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View Cart. Keywords quality improvement, abscesses, self-care treatment, persons who inject drugs. For referencing Kuhnke JL et al. Self-treatment of abscesses by persons who inject intravenous drugs: a community-based quality improvement inquiry. Author s. Objective This study had two objectives. First, to understand and then describe the experiences of persons who inject drugs PWID and who use self-care treatment s to deal with resulting skin and tissue abscesses. Next, to understand and describe their journeys to and experiences with formal healthcare service provision. Methods Semi-structured interviews were conducted with ten adults who have experience with abscesses, engage in self-care treatment s , and utilise formal healthcare services in Nova Scotia, Canada. Results Participants lived with abscesses and utilised various self-treatment strategies, including support from friends. Participants engaged in progressive self-care treatment s as the abscesses worsened. They reluctantly made use of formal healthcare services. Finally, participants discussed the importance of education. Moreover, they shared their thoughts in terms of how service provision could be improved. Conclusions Participants described their lives, including their journeys to intravenous drug use. They also described the self-care treatments they used to heal resulting abscesses. They used these self-care treatments because of a reluctance to utilise formal healthcare services. From a quality improvement perspective, participants outlined suggestions for: 1 expanding hours of service at the community wound care clinic and the centre; 2 permitting pharmacists to include prescribing topical and oral antibiotics; 3 promoting abscess prevention education for clients and healthcare providers; and 4 promising practices for the provision of respectful care during emergency care visits. Persons who inject drugs PWID intravenously normally aim to inject a vein using a hypodermic needle and syringe 1. An abscess contains a collection of pus in the dermis or sub-dermis and is characterised by pain, tenderness, redness, inflammation and infection These are most often caused by bacterial infections Staphylococcus aureus, Methicillin-resistant S. Abscesses require prompt attention to minimise resulting complications. This attention often includes emergency visits and hospitalisations 17— However, PWID avoid seeking formal healthcare services e. Reasons for their reluctance to utilise formal healthcare services include experiencing lengthy clinic and emergency wait times, being judged and feeling discriminated against by care providers and the resulting experience of being othered 23 , and being asked questions about their drug use 24, In addition, PWID may delay accessing formal healthcare services due to a fear of drug withdrawal and inadequate pain management Reluctance to seek out and utilise formal healthcare services can result in self-care treatment s , including attempts to lance and drain abscesses 20— Our goal was to understand and describe the experiences of PWID and who use self-care treatment s and to understand and describe their journeys to and experiences with formal healthcare service provision. We also wanted to listen to and record their recommendations for the improvement of services. This was a significant goal of the research because it has the potential to prevent and decrease the number of abscesses resulting in hospital visits and admissions and, ultimately, to decrease the number of related deaths and suffering. Knowing much of the suffering and resulting deaths are preventable, our goal was to listen carefully and respectfully to participants, such that their voices become part of the solution. The study was conducted in partnership with a harm reduction centre the centre and university researchers. Qualitative data were collected from PWID using semi-structured interviews 30, The centre offers primary healthcare services to populations including those living with substance use disorder s , those experiencing homelessness, and sex workers 34, Interviews of 45—60 minutes using a semi-structured script occurred. After four were completed, we listened to the interviews triangulation to ensure the questions were respectfully resulting in useful data We also invited participants to describe recommendations for improvement to the provision of abscess care. We regularly communicated the study progress with the team. Throughout the study we adhered to pandemic guidance Approval for the study was granted by Cape Breton University. Adults who met the inclusion criteria received, discussed and were invited to ask and have answered their questions. A letter of information was provided and written informed consent was obtained. Data collected included gender, age, age of first abscess, products, medications used to self-treat, and when and to whom they reached out for formal healthcare. Data were recorded, secured, and transcribed verbatim 30— We read and re-read the transcripts, seeking patterns and themes. From the analysis, four themes emerged: 1 lack of experiential knowledge; 2 progression of self-treatment strategies; 3 utilisation of formal healthcare; 4 education matters; do not rush. Ten participants, four women and six men, who experienced one or more abscess es participated mean age Five participants were unsure of the date of their first abscess, two identified a range of dates, and three knew the specific date as they included a critical hospital event. One participant had an active skin infection and seven showed the locations of one or more healed abscess sites Table 1. When first injecting drugs, participants described limited knowledge of skin infections, cellulitis and abscess es. The abscess, was so, so painful. I could not sleep, I was scared; I did not know what it was. My hand was blowing up! I could not work. It was not until someone told me my hand was infected that I panicked. I ended up going to the hospital. The pill or dirt in the cocaine or whatever was added will build up in your system and cause an abscess, I learned this over time. The dirty needle and water made it worse. Your body pushes the foreign substance out, you have headaches, your tired, all your blood is going to the wound to try to heal it. The area is hot. It feels like it is dragging you toward death. I thought I was dying. The pain was extreme and unbearable. I hid the wounds. I used to miss the vein if I was shaking and rushing to inject. Some pills like Ritalin, hydromorphone, Dilaudid, and Effexor were worse than others. I did not get them from cocaine. I had abscesses in my hands, wrists, ankles. My teeth got abscessed due to the infections, I lost all my teeth; I have dentures. Participants described engaging in abscess self-care treatment s and identified additional steps taken if the abscess worsened. They also described extreme pain when pressing the abscess es with their fingers to pop or squeeze the abscess, or when using a pen knife, surgical blades or a big needle to lance, drain or draw out the infection from the infected area s. These activities may take place in a kitchen, bathroom e. One participant described his self-care:. I use soap, water, or what I can find to clean it. I try to keep it covered. I use clean needles or blades to lance it myself. If it does not fill back up with stuff, I leave it alone. I have stuffed bread in them before, the bread turns green and takes the infection out. It helps. I have had quite a few, the last one was on my finger. It is fine now, but it was discoloured. These were not the nasty ones. I have had to clean abscesses on my hands and legs, but they were not so bad that I had to go to the hospital. When I have them bad, they physically drain me, literally like I am dragging around, exhausted. If it was infected, I would get half a prescription of antibiotics from someone else. I drank water to flush out the infection. I kept a face cloth on top of the abscess to collect the drainage. It is important to clean your skin first with alcohol swabs to reduce the bacteria. I used antibiotic ointment on small abscesses unless the redness did not go away. Sometimes I used a hot facecloth on the area. I drain the abscesses myself, I use aloe, a topical antibiotic, and if it gets worse, I try to get an oral antibiotic from a friend at no charge, it is not good to charge money you know, you could die. I try to get a three-day supply. At first, I did not know what to do. I started treating the abscess with hot water, then cold, then both. I bought a heat bag to put on it to draw out the infection. I told the nurses at the centre, and they drew a line around it. These are my six, three, and two-inch scars. See the length? They were bad ones. One participant said that, when they have an abscess, they may tell a partner or friend. Participants stated partners or loyal friends would do the following — help incise and drain an abscess in any location, find topical and oral antibiotics and not charge them, and locate wound supplies. Friends would help organise or drive them to an appointment e. Participants shared the following:. There is a code on the street you know, abscesses can kill you, so you help each other. My friend had an abscess, I cleaned it for him with alcohol, it burned, it helped. My friends will help if I ask. But I usually treat the abscess myself. With my first abscess I got a hot fever, so I wrapped myself in four blankets. Ate black pepper. I injected water to take it away, it does not last long. My blood went septic with a big abscess, my friend took me for care. I would only wait a day before getting care from the nurses. I would not wait longer. I do not rely on anyone else to know how bad my skin is, that is my job. Abscesses can kill you. I get care right away. I got care for my wrist abscess from the community nursing team. I am prepared, I keep a kit ready for abscesses in case… people die. My last one in my elbow was so big I could fit a whole roll of gauze in the hole. The home care nurses helped me. I know I can come to the centre for care, they are amazing, I rely on them. Supplies for abscesses are not easy to find, the pharmacies are expensive, I get what I need at no cost, this is serious stuff. It should be easier to get basic antibiotic prescriptions. Why is it so hard to get oral antibiotics? I could die. From these comments we began to understand self-care as part of a continuum of care and we understood PWID quickly experience how fast abscesses can become serious and the resulting need to seek out formal healthcare providers. Participants preferred to receive abscess care at the community nursing wound clinic or the centre where they were respected. Participants expressed concern when interacting with emergency care teams the three provinces mentioned were Alberta, Ontario and Nova Scotia because it regularly evoked feelings of shame and being judged when asked assessment questions and planning abscess care e. Their reluctance to access or remain in care once assessed was related to prior experiences. Participants shared:. It would take a lot for me to ask for help! I would have to be really sick to ask for help from the hospital! We really need a safe injection site, then the abscesses would not be happening. I would cut open my abscess myself ahead of going to the hospital. I would get oral antibiotics first from someone, then if it got worse, I would go to the hospital. It would be my last stop. There should be a priority for abscess care at the hospital. If you need intravenous antibiotics four times a day, and you can hardly make up your mind to plan to go back to the hospital… it is not a surprise that I did not go back. Many people do not have cars or parking money, so we do not go back! If you miss a dose, it is worse, as you must be readmitted and wait, wait, and wait. My abscess was so infected I went for care. They were good to me. I needed care, I went to emergency, they treated me well. I was ashamed to go, I just knew I had to get there. I went alone. They let me have a cigarette, so I stayed. I did not want to go to the hospital. People were initially judgemental. They asked me about being an intravenous drug user, then they backed up in the room. I did not like this. Yet, they did drain my hand. The care was okay… actually, it was good when the walls come down and you know you are accepted, care was good for me. The hospital was okay. I just focused on the abscess. They treated me good, they were fair. The abscess smelled so bad when they cut it open. I have not experienced stigma at the hospital. They were good to me; I waited a few hours and it was okay. Everyone else was waiting for care too. You have to be kind and put out kindness, then they will be kind to you. I went to emergency and the doctors and nurses treated me well. I went back twice a day, for three days and then I took a week of oral antibiotics. It saved my life, from the sepsis. I could have died tears up. I was treated well in emergency, though I do hear negative stories. I was really scared, yet, I got good care from the team. I would tell people to go to emergency, after I treat the area myself. I would never lance my abscess. I am too afraid. I got good care in ambulatory care, they used iodine and lots of packing, I think I got the good nurses. They were kind to me, that matters. I do not want to be looked down on by anyone as that upsets me. I went for care, they were good to me. When I need antibiotics, I go and get them. I do not get them from people on the street. I do not want to take a chance on my life. People will sell you anything and call it an antibiotic. I know I get embarrassed when I ask for help, but that is me. I needed care. During the pandemic, I received a virtual wound assessment and then I felt better. They taught me to mark the edges of the redness and told me that if it gets redder to go to emergency. Well, I went to emergency and got good care. My emergency visit was better as I did not go alone, having a support person with me was a huge help — then I did not leave. We understand this theme as a counter to the narrative of avoiding hospital care. PWID understand there are times when hospital care is necessary. In addition, counter to stories that circulate among PWID, hospital care may be experienced as respectful. Participants expressed the importance of education related to the safe injection of drugs and skin hygiene. Each participant reflected on the person s who initially taught them how to inject drugs and practise skin hygiene. They described the risks of a missed hit, when they inadvertently injected into the fatty, subcutaneous or intramuscular layers, or when the drugs leaked into the skin. One participant learned how to inject from an internet video. Another learned from a former partner who taught him to use new filters and needles:. She taught me about cotton fever as I was doing it wrong. As well, I was using little veins with a big needle and got an abscess. No one taught me, I learned from other people using. I have only had one abscess from missing, and it made my upper arm and breast area swell. I could not sleep and could not use my arm and hand. Someone could show you a bad, bad, bad technique. You must see blood, then you push it in, the correct way matters. Education sessions should remind people to not rush, if they do not see blood, do not inject. People are rushing to inject, do not rush, no blood — no injecting, then you will not miss. Also, if you are not feeling good and you are relying on someone else to inject you, that is not good as the person may rush and miss. Four participants expressed they learned how to safely inject from nurses at the centre. They readily described the importance of using clean equipment, cookers, needles and cleansing the skin with alcohol swabs. Three stated education classes should include correct injecting techniques, discussions of the risk of missing, and pictures of SSTIs and abscesses to compare their abscess to in order to determine the level of seriousness. This small quality improvement study 28 was conducted at a harm reduction centre in partnership with university researchers. Interview data revealed thick descriptions 30, Findings demonstrate that PWID experience a learning curve related to injection and abscesses. Participants most often begin with self-care and utilise formal healthcare services when they experience urgency as the wound worsens. From a quality improvement perspective, they outlined improvements including suggestions for: 1 expanding hours of service at the community wound care clinic and the centre; 2 permitting pharmacists to include prescribing topical and oral antibiotics; 3 promoting abscess prevention education for clients and healthcare providers; and 4 promising practices for the provision of respectful care during emergency care visits. Dechman and colleagues discussed the complex and unique journeys PWID experience PWID aim to inject drug s intravenously and do not plan to miss or inadvertently inject into the tissues subcutaneous or intramuscular 2. Our findings showed participants, when first injecting, do not always know about SSTIs and abscess formation from bacterial or viral sources. However, over time they learn the seriousness of missing the vein e. They also learn the risk associated with sharing or re-using equipment, the relationship to the development of collapsed and sclerosed veins, cellulitis, abscess es , and serious infections. Participants were able to consistently describe early and late signs of abscesses 21, Moreover, once participants knew they had an abscess, they began with self-care interventions. If improvement was not experienced, they accessed formal healthcare. These findings demonstrate PWID are knowledgeable, begin with self-care and when required will seek out formal care, regardless of the reticence. We understand this process as a meaningful continuum of care. They also described the importance of maintaining and growing the wound care nurse role in the Ally Centre and with the community nursing teams. For participants there was reluctance to seek formal healthcare though they understand abscess es lead to sepsis, hospitalisation and death Participants want to be treated respectfully when engaging in acute care. Reluctance was related to perceptions of formal healthcare staff and fears of being disrespected. Participants want to be treated respectfully throughout the entire encounter. They also required access to reliable transportation and parking fees. Waiting at the hospital was not preferred, though having a friend and being able to go outside for a cigarette eased the waiting time. Participants recommend healthcare professionals receive education related to the compassionate and respectful care of PWID and living with skin and wound complications Antibiotic stewardship for PWID is of concern and challenging to address 37, Participants discussed the need for pharmacists to be involved in prescribing antibiotics. Topical and oral antibiotics may be consumed as prescribed, shared with another person whose abscess is judged to be worse, given or sold to another, or kept secure for future use 20— For PWID this translates to accessible education materials e. Professionals disclosed they received little to no education on harm reduction, were not comfortable counselling PWID, and lacked knowledge on where to refer PWID for education or supplies. The toolkit emphasises a broad framework focused on infection prevention for PWID. Participants in this study repeatedly shared they were willing to learn, and they wanted to be safe to avoid complications. They requested development of videos and a phone application app depicting mild cellulitis to complex abscesses. There are risks associated with the latter request, as solely relying on wound images as a diagnostic tool for mild, progressing and serious infections is not recommended In this study, participants became knowledgeable about SSTIs and abscess development. Though they were aware of the risks of mortality, morbidity , they remained reluctant to access formal healthcare. More research is needed to fully understand the maintenance and expanding of wound care services, including the role of pharmacists in the community. Finally, PWID want to know they will be respected when accessing healthcare services. Our experience of the interviews left us wondering how best to describe the humility, intelligence and kindness of the participants. They were thoughtful, and wanted to improve the experience for themselves and others. We are grateful to the participants for sharing their stories and for their thoughtful recommendations. Los participantes aplicaron tratamientos progresivos de autocuidado a medida que empeoraban los abscesos. Eran reticentes al uso de los servicios sanitarios oficiales. Conclusiones Los participantes describieron sus vidas, incluida su trayectoria hacia el consumo de drogas intravenosas. Sin embargo, las PWID evitan acudir a los servicios sanitarios formales p. La reticencia para buscar y utilizar servicios sanitarios formales puede dar lugar a tratamientos de autocuidado, incluidos los intentos de extirpar y drenar los abscesos Se recogieron datos cualitativos de las PWID mediante entrevistas semiestructuradas 30, Se realizaron varias visitas al centro para desarrollar la confianza con el equipo del centro y los posibles participantes 32, A lo largo de todo el estudio nos adherimos a las directrices sobre pandemias El estudio fue aprobado por la Universidad de Cape Breton. Los datos se grabaron, se aseguraron y se transcribieron literalmente Leemos y releemos las transcripciones en busca de patrones y temas. Debatimos los temas para asegurarnos de captar la esencia de las historias de los participantes. Tabla 1. El absceso, era tan, tan doloroso. La aguja sucia y el agua lo empeoraron. Se siente como si te arrastrara hacia la muerte. El dolor era extremo e insoportable. Algunas pastillas como Ritalin, hidromorfona, Dilaudid y Effexor eran peores que otras. Intento mantenerlo cubierto. Yo mismo uso agujas o cuchillas limpias para extirparlo. Si no se vuelve a llenar de cosas, lo dejo. Estos no eran los desagradables. He tenido que limpiarme abscesos en las manos y las piernas, pero no eran tan graves como para tener que ir al hospital. Los participantes explicaron que el tratamiento o tratamientos de autocuidado cambiaban a medida que el absceso empeoraba. Por ejemplo:. Es importante limpiar primero la piel con bastoncillos con alcohol para reducir las bacterias. A veces usaba una toallita caliente en la zona. Estas son mis cicatrices de seis, tres y dos pulgadas. Los participantes compartieron lo siguiente:. Pero suelo tratar el absceso yo mismo. Los abscesos pueden matarte. Me atienden enseguida. Estoy preparado, tengo un kit listo para abscesos en caso de que Su reticencia para acceder a la asistencia o a permanecer en ella una vez evaluados estaba relacionada con experiencias anteriores. Los participantes compartieron:. Si se salta una dosis, es peor, ya que debe ser readmitido y esperar, esperar y esperar. Mi absceso estaba tan infectado que fui a que me atendieran. Fueron buenos conmigo. Necesitaba cuidados, fui a urgencias, me trataron bien. Fui solo. Al principio, la gente me juzgaba. Esto no me ha gustado. Sin embargo, me drenaron la mano. El cuidado estuvo bien El hospital estaba bien. Me trataron bien, fueron justos. Tengo demasiado miedo. Fueron amables conmigo, eso importa. No quiero que nadie me menosprecie, porque eso me molesta. Fui a que me atendieran, se portaron bien conmigo. No me los da la gente de la calle. No quiero arriesgar mi vida. Necesitaba cuidados. Fui a urgencias y me atendieron bien. Mi visita a urgencias fue mejor porque no fui sola, tener a una persona de apoyo conmigo fue de gran ayuda, por eso no me fui. Tienes que ver la sangre, luego la empujas, la forma correcta importa. Las sesiones educativas deben recordar a la gente que no se precipite, que si no ve sangre, no se inyecte. Describieron con facilidad la importancia de utilizar equipos, cocinas y agujas limpios y de limpiar la piel con hisopos con alcohol. Los datos de las entrevistas revelaron descripciones detalladas 30, Entendemos este proceso como una continuidad asistencial significativa. Los participantes quieren que se les trate con respeto cuando reciben cuidados intensivos. Los participantes quieren que se les trate con respeto durante todo el encuentro. No era preferible esperar en el hospital, aunque tener un amigo y poder salir a fumar un cigarrillo aliviaba el tiempo de espera. En este estudio, los participantes adquirieron conocimientos sobre las SSTI y el desarrollo de abscesos. Agradecemos a los participantes que hayan compartido sus historias y sus atentas recomendaciones. Canadian Centre on Substance Abuse. Int J Drug Policy ;— Association of self-reported abscess with high-risk injection-related behaviors among young persons who inject drugs. Wounds and skin and soft tissue infections in people who inject drugs and the utility of syringe service programs in their management. Adv Wound Care ;— Skin and soft tissue infections. Am Fam Physician ;— Neck abscesses secondary to pocket shot intravenous drug abuse. BJM Case Report ;—2. Pastorino A, Tavarez MM. Incision and drainage. Practice guidelines for the diagnosis and management of skin and soft tissue infections: update by the Infectious Disease Society of America. IDSA Guideline ;e1-e Stanway A. Skin infections in IV drug users Acute infections in IDU. Royal College Physicians ;— What are the risk factors for soft tissue abscess development among injection drug users? Nursing Times ; Diagnostic and treatment options for skin and soft abscesses in injecting drug users with consideration of the natural history and concomitant risk factors. Eur J Med Res ;— A systematic review of injecting-related injury and disease among people who inject drugs. Drug Alcohol Depend ;— Severe bacterial infections in people who inject drugs: the role of injection-related tissue damage. Harm Reduct J ;— Prevalence and correlates of abscesses among a cohort of injection drug users. Harm Reduct J ;—4. Prevalence and behavioural risk factors of Staphylococcus aureus nasal colonization in community-based injection drug users. Epidemiol Infect ;— Luktke H. Rush University Medical Center; Skinner S. Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review. Harm Reduct J ; National findings from the Tracks survey of people who inject drugs in Canada, Phase 4, — Can Commun Dis Rep ;— Risk practices associated with bacterial infections among injection drug users in Denver, Colorado. Am J Drug Alcohol Abuse ;— Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis. Harm Reduc J ;— Abscess and self-treatment among IDU at four California syringe exchanges and their surrounding communities. Subst Use Misuse ;— Othering and being othered in the context of health care services. Health Comm ;— Paths leading into and out of injection drug use. Approaching the health and marginalization of people who use opioids. Under-served: health determinants of Indigenous, inner-city, and migrant populations in Canada. Toronto: Canadian Scholars; ; Injection-site vein loss and soft tissue abscesses associate with black tar heroin injections: a cross sectional study of two distinct populations in USA. Evaluation flash cards: embedding evaluative thinking in organizational culture. Otto Bremer Trust; Freire P. Pedagogy of the oppressed. London: Continuum; Braun V, Clarke V. Successful qualitative research a practical guide for beginners. Creswell JW. A concise introduction to mixed methods research. Liamputtong P. Researching the vulnerable. Sage; Trust and people who inject drugs: the perspectives of clients and staff of needle syringe programs. Bickerton J. Ally Centre outreach street health pilot: final report Diagnostics for wound infections. Antimicrobial stewardship can help prevent inject drug use-related infections. Contagion ;6 2 Clin Infect Dis. Antimicrobial stewardship interventions: a practical guide; Six moments of infection prevention in injection drug use: an educational toolkit for clinicians. Open Forum Infect Dis ;6. Fact-finding survey of pressure and shear force at the heel using a three-axis tactile sensor. WHAM evidence summary: traditional hypochlorite solutions. View Issue. Sign in. Abstract Objective This study had two objectives. Analisis de datos Los datos se grabaron, se aseguraron y se transcribieron literalmente Agradecimientos Agradecemos a los participantes que hayan compartido sus historias y sus atentas recomendaciones. Conflicto de intereses Los autores declaran no tener conflictos de intereses. Previous Article. Next Article.