People who inject drugs (PWID) are at risk of a series of conditions related to this mode of drug administration. These conditions are grouped under the term ‘injecting-related injury and diseases’ (IRIDs). There is, however, significant variation in the definition and classification of these conditions in the scientific literature. Most often, cutaneous conditions, such as abscesses and cellulitis, are included as IRIDs, together with other injecting-related sequelae, such as septic arthritis, osteomyelitis, septicaemia, thrombosis and endocarditis. Other clinical signs associated with injecting, such as bruising, redness and skin hyperpigmentation (‘track marks’), are also sometimes classified as IRIDs¹ or in a separate category of injecting-related problems.^2,3 Various factors, such as repeated injection in the same area, not cleaning the injection site, use of non-sterile injecting equipment, ubiquitous skin flora (eg Streptococci, Staphylococci), as well as physical and chemical proprieties of the substances being injected, can all contribute to skin damage and the development of cutaneous and vascular IRIDs.^4–7

Barriers to accessing medical assessment and care are well documented among PWID. In relation to IRIDs, delayed treatment and access to hospital emergency departments for care have been reported and are associated with large healthcare costs.^8–11 Australian studies have consistently reported that a considerable proportion of PWID experience IRIDs during their lifetime.^1–3 While the risk factors associated with IRIDs are targeted by broader harm reduction/bloodborne virus prevention messages, few, if any, specific interventions have been developed or reported in the literature to date.

The Kirketon Road Centre (KRC) is a targeted primary healthcare facility of the South Eastern Sydney Local Health District (SESLHD), located in Sydney’s Kings Cross. KRC is focused on the prevention and treatment of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and other transmissible infections among ‘at risk’ young people, sex workers and PWID. KRC is among the most integrated services of its kind,¹² offering free, anonymous and confidential medical and nursing care, counselling, social welfare assistance, a needle syringe program, outreach services and a methadone access program. Thus, KRC was well placed to assess and treat IRIDs and implement preventive interventions among PWID.

Serological testing for exposure to transmissible infections (including HIV, hepatitis B and C, and syphilis) is routinely offered by experienced nurses and medical practitioners to all KRC clients who report a history of injecting and/or sexual risk behaviour. Clinicians are required to have considerable knowledge and manual skills in order to perform venepuncture associated with such testing, particularly among PWID with poor venous access as a result of previous cutaneous IRIDs. Communicating this expertise to PWID through demonstration during such procedures seemed to be an avenue worthy of further exploration. Moreover, the efficacy of safer injecting education for PWID,¹³ as well as the unmet need for non-judgemental venous access information and advice, had been documented.¹⁴

This study aimed to assess the impact of a clinician-led brief intervention involving the communication of specific, safer injecting messages and demonstration of injecting techniques delivered at the time of venepuncture for serological testing among PWID attending KRC.

Method

A before and after study design was used to evaluate the intervention. All KRC patients who self-identified as PWID and underwent serological testing between June 2011 and March 2012 were invited to participate in the study. The study was approved by SESLHD’s Human Research Ethics Committee (reference number 11/01).

At baseline, clinicians administered a brief survey exploring lifetime and recent history of a wide range of IRIDs, including:

• cutaneous conditions (cellulitis, abscess, skin ulcer)
• vascular conditions (thrombosis, phlebitis, distal limb amputation)
• osteo-articular and systemic infections (osteomyelitis, septic arthritis, septicaemia, endocarditis)
• any other drug-related conditions (drug-induced psychosis, convulsions, cardiac arrhythmia).

These IRIDs were described in lay language (eg ‘skin is red, hot, swollen and tender’ for cellulitis) to facilitate identification.

Injecting risk behaviours in the last month were also documented, including:

• frequency of injecting
• drugs used
• injecting alone
• being injected by other persons
• injecting in public places (street, park, beach, public toilet or squat)
• ability to locate a vein
• injecting sites used
• use of a tourniquet
• re-using injecting equipment
• injecting site
• hand hygiene.

To ensure consistency, KRC clinicians received training in venepuncture and safer injecting technique prior to implementing the intervention. Written reminders containing the key health messages were placed in the clinical consultation rooms.

Informed by the scientific literature on venepuncture technique, KRC clinicians delivered the following harm reduction messages:

• Preparing to inject: participants were advised to wash their hands with soap and water for a minimum of 15 seconds, or to rub their hands with alcohol-based hand rubs or swabs.¹⁵ They were shown how to assume a comfortable sitting position with the arm extended downward to ‘fix’ the veins, making them easier to puncture.¹⁶
• The correct application of a tourniquet: the advantages of using a tourniquet to dilate veins were discussed. This included a detailed explanation and demonstration showing that a tourniquet needs to be applied such that its pressure does not exceed arterial pressure and arterial blood flow from the heart into the limb is not obstructed, yet exceeds venous pressure such that venous blood flow from the distal limb back to the heart is restricted, thereby dilating the veins. Participants were also shown how the tourniquet should be released prior to the slow injection of drugs to prevent damage to the vein wall and regurgitation of the drug solution into the surrounding tissues.^16,17
• Correct injecting technique: a diagram of the veins in the upper limb was used to illustrate the location of the median cubital vein. Participants were then shown this vein and informed that it is usually larger, closer to the surface and more stationary, making it the easiest to puncture and least likely to bruise. Other options and the need to rotate injecting sites were also discussed.¹⁶

Participants were advised that the injection site should be cleaned with a circular motion for 4–6 cm for approximately 30 seconds, and that the area should be left to dry for a further 30–60 seconds.^18,19

As the clinician performed venepuncture, the upward position of the needle’s bevel and its insertion into the skin at a 15–30 degree angle was demonstrated, also showing how after some initial resistance, the needle will be felt to enter the vein.¹⁴ The clinicians demonstrated how pressure with gauze or a cottonwool ball was to be applied for up to two minutes to the injection site once the needle had been fully removed with the arm extended.

Participants were followed up on their return for serological test results or opportunistically at subsequent visits to KRC. A clinician-administered survey was used to document changes in injecting-related behaviours following the intervention or in the last month (whichever was shorter).

Data analysis was completed using Stata12 software (Stata Corporation, College Station, Texas). A McNemar test for paired proportions was used to assess significant changes in self-reported behaviours at follow-up, compared with baseline.

Results

Fifty-eight participants completed the baseline and follow-up surveys. The majority were male (58.5%) and the mean age was 35 years (range 19–53 years). Mean duration of follow-up was 42 days (range 2–303 days). Thirteen participants did not inject between intervention and follow-up, and were excluded from further analysis.

At baseline, almost half (44%) of the participants reported injecting daily or more in the previous month (Tables 1, 2). Just over half (51%) reported having had difficulties finding a vein at least some of the time, and the majority (67%) had missed a vein at least some of the time. At the last injecting episode, a large majority of participants used a new needle and syringe (90%). More than half (56%) used either soap and water or alcohol swabs to clean their hands prior to injecting. Less than half (47%) used a tourniquet. Of those who did use a tourniquet, less than half applied it correctly (43%). More than half (56%) of the participants used cottonwool to stop the bleeding after injecting; however, only a small minority (16%) applied pressure for one to two minutes.

Twelve participants (27%) reported lifetime history of abscesses (Table 3). Phlebitis was reported by 11 (24%) of participants.

At follow-up, significantly fewer participants reported not cleaning their hands (16% cf 31%; P = 0.039), and significantly more reported applying a tourniquet correctly (38% cf 24%; P = 0.008), never missing a vein (56% cf 31%; P = 0.007) and applying pressure for at least one to two minutes after injecting (33% cf 13%; P = 0.035) compared with baseline (Table 4).

Discussion

Previous studies have reported a high burden of disease from IRIDs in PWID.^1–3 A recent study conducted at KRC found that the lifetime prevalence of cutaneous IRIDs was 23% among PWID.²⁰ Our study results are consistent with those previous studies, with 27% of participants reporting a lifetime history of abscesses, and 24% with a history of cellulitis and phlebitis. Despite this considerable disease burden, interventions seeking to reduce IRIDs have not been reported in the literature. To our knowledge, this is the first study reporting the results of a clinician-led intervention specifically targeting IRIDs.

The baseline assessment of injecting-related behaviours revealed a significant proportion of participants could benefit from safer injecting advice. The intervention provided an opportunity for clinicians to initiate discussion with clients about IRIDs and the importance of prevention and early presentation to avoid more serious complications. Importantly, there were significant changes in self-reported behaviours at follow-up. However, it should be noted that for a considerable proportion of participants, risk behaviours remained unchanged, highlighting the need for ongoing safer injecting education.

Our study provides initial evidence of the feasibility of incorporating a clinician-led safer injecting intervention into serological testing procedures offered to PWID. The results of the study were encouraging and justified inclusion of the intervention into routine care at KRC. Clinicians did not report any difficulty in incorporating the intervention into their routine practice, and the costs associated with its implementation were negligible.

The study is part of a broader initiative at KRC into monitoring the burden of IRIDs in PWID, and designing and evaluating prevention interventions within a harm reduction framework. As part of this, KRC has developed a surveillance system for IRIDs that incorporates a comprehensive list of IRIDs-related diagnostic codes within its client database. This allows clinicians to report all IRIDs-related presentations, as well as associated treatment, referral and outcomes. This system will enable evaluation of the longer term impact of the current intervention on the prevalence of IRIDs among KRC clients.

Our study has several limitations. The study’s small sample size may have limited our ability to determine other significant changes in injecting-related behaviours. We relied on self-reported data, which may be subject to social desirability and recall bias, and thus some risk behaviours may have been under-reported. However, the literature suggests that behaviours self-reported by PWID are reliable and valid.^21,22 Furthermore, our study focused on injecting behaviours in the last month only, thus minimising recall bias.

Our study participants were similar in demographic characteristics and risk behaviours to the broader base of KRC’s PWID clients.²⁰ However, KRC is accessed by a very socially marginalised population of PWID who are at high risk of IRIDs. Thus, our results may not be generalisable to the broader population of PWID, including those who do not access health services. The burden of IRIDs may be higher in PWID not attending health services, warranting further exploration of the feasibility of integrating the current intervention in non–health service settings. Our study did not include a comparison group, and the same clinicians administered the intervention and collected the survey data at baseline and follow-up. The surveys administered at baseline and follow-up contained only structured questions and recorded self-reported behaviours. Thus, any impact associated with a lack of blinding would have been minimal. Moreover, data analysis was completed by a researcher who did not participate in data collection.

Our study demonstrated that a clinician-led brief intervention targeting IRIDs was acceptable to both clients and clinicians, and could be easily implemented in KRC’s primary care setting. We recommend that clinicians experienced in working with this client group consider incorporating similar interventions into their routine practice to reduce the burden of IRIDs and related healthcare costs, including those associated with hospital presentations.

Authors

Mihaela Ivan MD, MSc, FAFPHM, Lecturer, The Kirby Institute, University of New South Wales, NSW; Research Coordinator, Kirketon Road Centre, SESLHD, NSW

Craig Rodgers BMed, FRACGP, FAChAM, Medical Unit Manager, Kirketon Road Centre, SESLHD, NSW

Lisa Maher PhD, Professor and Program Head, The Kirby Institute, University of New South Wales, NSW

Ingrid van Beek MBBS, MBA, FAFPHM, FAChAM, MD, Director, Kirketon Road Centre, SESLHD, NSW; School of Public Health and Community Medicine, University of New South Wales, NSW. ingrid.vanbeek@sesiahs.health.nsw.gov.au

Competing interests: Outside this work, Ingrid van Beek has received a National Health and Medical Research Council (NHMRC) grant; and Lisa Maher has received an NHMRC and National Institute of Health (NIH) grant.
Provenance and peer review: Not commissioned, externally peer reviewed.

Acknowledgements

We would like to acknowledge the contribution of KRC clients and clinicians.