![]() perfringens infections ( Centers for Disease Control and Prevention, 2000). ![]() In the UK a notable community outbreak of SSTI among PWID had a high mortality rate with evidence of C. sordellii (necrotizing fasciitis) ( Kimura et al., 2004). perfringens (myonecrosis) ( Bangsberg et al., 2002) and. tetani (tetanus) ( Centers for Disease Control and Prevention, 1998), C. botulinum (causing wound botulism) ( Gollober et al., 1995 Passaro, Werner, McGee, Mac Kenzie, & Vugia, 1998) C. In the US context BTH, colloquially named by its color and consistency when warm, has been associated in case-series with less common forms of SSTI due to exogenous contamination with hardy spore-forming Clostridium species, including C. aureus (MRSA) ( Fleisch, Zbinden, Vanoli, & Ruef, 2001), as well as oral commensals ( Summanen et al., 1995). A recent US national study found a doubling of hospitalization rates for heroin-related SSTI and confirmed the geographic disparity noted above: US cities with a dominance of Mexican-sourced “Black Tar” heroin (BTH) had 40% higher rates of SSTI compared with cities supplied by Colombian-sourced powder heroin ( Unick, Rosenblum, & Ciccarone, 2015).ĭocumented infectious agents for SSTI include skin commensal bacteria, for example, Staphylococcus aureus ( Bassetti et al., 2004 Summanen et al., 1995), including methicillin-resistant S. In the UK context 29% ( Public Health England, 2012) to 36% of surveyed PWID reported an SSTI symptom in the past year ( Hope, Kimber, Vickerman, Hickman, & Ncube, 2008). The prevalence of SSTI varies: in the North American context point prevalence by clinical exam ranges from 10% (Vancouver) ( Lloyd-Smith et al., 2008) to 19–32% (San Francisco) ( Binswanger, Kral, Bluthenthal, Rybold, & Edlin, 2000 Ciccarone et al., 2000) similarly, self-reported prevalence ranges from 11% (NYC, past 6 months) ( Vlahov, Sullivan, Astemborski, & Nelson, 1992) to 27% (San Francisco past year) ( Ciccarone et al., 2000) and self-reported lifetime prevalence approaches 70% (San Francisco) ( Ciccarone et al., 2000). In some locations, SSTI, predominantly the clinical entities of abscess and cellulitis, are a common reason for hospitalization of PWID ( Ciccarone et al., 2001 Ebright, 2002) and emergency department visits ( Ciccarone et al., 2001 Palepu et al., 2001), leading to high societal ( Ciccarone et al., 2001 Takahashi, Maciejewski, & Bradley, 2010) and personal costs, such as skin grafting and limb amputation ( Bourgois & Schonberg, 2009 Messac, Ciccarone, Draine, & Bourgois, 2013). Venous sclerosis, that is scarring of veins and loss of functionality, can lead to myriad medical consequences for example deep venous thrombosis secondary to repeated femoral injections ( Maliphant & Scott, 2005 Mackenzie, Laing, Douglas, Greaves, & Smith, 2000) and particularly the spectrum of skin and soft tissue infections (SSTI) ( Ciccarone et al., 2001). ![]() ![]() PWID may also inject into sub-cutaneous tissue (aka “skin-popping”) as well as muscle (aka “muscling”) when venous access fails ( Ciccarone et al., 2000, 2001). Ultimately, frustration can lead to desperation and a transition to injection into central veins including the femoral ( Coffin, Coffin, Murphy, Jenkins, & Golden, 2012) and neck veins ( Bourgois & Schonberg, 2009). Loss of peripheral venous access can lead to frustration and pain, increased time spent in search of patent veins, multiple injection attempts and the use of smaller veins in the hands, feet and legs in search of a successful injection ( Ciccarone, 2013). Our preliminary findings, for example, that different heroin source-forms and preparations have a two log difference in acidity, have potentially broad, vital and readily implementable harm reduction implications.Īccess to functioning veins is a primary concern among people who inject drugs (PWID) ( Harris & Rhodes, 2012). Heroin pH testing in natural settings is feasible and a useful tool for further research. We report pilot study data on first ever in vivo measurements of heroin pH and as well as qualitative data on users’ concerns and perceptions regarding the caustic nature of heroin and its effects. This commentary stems from our hypothesis that venous sclerosis is causally related to heroin acidity, which varies by heroin source-form and preparation. The etiology of venous sclerosis is unknown and users’ perceptions of cause/meaning unexplored. In addition to perpetual frustration and loss of pleasure/esteem, venous sclerosis leads to myriad medical consequences including skin infections, for example, abscess, and possibly elevated HIV/HCV risks due to injection into larger jugular and femoral veins. The loss of functioning veins (venous sclerosis) is a root cause of suffering for long-term heroin injectors.
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