Elsevier

Drug and Alcohol Dependence

Volume 171, 1 February 2017, Pages 39-49
Drug and Alcohol Dependence

Review
A systematic review of injecting-related injury and disease among people who inject drugs

https://doi.org/10.1016/j.drugalcdep.2016.11.029Get rights and content

Highlights

  • Skin and soft tissue infections are common among people who inject drugs.

  • There are few data on other injecting-related injuries and diseases.

  • Cleaning injecting sites and avoiding intramuscular and subcutaneous injecting may reduce injecting-related injury and disease (IRID) risk.

  • Better epidemiological data are needed to inform prevention and care interventions.

Abstract

Background

Non-viral injecting-related injuries and diseases (IRID), such as abscesses and vascular damage, can result in significant morbidity and mortality if untreated. There has been no systematic assessment of the prevalence of non-viral IRID among people who inject drugs; this review aimed to address this gap, as well as identify risk factors for experience of specific IRID.

Methods

We searched MEDLINE, Embase and CINAHL databases to identify studies on the prevalence of, or risk factors for, IRID directly linked to injecting in samples of people who inject illicit drugs.

Results

We included 33 studies: 29 reported IRID prevalence in people who inject drugs, and 17 provided data on IRID risk factors. Skin and soft tissue infections at injecting sites were the most commonly reported IRID, with wide variation in lifetime prevalence (6–69%). Female sex, more frequent injecting, and intramuscular and subcutaneous injecting appear to be associated with skin and soft tissue infections at injecting sites. Cleaning injecting sites was protective against skin infections. Other IRID included infective endocarditis (lifetime prevalence ranging from 0.5–12%); sepsis (2–10%); bone and joint infections (0.5–2%); and thrombosis and emboli (3–27%).

Conclusions

There were significant gaps in the data, including a dearth of research on prevalence of IRID in low- and middle-income countries, and potential risk and protective factors for IRID. A consistent approach to measurement, including standardised definitions of IRID, is required for future research.

Introduction

Although the transmission of blood-borne viral infections such as HIV and hepatitis C virus among people who inject drugs has garnered substantial attention, there has been less focus on other injecting-related injuries and diseases (IRID) in this population. These commonly include soft tissue infections such as abscesses and cellulitis, which occur as a result of micro-organisms (i.e., bacteria and fungi) in the injecting environment. Other infections may include bone and joint infections, infective endocarditis, and sepsis; these can arise as a result of direct introduction of bacteria to the bloodstream, or as complications of untreated of soft tissue infections (Salmon et al., 2009).

In addition to infections, repeated injecting and poor injecting technique may lead to vascular injury and poor venous access; furthermore, drug solutions may contain inactive ingredients that are not water soluble, leading to particles in the vasculature that can cause inflammation and clot formation (Darke et al., 2015, McLean et al., 2009). The likelihood of vascular injury can be further exacerbated by the delivery method (e.g., intravenous versus intramuscular injection), injecting site (e.g., subcutaneous tissue and muscle, major vessels), and type of equipment used (Darke et al., 2001).

Some IRID necessitate urgent medical care, and all can result in poorer health outcomes for people who inject drugs, including risk of mortality, if untreated (Dwyer et al., 2009). From an economic perspective, the costs of hospital care for IRID can be substantial (Sweeney et al., 2009, Tookes et al., 2015). A clearer understanding of the prevalence of IRID is needed to determine the scale of the problem and guide the development of evidence-informed responses. This review aimed to assess prevalence of, and risk factors for, non-viral IRID among people who inject drugs.

Section snippets

Method

This review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist (Moher et al., 2009).

Results

The literature searches returned 3578 unique records. Of these, 3254 were deleted following screening of titles and abstracts, leaving 324 reports to be reviewed in full. Thirty-three reports met the inclusion criteria; 29 reports provided data on IRID prevalence, and 17 provided data on IRID risk factors (Fig. 1). Included studies were largely based on samples from high-income countries, and participants were typically recruited from needle and syringe programs and drug treatment clinics (

Discussion

This review has shown that IRID are a common consequence of injecting drug use. Existing studies have found that up to one-third of people who inject drugs may have experienced infections at injecting sites within the previous month. Serious complications of injecting are also a risk, with studies showing that up to one-tenth may have experienced infective endocarditis or septicaemia at some point in their lives. Although risk factors for skin infections were not able to be formally

Role of funding

No specific funding was received for this study. Sarah Larney had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Contributors

Sarah Larney, Amy Peacock, Bradley Mathers, Matthew Hickman, Louisa Degenhardt

Conflict of interest

No conflict declared

Declaration of interests

We declare no relevant conflicts of interest.

Author contributions

Sarah Larney led the literature search and selection, completed the data analysis and wrote the manuscript. Amy Peacock contributed to the data analysis and manuscript writing. Bradley Mathers contributed to defining/categorising IRID and study design, and critically reviewed the manuscript. Matthew Hickman provided advice on data analysis and critically reviewed the manuscript. Louisa Degenhardt originated the idea for the review, and contributed to study design and manuscript writing.

Acknowledgements

Thank you to Mary Kumvaj for assistance with designing the literature search, and Angus Liu for conducting the initial literature search and assisting with study screening and selection. Amy Peacock, Bradley Mathers and Louisa Degenhardt are supported by fellowships from the Australian National Health and Medical Research Council (nos. 1109366, 1054244, 1041742). The National Drug and Alcohol Research Centre at the University of NSW is supported by funding from the Australian Government

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