INTRODUCTION
There has been a dramatic increase in opioid use, resulting in a precipitous rise in hospitalizations across the United States.1,2 Based on early evidence, there has been an increase in upper extremity complications secondary to intravenous drug use (IVDU),3 but the quantitative impact and morbidity of this problem to hand surgeons are not precisely known. These patients often present with complex problems along with difficult to manage medical and social comorbidities.4 The number of inpatient hospitalizations due to IVDU-associated complications has risen dramatically over the past 10 years, and the most common reason for hospitalizations is due to skin and soft-tissue infection.5,6 According to data available from 2010 and 2015, the number of opioid-related deaths per 100,000 people in Massachusetts was 11.3 in 2010 and 25.4 in 2015, compared with 12.39 and 16.33 deaths nationally in 2010 and 2015, respectively.7 According to the Massachusetts Department of Public Health, there was a 200% increase in opioid-related deaths per 100,000 people from 2010 to 2015. Although this information includes all opioid- related deaths, the Massachusetts Department of Public Health has reported that the presence of fentanyl in the system has continually increased from 2014 to 2017, whereas prescription opioid has been decreasing, which may explain the increase in IVDU-related infections.8
The upper extremity is a common injection site and prone to infection or other sequelae.4,6 Anecdotally, many patients with active IVDU present to the emergency room with infections in the upper extremity and are treated by hand surgeons.9 The growing problem of IVDU-related infections of the upper extremity is not well described.
The primary aim of this study was to evaluate the differences in the patient population and treatment course for upper extremity infections within a cohort of intravenous (IV) drug users and non-IV drug users over three 1-year intervals within a 10-year period at 1 level I emergency department (ED). We tested the primary null hypothesis that there are no demographic or treatment-related factors independently associated with complications after an upper extremity infection.
MATERIALS AND METHODS
This study was approved by our institutional review board and granted a waiver of informed consent for this retrospective chart review.
Subjects
We used the ninth revision of the International Statistical Classification of Diseases and Related Health Problems codes and Current Procedural Terminology codes to identify patients 18 years old or older who were seen for an upper extremity infection at 1 level I ED in calendar years 2005 (n = 1,251), 2010 (n = 1,729), and 2015 (n = 1,428) (see Appendix, Supplemental Digital Content 1, which displays ninth revision of the International Statistical Classification of Diseases and Related Health Problems codes, https://links.lww.com/PRSGO/A986).
To identify patients presenting with intravenous drug use (IVDU), all patients were filtered with IVDU, “IV drug use,” “IVDU,” “intravenous drug abuse (IVDA),” and “Heroin,” in any of their notes in the medical records within that specific year with text searches using STATA 14.0 statistic software (StataCorp LP, College Station, Tex.). After manually reviewing the medical records of patients with possible IVDU (138 in 2005, 202 in 2010, and 299 in 2015), we identified 65 patients in 2005, 109 patients in 2010, and 147 patients in 2015 who had an IVDU-related infection.
A case–control design was used to study differences in demographic factors, specific details of the infection, and treatment parameters between patients with and without a history of IVDU. All patients were categorized into age groups (<30, 31–40, 41–50, 51–60, 61–70, or >70). Every patient with a history of IVDU was randomly matched with a patient without a history of IVDU, based on age group, gender, and race using Data Analysis and Statistical Software STATA 14.0.
We reviewed the electronic medical records to collect additional patient-related demographic factors (tobacco use, employment status, and insurance status), specific details of the infection (location of the soft tissue, type and extent of infection), and treatment parameters (type of intervention, length of stay, use and extent of imaging), between the 2 groups for each year. Admission rate was defined as the number of times a patient presented at the ED for the same infection (see Appendix, Supplemental Digital Content 2, which displays patient-related factors and infection-related factors, https://links.lww.com/PRSGO/A987).
Statistical Analyses
We calculated the rate of IVDU-related upper extremity infections as a percentage of the total number of upper extremity infections that presented to the ED for treatment. Categorical variables are reported as frequencies and percentages and continuous variables as mean and SD or median and interquartile range based on normality of the data. We used the McNemar test for paired dichotomous variables and McNemar–Bowker test for symmetry for paired nominal variables. A paired t test was used for paired continuous variables (eg, days of stay in hospital). A P value <0.05 was considered statistically significant. All statistical analyses were performed using the STATA 14.0.
RESULTS
Patient Demographics (2005)
In 2005, there were 1,251 total patients who presented to the ED with an upper extremity infection; 794 were male (63%) and 1,022 (87%) were white. The mean age was 47 (SD, 18). A total of 1,186 patients presented to the ED with a non-IVDU upper extremity infection and 65 had an IVDU-related upper extremity infection (rate, 5.2%).
In the IVDU cohort alone, 44 were male (68%) and 59 (94%) were white. The mean age was 35 years (SD, 11). In comparison, the non-IVDU cohort consisted of 750 males (63%) and 963 were white (86%). The mean age of the non-IVDU cohort was 48 years (SD, 18) (Table 1).
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Table 1.: Factors Associated with IVDU in Patients with an Upper Extremity Infection Visiting the ED in 2005
Patient Demographics (2010)
In 2010, the total cohort consisted of 1,729 patients with an upper extremity infection, of the entire cohort, 995 were male (58%) and 1,397 (85%) were white. The mean age was 50 (SD, 19). The non-IVDU cohort consisted of 1,620 patients and the IVDU cohort consisted of 109 patients (rate, 6.3%).
In the IVDU cohort, 69 were male (63%) and 99 (96%) were white. The mean age of the IVDU cohort was 34 years old (SD, 10). In comparison, the non-IVDU cohort consisted of 926 males (57%) and 1,298 were white (84%). The mean age of the non-IVDU cohort was 52 years old (SD, 19) (Table 2).
Table 2.: Factors Associated with IVDU in Patients with an Upper Extremity Infection Visiting the ED in 2010
Patient Demographics (2015)
Of the 1,428 total patients identified, 824 were male (58%) and 604 were female (42%). A total of 1,140 (79%) subjects were white. The average age of the total cohort was 49 years (SD, 18). Of the entire cohort, 1,281 subjects presented with a non-IVDU upper extremity infection and 147 had an IVDU infection (rate, 10.3%).
In the IVDU cohort, 87 subjects were male (59%) and 130 (92%) were white. The mean age of the IVDU cohort was 36 years old (SD, 9.1). In comparison, the non-IVDU cohort consisted of 737 males (58%) and 1,010 (84%) were white. The mean age of the non-IVDU cohort was 50 years old (SD, 19) (Table 3).
Table 3.: Factors Associated with IVDU in Patients with an Upper Extremity Infection Visiting the ED in 2015
Patient-related Factors
In 2005, the rate of IVDU-related infection was 5.2%. The patients in the IVDU cohort were younger (35 versus 48 years; P < 0.001) (Table 1). These patients were more likely to smoke (P < 0.001), have hepatitis C (P < 0.001), to be unemployed (P < 0.001), to be homeless (P < 0.001), and have a diagnosis of a psychiatric disorder (P = 0.046). These patients in the IVDU cohort were more likely to have a form of government insurance (Medicare, Medicaid; P < 0.001) (Table 4).
Table 4.: Factors Associated with IVDU in Patients with an Upper Extremity Infection Visiting the ED in 2005
In 2010, the rate of IVDU-related upper extremity infection was 6.3%. The patients in the IVDU cohort were younger (34 versus 52 years; P < 0.001), and most were white (P = 0.014) (Table 2). IVDU patients were more likely to be smokers (P < 0.001) and have medical comorbidities (hepatitis C, P < 0.001; psychiatric disorder, P < 0.001). These patients were more likely to be homeless (P < 0.001) and unemployed (P < 0.001), and have a form of government insurance (Medicare, Medicaid; P < 0.001), when compared with the patients in the non-IVDU cohort (Table 5).
Table 5.: Factors Associated with IVDU in Patients with an Upper Extremity Infection Visiting the ED in 2010
In 2015, the rate of IVDU in all upper extremity infections was 10.3%. IVDU patients were significantly younger on average (36 versus 50 years; P < 0.001) (Table 3). Patients with an IVDU-related infection were more likely to be smokers (P < 0.001) and have comorbidities (hepatitis C, P < 0.001; psychiatric disorders, P < 0.001). These patients were more likely to be homeless (P < 0.001), unemployed (P < 0.001), and have a form of government insurance (Medicare, Medicaid; P < 0.001) when compared with patients presenting to the hospital with a non-IVDU–related upper extremity infection (Table 6).
Table 6.: Factors Associated with IVDU in Patients with an Upper Extremity Infection Visiting the ED in 2015
In 2015, the number of IVDU-related infection was 2.3 times higher than in 2005 and the incidence was 2.0 times higher (Figs. 1 and 2).
Fig. 1.: The number of IVDU cases presenting to the emergency department of a single urban center with an upper extremity infection in 2005, 2010, and 2015.
Fig. 2.: The incidence of IVDU cases presenting to the emergency department of a single urban center with an upper extremity infection in 2005, 2010, and 2015.
Infection-related Factors
In 2005, the patients in the IVDU cohort were more likely to have an infection in a typical injection site (wrist, P = 0.020; elbow, P = 0.001), compared with the patients in the non-IVDU group, which were more likely to have an infection in other locations (finger, P = 0.001; shoulder, P = 0.007). The primary diagnosis for patients presenting to the ED in the IVDU group was due to an abscess (P < 0.001), whereas the patients in the non-IVDU group were more likely to present to the ED for a different diagnosis, such as paronychia (P = 0.025).
In 2010, the IVDU patients were more likely to present with an infection in a common injection site (wrist, P = 0.012; forearm, P < 0.001; elbow, P < 0.001) and have multiple infection sites per patient (1.3 versus 1.0; P < 0.001). The non-IVDU patients were more likely to have an infection in the finger (P < 0.001). The IVDU group was more likely to have a methicillin-resistant Staphylococcus aureus infection (P = 0.003) (Table 5). Culture-positive infections were not recorded for all patients.
In 2015, the infection location in the IVDU group was more likely to be in a common injection site (forearm, P < 0.001; wrist, P = 0.002), whereas the infection location in the non-IVDU group was more often at other sites (finger, P < 0.001). The reason for hospital presentation within the IVDU group was more likely to be an abscess (P < 0.001) or cellulitis (P = 0.002), whereas the non-IVDU group typically presented with a different type of upper extremity diagnosis, such as paronychia (P < 0.001). The type of infection was more likely to be caused by methicillin-resistant S. aureus (P = 0.009) in patients with IVDU (Table 6).
Treatment Parameters
Compared with the non-IVDU group, the IVDU group had 33% more hospital admissions and had greater duration of hospital stay (3 days versus 0.59; P < 0.001). The IVDU patients were more likely to leave against hospital medical advice (P < 0.001) and had a higher number of subsequent ED admissions related to the initial upper extremity infection. The IVDU group underwent a computed tomography (CT) scan more frequently (12% versus 1.4%; P < 0.001), and the mean number of upper extremity radiographs was higher in the IVDU group in 2005. Compared with 2005, in 2015, patients with an IVDU-related infection were more likely to receive more imaging than the respective non-IVDU cohorts. In 2015, 17 IVDU cases received a CT versus only 2 in the non-IVDU group (P < 0.001), whereas in 2005, 6 IVDU cases received a CT versus 1 in the non-IVDU group (P = 0.059). Patients with IVDU-related infections were more likely to undergo surgical incision and drainage [49 cases versus 30 controls in 2005 (P < 0.001), 72 cases versus 55 controls in 2010 (P = 0.017), and 92 cases versus 72 controls in 2015 (P = 0.031)] and more often received IV antibiotics [48 cases versus 29 controls in 2005 (P < 0.001), 80 cases versus 55 controls in 2010 (P < 0.001), and 82 cases versus 46 controls in 2015 (P < 0.001)]. The IVDU group was discharged more often to a rehabilitation center for further care due to their upper extremity infection in 2015 (P = 0.011) (Tables 4–6).
DISCUSSION
This study examines the differences in demographics and treatment factors related to upper extremity infections in IV drug users compared with non-IV drug users. The number of patients presenting to our emergency room with an IVDU-related upper extremity infection more than doubled in 10 years, and our rate of upper extremity infections related to IVDU rose to 10.3% in 2015 (up from 5.2% in 2005 to 6.3% in 2010).
Due to the more complex and advanced nature of their infections (more sites of infection, more abscesses, more frequent operative debridements, and more MRSA infections), IVDU patients often required more complex and costly workup and treatment. In our study population, they underwent more imaging studies and more infectious disease consultations. Additionally, they more often required treatment with IV antibiotics and needed a higher number of total procedures in the treatment of their infection. The IVDU cohort was more likely to have methicillin-resistant S. aureus infections compared with the non-IVDU group.
IVDU patients trended toward more complex procedures such as amputation and flap coverage of open wounds, which may be a significant finding in a larger cohort. Finally, IVDU patients had overall longer hospital admissions and were more likely to require discharge to a rehabilitation facility.
There are limitations to our study. Any database study is subject to coding errors. To account for this, we manually reviewed patient medical records with a mention of IVDU or synonyms in any report to confirm that patients in fact presented with an upper extremity infection, and to determine the presence or absence of IV drug use. Second, this study represents the population at one academic medical center in the Northeast United States, and some results may not be generalizable to other geographic regions and metropolitan areas. Third, we determined the rate of IVDU based on retrospective medical records, which relies on the patient population to report participation in illegal behavior, so the rate of IVDU-related infections may be underestimated and some patients in the non-IVDU cohort may have been miscategorized. Fourth, due to the retrospective nature of this study, we cannot comment on patients who sought care at another institution after receiving initial treatment at our facility. Fifth, the reasons for more IVDU infections are not explored in this study. Finally, it may be that ED physicians were more likely to admit patients with a history of IVDU, more aggressive in their imaging, more concerned about compliance, or in some other way altered the management of these patients when it is possible they could have been treated with emergency room drainage and then discharge like the non-IVDU patients.
These findings are consistent with previous studies about IVDU-related infections, which demonstrated that patients with IVDU-related infections tend to be younger, have psychiatric comorbidities, need more intensive treatment, and, therefore, have a longer hospital stay.10,11 A study conducted by Buckland et al.12 found that the most common sites of infection in the IVDU population were the antecubital fossa and hand and the most common treatments performed were incision and drainage and provision of IV antibiotics. In a similar study performed by Chotai et al.,4 patients in the IVDU cohort tended to be smokers and unemployed, with a significant medical history for hepatitis C and other mental health disorders.
Additionally, these patients are difficult to manage due to the complexity of infection and a lower medical compliance, and often require coordination between multiple specialties.4 In our study, IVDU patients received consults from infectious disease, psychiatry, plastic surgery, orthopedics, and some patients were discharged to a rehabilitation facility for further care. Treatment may be also complicated because IVDU patients with upper extremity infections may delay presentation to the ER because of other personal or social factors. A study conducted by Gonnella et al.13 found that late presentations to the hospital tend to increase the mean length of stay required, which led to increased costs per hospitalization. IVDU patients leaving against medical advice is another challenge.
Our data are consistent with previous literature findings that show the most at-risk population tends to be younger, white males.9 In addition, the number of women presenting to the ED with an IVDU-related upper extremity infection increased. This is consistent with national trends based on hospital inpatient utilization for opioid overuse, which demonstrated that although there is a higher rate of male IV drug users, the difference between the sexes is decreasing over time.14
Despite several public health initiatives to combat the opioid crisis, our institution still saw an increase in IVDU infections. For instance, compared with other areas in the United States, our area has implemented 10 locations for needle exchange programs and several locations for suboxone treatment.15 The needle exchange programs in the area studied were implemented before our study period, in 1994.16 These locations are closer to other local hospitals and probably do not impact the number of patients presenting to our institution, but could increase the number of IVDU-related patients presenting to other local EDs. However, our institution does have a center for addiction medicine (started in 2005) which provides suboxone treatment for opioid addiction, among other therapies. Based on data from the 2010 U.S. Census and Population Estimates Program, there was population growth between 2010 and 2015; however, we expect that the reason for the increase in IVDU-related infections would be related to the steep increase in IV drug abuse in our community.17 Our study period includes data before and after the 2008 financial crisis, which led to a national increase in unemployment rates; however, our community had lower rates of unemployment compared with the national levels (Massachusetts peak unemployment rate in 2009 was 8.8% compared with the national rate of 9.9%).18,19 We would expect other areas in the nation, which experienced higher rates of unemployment, to have higher rates of IV drug abuse after the financial crisis.
The opioid crisis has a direct and tangible effect on the practice of hand surgery. IVDU-related infections are more severe and more difficult to treat than traditional upper extremity infections. Patients have substantial medical and social comorbidities that also cannot be resolved by a single episode of care. To better treat these individuals presenting to the ED, a multidisciplinary approach is optimal. Providers should work with addiction medicine specialists and social workers to provide ongoing treatment for this population. By providing early access to substance abuse therapies, physicians can hope to increase patients’ treatment compliance and reduce the loss to follow-up in this population. There is a large burden associated with the care of IVDU-related upper extremity infections, and our data support that (1) efforts to stem the opioid crisis are critically important to hand surgery; (2) institutions should anticipate substantial resource utilization in the future as the opioid crisis persists; and (3) additional financial support for institutions and practitioners caring for these patients may be warranted.
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