Prevalences and correlates of non-viral injecting-related injuries and diseases in a convenience sample of Australian injecting drug users

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Abstract

Background

The prevalences and correlates of non-viral injecting-related injuries and diseases (IRIDs) in Australian injecting drug users (IDUs) remain unknown.

Methods

A cross-sectional survey of IDUs was conducted in six sites across Australia's eastern states to investigate IRID experience among Australian IDU. Correlates of IRIDs were explored using logistic and negative binomial regression analyses.

Results

393 IDUs were recruited. Lifetime experience of non-serious IRIDs was common (e.g., ‘dirty hit’ 68%); potentially serious and serious IRIDs were less commonly experienced (e.g., abscess 16%; gangrene <1%). Factors independently associated with potentially serious or serious IRIDs in the previous 12 months were: injecting in sites other than arms (Adjusted Odds Ratio 3.0, 95% confidence interval 1.7–5.4), injecting non-powder drug forms (5.0, 2.2–11.2), unstable accommodation (2.0, 1.1–3.5), being aged 25 years or older (4.3, 1.7–10.6) and not always washing hands before injection (9.3, 2.1–41.8). Factors independently associated with multiple IRIDs in the preceding 12 months were using three or more injecting sites (Adjusted Incidence Rate Ratio 1.5, 95% CI 1.1–2.0), injecting in sites other than arms (1.7, 1.3–2.2), using non-powder drug forms (1.9, 1.4–2.5), injecting daily or more often (1.7, 1.3–2.2), current pharmacotherapy experience (1.5, 1.1–1.9), and not always washing hands before injecting (1.9, 1.2–2.9).

Discussion

Some IRIDs are widespread among Australian IDUs. Observed associations, particularly the protective effect of handwashing, have useful public health implications.

Introduction

The process of injecting can give rise to both vascular and soft-tissue injuries and expose injecting drug users (IDUs) to a range of organisms that can cause localised or systemic infections. Some injecting-related injuries and diseases (IRIDs), such as infective endocarditis and deep vein thrombosis (DVT), are serious and require urgent medical attention. Others (e.g., abscesses, cellulitis), although requiring less urgent care, are potentially life-threatening if neglected. Others still are minor but common conditions (e.g., hives), and may contribute significantly to reduced health and wellbeing among injecting drug users (Ciccarone et al., 2001, del Giudice, 2004, Pieper and Templin, 2001, Woodburn and Murie, 1996).

The literature on non-viral IRIDs is relatively limited, confined largely to case-reports (Aboltins and Daffy, 2005, Cassoux et al., 2002, Crossley, 2003, Feeney and Fairweather, 2003) and outbreak studies from hospital presentations (Brett et al., 2005, Centres for Disease Control and Prevention Update, 2001, Finn et al., 2003, Kimura et al., 2004). Prevalence and incidence studies are uncommon although notable exceptions exist. In Glasgow, Morrison et al. (1997) surveyed current IDUs attending Needle Syringe Programs (NSPs), who also underwent medical examination by a clinical team. Clinical assessment indicated a prevalence of 21% active abscess, 49% thrombosis, 84% prominent scarring/bruising and 76% other injecting-related problems, including oedema, fasciitis, arterial damage, limited venous access and DVT. There were no significant differences between clinical assessment and IDU self-reports of current problems. In San Francisco, among a community sample of 169 IDU, Binswanger et al. (2000) found that 32% reported abscesses, cellulitis or both. In their cohort study of 1585 IDU in Vancouver, Lloyd-Smith et al., 2005 found 21% self-reported an abscess in the preceding 6 months. Prevalence and incidence IRID studies most commonly investigate abscess and cellulitis, followed by endocarditis. A study in Amsterdam between 1986 and 1994 found an abscess incidence rate of 33/100 person years and an endocarditis incidence rate of 1.3/100 person years among 758 IDUs (Spijkerman et al., 1996) while Tsao et al. (2002) identified 186 cases of endocarditis (2.4% of 7795 hospital visits) among IDU attending a San Francisco hospital between 1994 and 1999.

Associations have been documented between IRIDs and specific injecting practices such as subcutaneous injection, referred to as ‘skin-popping’ (Binswanger et al., 2000, Passaro et al., 1998) and groin injection (Rhodes et al., 2006a, Rhodes et al., 2006b). Injecting anywhere other than arms is considered high risk, increasing the likelihood of IRID such as thrombosis and DVT (Derricot et al., 2003).

Associations have also been documented between IRIDs and specific drug types and forms. In the UK and Australia, for example, the injection of temazepam capsules has been linked with DVT (Aitken and Higgs, 2002, Woodburn and Murie, 1996). In Australia, France and India, injecting-related injuries have been associated with the injection of sublingual buprenorphine tablets (Jenkinson et al., 2005). Finally, the black-tar heroin available in San Francisco has been associated with increased incidence of wound botulism (Passaro et al., 1998).

In Australia, the Illicit Drug Reporting System (IDRS) collects annual self-report information from IDUs on five injecting-related complications (difficulty injecting, scarring/bruising, ‘dirty hits’, thrombosis and infection/abscess) experienced in the month preceding the survey (O’Brien et al., 2007). Among 914 IDU, 7% reported experiencing infection/abscess in the past month, 6% reported thrombosis, 45% scarring/bruising and 43% reported difficulty in injecting. In 2006, the annual Australian NSP Survey, which measures blood-borne virus (BBV) prevalence and risk behaviours among clients of Australian NSPs, included additional self-report questions concerning experience of a small series of IRID and injecting-related problems. Of 1961 IDUs, 43% reported having experienced problems finding a vein and 40% reported scarring and bruising around their injection sites. Self-reported lifetime prevalence of abscess was 27%, thrombosis 12% and endocarditis (4%) (Topp et al., 2008).

Although these studies provide some relevant data no comprehensive assessment of IRIDs has been undertaken among Australian IDU, and the factors that increase the likelihood and severity of IRIDs have not been systematically investigated. This paper describes findings from an exploratory study investigating the prevalence and associations of a range of IRIDs among IDUs located in metropolitan and regional settings across eastern Australia.

Section snippets

Methods

A cross-sectional survey of current IDUs was conducted during November–December 2006 in three Australian states: Queensland, New South Wales and Victoria. Participants were recruited through NSPs and street and social networks. One metropolitan location (Brisbane) and one regional location (Toowoomba) were chosen in Queensland, one metropolitan location (outer Sydney) and one regional location (northern rivers—specifically Lismore and Nimbin) were chosen in New South Wales and one metropolitan

Results

A total of 393 IDUs were interviewed; their average age was 33 years (S.D. 8.5, range 18–65 years, median 32 years) and 73% were male. The majority (74%) were unemployed, and 33% had unstable accommodation (either homeless or living in four or more different places) in the previous 12 months. Two-third of the respondents were born in Australia. Of the overseas-born, 58% were born in Vietnam, 8% in New Zealand and 6% in the United Kingdom. Thirty participants (8%) identified as Indigenous

Discussion

Most IRIDs defined in this study as non-serious (e.g., transient redness, hives, ‘collapsed’/blocked veins) had been experienced by large majorities of IDUs; the most common non-serious IRID was the ‘dirty hit’ (indicative of transient bacteraemia) at 68%. In contrast, the most common potentially serious IRID was skin abscess (16%), and less than a quarter of participants reported any potentially serious IRID in the previous 12 months. Likewise, only 4% reported ever suffering septicaemia (the

Role of funding source

Funding for this study was provided by the Australian Government, Department of Health and Ageing, Australia. The funding source had no further involvement in the study.

Contributors

Robyn Dwyer designed the study, coordinated and oversaw of data collection, analysed and interpretation of data, drafted the article, revised it critically for important intellectual content and final approval of the version to be published. Guarantor of the study. Campbell Aitken designed the study, coordinated and oversaw of data collection, interpretation of data, drafted the article and revised it critically for important intellectual content and final approval of the version to be

Conflict of interest

None declared.

Acknowledgements

The authors are grateful to the people who participated in the IDU survey and contributed their experiences of injecting-related injuries and diseases. The authors also thank the anonymous reviewers for their thoughtful comments.

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