It Takes a Village: The Management of Extreme Sequelae of Skin Popping

Skin popping (SP) is the practice of subcutaneous injection of unsterile prescribed or recreational drugs. Skin popping is a method used by chronic drug users who have exhausted superficial venous access. It has gained popularity because it requires less accurate injection and leads to slower drug absorption. The resulting experience is less of a rush with a longer high.^1,2 However, unlike intravenous injection, SP is inexact, resulting in injection to variable depths.^1,3 

In the absence of infection, SP initiates a local inflammatory response. The result of ongoing inflammation is ischemic necrosis, ulceration, and fibrosis.^4,5 In most cases, this leads to the characteristic circular scars that are often mistaken for cigarette burns early in the course of SP.^1,6 With repetitive SP, a generalized fibrotic thickening and edema is observed, as well as nonhealing ulceration. Ulcer formation does not always compel skin-poppers to seek immediate medical attention; instead, the ulcer is maintained as a shooter’s patch, which permits easy SP through an open wound.^3,7

The practice of SP commonly results in acute infectious diseases of the skin (eg, cellulitis and abscess).^8-10 Takahashi et al,¹¹ observed the rate of abscess formation to be as high as 72% in people who inject drugs (PWID). In addition, SP increases the risk of more dangerous and life-threatening sequelae of drug use that require combined medical and surgical intervention for cure (eg, necrotizing fasciitis, necrotizing myositis, and acute osteomyelitis).^3,7 

When sequelae of SP occur, hospitalization and surgical intervention are necessary. This leads to complications of addiction, including drug withdrawal and nonadherence with medical advice. Following hospital admission, it is a priority to prevent acute drug withdrawal and manage symptoms that contribute to drug misuse. Up to 43% of PWID leave the hospital against medical advice (AMA) unless medications for opioid use disorder (OUD) can be promptly initiated.¹² Postoperative pain control is not easily achieved in this patient population with standard opioid regimens.  

Publications on the multidisciplinary management of serious complications of SP are lacking. The sparse existing research on SP focuses on the microbiology of superficial infections and offers case reports on wound care. This case series highlights the necessity of a multidisciplinary approach in the management of the sequelae of SP. This complex approach addresses the medical, surgical, psychiatric, addiction, infection, social, and rehabilitation issues associated with the dangerous practice of SP. To the authors' knowledge, there is nothing in the literature to date that reflects this approach.  

This is a case series of 5 heroin addicts who presented to Rush University Medical Center with infected SP ulcers between 2017 and 2019. Each case was selected for inclusion in this series because of the dramatic nature of the disease observed. Each patient reported using heroin or tested positive for heroin on admission, and each admitted to practicing SP or maintained a shooter’s patch in the lower extremity. 

In each case, a multidisciplinary approach was employed to care for the patient. Members of the departments of medicine, surgery, nursing, addiction medicine, infectious disease, physical/occupational therapy, and social work collaborated in the complex management of each patient. Each specialist team addressed issues under their purview, as detailed in Table 1. In each case, the patient underwent supportive medical care, antibiotic therapy, surgery for source control and tissue culture, postoperative pain management with OUD therapy (unless declined by patient), and dressing care. The surgical management of each patient’s disease followed standard evidence-based surgical practice, dictated by severity of infection, depth of infection, and the patient’s comorbid conditions. 

Five patients presented to Rush University Medical Center between 2017 and 2019 with lower extremity ulcers due to SP. The age range was 27 years to 51 years; 60% were male. All 5 patients were actively using nonprescription opioids at the time of presentation; 2 of the patients were concurrently receiving OUD treatment (Table 2). 

All patients underwent definitive surgical intervention for infection due to necrotic lower extremity SP ulcer. In 3 cases, sharp excisional debridement was performed for source control in the setting of infected necrotic lower extremity ulcer; tissue cultures were obtained for each patient in the operating room. In 2 cases, the authors performed amputation for chronic osteomyelitis due to chronic bone exposure within the infected necrotic lower extremity ulcer; tissue culture was obtained in the operating room for 1 of the 2 patients who underwent amputation. The authors neglected to obtain a tissue culture during 1 of the amputations. Routine dressing care and medical treatment for infection was provided thereafter. For the 3 patients with open wounds, simple once-daily dressing plans were employed to optimize adherence (Table 2). Length of inpatient stay ranged from 3 days to 18 days.  

In each of the 4 tissue cultures, a polymicrobial bacterial pattern was observed, including gram-positive and gram-negative bacteria (Table 3). Anaerobic bacteria were isolated in 1 case; methicillin-resistant Staphylococcus aureus (MRSA) was isolated in 2 cases, 1 of which was associated with MRSA bacteremia. In all but 1 case, antibiotic selection reflected the authors' typical practice of broad coverage for gram-positive and gram-negative bacteria, as well as MRSA. Antibiotic regimens included vancomycin plus piperacillin-tazobactam, and vancomycin plus cefepime and metronidazole. In 1 case, an oral antibiotic regimen was needed at the time of discharge, which was tailored to the tissue culture. In 1 case, the patient received only vancomycin prior to amputation, which was felt to achieve source control; no further antibiotics were administered after surgery.  

Case 1
A 27-year-old female with OUD and hepatitis C presented with a chief complaint of lower extremity pain and drainage. The patient was hypotensive; physical examination revealed a large, malodorous right necrotic lower extremity ulcer with purulent drainage and surrounding erythema. Radiographs showed no evidence of osteomyelitis. The patient underwent emergent sharp excisional debridement of the infected lower extremity ulcer into muscle (Figure 1) for source control. The operative tissue culture confirmed polymicrobial infection (Table 3), including the presence of MRSA. Treatment for MRSA bacteremia/sepsis was begun. The patient underwent twice-daily moist saline gauze dressing (MSGD) changes while receiving opioid replacement therapy (ORT) with buprenorphine-naloxone (B-N). After 3 days, significant granulation tissue was observed in the wound. 

The patient was transferred to a nursing facility for ongoing intravenous antibiotic therapy for bacteremia and cellulitis, OUD treatment, and daily wound care. While at the nursing facility for an 11-day stay, the patient was referred to a surgeon for skin grafting to close the wound. The surgeon advised the patient to stop B-N therapy several weeks prior to the procedure, explaining that only ibuprofen would be provided for pain management after surgery. The patient obtained a second opinion in the authors’ surgery clinic, 2.5 months after her debridement, at which time she acknowledged occasional nonadherence with B-N therapy. A multidisciplinary plan was created for the patient to continue B-N therapy until the morning of the procedure, followed by postoperative admission to the intensive care unit (ICU) for multimodal pain management. On the day of surgery, the patient acknowledged snorting heroin 6 days prior to surgery. Urine drug screen was positive for benzodiazepines, opioids, and marijuana. Her procedure was cancelled. The patient discontinued ORT and resumed SP. She was lost to follow-up for 10 months; the patient became homeless during this time.  

She returned to the surgery clinic for wound care; staff observed the patient displaying drug-seeking and irregular behavior on a consistent basis. The patient declined skin grafting and addiction treatment outside of a rehabilitation center. She underwent serial curettage for heavy biofilm and hypertrophic granulation associated with epibole with a good result. By 1 year, the wound was greater than 50% closed (Figure 2) through consistent wound care with serial curettage and adherence with dressing care using daily xeroform gauze, abdominal (ABD) gauze pad, and gauze wrap. At the time of the coronavirus 2019 (COVID-19) pandemic, the patient was lost to follow-up.

Case 2
A 42-year-old male with a history of bipolar disorder, OUD, chronic osteomyelitis, and chronic bilateral lower extremity SP ulcers presented with worsening right lower extremity pain. The patient had undergone surgical debridement of the ulcer 1 year earlier. One day prior, he endorsed using an ulcer as a shooter’s patch. Physical examination demonstrated a large lower extremity ulcer with patchy areas of necrosis, purulent drainage, and exposed bone (Figure 3). Vital signs were normal. Urine toxicology was positive for opiates. Radiographs demonstrated a fibular periosteal reaction and cortical thickening adjacent to a large soft tissue ulcer, suggesting chronic osteomyelitis. The patient was advised to undergo amputation. He began B-N ORT and piperacillin-tazobactam therapy. He underwent a guillotine below-the-knee amputation for source control; his operative tissue culture was polymicrobial (Table 2). After surgery, he was admitted to the ICU, where he received B-N, ketamine infusion, and gabapentin for pain management. He received twice-daily MSGD changes to the guillotine site. Five days later, the patient underwent closure of the guillotine amputation to a right above-knee amputation without complication. Prior to discharge to an acute rehabilitation facility, the patient completed antibiotic therapy and worked with a substance-use intervention team to facilitate continued OUD treatment upon discharge. He completed rehabilitation, remains abstinent on B-N, and follows up regularly with the addiction team. 

Case 3
A 51-year-old homeless male with a history of OUD and SP presented to the emergency department with right lower extremity pain and malodorous ulcer for 2 weeks. The ulcer originally developed 3 years ago after the patient sustained a burn; at that time, he declined skin grafting in favor of a daily dry gauze wrap. The patient reported daily nasal heroin use; he denied SP. Physical examination demonstrated a diaphoretic patient with 2 malodorous right lower extremity ulcers with purulent drainage and small circular SP scars (Figure 4). Vital signs were normal except for intermittent tachycardia. Urine drug screen was positive for opiates. Radiographs showed no evidence of osteomyelitis. The patient received intravenous buprenorphine followed by oral buprenorphine for pain and OUD management. Intravenous vancomycin therapy was started for infected lower extremity ulcers, and the patient underwent surgical debridement. Grossly necrotic tissue was excised except in the periphery, where collagenase therapy was started for superficial enzymatic debridement. The operative tissue culture was polymicrobial (Table 3). 

The patient awoke from the procedural sedation with agitated delirium, swinging and attempting to bite the staff. He was immediately sedated and transferred to the ICU for acute opioid withdrawal-associated delirium, which required continued sedation for 1 day. Dressing care was continued with twice-daily collagenase and MSGD. He completed antibiotic therapy and resumed B-N for OUD before discharge from the hospital.

In the outpatient clinic, the patient was switched to extended-release buprenorphine. The patient underwent outpatient minor serial debridement of the residual scant peripheral tissue necrosis that had undergone liquefaction with collagenase therapy. The patient declined skin grafting of well-granulating wounds in favor of closure by secondary intention. His wounds were greater than 50% closed 1 year following his major surgical debridement. The patient continues to deny non-prescribed drugs; he visits the addiction medicine clinic regularly (with occasional missed visits), where he receives extended-release buprenorphine for OUD. 

Case 4
A 34-year-old male with a history of OUD and SP, bipolar disorder, left above-knee amputation and left above-elbow amputation presented with right leg pain associated with a nonhealing SP ulcer extending to bone. Prior to this presentation, the patient had been evaluated on numerous occasions and advised to undergo amputation of the right lower extremity due to chronic osteomyelitis associated with exposed bone in the ulcer. At those times, he declined the procedure and left AMA. He enrolled in a methadone program but continued to use heroin with financial assistance ($800 daily) from his father. The patient lived in a hotel room with a girlfriend who also had a history of drug misuse. 

On physical examination, vital signs were normal. The right lower extremity wound exhibited a necrotic ulcer extending to bone with purulent drainage. For opioid withdrawal and pain management, the patient received hydromorphone. The patient received intravenous antibiotic therapy with vancomycin, cefipime, and metronidazole. He underwent right above-the-knee amputation 1 day after admission. Postoperative pain was managed with epidural fentanyl and subsequently with intravenous hydromorphone. The patient was given the recommendation to titrate down the hydromorphone and initiate B-N, but the patient refused this plan and stated his intention to manage his pain with hydromorphone. He planned to re-enroll in a methadone program upon discharge. The patient left the hospital without narcotics AMA, and he did not follow up in the surgery clinic as directed.

The patient was readmitted to the hospital 9 months later for right lower extremity stump ulceration with malodorous, purulent drainage (Figure 5). He reported SP into the stump incision since the time of surgery. Biopsy demonstrated osteonecrosis and acute inflammation consistent with acute-on-chronic osteomyelitis. He underwent treatment of the stump infection with surgical debridement. Intravenous vancomycin and ceftriaxone were administered for stump infection and sepsis. On postoperative day 1, the patient left the hospital AMA. 

Four days later, he returned with purulent drainage from the stump wound. He appeared nontoxic. He was admitted to the hospital for suspected wound infection and acute-on-chronic osteomyelitis. Later that day, the patient admitted to using cocaine in the hospital and was subsequently found unresponsive with agonal breathing consistent with opioid overdose. An empty syringe was found. Naloxone was administered, and the patient regained consciousness. The security service searched his room per hospital policy and found several bags of white powder and drug paraphernalia among the patient’s belongings. The patient left AMA.  

On telephone interview performed 20 months after the patient's last visit to the treatment institution, his mother reported that he received care at an outside hospital but was suffering from infection in his right upper extremity (ie, his only remaining limb), extending into the shoulder joint due to self-administered, intra-articular SP. He left the facility AMA, continued to use drugs, and later returned to the same facility when he was found to be unresponsive at home (suspected to be due to sepsis from infected wounds). His mother reported there was a warrant out for the patient’s arrest for drug-related activity. The patient has not returned to the authors’ hospital in 23 months.

Case 5
A 42-year-old female with a history of OUD with SP presented because of painful bilateral lower extremity SP ulcers. The patient’s history was also remarkable for total abdominal hysterectomy for ovarian cancer. On physical examination, the patient appeared nontoxic with necrotic, malodorous bilateral lower extremity ulcers. Intravenous antibiotic therapy (vancomycin and piperacillin-tazobactam) was initiated, and the patient underwent serial surgical debridement of the bilateral infected lower extremity ulcers into muscle. The operative tissue culture was polymicrobial (Table 3). 

The addiction team offered B-N therapy for OUD, which the patient declined, citing side effects and poor pain control. She was not a candidate for outpatient methadone because she did not have an active identification card, which was required for the prescription of methadone. Negative pressure wound therapy was employed to facilitate granulation in the largest wound of the left lower extremity; smaller wounds were dressed with MGSD twice daily. Split-thickness skin grafting was performed on the same admission for rapid closure of the largest wound. Her postoperative pain was poorly controlled with an epidural, such that a femoral nerve catheter was placed for 4 days with concurrent methadone taper; hydromorphone and gabapentin were initiated for pain control, and lorazepam was begun for anxiety. The skin graft take in the left lower extremity wound was excellent, and daily treatment was continued with petrolatum gauze, ABD pad, and gauze wrap to protect the healing graft. She was transferred to a nursing facility for ongoing ORT and wound care (Table 2). 

The patient returned to the surgery clinic as instructed and was noted to have a well-healing graft. Upon her discharge from the nursing facility, methadone was discontinued. She resumed using illicit drugs and began SP at the edge of the graft site, which she maintained as a shooter’s patch. She did not return to the surgery clinic for follow-up but was readmitted to the hospital 7 months later with recurrent infection of the right lower extremity SP ulcer adjacent to the skin graft scar (Figure 6). She was admitted to the hospital monthly for serial surgical debridement at least 7 times thereafter. She has continued to decline treatment for addiction. 

The 5 cases presented demonstrate common challenges that are encountered in the surgical treatment of sequelae of SP. These extreme cases highlight the clinical, psychiatric, nursing, rehabilitation, safety, and social issues that make the delivery of medical and surgical care challenging. A multidisciplinary approach to the care of such patients should, ideally, become the standard of care. A good surgical outcome for these patients would have been difficult to achieve without collaboration with the authors’ specialist colleagues.

The primary physician will typically engage all specialty colleagues in the care of these complex patients. The process usually begins in the emergency department, where the acute care surgery service is consulted. The surgical arm of this effort is composed of surgeon intensivists who specialize in the surgical management of infection in critically ill patients; they are adept at emergent debridement, resuscitation, limb salvage, amputation, and wound care. However, as detailed in this case series, the surgeon’s role in the care of these complex patients is limited after successful surgery. Following surgery, the care of the patient depends heavily on the participation of specialists from addiction medicine, internal medicine, psychiatry and crisis intervention, nursing, social work, and physical/occupational therapy teams. A daily multidisciplinary meeting in each ward further engages bedside nurses in a collaborative effort to create daily treatment plans for patients, as well to optimize discharge planning and rehabilitation. 

The clinic’s multidisciplinary team commonly encounters the following challenges in the care of patients with SP: polymicrobial infection, postoperative pain and anxiety management, recidivism, acute drug withdrawal, and nonadherence with dressing care.  

Polymicrobial infection
The tissue cultures universally demonstrated polymicrobial infection (Table 3). Unlike single-organism, gram-positive skin infections (eg, MRSA and Streptococcus pyogenes)¹³ seen early in intravenous drug use and reported extensively in older literature, chronically infected necrotic ulcers host gram-positive, gram-negative, anaerobic, and resistant bacteria. In 2 cases, MRSA was identified in tissue, likely the result of repeated treatment with antibiotic therapy and repeated hospitalizations where exposure to MRSA is more common. 

For this reason, in keeping with more recent wound literature, broad antibiotic therapy is advocated prior to source control, including gram-positive, gram-negative, anaerobic, and MRSA bacterial coverage.¹³ The authors aim to achieve source control quickly (ie, within 12 hours of admission) and, thereafter, limit antibiotic therapy as much as possible, tailoring regimens with guidance from the infectious disease service. Oral antibiotic regimens are employed whenever possible to avoid the temptation of intravenous drug use with indwelling venous catheters. Cultures of tissue obtained in surgery guide the antibiotic selection and inform on antibiotic resistance, which is helpful in isolating patients to prevent the spread of resistant bacteria, in treating concurrent infection (ie, bacteremia, osteomyelitis), as well as in treating future infection. In this way, collaboration with colleagues promotes responsible stewardship of antibiotic use.

Postoperative pain and anxiety management in the setting of opioid cessation
It is impossible to achieve cessation of SP unless postoperative pain and anxiety are well controlled. In patients with OUD, inadequate pain control and withdrawal are highly anxiety-provoking. The authors routinely employ a multimodal treatment plan that incorporates addiction medicine, psychiatry specialty care, and perioperative pain management by the anesthesia service. 

The addiction medicine team endeavors to treat OUD and postoperative pain concurrently in the hospital setting, offering patients long-acting medication options (eg, methadone, B-N) whenever possible. In some cases, these can be tapered off or continued on discharge at an equal dose, lower dose, or even in depot dose. It is important to ensure appropriate follow-up plans are in place and that there are no barriers to accessing treatment (eg, lack of identification card, insurance coverage, transportation). It is strongly recommended that surgeons avoid the prescription of long-acting specialty pain medications outside of the hospital, instead deferring all prescription to the addiction medicine specialist. 

In some cases, patients decline OUD treatment but remain compliant with their postoperative care plan when their postoperative pain and anxiety are adequately controlled. If adequate pain and anxiety control are not achieved, the patient commonly attempts to leave AMA in order to engage in SP for relief. The authors rely heavily on  nursing colleagues to report all issues in real time through text and telephone communications with house staff and attending physicians. In this way, a true multidisciplinary approach is employed to optimize the patient experience and prevent recidivism, which is the approach advocated by Ward et al¹⁴ for this challenging issue. The skill sets of a psychiatry crisis-intervention nurse liaison and case manager are invaluable in crisis moments. In some cases, uncontrollable social factors drive a patient’s departure and can be resolved by a skilled case manager. 

The authors employ directed anesthetic therapy (eg, epidural, long-acting nerve block) whenever possible as they are tamper-proof and very effective. Nonopioid adjuncts are also used frequently to optimize patient comfort and minimize the amount of opioid necessary to achieve satisfactory analgesia. This practice shortens the anticipated duration of ORT and is ideal for long-term recovery from OUD. Scheduled doses of nonsteroidal anti-inflammatory medications are routinely employed as renal and hepatic function permit (eg, intravenous ketorolac 15 mg every 6 hours; oral ibuprofen 400 mg to 800 mg every 6 hours); oral analgesics, such as acetaminophen (500 mg–100 mg every 6 hours) or gabapentin (100 mg–600 mg 3 times daily), and a muscle relaxant (eg, cyclobenzaprine 5 mg–40 mg daily in divided oral doses 1 to 3 times daily; tizanidine 2 mg–4 mg by mouth every 6 hours) may also be used. Prescription of regulated medications is deferred to the addiction specialist after discharge to avoid duplications in prescription and confusion.  

Although anxiety is commonly observed in the postoperative period, routine use of benzodiazepines, which are also addictive, is not advised. Instead, antipsychotics (eg, quetiapine, mirtazapine) and antidepressants (eg, duloxetine) may be used as alternatives. The short-term use of titratable infusion treatments, including dexmedetomidine (0.2 µg/kg/hour to 1.5 mcg/kg/hour) and ketamine (0.1 mg/kg/hour to 5.1 mg/kg/hour), are very helpful. Infusion treatments are employed for 1 to 3 days in the postoperative period. Although dexmedetomidine is only available in the ICU, the hospital’s ketamine protocol allows treatment to be continued outside of the ICU on the medical and surgical wards.

The nonopioid adjuncts are associated with drowsiness, which can be an advantageous side effect; higher evening doses may be employed to ensure restful sleep for the patient. Lastly, cannabis remains an excellent option for postoperative anxiety and was recently legalized in the authors’ home state of Illinois. However, as of this writing, it has not yet been approved by the US Food and Drug Administration, and the authors do not formally prescribe cannabis in the absence of prescription guidelines and standardized availability. Despite this limitation, many patients now purchase cannabis to supplement their prescribed analgesic regimen.¹⁵   

Opioid replacement therapy continues on discharge; patients are followed in the addiction medicine clinic closely, with regular drug testing and monitoring of the State of Illinois narcotic prescription database. The team’s outpatient social worker is available to the patient for ongoing issues requiring assistance (eg, housing, transportation, insurance application). Addiction medicine specialists are adept at uncovering and managing nonadherence, as well as issues that contribute to OUD. Only 1 of the patients in this case series (Case 2) remained compliant with OUD treatment after discharge; he recovered from amputation and completed drug rehabilitation. To date, he is the only patient to achieve a successful surgical outcome. The patient in Case 3 has been following in the addiction clinic with occasional missed visits but maintains a negative toxicology screen and denies use of non-prescribed drugs. This example highlights the importance of the multidisciplinary approach. 

Effective surgical treatment for complications of SP is carried out in a staged fashion due to the need to clear the infection that is universally present on admission. It ends with skin grafting, primary wound closure, amputation revision/closure, or delayed closure by secondary intention. While undergoing staged procedures, patients are typically hospitalized and will generally cooperate with dressing care by the staff if their addiction and psychiatric issues are well managed. Before planning future closure procedures (eg, skin grafting), it is imperative for the surgeon to collaborate with the addiction medicine specialist and anesthesiologist to ensure appropriate medication management immediately before and during surgery. Inappropriate discontinuation plans place the patient at high risk for a relapse, with concurrent surgical failure.  

Recidivism with return to undisclosed SP
Clinicians should monitor patients closely for signs of recidivism during the hospital stay or after discharge; fresh surgical incisions and open wounds are tempting sites to employ as a shooter’s patch. This is especially true when healing slows or ceases after an initial period of normal healing in an otherwise healthy patient. In this series, shooter’s patches were observed in 4 of the 5 patients (Cases 1, 2, 4, and 5). 

The nursing staff maintains a constant presence on the ward, where they observe patients engaging in substance misuse during their hospital stay. For example, 1 patient (Case 4) used both cocaine and heroin in the same day and required naloxone administration for his witnessed overdose. In the hospital, harm reduction is a concept of vital importance; Strike et al¹⁶ reported that patients attempt to conceal illicit drugs when admitted to institutions for which an illicit drug use policy did not exist. To ensure the safety of patients and staff, hospital policy on illicit drug use on campus is enforced by a team approach; any member of the team can request a search of the patient’s room and belongings. Nursing staff, under the protection of a security service, conduct these searches that are critical to patient care.

Long-term, chronic wounds create chronic pain. It is of the utmost importance to close these painful wounds as quickly as possible. It is difficult to achieve abstinence from drugs and adherence with dressing care. In fact, many patients use their wounds as a shooter’s patch and continue to inject into them during active wound care treatment. This practice generates a distinct purple-tinged hue with a fibrotic texture to an otherwise healthy-appearing bed of granulation. Ironically, some patients become insensate due to concurrent neuropathy, but they continue to engage in opioid misuse and report pain.

Acute drug withdrawal and delirium
The estimation of opioid needs is an inexact process. The frequent result is undertreatment or overtreatment in the early postoperative period. Undertreatment results in recidivism; such patients are often caught using drugs on the wards to control their postoperative pain. For safety reasons, however, overtreatment (ie, prescribed overdose) is avoided. For this reason, undertreatment is observed far more commonly than overtreatment. While most providers are in tune to overtreatment, it is also important to monitor patients closely in the postoperative period for signs of undertreatment that can result in acute opioid withdrawal.¹⁷ An ICU stay is preferred where the nurse-to-patient ratio permits closer monitoring, visitor traffic is limited, and less privacy limits SP behavior. Most importantly, the ICU setting allows for ongoing adjustment of the postoperative pain control regimen. Delivery of tamper-proof treatment is the aim whenever possible, with early recognition of under- and overtreatment. The patient in Case 3 suffered from acute opioid withdrawal after surgery; the surgeon and anesthesiologist may not have appreciated early signs of withdrawal when coordinating the expeditious surgery required for infection control in the setting of sepsis. It is easy to mistakenly attribute diaphoresis and tachycardia to sepsis in the setting of infection when, in fact, a component of drug withdrawal may be present.  

Nonadherence
Nonadherence with dressing care results in poor healing and recurrent necrosis and infection. When pain and anxiety are poorly controlled, patients frequently discharge from the hospital AMA in favor of ongoing SP, which is associated with neglect of the wound and subsequent complications. However, many patients want to adhere to recommendations but are uninsured and cannot afford basic dressing materials, such as gauze and saline. Patients report wanting to attend clinic but have no independent means of transportation, relying on public aid for transportation. Similarly, many are homeless and live in nonhygienic environments; they do not qualify for shelters because of open wounds and/or active drug use. Many patients are without an identification card, which restricts their ORT candidacy. In particular, these patients may not receive ongoing addiction and psychiatric treatment, which contributes to recidivism.¹⁸

Discharge planning with a case manager or licensed social worker is essential to good outcomes. A balance must be struck between providing enough supplies for ongoing care and providing supplies that will, in many cases, be sold on the street in exchange for heroin. These patients must also be ensured access to busy surgery clinics. Continuity in care builds relationships with patients that promote trust and long-term adherence. For example, the patient in Case 1 has continued to use heroin but now obtains clean needles through a public service program. She moved back into her parent’s home for support after a period of homelessness, and, until the COVID-19 pandemic, was returning to clinic weekly for care of a healthy-appearing wound that was closing. Lastly, it is essential to include addiction medicine specialists in the discharge plan; they have additional resources, including social workers, to ensure that transportation, clinic access, and medication access are not barriers to success. In some cases, providers, nurses, and social workers, can mitigate patient risk through a combined effort to educate the patient on high-risk behaviors to avoid (eg, SP, homelessness, reuse of dirty needles)¹⁹ while supporting the patient in their recovery.

Patients with poorly controlled addiction and active SP will return with complications, commonly at their surgical sites, in a delayed fashion. For this reason,  surgeons are strongly encouraged to delay elective closure until the patient’s addiction is controlled by an addiction specialist. In cases of exposed bone after guillotine amputation, this may not be an option. Whenever possible, a subacute nursing facility admission is advocated for ongoing wound care and addiction management. This seems to improve short-term surgical outcomes by ensuring wound healing through reliable dressing care, steady nutrition, and the maintenance of a hygienic healing environment. However, most of these facilities do not have addiction specialists on site. It is imperative that the addiction team remains closely engaged in the patient’s treatment as the patient progresses from hospital, to facility, to home. 

Discharge from the subacute nursing facility is a prime time for recidivism. Once patients leave the hospital, they return to their home or homeless environment, where they often resume SP. Patients who are able to receive ongoing care in a subacute nursing facility tend to do better early in their recovery, but they are often lost to follow-up. These independent facilities usually arrange on-site visits by a wound care provider to minimize the cost of patient care, which promotes disruption in the close relationship between the patient and provider team, which is highly detrimental to a recovering SP patient. This is more cost-effective in the short term but sets the patient up to fail. A patient rarely advocates for a return to surgery clinic or ongoing follow-up in the substance misuse clinic. A well-intending wound care provider may arrange for further care, unaware of the significant addiction/psychiatric issues the inpatient team addressed. In such cases, patients are often advised to discontinue medication in anticipation of a routine surgery, which sets up the patient for drug withdrawal, a return to SP, and ongoing nonadherence. This is a recipe for surgery failure, as demonstrated in Cases 1, 4, and 5. Patient outcomes following discharge follow 1 of 2 paths: (1) ORT with sobriety and wound healing; or (2) relapse and ulcer progression. 

The length of stay was substantial for the patients in this case series, ranging from 3 to 18 days, and discharges AMA were a common occurrence. This is consistent with previous studies that have reported an average length of stay for drug-use-related abscesses as 3 to 13 days.^5,20-22 Providers who care for patients with OUD struggle to manage drug-seeking behavior and psychiatric issues that make caring for these patients frustrating. Neither the patient nor the system is served by encouraging discharges AMA out of frustration.  

Today, the authors do not perform elective closure procedures without consultation with multiple colleagues. To ensure that care is both effective and cost-efficient, a multidisciplinary plan for wound closure is needed to address addiction, postoperative pain, psychiatric illness, and social issues. As demonstrated in this case series, patients who are actively using drugs will misuse their fresh surgical sites as shooter’s patches, guaranteeing a poor outcome for any elective closure procedure. Surgeons should be aware of this and monitor closely for this development.

This case series was selected to highlight the complex aspects of surgical management of the sequelae of SP and is subject to selection bias. However, the issues presented are common to most patients encountered with complications of SP. 

There was a limited scope of reporting due to lack of follow-up in the clinic. Many patients do not maintain active contact information to permit long-term staff follow-up when they fail to attend clinic. Many patients are intermittently jobless, homeless, and without access to a phone.

Reporter bias (ie, the inclination to select good results) is also a limitation. To minimize this bias, this case series was chosen to highlight dramatic surgical cases, most of which did not have a good outcome. 

There is also the issue of employment of outdated dressing care. Due to lack of resources available to this patient population, less novel dressing regimens are often employed. Current products are more desirable and may decrease healing time, but these more expensive products are not typically available to these patients. As such, the authors rely heavily on older regimens. 

Lastly, there is the limitation of resource availability. Most of the patients seen in the authors’ clinic face an insurmountable issue, which is the lack of inpatient drug rehabilitation programs that accept patients with open wounds. Ideally, patients would transfer from the inpatient stay to a drug rehabilitation center. However, with open wounds, they are not candidates for most of these programs. This inflexibility in the current US medical system is a significant shortfall for this patient population. 

The patients presented in this case series required treatment for surgical, medical, and addiction/psychiatric illness, along with support for social issues that endanger successful outcomes. The short-term results were good, but long-term results reflect the impact of uncontrolled OUD on surgical outcome. A multidisciplinary treatment approach should be the standard of care for patients with complications of SP, and further research on this topic is welcomed. 

Authors: C.J. Michet, BA¹; Courtney Whitelock, BS¹; and Nicole Siparsky, MD, FACS²

Affiliations: ¹Rush Medical College, Chicago, IL; and ²Rush University Medical Center, Chicago, IL

Correspondence: Nicole Siparsky, MD, FACS, Associate Professor of Surgery, Rush University Medical Center, Surgery, 1725 W. Harrison Street, #810, Chicago, IL 60622; Nicole_Siparsky@rush.edu 

Disclosure: The authors disclose no financial or other conflicts of interest.