Guidance

Wound aware: a resource for commissioners and providers of drug services

Published 11 January 2021

Applies to England

1. How services can be ‘wound aware’

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:

• helping PWID prevent injection-related wounds
• identifying wounds and other problems early and getting them treated
• helping PWID access wound care and harm reduction support
• promoting wound awareness with guidance and information
• offering general health assessments that include checking wound status and referring to relevant services (including tissue viability nurses or inpatient hospital care)

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:

• drug services (including needle and syringe programmes)
• local authority commissioners
• GPs
• wound care services
• local health protection teams
• A&E
• housing services
• other services for people who experience homelessness

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.

2. Risk and signs of wounds among PWID

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:

• abscesses
• inflammation of the veins
• blood clots
• deep skin infections
• leg ulcers

Signs and symptoms of wound infections include:

• high fever, chills
• heat, swelling, redness, aches and pain around the wound, joint or muscles
• pus and an unpleasant smell from the wound site
• a wound that will not heal
• skin abscess – a painful collection of pus in a lump under the skin
• cellulitis – red, painful, hot, swollen, tender, blistered skin
• a fast heartbeat
• dizziness, confusion, disorientation
• shortness of breath, fast breathing or having difficulty breathing
• coughing up mucus
• pain in the chest

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.

3. Types of wounds and other damage associated with injecting drugs

3.1 Risks of injecting site damage

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’).

3.2 Risk of soft skin and tissue infections, abscesses and sores

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.

3.3 Risk of vascular disease

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).

3.4 Wounds caused by self-harm and other injuries

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.

4. Barriers to treatment and care

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:

1. The person may be sleeping rough or in unsatisfactory living conditions, where there is no access to water or other facilities for personal and environmental hygiene and safe injecting behaviour.
2. They may be unwilling or unable to access prevention or early intervention services due to previous bad experiences of healthcare, lack of transport, or if available services were not being promoted to them in the right way.
3. Diagnoses and treatment of wound and skin problems can be late if the person is not able or willing to report early signs to professionals. People who are used to self-managing their wounds may have large and severe infections by the time they seek care.
4. They may be reluctant to wait in A&E or for admission to hospital. They might be concerned that their opioid substitution treatment (OST) will be interrupted or feel the need to take drugs to ease drug withdrawal.
5. Wounds can heal more slowly if the person finds it difficult to access appropriate nutrition and hydration. The negative effects of smoking, alcohol and illicit drug use can also affect healing.
6. As a person gets older, their ability to heal slows down, and they may have other health problems and weakened immune systems.
7. Wound-related care needs might not be easily identified or prioritised if the person has multiple health problems they need care for, such as hepatitis C, HIV infection, diabetes, hypertension, mental health problems and chronic pain.

5. Reducing the risk of harm from wound infections

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

• make sure they talk to service users regularly about safer injecting techniques
• ensure they provide enough clean injecting equipment to all service users
• give advice on self-care of wounds, and how to seek help, even if the service user does not admit to having any infections
• train staff so they are aware of the barriers to accessing care that affect PWID
• regularly discuss wound infections with service users and support them to disclose any concerns, even if they deny ongoing injecting

Read more about safer injecting advice for service users.

6. What a ‘wound aware’ service looks like

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

6.1 It prevents infections

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

1. The service provides an initial health assessment which discusses injecting behaviour and past and current wounds and infections with the service user.
2. Safer injecting advice and wound care are part of the care plan and are regularly reviewed.
3. Staff are aware of the risks carried by different injecting practices and are confident to try to prevent these by offering advice on safer injecting, discussing safer ways of drug use and promoting self-care.
4. Smoking, snorting and rectal use of drugs (as alternatives to injecting) also have risks, so staff discuss the wider risks of drug use and support service users to make informed decisions.
5. Information and advice, both written and oral, are easily available for service users and prominently displayed throughout the service.
6. Peer-led programmes promoting safer injecting are developed.
7. Service users are provided with or signposted to supplies of clean injecting equipment and wound care packs.
8. Service users are made aware of community services where they can get clean clothes, food and showers as required, while intensive efforts are made to resolve homelessness or poor accommodation problems.

6.2 It will identify worsening injection sites

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:

1. Keyworkers have regular check-ins with service users about their injecting experiences.
2. All staff, including reception and business support staff, keep an eye on their service users’ health and know who to tell or what to do if they spot a problem.
3. Other services involved in infection control and wound care (GPs, health protection and community wound services) are part of staff induction, group programmes, and health promotion and staff training events.
4. Trained ‘wound aware’ peer champions and staff are able to identify likely infections and provide information and reassurance to service users.

6.3 It will provide advocacy and access to treatment

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:

1. Staff know the contact details of local services, including GPs and wound care specialists, tissue viability nurses and A&E.
2. Staff are confident about referring people to NHS primary care for early interventions and to specialist services where these exist.
3. There is a clear protocol for dealing with wound-related emergencies, such as bleeding or signs of severe infection.
4. Arrangements are in place to support and continue OST for people with wound-related issues who are admitted to hospital.
5. Staff are aware of infection prevention issues and the service has a link with its local NHS infection prevention and control (IPC) team.
6. The service records and monitors cases of serious infection, including details of referrals they make.

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

7. Case studies

7.1 Blackpool pilot of nursing services for people rough sleeping or homeless

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:

1. The local authority should consider commissioning a longer-term service targeting the physical health care needs of this vulnerable group, given their level of need and the potential to reduce acute admissions to local hospitals and the associated cost.
2. Structured appointment times are not feasible or effective for this group, so services need to be more flexible.
3. Services should offer a ‘one stop shop’ with access to the full range of interventions to address physical health needs including outreach support and transport.
4. As well as having core staff focused on drug-related physical health needs, the service should also host clinics delivered by other professionals to address a range of healthcare needs such as sexual health, chronic disease and mental health.

For further information contact PublicHealth@blackpool.gov.uk

7.2 Doncaster specialist wound service for drug service users

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:

• over 50% of the people it supported had ‘complex wounds’ (defined by having had the wound for over 12 months)
• attendance at wound care appointments was 79%
• 52% of referrals had a positive outcome of either completed wound treatment or referral to a GP practice nurse for ongoing care

8. Practice notes

8.1 Safer injecting advice

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.

Prevent bacterial infections

To prevent bacterial contamination of your hit, you should:

• use a new filter every time, do not tear filters in half (used filters grow bacteria and tearing filters risks fibres in your mix)
• do not lick your needle or injecting site (saliva contains bacteria)
• clean and prepare the area (use a magazine or newspaper to cover the surface)
• wash hands (or at least use an alcohol wipe)
• clean the injection site – alcohol swabs are best, soap and water or baby wipes are also fine
• use clean water

Risk of infection from different water sources

Water source	Risk of infection
Unopened ampoule of sterile water for injection	No added risk
Water boiled in a kettle and left to cool	No added risk
Cold water freshly run from kitchen tap	Low
Hot water from tap	Some
Bottled water (not drunk from)	Some
Shared cup of water	Medium to high
Part-used ampoule of water for injection	Medium to high
Toilet water	High
Puddle water	Very high
Saliva	Very high

Looking after your veins

Look after your veins by following the advice below.

1. New, sharp works give a quick hit and veins stay in better condition.
2. Ascorbic acid (vitamin C) is better than citric acid. Do not use more than half a sachet (a pinch should be enough). Impurities may make the solution look cloudy, but the drug will have dissolved.
3. Rotate injecting sites to give your best veins a rest and avoid your neck and groin.
4. Drink plenty of water and try injecting somewhere warm, both help veins come up.
5. Take it slowly – try to find a space with decent light and where you can take your time.
6. Take a break – smoking, snorting, swallowing or ‘shafting’ (up your bum) drugs are all good alternatives to injecting and help give your veins a rest.

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.

8.2 Wound care pack contents

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:

• soak up oozing liquid produced by the body when tissue is damaged
• prevent the wound surface from becoming dry (dry wounds heal more slowly)
• reduce the risk of infection
• prevent clothing further damaging the delicate healing surfaces

A wound care pack might contain:

• wipes to clean the wound and the skin around it
• a non-irritant, non-adherent, highly absorbent dressing pad with an absorbent core, a tissue layer for distributing oozing liquids, and a non-woven layer on the back of the dressing to protect against contamination
• non-woven swabs to cushion and protect, and prevent dryness in an open wound
• double-sided absorbent dressings to cover the wound area
• bandages suitable for self-application to hold the dressings in place and provide further protection
• a roll of hypoallergenic medical tape to secure the bandage
• a sealable plastic bag to put used dressings in
• a wound care advice and information leaflet

8.3 What a drug treatment and recovery worker can do to help

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).

9. Resources

‘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.