Opioid dependent patients’ experiences of and attitudes towards having their injecting sites examined

Introduction 

A clinical assessment of injecting drug users (IDUs) in opioid pharmacotherapy treatment can include questions concerning current substance use patterns, risk related behaviours, and past treatment experience. Many guidelines also suggest the routine physical examination of patients, including an examination of injection sites, as part of clinical review (Department of Health, 1999, NSW Department of Health, 2006).

Surprisingly, this potentially important area of assessment has received scant attention in the research literature, except for one study which provided a classification system to determine the age of injecting sites (Cagle, Fisher, Senter, Thurmond, & Kastar, 2002). No articles were identified concerning the clinical practice and utility of reviewing drug injection sites, the frequency of this practice among clinicians, nor patient's attitudes, experience and responses to having sites inspected. Diabetes is the only area of medicine where the routine inspection of injecting sites has been reported (Partanen & Rissanen, 2000; Seyoum & Abdulkadir, 1996; Young, Steel, Frier, & Duncan, 1981).

During training to experienced opioid pharmacotherapy prescribers on assessing stability in people on opioid pharmacotherapies (Winstock & Bell, 2006), it became evident that many clinicians did not routinely examine injection sites during clinical assessments of IDUs. They cited concerns over the possible effects of inspection on patients. This included potential negative effects on the therapeutic relationship, concern that patients would feel they were not being trusted, and that inspection of the upper limbs might influence some to inject in less easily observable and potentially more risky sites. Other clinicians were uncertain of their ability to correctly identify the age of injection sites.

In the absence of research in this potentially important aspect of the clinical assessment of IDUs, this study aimed to assess patients’ attitudes and experiences of injection site inspection by their prescribing clinicians.

Method 

Results 

Experience of having injecting sites inspected 

Participants were asked to identify which areas of their body were examined for injecting sites at the clinical review appointment they had just attended. Almost all participants reported having their upper limb inspected (98%, n=147), 7% (n=11) had their leg inspected, 7% (n=11) had their neck inspected, and 4% (n=6) had their groin inspected. Other sites inspected included stomach (n=1) and back (n=1).

Participants were asked to consider how they felt during previous inspections. The majority reported that they were “happy to have their sites inspected” and felt it was “an appropriate part of routine examination”. Over a third reported that they “found it embarrassing”. Results are presented in Table 1.

Table 1. Ratings of how participants felt while having their injecting sites inspected by their prescriber during previous inspections

	Statement	Agree (%)	Not sure (%)	Disagree (%)
	I felt like the doctor did not believe me	20	21	59
	I found it embarrassing	39	10	51
	I found it interesting to talk about the site with my doctor	47	29	24
	I was happy to have my sites inspected as it confirms the history I have given the doctor	78	12	10
	I felt it was an appropriate part of routine examination for someone who has a history of injecting drugs	72	17	11

Participants were asked to report how many times, of their last five clinical review appointments, their doctor had asked to look at injecting sites. Over a third (34%, n=50) had been asked to show current or previous injecting sites at each appointment, 15% (n=22) on three to four occasions, 38% (n=56) on one to two occasions, and 12% (n=18) not at all.

When considering all appointments concerning their drug and alcohol problems, a minority (12%, n=18) reported that injection site examination had occurred all or nearly all of the time, 18% (n=26) that it occurred about 75% of the time, 13% (n=19) about 50% of the time, 31% (n=45) about 25% of the time, and 26% (n=38) reported that they had never or almost never had a doctor ask to look at their injecting sites.

Discussion 

This is the first study to explore experience and attitudes of IDU about the inspection of injecting sites by their doctor, and the impact this might have upon information disclosure and future injecting practices.

Most patients were broadly accepting of such inspection and believed it to be a reasonable part of routine clinical examination. In addition, the results support a high level of accurate self-report of recent injecting by patients in an opioid treatment setting, with site examination corroborating self-report in over 90% of cases. Consistent with these findings is the relatively small proportion of participants (18%) who denied recently injecting drugs but were found, upon examination, to have recent injection sites. When challenged most admitted to recent injecting. These findings lend support for the validity of self-reported drug use among IDUs in treatment (Darke, 1998; Jain, Triapthi, Varghese, Kumar, & Kumar, 2006).

Although there remains wide variation in the frequency and experience of injection site inspection among patients, it is perhaps surprising that a quarter reported never or rarely having their sites inspected and a further quarter reporting only occasional site inspection. This appears incongruent with what might be considered good routine clinical practice. Changes in the practice of the clinicians involved in the present study during the 6–12 months period prior to the study may explain the higher incidence and frequency of recent injection site inspection experiences, with only a minority reporting no site inspection in their last five clinical reviews.

Perhaps the most significant finding is that patients would be more honest as a result of routine injecting site examination. Improved honesty in self-report among the majority would need to be weighed against potentially more risky injecting practices among a minority if faced with routine upper limb inspection. Injecting in sites other than the upper limb is associated with a greater risk of complications (Darke, Ross, & Kaye, 2001; Rhodes et al., 2006; Roszler, McCarroll, Donovan, Rashid, & Kling, 1989; Woodburn & Murie, 1996). This might be motivated by a desire to avoid detection and any potential consequences of continued illicit drug use upon treatment provision (Darke, 1998). Good practice would dictate that in most instances ongoing drug use (especially heroin use) should not result in the termination of methadone or buprenorphine treatment. Through providing better explanation as to the purpose of the examination and the treatment consequences of continued injecting, any shift to more dangerous injecting practices may be minimised. Patients should be assured that the detection of injecting sites will not result in their removal from the programme and generally will not be met with a punitive response. The risks that continued injecting may pose should be the major focus of the clinical interaction that accompanies injection site inspection.

Recent use episodes were overwhelmingly in the upper limb, suggesting that upper limb inspection is adequate in the vast majority of consultations. This is consistent with the results of an earlier survey of Australian IDU in which almost all (99%) had injected in the upper limb and only 10% in their neck and 6% in their groin (Darke et al., 2001). The upper limb is chosen primarily for its ease of access and secondarily because it can be concealed by wearing long sleeves (Vollum, 1970). It is usually only after these sites have been exhausted, that a patient will resort to riskier sites such as the groin, lower limb or neck. Within an Australian context it may be appropriate to reserve more extensive examination to those cases where alternative sites are disclosed by the patient, when upper limb access is very poor in clients or where evidence (e.g., intoxicated presentation, positive urine drug screens) suggests the consumption of injectable drugs.

The relevance of these findings to other IDU populations is less certain and may be limited by different drug treatment paradigms in different countries, and to variations in available drug preparations, consumer preference and injecting practices. For example, recent research from the UK estimates that 45% of IDU report groin injecting in the last 4 weeks (Rhodes et al., 2006). In such cases routine upper limb inspection is less useful in corroborating self-report data and may require a revision of what injection sites are included in these examinations. Although potentially intrusive, given the high rates of groin injecting related complications (Rhodes et al., 2006, Roszler et al., 1989) regular inspection of this site may be important, acknowledging the resource implications where chaperones are considered appropriate.

The demographics of the study group were broadly similar to those reported in a study of clients attending opioid treatment services in New South Wales (Bell, Burrell, Indig, & Gilmour, 2006). The sample size is moderate and represents 15% of patients managed by the three clinics.

Interrater reliability of clinicians’ ability to identify and determine the age of injection sites was not assessed. As such, the degree of congruence between patient self-report and clinical examination cannot be considered constant between clinicians. In addition, it is difficult to accurately assess the age of an injection site by visual inspection alone as it is complicated by a wide variation in healing rates, the substance injected, injection techniques, existing trauma and skin tone. For example, recent injection in old sites may be very difficult to see on cursory examination. In routine clinical practice the ability to age a site may not need to be refined much beyond being able to differentiate between a very recent injecting site (within a day or 2), recent injecting sites (less than 1 or 2 weeks old), and older healed injection sites. This assertion is consistent with the only research attempting to provide a classification system to determine the age of injecting sites, and may have utility in routine clinical practice (Cagle et al., 2002). In this study clinicians corroborated self-reported recent injecting in 26% of the sample, which was broadly consistent with the responses from the 64% of the sample who provided anonymous information on their most recent injecting episode. There is, however, no information available that permits an objective assessment of the accuracy of individual attempts at identifying recent injecting sites in this study.

The examination of injection sites can provide useful corroborative information on self-reported injecting behaviour, provide an opportunity for harm reduction advice, and guide the clinician in determining appropriate changes in treatment in discussion with the patient. When conducted by the same clinician, the serial review of injecting sites can provide valuable support for a self-reported reduction or cessation of injecting use and an opportunity for positive feedback on the gradual disappearance of dermal evidence of injection. In instances where injecting sites are identified that have not been declared on interview alone, the approach should be one of enquiry as to what was motivating the patient to nondisclosure. Patients can only be expected to consistently disclose information on injecting habits in the context of a clinical relationship that is respectful of the possibly differing aims of treatment between patients and providers and a clear explanation of how information obtained in clinical interviews is used when formulating ongoing treatment decisions. It is important to identify patients’ concerns over the consequences of being found to have injected recently and to address misconceptions regarding the purpose of injection site examination and the treatment consequences of continued injecting. Injection site inspection appears acceptable to most patients and should form part of a routine clinical review of any IDU in treatment.