abscess, chronic venous insufficiency, peripheral arterial disease, persons who inject drugs, PWID, skin, soft tissue infection, substance use, vascular, wounds



  1. Pieper, Barbara PhD, RN, CWOCN, ACNS-BC, FAAN


GENERAL PURPOSE: To explore skin and soft-tissue infections and vascular damage in persons who inject drugs and relate these changes to wound development and care.


TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.


LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:


1. Review the issues surrounding wound infections in persons who inject drugs.


2. Describe the risk factors and manifestations of wound infections in persons who inject drugs.


3. Summarize the treatment options for wound infections in persons who inject drugs.


ABSTRACT: The number of persons who inject drugs (PWIDs) is increasing. The literature has placed a substantial focus on the association between injection drug use and the transmission of blood-borne viral infections such as HIV and hepatitis C, but there is less extant research on other injuries such as skin and soft tissue infections (SSTIs), vascular damage, and associated wounds. Both SSTIs and vascular injury can result in marked morbidity and mortality and wounds that are slow to heal, likely to reoccur, and lifelong. The aims of this article are to (1) explore SSTIs and vascular damage in PWIDs and (2) relate these changes to wound development and care. Providers must address the health and psychosocial problems of PWIDs; take physical, psychosocial, and substance use histories; and develop multifocal plans of care. Finally, care must be provided in a nonjudgmental manner.


Article Content


In the US, the number of persons who inject drugs (PWIDs) is about 2.6% of the population 13 years or older, or more than 6.6 million persons in 2011.1 Heroin tends to be the most common injected drug, and its use has increased across most demographic groups in the US, from 1.6 per 1,000 persons older than 12 years between 2002 and 2004 to 2.6 per 1,000 between 2011 and 2013.2 According to the National Survey on Drug Use and Health for 2016, about 948,000 Americans reported using heroin in the past year. The increased use has been largely seen among young adults 18 to 25 years old.3


The literature has placed a substantial focus on the association between injection drug use and the transmission of blood-borne viral infections (ie, HIV and hepatitis C), but there is less extant research on nonviral injection-related injuries such as skin and soft tissue infections (SSTIs) and vascular damage, which can result in marked morbidity and mortality.4


The aims of this continuing education article are to (1) explore SSTIs and vascular damage in PWIDs and (2) relate these changes to wound development and care. Some of the key aspects of care for these conditions are summarized in the Table.



Common SSTIs include cellulitis (Figure 1) and skin abscesses (Figure 2),5 and SSTI is common in PWIDs. In one needle exchange program (N = 152), 17.8% (n = 27) had an active abscess and 19.7% (n = 30) had a chronic wound.6 The upper extremities were the most common place for an abscess, and the lower extremities were most common for chronic wounds. In a study of active (injected in the past 30 days) PWIDs (N = 201) recruited in San Francisco between 2011 and 2013, Dahlman and colleagues7 noted the self-reported prevalence of lifetime SSTIs was about 70%. These infections can lead to serious morbidity and costly emergency room visits and hospitalizations. By assessing billing records through chart abstraction for 349 PWIDs in Florida, SSTIs were reported in 64% (n = 223); the total cost to the hospital for services rendered to treat injection drug use-related infections for a year was approximately $11.4 million.8 According to the Hospital Episode Statistics for England 1997-2016, about 6% (n = 63,671) of SSTIs and vascular infections are injection related.9 The most common causes were cutaneous abscess, phlebitis, and cellulitis. The number of injection-related admissions increased 33% per year from 1997 and 1998 through 2003 and 2004.9

Figure 1 - Click to enlarge in new windowFigure 1. CELLULITIS OF THE KNEEReprinted from Berg D, Worzala K. Atlas of Adult Physical Diagnosis. Philadelphia, PA: Wolters Kluwer Health; 2005.
Figure 2 - Click to enlarge in new windowFigure 2. ABSCESSReprinted from Lugo-Somolinos A, McKinley-Grant L, Goldsmith LA, et al. VisualDx: Essentially Dermatology in Pigmented Skin. Philadelphia, PA: Wolters Kluwer; 2011.

Two terms are important to aid in the understanding of SSTIs in PWIDs: skin popping and speedballing. Skin popping is extravasal (intramuscular or subcutaneous) injection into confined tissue compartments. When injected into a vascular space, drugs are quickly diluted. This dilution effect does not occur when drugs are injected into skin or muscle.10 Subcutaneous and intramuscular injections also bypass exposure to the bloodborne immunologic response, which may increase the risk of infection.11


Speedballing is injecting heroin in combination with a vasoconstrictor such as cocaine or methamphetamine. This decreases local blood flow to the injection site and exacerbates ischemia.11 The addition of crack cocaine to heroin is rationalized as providing a "better high."12 The use of crack cocaine in speedballing has been associated with the deterioration of injection sites.12 In general, speedballing is associated with an increased risk of infection.13


If venous access is difficult because of vein sclerosis and/or poor injection technique, accidental subcutaneous and intramuscular injections may occur; these are called missed hits.14 Hope and colleagues14 interviewed 329 PWIDs in England and reported only three intended to inject subcutaneous or intramuscular tissue. Accidentally missing a vein occurred in 56% (n = 181) of participants. For persons who aimed to inject intravenously, redness, swelling, and tenderness at the injection site were reported by 49% (n = 70) who did not miss hits versus 72% (n = 131) of those with a missed hit; abscesses were reported by 36% (n = 52) versus 51% (n = 93); and open wounds were reported by 9.7% (n = 14) versus 18% (n = 33), respectively.14


Nonetheless, some PWIDs intentionally inject subcutaneously or intramuscularly or are forced to do so because of lack of other access. This can lead to local muscle inflammation and necrosis.11 After interviewing 51 active PWIDs in Denver, Colorado, Phillips and Stein13 reported that bacterial skin infections were significantly more likely to occur when someone injected drugs intramuscularly (odds ratio [OR], 1.57; 95% confidence interval [CI], 0.90-2.69; P = .09) rather than in a vein and were more frequent with heroin injection (OR, 1.08; 95% CI, 1.01-1.16; P = .02).13 Persons who skin popped were more likely to have an abscess or cellulitis than those who only injected intravenously.15 The development of an abscess from skin popping can result in an ulcer called a shooter's patch.10


Serious infections have increased since 2012 in PWIDs.9 Risk factors for redness, swelling, and tenderness included an arrest or overdose in the past year, frequent injections, or multiple injection sites; these signs and symptoms were less common in those who injected in the groin or always cleaned mixing containers.16 Other research has reported that femoral vein injections are associated with higher risk of SSTIs, possibly because of the heavy bacterial load in the groin and genital area.7 According to another study,9 infection is correlated with loss of venous access, missed veins when injecting, older PWIDs, and heavily colonized injection sites. Dahlman and colleagues7 examined behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices associated with SSTIs among PWIDs (N = 201). The prevalence of SSTIs was 11% (n = 22) in the preceding 30 days and 29% (n = 58) in the past year. Factors significantly (P <= .05) associated with recent SSTIs included injecting nonpowdered drugs (OR, 3.57; 95% CI, 1.23-10.35; P = .01); needle licking before injecting (OR, 3.36, CI 1.28-8.81; P = .01); injecting with a syringe/needle used by someone else (OR, 7.97, 95%, CI 2.46-25.83; P < .001); being injected by another person (OR, 2.63; 95% CI, 1.02-6.78; P = .04); infrequent or improper skin cleansing before injection (OR, 2.47; 95% CI, 1.009-6.10; P = .04); and frequent injections.


In a qualitative study using semistructured, in-depth interviews (N = 19) at a syringe exchange program, risk factors for SSTIs included dirty works (used equipment), not injecting into a vein, rushing, and failure to properly prepare injection materials or clean the injection site.17 An abscess was more common in those who overdosed in the past year, injected daily, had multiple injection sites, injected in the legs, and less common when the injection site was always swabbed. Injection site wounds were more common among women, those injecting daily, those with multiple injection sites, and those for whom their main source of income was illicit.16,18,19


The largest relative increase in injection-related admissions between 2012 and 2016 was among 45- to 55-year-olds, at 18% per year.9 Lewer et al9 noted older PWIDs may lose venous access, miss veins more often when trying to inject, use less accessible and more heavily colonized injection sites, and have worse immunity and poorer underlying health. Other variables associated with infection at any age were increased frequency of injecting, used needles, injecting in the neck, subcutaneous and intramuscular injecting, injecting prescribed drugs (crushed tablets and liquids), and lack of skin cleaning and handwashing.8,13,18


In summary, risk factors for infection and abscesses in PWIDs are numerous and vary based on injection practices and sites, age and sex of the PWIDs, and substances injected.


Care Considerations for SSTIs

Many SSTIs have variable presentations; diagnosis is predominantly based on clinical features. Predisposing factors associated with lower limb cellulitis include older age, obesity, venous insufficiency, and edema. Major dermatologic features of cellulitis of the leg included redness, edema, pain, and warmth; many of these individuals were afebrile.20


Cellulitis and abscesses are the two types of bacterial SSTIs that are predominately seen in the emergency department.21Staphylococcus aureus (60% methicillin-resistant) was the predominant pathogen.21,22 In a CDC report released in 2018, PWIDs were 16.2 times more likely to develop invasive methicillin-resistant S aureus infections than other individuals, increasing from 4.1% in 2011 and 9.2% in 2016.23 For patients who lick their needles (to make an old needle more slippery, check the quality of the drug, clean the needle, etc), oral flora may be present.22 Other causes included Staphylococcus pneumoniae, gram-negative bacteria, Clostridium species, and fungi.22 Hirschmann and Raugi20 reported 75% to 90% of cases of leg cellulitis were caused by various streptococci because they reside in the interdigital toe spaces.


Seeking care for SSTIs is an issue for PWIDs. Harris et al17 examined how 19 PWIDs made decisions to seek or delay medical treatment for SSTIs. They reported PWIDs had a basic understanding of SSTIs and risk factors. Most waited to seek care because of stigma. Self-reported treatments included increasing drug use for pain and lancing/draining their own abscesses. For patients diagnosed with SSTIs in a medical record review (N = 49), Pirozzi and colleagues24 reported that most (n = 42 [85.7%]) underwent surgical debridement; 12% (n = 6) left the hospital against medical advice; and 73% (n = 36) did not return for scheduled outpatient follow-up visits. Clinicians will find that PWIDs have many reasons for not keeping clinic appointments such as a lack of transportation, forgetfulness, a lack of financial resources, incarceration, and so on.25


In a retrospective study of patient visits for community-acquired SSTIs in three urban emergency departments, antibiotics were prescribed to 86.1% (n = 806) of the 936 emergency department patients with suspected community-acquired SSTIs.21 Hurley et al26 have identified issues such as antibiotic resistance in the treatment of uncomplicated skin infections with antibiotics. The use of broad-spectrum Gram-negative antibiotics is questioned because most uncomplicated skin infections are caused by Gram-positive pathogens. Combination antibiotic therapy for uncomplicated skin infection and cutaneous abscesses that are drained should be avoided.


Further, treatment with antibiotics for 5 to 6 days seemed to be as effective as 10 days. The Infectious Diseases Society of America has clinical practice guidelines for methicillin-resistant S aureus infections in adults.27 Consideration of comorbidities is important; antibiotic therapy is recommended for abscesses associated with severe or extensive disease or rapid progression in presence of cellulitis. The guidelines should be consulted for antibiotic selection. A clinical decision should weigh whether the infection in PWIDs is uncomplicated and if the guideline can be used.


Other treatment strategies for SSTIs include lower extremity elevation to decrease the edema and inflammatory components. Anti-inflammatory medications (such as ibuprofen) may help the inflammation to resolve.20 Weight loss and treating tinea pedis between the toes may help. Effective interventions include syringe service/exchange programs for access to sterile equipment and safe disposal, education on safer injection practices, and educating patients about the early warning signs of serious infections. In a study to examine risk associated with SSTIs in 143 PWIDs, Phillips and colleagues28 noted the social environment of PWIDs, lack of needle/syringe exchange, and limited access to healthcare and housing negatively affect the success of interventions. In that study, PWIDs reported both good care (felt provider was honest and gave care) and negative experiences (felt labeled, painful incision and drainage, felt need to withdraw, etc).


Based on a study of a hypothetical supervised injection facility in Baltimore, by having PWIDs inject in the presence of medical staff, supervised injection facilities can prevent hospital days for SSTIs and save roughly $930,000 annually.29 Although there are many regulations in the US about supervised injection facilities, it is possible that increasing their number could reduce SSTIs. Further study is warranted.


Finally, although most people with opioid use disorder do not report attending substance use treatment,30 encouraging patients to seek treatment is critical. Clinicians should never dismiss patients from their practice because of a substance use disorder.31 Clinicians must be comfortable asking about and assessing for substance use. They should discuss their concerns with the patient and allow the patient an opportunity to disclose their concerns.31 If a patient indicates interest, clinicians should offer or arrange for evidence-based treatment, including medication-assisted treatment (ie, methadone or buprenorphine) and behavioral therapies31 and offer naloxone for overdose prevention.



Many PWIDs are at risk of deep vein thrombosis (DVT; Figure 3). A major risk factor for DVT is injecting in the femoral vein; this risk is significant regardless of type of illicit drug used, age, gender, smoking status, and history of blood clotting disorders.32 Damage to the veins has long been reported with clots extending centrally within the vein lumen and causing complete or partial vein blockage.33

Figure 3 - Click to enlarge in new windowFigure 3. FORMATION OF A VENOUS THROMBUS(C)Anatomical Chart Company/Wolters Kluwer.

According to a recent literature review,34 PWIDs may constitute about 50% of persons younger than 40 years with DVT; in general, 47.6% of PWIDs reported DVT. In a study about precipitating events for women with objectively confirmed DVT (n = 206), injection drug use via the femoral vein accounted for 21.4% (44 of 206) of all cases, and this percentage increased to 52.4% (44 of 84) for women younger than 40 years.35


A PWID may have many risk factors for developing DVT, including major surgery, organ damage caused by drug use, and so on. Drug-induced stupor, immobilization, lack of muscle activity, injuries to the lower extremity, repeated injections, vein wall lesions, venous stasis, and sociodemographic and drug risk factors also increase the risk of DVTs.34 In their literature review, Kwiatkowska and colleagues34 noted that there are no guidelines for the treatment of DVT in PWIDs; the direct effect of heroin, cocaine, amphetamines, and opioids on the coagulation system is not well known.34 However, Amin and colleagues36 reported that patients wearing compression stockings immediately following a DVT had lower vein obstruction than those who were not receiving compression, as well as less postthrombotic syndrome (ie, pain, swelling, increased leg pigmentation); providers should explore this option with patients.


Regardless of the development of DVT, individuals who inject in the groin, lower extremities, and feet are at an increased risk for vascular damage. Persons who inject drugs generally fit two groups: those who inject into the groin and lower extremities as a primary site and those who use these sites when other sites cannot be used. The use of the groin as a primary site is generally because of the larger vein and faster blood flow, providing a "better rush." In addition, it is discreet and convenient, and track marks are hidden; it can be found with a single injection versus repeated injection attempts.37,38 Those PWIDs who have been injecting substances for a longer period tend to use the femoral vein as a last resort as they sequence through various sites.37


Damage to the veins of the lower extremities increases the risk of chronic venous insufficiency (CVI) and results in the most common wound of the lower extremity: a venous ulcer (Figure 4). In a cross-sectional, comparative study stratified by age, gender, ethnicity, and method of drug use (N = 713), persons who inject in the arms are 5.15 times (P < .04) more likely and leg injectors 54.33 times (P < .001) more likely to have current or healed venous ulcers than persons who do not inject drugs.39 Venous ulcers are slow to heal; as many as 20% do not heal within 2 years of treatment.40 Long-standing ulcers, infection, poor adherence to compression, and longer topical and systemic antibiotics are associated with worse healing.41

Figure 4 - Click to enlarge in new windowFigure 4. CLEAN VENOUS ULCER BEFORE TREATMENTReprinted from Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Philadelphia, PA: Wolters Kluwer; 2011.

In a cross-sectional study of 204 PWIDs, the prevalence of CVI was 87.7% (n = 179), with 57.8% (n = 118) in the most advanced stages (skin changes, healed ulcers, and open ulcers).42 In comparison, venous ulcers affect 1% of individuals in the general population.43 Usually, CVI from venous damage develops after 6 years of injecting, and PWIDs experience CVI changes in their third or fourth decades of life.39


Besides the veins, the calf muscle pump has a key role in promoting venous outflow. Normal ankle mobility and painless calf muscle action are required for the calf muscle pump to function. Limited ankle range of motion is known to contribute to venous congestion and edema in persons with CVI. Nerve and muscle damage from injecting drugs may impair the functioning of the calf muscle and ankle joint.44-46 To control pain in their legs, PWIDs may not move their feet or ankle joints while walking, thus losing the calf pump mechanism.


Venous ulcers negatively affect daily living; there are issues of pain, drainage, odor, altered mobility, restricted functioning, isolation, and depression.47 In interviews with 101 PWIDs, many (81.2% [n = 82]) reported having an injection-related wound, and 93.9% (n = 77) reported self-management of the wound.48 Wound care involved cleaning (73.2% [n = 60]), use of an ointment (47.6% [n = 39]), and dressing (19.5% [n = 16]). In a community study of PWIDs (N = 152), 19.7% (n = 30) of participants had a chronic wound.49 Adults 45 years or older were more likely to be enrolled in drug treatment and have less risky injection and hygiene behaviors than their peers and younger PWIDs without wounds.49 Factors associated with poor wound healing include obesity, a fixed ankle joint, minimal activity, wound recurrence, a long-standing ulcer, poor adherence to compression therapy, and infection.41,50,51


Arterial insufficiency needs to be assessed in persons with venous disease because of the need for compression therapy. Even if the ulcer closes, venous ulcers tend to recur; in the general population, up to 70% of venous ulcers reopen after only 3 months posthealing.52 This number is not known for PWIDs, although it is likely very high because of the potential for marked venous damage.


In a descriptive, retrospective chart review (N = 140), the average size of a venous ulcer when PWIDs sought treatment was 7 x 8.5 inches; wounds that did not heal were larger than those that closed.53 Pain in PWIDs with ulcers was rated highest with working, walking outside, standing, and stair climbing.54-56 In a cross-sectional, comparative study stratified by age, gender, ethnicity, and method of drug use (N = 713), the fall risk for a 45-year-old leg injector was comparable with noninjectors 65 years of age.57,58 Balance and gait changes were critical issues affecting fall risk. Often, PWIDs with a venous ulcer have problems with sleep.57,58


Poor sleep in persons with venous ulcers has been related to pain, worry, and odor.59 These individuals are also at risk of malnutrition. In a cross-sectional pilot study (N = 31), food sufficiency/security was marginal or lower for 39% (n = 12) of PWIDs with a venous ulcer; about 52% (n = 16) were at risk of malnutrition.60 Low food sufficiency/security was associated with less motivation for activity and less walking.60


Lymphedema can be a problem for PWIDs because of the destruction of the lymphatic system by contaminants in injected substances. Lymphedema often is present with venous disease, called phlebolymphedema. Best practice for lymphedema includes compression bandaging, meticulous skin care, education, manual lymphatic drainage, exercise, and compression garments for maintenance.61


Care Considerations: Venous Disease

Early treatment for venous disease is important so that interventions are effective.62 Physical, psychosocial, and substance use histories are critical for care planning. The practitioner should understand illicit drug, alcohol, and cigarette use in terms of substance, amount, duration, and the respective effects of these variables. The patient's lower extremities should be evaluated, especially for the clinical manifestations noted by the CEAP (Clinical, Etiologic, Anatomical, and Pathophysiological) classification for venous disease.40 Treatment of venous insufficiency includes decreasing edema with compression products and lower extremity elevation.


Treatment can be challenging because of poor follow-up care, chaotic lifestyle, homelessness, mental changes, lack of health insurance, and lack of transportation. Patients may feel uncomfortable or judged in a clinical setting. They may seek care from an emergency department because they know they will not be turned away. They may also decide to self-treat, so every encounter about wound care should include information about self-care. If the ulcer closes, these patients need to be fitted for compression hose and taught how to use them. If treatment includes anticoagulation medications, educate patients about the assigned coagulation clinic and the prescribed medications.


Drainage and odor are common wound complaints. Patients have reported negative feelings toward odor from leg ulcers that resulted in shame, disgust, and self-loathing.63 They were fearful others could smell the wound, and they limited social activities because of odor and drainage.63 Patients who are employed in a job that requires a lot of standing typically cannot elevate their legs at work, making drainage difficult to control. Lower extremity elevation and wound closure help to decrease drainage and odor. Wounds with heavy drainage will need more than one compression dressing change per week.


Some providers have used negative-pressure wound therapy to reduce periwound edema, which contains inflammatory mediators and surface contaminants.64 Jull and colleagues65 performed a systematic review of prescribed exercise with compression versus compression alone in treating patients with venous ulcers. Exercise was associated with increased venous ulcer healing at 12 weeks, and the combination of progressive resistance exercise plus prescribed physical activity was also effective. They concluded that simple progressive resistance and aerobic exercises may be suitable for patients with venous ulcers.65


Pain management can be a challenge. In 2016, the CDC published the Guideline for Prescribing Opioids for Chronic Pain.31 The guideline focuses on prescribing for chronic pain other than for active cancer treatment, palliative care, and at end of life. The document points out the benefits and harms of opioids and encourages nonopioid prescriptions as well as nonpharmacologic treatments. Since the guideline was published, the number of opioid prescriptions has declined.66 When looking at diagnoses for opioid prescriptions in the general population, most were for conditions associated with pain such as back pain and diabetes. In an interview survey (N = 702), 47.7% (n = 335) of PWIDs reported pain primarily in the lower legs (27.1% [n = 190]) and back (19.7% [n = 138]).7 Activities associated with the most pain included walking outside, standing, working, and going up and down stairs; all were rated 6 or higher on a 10-point pain scale.54-56 Pain is a dominant theme of care among PWIDs and affects quality of life, sleep, mobility, and functioning.47 Voon and colleagues67 reported that self-management of pain occurred when PWIDs were refused a prescription for pain medication and were homeless. Common strategies to self-treat pain were injecting heroin and obtaining diverted prescription pain medication on the street.67


Providers must look carefully at pain prescriptions for PWIDs in relation to SSTIs and/or a wound. Most heroin users have a history of nonmedical use of prescription opioid pain relievers,2 so a major question is how to treat pain. Nonsteroidal anti-inflammatory drugs are commonly prescribed for musculoskeletal pain but are associated with increased risk of cardiovascular disease and renal complications. It is not recommended that nonsteroidal anti-inflammatory drugs be used to treat patients with hypertension, heart failure, or chronic kidney disease.68


Be sure to assess mental status. In a large retrospective cross-sectional study (N = 78,976) of physical and mental health in the criminal justice system, 451 participants used heroin, with 17.6% (95% CI, 12.6-22.6) having fair or poor health and 54.9% (95% CI, 48.5-61.3) having no mental illness.69 Persons with some form of opioid or heroin disorder had significantly worse self-reported health, more chronic conditions, and higher levels of disability than those without reported opioid use. Depression is common in patients with wounds.47 Finally, PWIDs have significantly poorer health outcomes and mental and physical comorbidities than persons who do not inject drugs.70



Acute limb ischemia can occur with inadvertent or occasional arterial puncture. Intense burning pain is common when the artery is injected.12,71 Individuals may also experience gangrene or pregangrenous changes and neuromuscular deficits. Distal pulses may still be present.71 The pathology may include chemical arteritis resulting in endothelial damage and swelling. There may also be vasospasm and embolism of foreign material added to muscle ischemia and necrosis. Good collateral circulation in the upper extremities reduces critical ischemia and amputation.71 Angiography should be performed immediately to diagnose arterial spasm and thrombosis.71


Infected pseudoaneurysms are a common arterial complication caused by embolism of septic material from distant sites, direct arterial trauma, or infection spread from soft tissues near the vessel.71 They present as pulsatile swelling (often with cellulitis) surrounding induration-infected pseudoaneurysms and may be misdiagnosed as abscesses. Late presentation includes hemorrhage from the aneurysm and hypovolemic shock. Duplex ultrasonography is often used in diagnosis, and surgery is the mainstay of treatment for infected pseudoaneurysms.


About 8.5 million people in the US are affected by peripheral arterial disease (PAD),72 and PWIDs have the same nondrug risk factors for PAD as the general population: cigarette smoking, diabetes mellitus, history of cardiovascular disease, age older than 40 years, male sex, and sedentary lifestyle. In a cross-sectional stratified design (N = 640), Pieper and colleagues73 found that 93.5% (n = 599) of their participants in drug treatment smoked cigarettes. An ankle brachial index of less than 0.90, indicating PAD, was identified in 16.7% (n = 107) of participants.73 Those who ever smoked cigarettes were about five times more likely to have PAD. Female sex (OR, 2.10; 95% CI, 1.2-3.4) and years of smoking cigarettes (OR, 1.7 per 10 years' smoking; 95% CI, 1.1-2.8) were risks for PWIDs; a positive attitude toward physical activity was protective (OR, 0.63; 95% CI, 0.45-0.91).73


To help prevent amputation, the use of peripheral vascular revascularization has increased.72 In a retrospective cohort study (N = 61,969), nonelective 30-day readmission after revascularization procedures for PAD was 2.7% (n = 295 of 10,924) for those with a history of illicit drug use.71 The presence of PAD can negatively affect venous disease treatment because compression therapy is contraindicated if a patient's ankle brachial index is less than 0.5.51


Care Considerations: Arterial Disease

When PAD is diagnosed, clinicians must do everything they can to impact modifiable risk factors. For example, diabetes and hypertension should be adequately treated. Encourage smoking cessation. There are many treatment strategies for cigarette use, so practitioners should be available to match the patient's need with their insurance coverage. A vascular assessment and procedure may need to be done to improve arterial flow. Because patients may have both venous and arterial disease, the severity of arterial disease will affect the compression allowed for treatment of venous disease.



The number of PWIDs is increasing. Although there is justifiable concern about the occurrence of HIV and hepatitis C virus in PWIDs, there is less research about SSTIs and vascular disease in this population. Be sure to obtain a physical, psychosocial, and substance use history when treating PWIDs. Infections and abscesses need to be evaluated in terms of antibiotic use, incision, and drainage. Principles of venous disease and venous ulcer wound care include decreasing edema with compression dressings and stockings, lower extremity elevation, and increased activity. Venous disease is chronic; early and continuous patient education and reinforcement are crucial. Arterial insufficiency requires assessment to determine adequate blood flow for limb salvage. Chronic illnesses can interfere with wound healing.


Most important, PWIDs should be treated with respect. Providers should look at clinic schedules and how they can be flexible to accommodate the needs of this patient population. Community resources can be helpful in terms of drug treatment, nutrition, shelters, and other common issues. Remember, PWIDs may have both general and substance use-related healthcare problems.




* The most common injection drug use-related SSTIs are cutaneous abscess, phlebitis, and cellulitis. Risk factors are numerous and include injection practices and sites, age and sex of the PWIDs, and substances injected.


* Most PWIDs are at risk of DVT. Vascular injury most commonly affects the lower extremities, especially from injecting in the femoral vein.


* Venous ulcers may develop; be a challenge to treat in terms of pain, drainage, odor, mobility, mental health, and lifestyle; and tend to reoccur.


* Because of destruction of the lymphatic system with contaminants of substances injected, lymphedema can be a problem.


* Acute limb ischemia can occur with arterial puncture causing intense, burning pain, gangrene or pregangrenous changes, and neuromuscular deficit. Peripheral arterial disease may also develop from the presence of typical risk factors.


* Most important, PWIDs should be treated with respect and should never be turned away when seeking treatment.




1. Lansky A, Finlayson T, Johnson C, et al. Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections. PLoS One 2014;9(5):e97596. [Context Link]


2. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users-United States, 2002-2013. MMWR 2015;64(26):719-25. [Context Link]


3. Ihongbe TO, Masho SW. Prevalence, correlates and patterns of heroin use among young adults in the United States. Addict Behav 2016;63(2016):74-81. [Context Link]


4. Larney S, Peacock A, Mathers BM, Hickman M, Degenhardt L. A systematic review of injection-related injury and disease among people who inject drugs. Drug Alcohol Depend 2017;171(2017):39-49. [Context Link]


5. Summers PJ, Struve IA, Wilkes MS, Rees VW. Injection-site vein loss and soft tissue abscesses associated with black tar heroin injection: a cross-sectional study of two distinct populations in USA. Int J Drug Policy 2017;39(2017):21-7. [Context Link]


6. Smith ME, Robinowitz N, Chaulk P, Johnson KE. High rates of abscesses and chronic wounds in community-recruited injection drug users and associated risk factors. J Addict Med 2015;9(2):87-93. [Context Link]


7. Dahlman D, Hakansson A, Kral AH, Wenger L, Ball EL, Novak SP. Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: a community-based observational study. J Subst Abuse 2017;38(1):105-12. [Context Link]


8. Tookes H, Diaz C, Li H, Khalid R, Doblecki-Lewis S. A cost analysis of hospitalizations for infections related to injection drug use at a county safety-net hospital in Miami, Florida. PLoS One 2015;10(6);e0129360. [Context Link]


9. Lewer D, Harris M, Hope V. Opiate injection-associated skin, soft tissue, and vascular infections, England, UK, 1997-2016. Emerg Infect Dis 2017;23(8):1400-2. [Context Link]


10. Canales M, Gerhard J, Younce E. Lower extremity manifestations of "skin popping" an illicit drug use technique: a report of two cases. Foot 2015;25(2015):114-9. [Context Link]


11. Gonzales y Tucker RD, Frazee B. View from the front lines: an emergency medicine perspective on clostridial infections in injection drug users. Anaerobe 2014;30(2014):108-15. [Context Link]


12. Rhodes T, Briggs D, Kimber J, Holloway G. Crack-heroin speedball injection and its implications for vein care: qualitative study. Addiction 2007;102(11):1782-90. [Context Link]


13. Phillips KT, Stein MD. Risk practices associated with bacterial infections among injection drug users in Denver, CO. Am J Drug Alcohol Abuse 2010;36(2):92-7. [Context Link]


14. Hope VD, Parry JV, Ncube F, Hickman M. Not in the vein: 'missed hits', subcutaneous and intramuscular injections and associated harms among people who inject psychoactive drugs in Bristol, United Kingdom. Int J Drug Policy 2016;28(2016):83-90. [Context Link]


15. Binswanger IA, Kral AH, Bluthenthal RN, Rybold DJ, Edlin BR. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Clin Infect Dis 2000;30:579-81. [Context Link]


16. Hope VD, Hickman M, Parry JV, Ncube F. Factors associated with recent symptoms of an injection site infection or injury among people who inject drugs in three English cities. Int J Drug Policy 2014;25(2014):303-7. [Context Link]


17. Harris RE, Richardson J, Frasso R, Anderson ED. Perceptions about supervised injection facilities among people who inject drugs in Philadelphia. Int J Drug Policy 2018;52:56-61. [Context Link]


18. Dahlman D, Hakansson A, Bjorkman P, Blome MA, Kral AH. Correlates of skin and soft tissue infections in injection drug users in a syringe-exchange program in Malmo, Sweden. Subst Use Misuse 2015;50(12):1529-35. [Context Link]


19. Saeland M, Wandel M, Bohmer T, Haugen M. Abscess infections and malnutrition-a cross-sectional study of polydrug addicts in Oslo, Norway. Scandinavian J Clin Lab Invest 2014;74:322-8. [Context Link]


20. Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics. Part I. Lower limb cellulitis. J Am Acad Dermatol 2012;67(2):163.e1-e12. [Context Link]


21. Merritt C, Haran JP, Mintzer J, Stricker J, Merchant RC. All purulence is local-epidemiology and management of skin and soft tissue infections in three urban emergency departments. BMC Emerg Med 2013;13:26. [Context Link]


22. Torok ME, Conlon CP. Skin and soft tissue infections. Medicine 2009;37:11. [Context Link]


23. Jackson KA, Bohm MK, Brooks JT, et al. Invasive methicillin-resistant Staphylococcus aureus infections among persons who inject drugs-six sites, 2005-2016. MMWR 2018;67:625-8. [Context Link]


24. Pirozzi K, Van JC, Pontious J, Meyr AJ. Demographic description of the presentation and treatment of lower extremity skin and soft tissue infections secondary to skin popping in intravenous drug abusers. J Foot Ankle Surg 2014;53(2014):156-9. [Context Link]


25. Pieper B, DiNardo E. Reasons for nonattendance for the treatment of venous ulcers in an inner city clinic. J Wound Ostomy Contin Nurs 1998;25(4):180-6. [Context Link]


26. Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med 2013;126:1099-106. [Context Link]


27. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52(3):e18-e55. [Context Link]


28. Phillips KT, Anderson BJ, Herman DS, Liebschutz JM, Stein MD. Risk factors associated with skin and soft tissue infections among hospitalized people who inject drugs. J Addict Med 2017;11(6):461-7. [Context Link]


29. Irwin A, Jozaghi E, Weir BW, Allen ST, Lindsay A, Sherman SG. Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility. Mar Reduct J 2017;14(1):[29]. [Context Link]


30. Wu L-T, Zhu H, Swartz MS. Treatment utilization among persons with opioid use disorder in the United States. Drug Alcohol Depend 2016;169(2016):117-7. [Context Link]


31. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR 2016;65(No. RR-1):1-49. [Context Link]


32. Wright NMJ, Allgar V, Tompkins CNE. Associations between injecting illicit drugs into the femoral vein and deep vein thrombosis: a case study. Drug Alcohol Rev 2016;35:605-10. [Context Link]


33. Kirchenbaum SE, Midenberg ML. Pedal and lower extremity complications of substance abuse. J Am Podiatr Assoc 1982;72:380-7. [Context Link]


34. Kwiatkowska W, Knysz B, Gasiorowski J, Witkiewicz W. Deep vein thrombosis of the lower limbs in intravenous drug users. Postepy Hig Med Dosw 2015;69:510-20. [Context Link]


35. McColl MD, Tait RC, Greer IA, Walker ID. Injecting drug use is a risk factor for deep vein thrombosis in women in Glasgow. Br J Haematol 2001;112(3):641-3. [Context Link]


36. Amin EE, Bistervels IM, Meijer K, et al. Residual vein occlusion in relation to immediate compression and postthrombotic syndrome in deep vein thrombosis. Blood 2018;3:836783. [Context Link]


37. Rhodes T, Briggs D, Kimber J, Jones S, Holloway G. Crack-heroin speedballing injection and its implications for vein care: qualitative study. Addiction 2007;102:1782-90. [Context Link]


38. Hope VD, Scott J, Cullen KJ, Parry JV, Ncube F, Hickman M. Going into the groin: injection into the femoral vein among people who inject drugs in three urban areas in England. Drug Alcohol Depend 2015;152(2015):239-45. [Context Link]


39. Pieper B, Templin TN, Birk TJ, Kirsner RS. Impact of injection drug use on distribution and severity of chronic venous disorders. Wound Rep Regen 2009;17:485-91. [Context Link]


40. Bergan JJ, Schmid-Schonbein GW, Coleridge Smith PD, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med 2006;355:488-98. [Context Link]


41. Scotton MF, Miot HA, Abbade LP. Factors that influence healing of chronic leg ulcers: a retrospective cohort. An Bras Dermatol 2014;89(3):414-22. [Context Link]


42. Pieper B, Templin T. Chronic venous insufficiency in injection drug use. Res Nurs Health 2001;24:423-32. [Context Link]


43. Shiman MI, Pieper B, Templin TN, Birk TJ, Patel AR, Kirsner RS. Venous ulcers: a reappraisal analyzing the effects of neuropathy, muscle involvement, and range of motion upon gait and calf muscle function. Wound Rep Regen 2009;17:147-52. [Context Link]


44. Pieper B, Templin TN, Birk TJ, Kirsner RS. Effects of injection-drug injury on ankle mobility and chronic venous disorders. J Nurs Scholarsh 2007;39(4):312-8. [Context Link]


45. Pieper B, Templin TN, Kirsner RS, Birk T. Injection-related venous disease and walking mobility. J Addict Dis 2010;29(4):481-92. [Context Link]


46. Pieper B, Templin TN, Birk TJ, Kirsner RS. The standing heel-rise test: relations to chronic venous disorders and balance, gait, and walk time in injection drug users. Ostomy Wound Manage 2008;54(8):18-32. [Context Link]


47. Green J, Jester R, Mckinley R, Pooler A. The impact of chronic venous leg ulcers: a systematic review. J Wound Care 2014;23(12):601-12. [Context Link]


48. Roose RJ, Hayashi AS, Cunningham CO. Self-management of injection-related wounds among injecting drug users. J Addict Dis 2009;28(1):74-80. [Context Link]


49. Smith ME, Robinowitz N, Chaulk P, Johnson KE. Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study. Harm Reduction J 2014;11:28. [Context Link]


50. Milic DJ, Zivic SS, Bogdanovic DC, Karanovic ND, Golubovic ZV. Risk factors related to the failure of venous leg ulcers to heal with compression treatment. J Vasc Surg 2009;49:1242-7. [Context Link]


51. Verma H, Tripathi RK. Algorithm-based approach to management of venous leg ulceration. Semin Vasc Surg 2015;28(2015):54-60. [Context Link]


52. Franks PJ, Barker J, Collier M, et al. Management of patients with venous leg ulcers: challenges and current best practice. J Wound Care 2016;Suppl 6:S1-67. [Context Link]


53. Pieper B. A retrospective analysis of venous ulcer healing in current and former users of injected drugs. J Wound Ostomy Contin Nurs 1996;23(6):291-6. [Context Link]


54. Pieper B, Templin T. Lower extremely changes, pain, and function in injection drug users. J Subst Abuse Treat 2003;25:91-7. [Context Link]


55. Pieper B, Vallerand AH, Nordstrom C, DiNardo E. Comparison of bodily pain: persons with and without venous ulcers in an indigent care clinic. J Wound Ostomy Continence Nurs 2009;36(5):493-502. [Context Link]


56. Pieper B, DiNardo E, Nordstrom CK. A cross-sectional, comparative study of pain and activity in persons with and without injection-related venous ulcers. Ostomy Wound Manage 2013;59(5):14-23. [Context Link]


57. Pieper B, Templin TN, Goldberg A, DiNardo E, Wells M. Falls and balance confidence in persons with and without injection-related venous ulcers. J Addict Med 2013;7(1):73-8. [Context Link]


58. Pieper B, Templin TN. Falls, balance confidence, and lower body strength in patients seeking outpatient venous ulcer wound care. Adv Skin Wound Care 2016;29(2):85-93. [Context Link]


59. Pieper B, Templin TN. Sleep quality: a pilot study comparing patients with and without injection-related venous ulcers. J Wound Ostomy Contin Nurs 2016;43(5):471-4. [Context Link]


60. Pieper B, Templin TN. A cross-sectional pilot study to examine food sufficiency and assess nutrition among low-income patients with injection-related venous ulcers. Ostomy Wound Manage 2015;61(4):32-42. [Context Link]


61. Keast DH, Despatis M, Allen JO, Brassard AS. Chronic oedema/lymphoedema: under-recognised and under-treated. Int Wound J 2015;12:328-33. [Context Link]


62. Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FGR. Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population. J Vasc Surg 2002;36:520-5. [Context Link]


63. Jones JE, Robinson J, Barr W. Impact of exudate and odour from chronic venous leg ulceration. Nurs Stand 2008;22(45):53-61. [Context Link]


64. Kruse CR, Nuutila K, Lee CCY, et al. The external microenvironment of healing skin Wounds. Wound Rep Regen 2015;23:456-64. [Context Link]


65. Jull A, Slark J, Parsons J. Prescribed exercise with compression vs compression alone in treating patients with venous leg ulcers. A systematic review and meta-analysis. JAMA Dermatol 2018; online:e1-8. [Context Link]


66. Bohnert ASB, Guy GP Jr, Losby JL. Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's opioid guideline. Ann Intern Med 2018;169(6):367-75. [Context Link]


67. Voon P, Callon C, Nguyen P, et al. Self-management of pain among people who inject drugs in Vancouver. Pain Manag 2014;4(1):27-35. [Context Link]


68. Bouck Z, Mecredy GC, Ivers NM, et al. Frequency and association of prescription nonsteroidal anti-inflammatory drug use among patients with a musculoskeletal disorder and hypertension, heart failure, or chronic kidney disease. [ published online ahead of print October 8, 2018]. JAMA Intern Med 2018. [Context Link]


69. Winkelman TNA, Chang VW, Binswanger IA. Health, polysubstance use, and criminal justice involvement among adults with varying levels of opioid use. JAMA Network Open 2018;1(3):e180558. [Context Link]


70. Novak SP, Kral AH. Comparing injection and non-injection routes of administration for heroin, methamphetamine, and cocaine users in the United States. J Addict Dis 2011;30(3):248-57. [Context Link]


71. Fiddes R, Khattab M, Dakka MA, Al-Khaffaf H. Patterns and management of vascular injuries in intravenous drug users: a literature review. Surgeon 2010;8(2010):353-61. [Context Link]


72. Secemsky EA, Schermerhorn M, Carroll BJ, et al. Readmission after revascularization procedures for peripheral arterial disease. A nationwide cohort study. Ann Intern Med 2018;168(2):93-9. [Context Link]


73. Pieper B, Kirsner RS, Templin TN, Birk TJ. Peripheral arterial disease among substance abusers in drug treatment. Adv Skin Wound Care 2009;22(6):265-72. [Context Link]