Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions

Abstract

Introduction Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced “Black Tar” heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination. Methods Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price. Results Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20 to 40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per–gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities. Discussion Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.

Increasing Infectious Endocarditis Admissions Among Young People Who Inject Drugs

“…Information for each de-identified discharge includes age, race, gender, as well as diagnosis and procedure codes. The NIS has been used in many studies to estimate trends in hospitalizations for a variety of medical conditions including but not limited to HCV and mental and substance abuse disorders [17, 19–21]. We applied for and received an exemption from the Tufts Health Sciences Institutional Review Board because the data from NIS are de-identified.…”

Fentanyl in the US heroin supply: A rapidly changing risk environment

“…Other drug injection injuries and infections, e.g. SSTI, endocarditis and hepatitis C, are also on the rise in the US (Larney et al 2017, Zibbell et al 2015, Ciccarone et al 2016). …”

Risk Factors Associated With Skin and Soft Tissue Infections Among Hospitalized People Who Inject Drugs

“…PWID present for medical care more often than the general population (Kerr et al, 2005; Stein et al, 1993) and in the U.S., are more likely to be uninsured, which may indicate lower access to health care (Tookes et al, 2015). Of particular concern, inpatient hospitalization rates of opiate-related SSTIs in the U.S. have grown substantially, with a recent study showing a doubling of these rates from 1993 to 2010 (Ciccarone et al, 2016). …”

“…Repeatedly injecting black tar intravenously can lead to necrosis, vascular collapse, and sclerosis, thus encouraging alternative injection methods that are risky for SSTIs (e.g., intramuscular injection; Dunbar & Harruff, 2007). Furthermore, recent data shows that cities where black tar is the dominant form of heroin (compared to powder forms) have higher rates of hospitalization for SSTIs (Ciccarone et al, 2016). …”