDUs with wounds

 

A. univariate (N = 30)

B. multivariatea(N = 21)

OR

95% CI

p

OR

95% CI

p

Race

      

 Caucasian

Ref

  

Ref

  

 African American

13.0

1.9 – 88.0

0.009*

4.3

0.06 – 290.1

0.502

 Native American

1.0

0.07 – 14.6

1.000

0.1

0.001 – 12.7

0.387

 Other

b

     

Exchange site (N = 29)

      

 Site A

Ref

  

Ref

  

 Site B

16.2

1.6 – 167.7

0.020*

2.0

0.03 – 146.2

0.751

 Site C

7.2

0.6 – 83.3

0.114

b

  

Injecting into leg

      

 No

Ref

  

Ref

  

 Yes

7.9

1.3 – 47.0

0.024*

31.3

1.1 – 873.6

0.043*

Cleaning injection site before injection (N = 26) c

      

 Do not clean

Ref

  

Ref

  

 Alcohol

6.5

1.1 – 38.6

0.040*

13.5

0.5 – 390.6

0.130

Abbreviations: OR odds ratio, CI confidence interval.

aVariables with at least one category with p ≤ 0.050 at the univariate level were included in the multivariate model.

bInsufficient observations for logistic regression

cOther categories within this variable were dropped in univariate and multivariate analysis due to insufficient observations. Dropped variables included water, soap/water, multiple or other.

*p ≤ 0.05.

Discussion

The high prevalence of chronic wounds in our community-recruited IDU study population (19.7%) and the disproportionate overrepresentation of older IDUs with chronic wounds (60%) suggests the need for focused interventions to improve awareness of injection-related venous damage and chronic wounds in IDUs to better prevent and treat this condition.

Upon comparing older IDUs with chronic wounds to their same-aged peers without chronic wounds and to younger IDUs with and without wounds, this group of older individuals with wounds appeared to engage in behaviors that were more consistent with self-care habits and less-risky injection practices. For example, they were more likely to have stable housing, use a clinic rather than an emergency room as the primary source of medical care, participate in a drug treatment program, clean needles with bleach, and clean their injection site with alcohol before injection. They were also less likely to have been recently in jail or prison, or to have used cigarette filters to draw up prepared drug. Use of cigarette filters, rather than needle exchange-distributed packed cotton filters, is considered riskier behavior and generally discouraged by harm reduction advocates because it is less effective at filtering particles out of the drug and can be associated with endocarditis or phlebitis[23, 31]. It is possible that older IDUs with wounds are in a different stage of life, as they have survived for many years with substance abuse issues and have perhaps learned to cope with their substance abuse and chronic health conditions better than younger IDUs. It remains to be determined if these differences in behaviors surrounding injection and cleanliness are a result of living with a chronic wound, maturing as an injection drug user and/or the internalization of the syringe exchange program’s ongoing harm reduction messages and education.

Older IDUs with wounds were more likely to be African American even after adjusting for exchange site. In contrast, younger IDUs were more likely to be Caucasian. These findings may be a reflection of the drug use patterns in Baltimore City and at the BNEP sites that were surveyed. This suggests that there are racial and/or socio-cultural differences among younger Caucasian IDUs that may lend preference for certain, and perhaps riskier, injection-related and other destabilizing behaviors that may lead to increased rates of homelessness and incarceration, among other factors, that we observed in this analysis. Understanding these differences within local subgroups of an IDU population may facilitate more targeted harm reduction efforts.

Other findings from this study are consistent with a population engaged in long-term injection drug use, which can lead to venous scarring and venous disease. As IDUs mature in their injection drug use habits, there may be increasing reliance on injecting into veins in other locations such as the leg or neck, as we observed among the older IDUs with wounds. Chronic wounds appear to be associated with prolonged drug use, even among the younger IDUs, as the majority of younger IDUs with chronic wounds had also been injecting for at least 15 years. Injecting into the leg together with prolonged injection drug use, resultant venous damage and physiologic aging of the veins, likely puts older IDUs at heightened risk for both CVI and lower extremity ulcers[32].

Our study had limitations. Participants were active members of the BNEP, and therefore they may report different injection and skin care practices than IDUs not accessing community-based harm reduction services and education. The survey also relied upon self-reported data. Additionally, there were limitations associated with the small sample size of individuals with chronic wounds, however the overall cohort size and survey design was sufficient to characterize some behaviors as truly distinct in the population with chronic wounds. Despite these potential limitations, we report for the first time self-care behaviors among older IDUs living with chronic wounds in a mobile metropolitan needle exchange program in Baltimore City.

Conclusions

Our findings suggest that older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene practices than their peers and younger IDUs without wounds. Moreover, older IDUs with chronic wounds may represent a different demographic among those using illicit substances and a distinct IDU subgroup that may be more receptive to local healthcare and/or substance abuse treatment messages. This subgroup may also be more likely to engage in meaningful relationships and therapeutic alliances with medical providers to address drug use and/or health conditions previously neglected.

Future public health and harm reduction interventions to raise awareness of the known associations between injection practices, venous damage, and chronic wounds among IDUs who have recently initiated injecting and among IDUs who have a prolonged injection history may represent valuable measures to prevent long-term wound-associated morbidity and disability. Harm reduction programs should consider including such educational information and referrals to local wound care centers in their regular encounters with IDUs.

Authors’ information

MES has a Bachelor of Science in Molecular and Cellular Biology and a Bachelor of Arts in History of Science, Technology and Medicine from the Johns Hopkins University. She is currently a research assistant for KEJ at the Johns Hopkins Medical Institutions.

NR obtained her Master of Science in Public Health from the Johns Hopkins Bloomberg School of Public Health. She has extensive experience with harm reduction efforts and works for the Baltimore City Health Department’s Community Risk Reduction Services.

PC, MD, MPH, is the Acting Deputy Commissioner, Division of Disease Control, Baltimore City Department of Health and has extensive experience in congressional, state, and municipal health and public health public policy.

KEJ, MD, MSc is Assistant Professor of Medicine in the Division of Infectious Diseases at the Johns Hopkins University School of Medicine. She completed a residency in Internal Medicine at the University of Colorado and a fellowship in Infectious Diseases at Johns Hopkins University. She has significant experience in translational research and public health program implementation. She is the primary physician for the BNEP’s wound care clinic and for this research study.

Abbreviations

IDUs: 

Injection drug users

CVI: 

Chronic venous insufficiency

IQR: 

Interquartile range

OR: 

Odds ratio

CI: 

Confidence interval

AOR: 

Adjusted odds ratio.

Declarations

Acknowledgements

The authors would like to acknowledge the Baltimore City Health Department Office of Community Risk Reduction Services, the Needle Exchange Program staff, clients, and study participants, the Johns Hopkins Bayview Medical Center Division of Infectious Diseases, and the Johns Hopkins Wound Healing Center. This work was supported by The Johns Hopkins University Woodrow Wilson Undergraduate Research Fellowship Program (MES); The Johns Hopkins University Center for AIDS Research, Baltimore HIV/AIDS Scholars Program 1P30A1094189 (MES); and The National Institutes of Health K23AI083100 (KEJ). The funding organizations had no role in the study design, data collection, data analysis, interpretation of data or writing and submission of the manuscript.

Authors’ Affiliations

(1)
Division of Infectious Diseases, Department of Medicine, Johns Hopkins Medical Institutions
(2)
Baltimore City Health Department

References

  1. DeBeck K, Small W, Wood E, Li K, Montaner J, Kerr T: Public injecting among a cohort of injecting drug users in Vancouver, Canada. J Epidemiol Community Health. 2009, 63 (1): 81-6. 10.1136/jech.2007.069013.View ArticlePubMedGoogle Scholar
  2. Gibson EK, Exner H, Stone R, Lindquist J, Cowen L, Roth EA: A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program. Drug Alcohol Rev. 2011, 30 (4): 360-5. 10.1111/j.1465-3362.2010.00219.x.View ArticlePubMedGoogle Scholar
  3. Small W, Kerr T, Charette J, Schechter MT, Spittal PM: Impacts of intensified police activity on injection drug users: evidence from an ethnographic investigation. Int J Drug Policy. 2006, 17 (2): 85-95. 10.1016/j.drugpo.2005.12.005.View ArticleGoogle Scholar
  4. Cooper H, Moore L, Gruskin S, Krieger N: The impact of a police drug crackdown on drug injectors' ability to practice harm reduction: a qualitative study. Soc Sci Med. 2005, 61 (3): 673-84. 10.1016/j.socscimed.2004.12.030.View ArticlePubMedGoogle Scholar
  5. Marshall BD, Kerr T, Qi J, Montaner JS, Wood E: Public injecting and HIV risk behaviour among street-involved youth. Drug Alcohol Depend. 2010, 110 (3): 254-8. 10.1016/j.drugalcdep.2010.01.022.PubMed CentralView ArticlePubMedGoogle Scholar
  6. Small W, Rhodes T, Wood E, Kerr T: Public injection settings in Vancouver: Physical environment, social context and risk. Int J Drug Policy. 2007, 18 (1): 27-36. 10.1016/j.drugpo.2006.11.019.View ArticlePubMedGoogle Scholar
  7. Briggs D, Rhodes T, Marks D, Kimber J, Holloway G, Jones S: Injecting drug use and unstable housing: scope for structural interventions in harm reduction. Drugs Educ Prev Pol. 2009, 16 (5): 436-50. 10.1080/09687630802697685.View ArticleGoogle Scholar
  8. Bourgois P: The moral economies of homeless heroin addicts: confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments. Subst Use Misuse. 1998, 33 (11): 2323-51. 10.3109/10826089809056260.View ArticlePubMedGoogle Scholar
  9. Rhodes T, Kimber J, Small W, Fitzgerald J, Kerr T, Hickman M, Holloway G: Public injecting and the need for 'safer environment interventions' in the reduction of drug-related harm. Addiction. 2006, 101 (10): 1384-93. 10.1111/j.1360-0443.2006.01556.x.View ArticlePubMedGoogle Scholar
  10. Rhodes T, Watts L, Davies S, Martin A, Smith J, Clark D: Risk, shame and the public injector: a qualitative study of drug injecting in South Wales. Soc Sci Med. 2007, 65 (3): 572-85. 10.1016/j.socscimed.2007.03.033.View ArticlePubMedGoogle Scholar
  11. Tempalski B, McQuie H: Drugscapes and the role of place and space in injection drug use-related HIV risk environments. Int J Drug Policy. 2009, 20 (1): 4-13. 10.1016/j.drugpo.2008.02.002.PubMed CentralView ArticlePubMedGoogle Scholar
  12. Masuda JR, Crabtree A: Environmental justice in the therapeutic inner city. Health Place. 2010, 16 (4): 656-65. 10.1016/j.healthplace.2010.02.003.View ArticlePubMedGoogle Scholar
  13. Taylor A, Cusick L, Kinder J, Hickman M, Rhodes T: The social impact of public injecting. Report of the Independent Working Group on Drug Consumption Rooms. 2006, York UK: Joseph Rowntree FoundationGoogle Scholar
  14. Flemen K: Blue light blues: The use of coloured lights as a deterrent to injecting.http://www.kfx.org.uk/resources/blue%20light%20blues.pdf,
  15. Parkin S, Coomber R: Fluorescent blue lights, injecting drug use and related health risk in public conveniences: findings from a qualitative study of micro-injecting environments. Health Place. 2010, 16 (4): 629-37. 10.1016/j.healthplace.2010.01.007.View ArticlePubMedGoogle Scholar
  16. Rhodes T, Stoneman A, Hope V, Hunt N, Martin A, Judd A: Groin injecting in the context of crack cocaine and homelessness: from 'risk boundary’ to 'acceptable risk’?. Int J Drug Policy. 2006, 17 (3): 164-70. 10.1016/j.drugpo.2006.02.011.View ArticleGoogle Scholar
  17. Thorne SE: Interpretive description. 2008, Walnut Creek CA: Left Coast PressGoogle Scholar
  18. Wood E, Tyndall MW, Montaner JS, Kerr T: Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Can Med Assoc J. 2006, 175 (11): 1399-404. 10.1503/cmaj.060863.View ArticleGoogle Scholar
  19. Wacquant LJD: Toward a social praxeology: the structure and logic of bourdieu's sociology. An Invitation to Reflexive Sociology. Edited by: Bourdieu P, Wacquant LJD. 1992, Chicago, Il: The University of Chicago Press, 1-59.Google Scholar
  20. Friedman SR: The political economy of drug-user scapegoating-and the philosophy and politics of resistance. Drugs Educ Prev Pol. 1998, 5 (1): 15-32.Google Scholar
  21. Petrar S, Kerr T, Tyndall MW, Zhang R, Montaner JS, Wood E: Injection drug users' perceptions regarding use of a medically supervised safer injecting facility. Addict Behav. 2007, 32 (5): 1088-93. 10.1016/j.addbeh.2006.07.013.View ArticlePubMedGoogle Scholar
  22. Fry CL: Injecting drug user attitudes towards rules for supervised injecting rooms: Implications for uptake. Int J Drug Policy. 2002, 13 (6): 471-6. 10.1016/S0955-3959(02)00076-2.View ArticleGoogle Scholar
  23. Small W, Ainsworth L, Wood E, Kerr T: IDU perspectives on the design and operation of North America's first medically supervised injection facility. Subst Use Misuse. 2011, 46 (5): 561-8. 10.3109/10826084.2010.517714.View ArticlePubMedGoogle Scholar
  24. Small W, Shoveller J, Moore D, Tyndall M, Wood E, Kerr T: Injection drug users' access to a supervised injection facility in Vancouver, Canada: the influence of operating policies and local drug culture. Qual Health Res. 2011, 21 (6): 743-56. 10.1177/1049732311400919.View ArticlePubMedGoogle Scholar
  25. Carruthers S: The organization of a community: community-based prevention of injecting drug use-related health problems. Subst Use Misuse. 2007, 42 (12–13): 1971-7.View ArticlePubMedGoogle Scholar
  26. Crofts N, Herkt D: A history of peer-based drug-user groups in Australia. J Drug Issues. 1995, 25 (3): 599-616.Google Scholar
  27. Friedman SR, Des Jarlais DC, Sotheran JL, Garber J, Cohen H, Smith D: AIDS and self-organization among intravenous drug users. Int J Addict. 1987, 22 (3): 201-19.PubMedGoogle Scholar
  28. Friedman SR, De Jong W, Rossi D, Touzé G, Rockwell R, Des Jarlais DC, Elovich R: Harm reduction theory: users' culture, micro-social indigenous harm reduction, and the self-organization and outside-organizing of users' groups. Int J Drug Policy. 2007, 18 (2): 107-17. 10.1016/j.drugpo.2006.11.006.PubMed CentralView ArticlePubMedGoogle Scholar
  29. Jose B, Friedman SR, Neaigus A, Curtis R, Sufian M, Stepherson B, Des Jarlais DC: Collective organising of injecting drug users and the struggle against AIDS. AIDS, Drugs and Prevention: Perspectives on Individual and Community Action. Edited by: Rhodes T, Hartnoll R. 1996, London: GBR: Routledge, 216-33.Google Scholar
  30. Kerr T, Douglas D, Peeace W, Pierre A, Wood E: Responding to an emergency: Education, advocacy, and community care by a peer-driven organization of drug users: A case study of the Vancouver Area Network of Drug Users (VANDU). 2001, Ottawa, ON: Health Canada Hepatitis C Prevention, Support, and Research ProgramGoogle Scholar
  31. Southwell M: People who use drugs and their role in harm reduction. Harm Reduction: Evidence, Impacts and Challenges. 2010, Lisbon: European Monitoring Centre for Drugs and Drug Addiction, 101-4.Google Scholar
  32. Curtis M: Drug user community organizing in harm reduction and the war on drugs. War on Drugs, HIV/AIDS, and Human Rights. Edited by: Malinowska-Sempruch K, Elovich R. 2004, New York: International Debate Education Association, 284-304.Google Scholar
  33. Kerr T, Small W, Peeace W, Douglas D, Pierre A, Wood E: Harm reduction by a “user-run” organization: a case study of the Vancouver Area Network of Drug Users (VANDU). Int J Drug Policy. 2006, 17 (2): 61-9. 10.1016/j.drugpo.2006.01.003.View ArticleGoogle Scholar
  34. Henman AR, Paone D, Des Jarlais DC, Kochems LM, Friedman SR: Injection drug users as social actors: a stigmatized community's participation in the syringe exchange programmes of New York City. AIDS Care. 1998, 10 (4): 397-408. 10.1080/09540129850123939.View ArticlePubMedGoogle Scholar
  35. Moore LD, Wenger LD: The social context of needle exchange and user-self-organization in San Francisco: possibilities and pitfalls. J Drug Issues. 1995, 25 (3): 583-98.Google Scholar
  36. Jauffret-Roustide M: Self-support for drug users in the context of harm reduction policy: a lay expertise defined by drug users' life skills and citizenship. Health Sociol Rev. 2009, 18 (2): 159-72. 10.5172/hesr.18.2.159.View ArticleGoogle Scholar
  37. Kravetz D: Consciousness-Raising groups in the 1970's. Psychol Women Quart. 1978, 3 (2): 168-86. 10.1111/j.1471-6402.1978.tb00532.x.View ArticleGoogle Scholar
  38. Sowards SK, Renegar VR: The rhetorical functions of consciousness‒raising in third wave feminism. Commun Stud. 2004, 55 (4): 535-52. 10.1080/10510970409388637.View ArticleGoogle Scholar

Copyright

© Smith et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Advertisement