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This publication is available at https://www.gov.uk/government/publications/wound-aware-a-resource-for-drug-services/wound-aware-a-resource-for-commissioners-and-providers-of-drug-services

People who inject drugs (PWID) are at risk of serious and potentially life-threatening wounds and other tissue and blood vessel damage, because of what they inject and how they inject it.

Local services can be ‘wound aware’ by:

Local areas can provide wound aware services through an integrated, multidisciplinary approach that looks at wound care, harm reduction, drug treatment and recovery, pain management and social circumstances. The approach can include a range of services and groups including:

If local services can reduce the number of wound infections and subsequent complications experienced by PWID, it will help to improve their health and wellbeing. It will also give them opportunities to engage with drug treatment and recovery services.

Wounds (skin lesions and infections) and other health problems are commonly caused by injecting drug use. These can occur because of the injection mixture, technique and site, or from years of repeated injecting. They can also occur when PWID do not have access to adequate supplies of clean water and clean injecting equipment, and they re-use damaged equipment that has not been cleaned properly.

Common problems related to injecting are:

Signs and symptoms of wound infections include:

Untreated bacterial infections can lead to serious complications, such as blood poisoning or infection of the inner lining of the heart (endocarditis), that carry a high risk of death. PWID often do not go to hospital until late on in their infection, and they might even need to be admitted to intensive care. Drug services can help prevent hospital admissions and deaths by providing early and rapid access to treatment for infections.

PWID commonly reuse injecting equipment, which can increase the risk of infection. Public Health England’s (PHE’s) report Shooting Up: Infections among people who inject drugs in the UK shows that just over 1 in 3 PWID said they shared injecting equipment in 2018 and only around 3 in 5 PWID said they had enough needle and syringe provision for their needs.

Analysis of unlinked anonymous monitoring surveys of infections and risk among PWID found that the range of drugs being injected has increased in recent years and injecting crack cocaine has increased in England and Wales. These increases may lead to more sharing of equipment, groin injecting and more frequent injecting. These all put PWID at higher risk of wound infections.

Repeated injections into a single area can damage the skin and surrounding tissue, making it more susceptible to infection. Drug services should provide regular guidance and support on rotating injecting sites and getting early treatment for wounds to prevent further complications.

Drug services should support access to appropriate care for people presenting with wounds associated with injecting drugs. This may be through their GP, pharmacy (for minor infections) or local wound management service. Staff need to know the local services that are available, and the pathways to get people into care quickly.

Scarring: when a needle scratches the inside of the vein wall, it can cause scarring which can lead to a build-up of clots on the internal wall. As the clots build, the vein becomes narrower, restricting blood flow. This can lead to complete blockage and collapse of the vein.

Phlebitis: an irritation of the vein wall caused by overuse of acidifier, contaminants in the drug solution, injecting irritant substances or by repeatedly drawing and depressing the plunger after accessing a vein (also known as ‘flushing’).

Bacterial infections among PWID range from localised injection site infections through to life-threatening invasive diseases, such as staphylococcus aureus (including community-associated MRSA), group A streptococcus (GAS), wound botulism and tetanus.

Severity can vary from relatively minor localised skin infections that can be treated successfully with antibiotics and appropriate dressings, to complicated and aggressive infections or complications that can result in limb amputation or death.

Outbreaks of wound infections can spread quickly, most notably the anthrax outbreak in Scotland in 2009 which resulted in 47 confirmed cases and 13 deaths related to contaminated heroin.

Femoral vein (groin) injecting increases the risk of venous insufficiency (veins cannot carry blood back to the heart properly) and of deep vein thrombosis (DVT, a blood clot). The DVT can become infected and lead to venous ulcers, tissue necrosis (cell death), amputation, and potentially fatal pulmonary embolism (blockage of an artery in the lungs).

Injecting drug use is associated with some mental health diagnoses that include self-harming behaviours that increase the risk of infections, such as cutting and piercing the skin.

PWID with injection-related wounds often experience complex health and social barriers which prevent them from accessing care, such as homelessness, mental health diagnoses or chronic diseases. These can make it more difficult for PWID to get appropriate treatment.

Healthcare professionals need to consider the following barriers to accessing care or treatment when they are identifying patients’ wounds or providing support and options to someone who needs care:

To reduce the risk of wound-related infections, and to reduce the risk of further complications, drug services should:

Read more about safer injecting advice for service users.

Read more about what a ‘wound aware’ service looks like in the case studies section.

A drug service that is ‘wound aware’ focuses on preventing infections and will have the following features:

A drug service that is ‘wound aware’ will be alert and able to identify worsening injection sites or infections in service users. It will have the following features:

A drug service that is ‘wound aware’ provides advocacy and access routes to specialist treatment and support for wound infections. It will have the following features:

Read more about what a drug worker can do to help.

The need for a pilot service was identified after an outbreak of GAS infection among PWID. Many of the service users who were identified as being at risk had multiple complex needs including homelessness. Existing services were not engaging this group, who tended to only access healthcare when their problems had become acute and often needed hospitalisation.

A wound management clinic was set up in response to the outbreak and it was successful in initially engaging with this group but failed to encourage them to complete follow up treatment in generic health services.

Senior officers of the Blackpool and Fylde and Wyre clinical commissioning groups and the director of public health worked together to set up a dedicated nursing team for homeless people. This included general nursing and mental health posts and outreach support, to support people to access wound clinics and hepatitis C treatment. The nursing team worked together with Blackpool Fulfilling Lives peer navigators and Horizon, the integrated drug service’s assertive outreach team.

Recommendations from the pilot included the following:

For further information contact PublicHealth@blackpool.gov.uk

In Doncaster, a new role started in January 2019 as a partnership between Rotherham, Doncaster and South Humber NHS Trust’s (RDASH) tissue viability service and Doncaster’s Aspire drug service.

RDASH tissue viability service noticed that drug service users were often not attending appointments. At the same time, the Aspire drug service team asked the tissue viability service to help them meet the needs of people who were not in regular contact with primary care and were often using A&E for routine dressings. The role of a specialist drug wound care nurse was created to work with drug services and homeless people in the area. This was pilot funded for a year.

Findings from the first 8 months of the service included:

Adapted from Exchange Supplies’ Injecting tips: bacterial infections information leaflet.

Below is an example of the information that could be provided to a service user.

To prevent bacterial contamination of your hit, you should:

Look after your veins by following the advice below.

If you do get an infection, get medical help as soon as possible. Catching infections early will reduce the chance you will develop complications and need to be admitted to hospital.

Adapted from Exchange Supplies’ wound care pack contents list, which is based on work by the Bristol Drugs Project.

A wound care pack contains what someone needs to clean and cover a wound. This can reduce the risk of further damage until they can get to a healthcare professional who can assess and treat it.

Services can get advice on wound care pack contents from local tissue viability services, GPs and NHS trusts.

Different types of wound dressings can:

A wound care pack might contain:

Adapted from Wound Aware Australia.

Drug treatment and recovery workers can advise people who have wound care issues, including about their options for care and support.

A person with a wound is likely to be anxious about it, especially if they have had it for a while, if it has returned or if it’s their first wound. Drug treatment and recovery workers can reassure people that chronic wounds can heal with the right treatment.

The person may be embarrassed by how a wound looks or smells. This could result in less contact with their family, friends or healthcare professionals who can help. They might feel alone and isolated. A drug treatment worker can acknowledge these feelings and help the person with emotional and psychological support, while they support them to get the right healthcare.

Wounds can be painful which can lead to slower healing. Pain could be chronic background pain, pain experienced during treatment of the wound or anticipatory pain before treatment has started. People should be encouraged to request pain relief, or workers can advocate for it on their behalf. Good pain relief can stop people trying to cut out their own wounds or drain abscesses, which can lead to more damage and the need for more intensive and expensive interventions, including hospital admission.

Service users should be helped to understand that treatment can reduce how long it takes a wound to heal, and that specialist help is important. Explain that some wounds need specialist care from more than one type of health professional, for example a doctor (specialist or GP), a wound care nurse and perhaps a podiatrist (foot specialist).

‘Injecting tips: Preventing and caring for bacterial infections’ is an information leaflet for PWID. It was developed by Dr Magdalena Harris, from the London School of Hygiene and Tropical Medicine, in collaboration with the Bacterial Infections in PWID Working Group and London-based service users.

‘Keep it clean’ by Dr Magdalena Harris for The Pavement magazine outlines tips that can help PWID practise safe injecting.

Harm Reduction Works’ safer injecting resources include DVDs for injectors and booklets that offer advice on how to prolong the life of superficial veins, and to reduce the risk of infections and other problems.

Public Health Wales’ ‘Check mate … Ask, Check, Treat (ACT)’ campaign resources will soon be available. Email phw.hpadmin@wales.nhs.uk and include ‘ACT project’ in the subject line for further information.

Exchange Supplies’ wound care pack is available to buy on their website. The pack gives people the means to clean and cover a wound until they can get to a healthcare professional who can assess and treat it.

Scottish Drugs Forum’s e-learning course on injecting wound care, ‘How are your sites?’.

Bacterial and other infections are covered in the drug treatment clinical guidelines: pages 172-3.

Nursing Times’ article on understanding leg ulceration.

Nursing Times’ article on self-management of injection-related wounds.

PHE’s annual reports on infections among PWID in the UK, Shooting Up: Infections among people who inject drugs in the UK.

PHE’s unlinked anonymous monitoring (UAM) surveys of infections and risk among PWID.

PHE’s guidelines on preventing and managing bacterial wound infections in prison and other places of detention.

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