It Takes a Village

The Management of Extreme Sequelae of Skin Popping

C.J. Michet, BA; Courtney Whitelock, BS; Nicole Siparsky, MD, FACS

Wounds. 2021;33(1):9-19.

Abstract and Introduction

Abstract

Introduction: Skin popping (SP) is a popular technique for drug misuse, for its ease of administration and longer duration of effect. Skin infection is a well-described sequela of SP, but less is known about the more extreme sequelae of this practice.

Methods: Five patients who engaged in SP requiring major surgical intervention were identified on case review to highlight extreme diseases resulting from the practice of SP. Each patient reported using heroin or tested positive for opioid on admission. Each patient admitted to practicing SP or maintained a shooter's patch. A multidisciplinary approach was employed to care for the patient. Members of the departments of medicine, surgery, nursing, addiction medicine, infectious disease, rehabilitation, and social work collaborated in the complex management of each patient.

Results: Five patients presented to Rush University Medical Center between 2017 and 2019 for complications of SP. All 5 patients were actively using nonprescription opioids; 2 were concurrently undergoing treatment for opioid use disorder. Recurrent SP led to failed surgical treatment in all but 1 patient. Surgical outcome was directly related to recidivism.

Conclusion: The successful surgical management of severe sequelae of SP depends upon the successful management of the patient's addiction. Multidisciplinary care by surgical, medical, psychiatric, addiction, nursing, rehabilitation, and social work specialists is necessary to achieve a successful outcome. Based on this experience, the author's institution no longer offers nonurgent closure procedures to patients whose addiction is not well controlled.

Introduction

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.

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Table 1. Roles of the multidisciplinary team
MEDICINE PROVIDER	• Identify and treat medical, surgical, and psychiatric conditions in addition to SP • Collaborate with specialists to create a comprehensive inpatient treatment plan • Monitor patient for signs of ongoing drug misuse and drug withdrawal
SURGEON	• Identify and treat surgical disease associated with SP • Select affordable and simple dressing regimens to optimize compliance • Monitor patient for signs of surgical complications • Defer prescription of long-term pain medication to addiction/pain specialist • Obtain tissue cultures, which will help inform an antibiotic treatment plan
ADDICTION MEDICINE PROVIDER	• Identify and treat addiction and withdrawal • Provide appropriate psychiatric referral for conditions that contribute to addiction (eg, bipolar disorder, depression) • Implement long-acting medication regimens for the treatment of pain when possible to minimize ongoing addiction and optimize patient adherence • Coordinate outpatient care and ongoing monitoring for addiction • Optimize nonopioid medication options in a multimodal, opioid-sparing treatment plan
PSYCHIATRY PROVIDER/PSYCHIATRIC NURSE LIAISON	• Identify and treat psychiatric illnesses that contribute to ongoing substance use • Optimize nonopioid medication options in a multimodal, opioid-sparing treatment plan • Provide counseling and/or therapy for ongoing issues, including crisis intervention
NURSE	• Educate the patient on the benefits of multimodal, opioid-sparing treatment plans • Monitor for subjective and objective signs of drug and alcohol withdrawal • Monitor for ongoing drug abuse behavior and drug-seeking behavior • Coordinate patient room searches with security service to ensure patient and staff safety • Perform dressing care in conjunction with the surgeon • Communicate concerns to providers
INFECTIOUS DISEASE PROVIDER	• Identify apparent and occult sources of infection related to SP • Recommend surgical intervention for disease requiring surgical treatment • Recommend appropriate empiric treatment until tissue cultures are obtained • De-escalate antibiotic therapy as the patient's condition permits • Narrow antibiotic therapy based on tissue culture evidence • Choose oral antibiotic treatment whenever possible; minimize venous access device use (peripheral IV catheter, central venous catheter) to minimize IV drug abuse
SOCIAL WORKER CASE MANAGER	• Coordinate inpatient and outpatient care services based on available local and regional resources • Identify environmental, financial, and social barriers to recovery and offer guidance to providers on how to overcome these issues • Identify resources for dressing care and medication therapy for outpatient continuity of care; make referrals to inpatient physical rehabilitation or drug rehabilitation • Follow up with patient to ensure access is not restricted during recovery
PHYSICAL THERAPIST/OCCUPATIONAL THERAPIST	• Identify impediments to normal function resulting from medical and surgical therapy for which support devices and training are needed • Provide ongoing treatment for pre-existing or new functional deficits resulting from tissue loss • Educate patients on how to safely navigate their environment with a new wound or amputation stump; provide rehabilitation placement guidance

SP: skin popping; IV: intravenous

Table 2. Patient characteristics
CASE	AGE (y)	SEX	PRESENCE OF CHRONIC OSTEOMYELITIS (EXPOSED BONE)	OPIOID MISUSE ON ADMISSION	UNDERGOING OPIOID USE DISORDER TREATMENT AT ADMISSION	ASSOCIATED MEDICAL DIAGNOSES	DAILY DRESSING PRESCRIBED ON DISCHARGE	OPIOID USE DISORDER TREATMENT DURING ADMISSION	LONG-TERM OPIOID USE DISORDER TREATMENT
1	27	F	No	Yes	B-N	Hepatitis C MRSA bacteremia Shooter's patch Homelessness	Xeroform ABD pad Gauze wrap	B-N	Declined
2	42	M	Yes	Yes	None	Bipolar disorder Shooter's patch Mood disorder	Gauze wrap	B-N	B-N with ongoing treatment
3	51	M	No	Yes	None	Nonhealing burn Drug withdrawal Homelessness	Collagenase and MSGD Gauze wrap	B-N	Extended-release buprenorphine with ongoing treatment
4	34	M	Yes	Yes	Methadone	Bipolar disorder Anxiety Depression Shooter's patch	None	Opioid therapy	Declined
5	42	F	No	Yes	None	Ovarian cancer Chronic back pain Shooter's patch	Petrolatum gauze ABD pad Gauze wrap	Opioid therapy	Methadone

B-N: buprenorphine-naloxone; MRSA: methicillin-resistant Staphylococcus aureus; ABD: abdominal; MSGD: moist saline gauze dressing

Table 3. Tissue cultures
CASE	TISSUE CULTURE	BLOOD CULTURE	ANTIBIOTIC THERAPY
1	More than 3 species of aerobes: MRSA Pseudomonas aeruginosa Klebsiella oxytoca Citrobacter freundii	MRSA	Vancomycin Piperacillin-tazobactam (both continued on discharge)
2	More than 3 species of aerobes: Proteus mirabilis P aeruginosa Staphylococcus aureus Providencia stuartii Enterobacter cloacae Enterococcus raffinosus Enterococcus faecalis	No growth	Piperacillin-tazobactam (completed prior to discharge)
3	P mirabilis Streptococcus dysgalactiae Actinomyces spp	No growth	Vancomycin (completed prior to discharge)
4	No tissue culture obtained (limb amputation)	No blood culture obtained	Vancomycin Cefipime Metronidazole (completed prior to discharge)
5	S aureus Enterococcus spp Group A streptococci P mirabilis MRSA Klebsiella pneumoniae	No growth	Vancomycin Piperacillin-tazobactam; narrowed prior to discharge to Sulfamethoxazole-trimethoprim Metronidazole