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

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.


Background
Older injection drug users (IDUs) are a growing subgroup of active IDUs and IDUs seeking treatment [1][2][3][4][5]. 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 gendermatched 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 [17][18][19][20][21][22][23][24][25]. 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 injectionrelated 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,[26][27][28][29]. 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 drugrelated 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).
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).

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,    (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).

Discussion
The high prevalence of chronic wounds in our communityrecruited 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.