An increasing number of people appear to be experiencing wounds and bacterial infections related to injecting drugs in Canada. This article summarizes a qualitative systematic review that identified social and structural factors that increase the risk of wounds and bacterial infections.1 These factors create harmful situations that limit people’s ability to implement safer injecting practices and lead people to avoid healthcare. The review highlights the importance of addressing social and structural factors to support the health of people who use drugs.
Wounds and bacterial infections among people who inject drugs
If bacteria get into the body when a person is injecting drugs, they can lead to wounds on the skin (e.g., abscesses), heart infections (e.g., endocarditis) and infections in other parts of the body (e.g., bones, blood). These infections can cause significant harms and often require medical treatment. Delaying, avoiding or leaving medical treatment before it has been completed can make infections worse. Evidence indicates that rates of hospitalization for bacterial infections related to injecting drugs are increasing in many parts of Canada.2,3
Social and structural factors play a key role in shaping the risk of bacterial infection at each step in the process of getting, preparing and injecting drugs. Understanding how these factors increase the risk of infections can help identify areas where policy changes are needed and ways to support people who use drugs.
What research did the qualitative systematic review include?
The systematic review included 26 studies that analyzed qualitative data published between 2000 and 2021. A study was included if it reported on all of the following:
- people who inject drugs
- social, structural or environmental factors (e.g., housing or policing) that can affect the risk of infections or treatment of infections
- experiences of bacterial infections, treatment of infections or consequences of infections
Most included studies were from North America (n = 20). Data in the studies came from individual interviews (n = 23), observation (n = 4) and focus groups (n=2), with some studies using multiple methods. All studies were assessed for quality and analyzed for themes.
What social and structural factors affect risk of wounds and bacterial infections?
The review identified four social and structural factors that increase the risk of wounds and bacterial infections for people who inject drugs. It also identified two ways that people who use drugs attempt to navigate these factors to reduce the risk of bacterial infections for themselves and each other.
The review found that the following social and structural factors increase the risk of bacterial infections for people who inject drugs.
1. The unregulated drug supply
The review identified low quality and variation in the unregulated drug supply as a factor that increases the risk of infections. Unregulated drugs are often of low quality, containing fillers, particles that do not dissolve and bacteria. These can damage blood vessels, cause wounds and increase the risk of bacterial infections. The varying characteristics (e.g., between regions and over time) of the unregulated drug supply can also increase the risk of infections by impacting drug preparation and injecting practices (e.g., injection frequency; overuse of acidifiers to dissolve drugs, which can cause vein damage).
2. Unsafe spaces
The review found that lack of housing and criminalization of drug use increased the risk of infection by driving people to inject in unsafe spaces. Lack of housing made it more difficult for people to engage in safer injecting practices in a variety of ways (e.g., no clean surface to prepare drugs on; no running water to wash hands; poor lighting, which led to missing the vein). It also made it more challenging for individuals to receive medical care for bacterial infections (e.g., lack of housing can make people ineligible for outpatient intravenous antibiotic treatments, and it can make following up with healthcare providers challenging).
Criminalization of drug use leads people to try to avoid the police when using in public spaces, pushing them into unsafe spaces. This increases the risk of infections because it leads people to rush injections and skip safer injecting practices (e.g., not using filters, not using sterile water), inject in unhygienic places (e.g., abandoned buildings) and miss their vein.
The review showed how supervised consumption services (SCS) create safer spaces, reducing the risk of infections caused by lack of housing and criminalization. SCS are services where people can receive education on safer injecting and implement safer injecting practices (e.g., by having access to hygienic, well-lit space where they can take their time to inject). They also enable people to access trusted healthcare providers for wound or infection care when needed.
3. Healthcare policies and practices
The review identified multiple ways that healthcare policies and practices caused people to delay, avoid or leave medical care, making infections worse. People’s previous experiences of stigma, discrimination and untreated pain or withdrawal when seeking healthcare were all factors that contributed to them avoiding medical care for infections. The review also found that people left the hospital before completing treatment because of experiences of discrimination or were involuntarily discharged because of their drug use. These experiences can be related to hospital policies and practices that are not based in harm reduction.
The review explored how race and gender were associated with disproportionate impacts of healthcare policies and practice. For example, Indigenous people described how racism led healthcare providers to see them as "drug seeking” and deny them pain or withdrawal management, causing them to avoid or leave medical care. Another example is that mothers reported fearing that disclosing their substance use to a healthcare provider could lead to their children being apprehended, causing them to avoid medical care.
4. Restrictions on harm reduction programs
The review identified how insufficient access to adequate amounts and types of harm reduction supplies increased the risk for bacterial infections. When funding or policy challenges resulted in restricted access to harm reduction programs, such as limited operating hours (e.g., programs that were closed over weekends or at night), limited program eligibility, lack of funding for certain supplies (e.g., sterile water, different types of needles) and lack of access to harm reduction supplies in hospital, the restrictions led people to reuse supplies or to use non-sterile equipment to inject drugs, increasing their risk of bacterial infections.
The review identified the importance of having multiple ways to access harm reduction supplies (e.g., harm reduction programs, pharmacies). Providing options can enable people to access supplies from sites that they prefer; for instance, they can choose a site that offers anonymity or reduces the risk of discrimination.
The review showed how poor delivery of opioid agonist treatment (OAT) after discharge from hospital increased risk of infections. OAT helps people to stabilize their substance use, reduce their injection frequency and reduce their risk of overdose.4 The barriers that people reported included long waiting times to access OAT after discharge, a lack of coordination between OAT prescriptions provided in the hospital and in the community, and loss of access to OAT because they used drugs.
The review identified the following ways that people who use drugs navigate the social and structural factors discussed above to try to reduce their risks of wounds and bacterial infections.
1. Mutual care
The review identified how people who use drugs cared for each other to try to reduce the risk of bacterial infections. Mutual care practices included giving or receiving education about safer injecting practices, distributing new safer injecting supplies in places where access is limited, and giving or receiving help to inject. Receiving help to inject can reduce the risk of bacterial infections by reducing the chance of missing a vein. However, being injected by someone else is associated with increased risk of infections such as HIV and hepatitis C. This increased risk can stem from gender-based power dynamics and various social and structural factors, such as limited access to harm reduction resources, potentially leading to sharing supplies used to inject drugsClick or tap here to enter text..5,6
The review identified ways that people who use drugs cared for each other’s wounds (e.g., by sharing antibiotics, providing non-medical wound care) to try to help people avoid negative experiences with healthcare. However, these practices can make infections worse. People should seek medical care as early as possible when they notice an infection.
2. Self-care
The review identified how people who use drugs cared for themselves to try to prevent and care for bacterial infections. Self-care practices include vein and skin health practices (e.g., staying hydrated, rotating injecting sites, self-drainage of wounds) and practices to attempt to reduce risks caused by poor-quality drugs (e.g., using ascorbic acid instead of lemon juice to try to help certain drugs or particles dissolve) or lack of access to injecting supplies (e.g., sharpening needle tips when unable to access new supplies). However, because of the social and structural factors described above, some of these practices could increase the risk of bacterial infections and other health issues. For example, sharpening needle tips or using too much ascorbic acid when preparing drugs can damage veins.
Self-care practices also included steps that people took after an infection to avoid another (e.g., using newly learned safer injecting practices, switching from injecting to smoking, seeking earlier medical attention).
What are the implications of this review for service providers?
The review highlights the importance of addressing social and structural factors to reduce the risk of wounds and bacterial infections. These factors create situations that severely limit the ability of people who use drugs to prevent and care for infections. Recognizing how social and structural factors lead to infections is important because it highlights the need to address these factors — both in individuals’ lives and at a policy level. Changing the conditions within which people get, prepare and inject drugs is necessary to reduce the risk of bacterial infections. Service providers should support individuals to navigate harmful social and structural factors in a number of ways, including distributing harm reduction supplies, providing referrals and support to access safe housing, and accompanying people if they go to the hospital. Additional funding may be required to carry out this type of work.
Social and structural factors can also be changed, but doing so is often very challenging. Interventions that can change these factors may not be considered harm reduction or public health interventions (e.g., policies that aim to address poverty and the affordable housing crisis) or may not be evaluated for their impacts on bacterial infections (e.g., programs that provide system navigation to support people to access safe housing or healthcare).
There are also a number of programs and interventions designed to create safer environments for people who use drugs. Service providers can advocate for these to be implemented in their communities. They can include:
- injectable OAT (iOAT) and safer supply programs, which provide pharmaceutical-quality alternatives to the unregulated drug supply
- decriminalization of drugs, which can reduce people’s need to hide or rush their drug use to avoid police
- social and supportive housing programs, which provide people with a safe place to live (these programs can be combined with other services, such as SCS, OAT, iOAT and safer supply to further reduce risks)
- changes to healthcare policies and practices, which can support the implementation of harm reduction in hospitals, including offering specialized substance use care and providing patients with access to harm reduction supplies and SCS
- changes to policies and funding related to harm reduction programs, which can involve increasing program hours and ensuring distribution of adequate amounts and types of harm reduction supplies
When considering this review, it is important to remember the following:
- The review included only studies that described people’s experiences with infections related to injecting drugs. Studies examining factors that led to specific practices known to increase the risk of infection (e.g., injecting under the skin, reusing supplies) were not included unless they reported on outcomes related to infections.
- Reports that were not published in academic journals were not included in the review. There may be social and structural factors that are related to bacterial infections that are not described in the literature.
What is a systematic review?
Systematic reviews are important tools for informing evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a rigorous process to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and their results summarized to identify and present key findings and limitations. In this systematic review, qualitative data from eligible studies were coded and analyzed for themes. These themes focused on the original study authors’ interpretations of their study’s data.
References
- Brothers TD, Bonn M, Lewer D et al. Social and structural determinants of injection drug use-associated bacterial and fungal infections: a qualitative systematic review and thematic synthesis. Addiction. 2023;118(10):1853-77. Available from: https://doi.org/10.1111/add.16257
- Maguire DJ, Arora RC, Hiebert BM et al. The epidemiology of endocarditis in Manitoba: a retrospective study. CJC Open. 2021;3(12), 1471–1481. Available from: https://doi.org/10.1016/j.cjco.2021.07.014
- Mosseler K, Materniak S, Brothers TD et al. Epidemiology, microbiology, and clinical outcomes among patients with intravenous drug use-associated infective endocarditis in New Brunswick. CJC Open. 2020;2(5):379-85. Available from: https://doi.org/10.1016/j.cjco.2020.05.002
- Barocas JA, Morgan, JR, Wang J et al. Outcomes associated with medications for opioid use disorder among persons hospitalized for infective endocarditis. Clinical Infectious Diseases. 2021;72(3):472-8. Available from: https://doi.org/10.1093/cid/ciaa062
- Cheng T, Kerr T, Small W et al. High prevalence of assisted injection among street-involved youth in a Canadian setting. AIDS and Behavior. 2016;20(2):377-84. Available from: https://doi.org/10.1007/s10461-015-1101-3
- O’Connell JM, Kerr T, Li K et al. Requiring help injecting independently predicts incident HIV infection among injection drug users. JAIDS. 2005;40(1):83-8. Available from: https://journals.lww.com/jaids/abstract/2005/09010/
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Externally reviewed by: Dr. Thomas Brothers
About the author(s)
Magnus Nowell is CATIE’s knowledge specialist in harm reduction. Magnus has previously worked in harm reduction research, community organizing and housing. He has a master’s degree in health promotion.