The American Psychiatric Association defines addiction as
[horizontal ellipsis]a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence. People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s)[horizontal ellipsis] to the point that it takes over their life.1
With addiction, there are accompanying physical changes in the frontal cortex of the brain that impair judgment, decision-making, learning, memory, and behavior.1 The biochemical rewiring of the brain may make it difficult to overcome addictions even if a patient is motivated to change! One of the most difficult aspects of care is treating persons who inject drugs (PWIDs).
This month's CE/CME article by Dr Barbara Pieper focuses on certain aspects of care for PWIDs, including skin and soft tissue infections, vascular damage/disease, and wounds. Other important findings inlcude the presence of cellulitis and abscesses, especially in the groin and on the legs and feet. Skin and wound healers must be aware of these complications, which can lead to a high morbidity and mortality in this growing patient population. These complications are not always given as much attention in the literature compared with the susceptibility to viral diseases such as HIV or hepatitis C.
Dr Pieper and other practitioners like her are very specific in their plea for PWIDs to receive respectful, nonjudgmental care. We must provide a safe environment for PWIDs to seek treatment because they may experience negative attitudes from other healthcare professionals based on their addiction. For regular follow-up of nonacute signs and symptoms, PWIDs should avoid the fragmented treatment from frequent visits to the emergency department, but these patients need to be comfortable with their healthcare providers to access ongoing care.
As part of our review of this topic, we reread a 2014 report published by UNAIDS.2 There were several statements in the document that highlight the patient's voice:
* "Health-care workers do not trust me, as if I just want drugs,"
* "I would like to give up drugs, but I cannot get help,"
* "There are no friendly health-care services near where I live,"
* "I am treated as a criminal and this makes it hard to take care of my health," and
* "Without clean needles and syringes, I have to share."
Statements such as these may help providers understand why PWIDs recognize the signs and symptoms of infection but are reluctant to access healthcare and may delay seeking needed treatment. Dr Pieper recognizes how this stigma can also result in some PWIDs creating their own solutions to address their care needs. Their ad hoc treatment plans can include draining their own abscesses as well as increasing drug use to manage pain, neither of which is likely to lead to desirable health outcomes.
An improved and empathetic approach to the management of addictive disorders and patients with these often devastating skin and vascular complications is needed. Closing the gap for these patients could involve healthcare providers advocating to change punitive laws that criminalize drug use, expanding evidence-informed services such as needle exchanges and expert interprofessional addiction services, and reducing stigma and personal discrimination against persons with addiction disorders.2
Elizabeth A. Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN
R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
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