It Takes a Village

The Management of Extreme Sequelae of Skin Popping

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

Disclosures

Wounds. 2021;33(1):9-19. 

In This Article

Discussion

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 al[14] 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 al[16] 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.

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