Barriers to abscess care among people who inject heroin: fears of pain, withdrawal, and mistreatment. A mixed methods analysis.

Phillip Summers

Background
Skin and soft tissue infections are a prevalent problem for people who inject drugs, yet delayed presentation leads increased morbidity and potentially mortality. Little research has explored the barriers to care experienced by this population.

Methodology
At syringe exchange programs in two cities, we performed semi-structured interviews with 12 participants and administered a survey to 145 participants.

Results
We found that 66% of participants had experienced at least one abscess. Self-care tactics were common, with 40% reporting taking non-prescribed antibiotics and 57% reporting undergoing a drainage procedure by a non-medical person. Regarding the primary sources of abscess care, 45% reported that it was the emergency department, and 22% reported that it was a non-medical person. 43% reported waiting two weeks or more to seek care and 59% reported leaving the hospital against medical advice. The most common reasons cited for both were fear judgment or mistreatment from staff, fear of withdrawal in the hospital, inadequate pain control, and legal concerns. Our qualitative findings underscored these trends in detailed narrative examples and illustrated a good understanding of the natural history of skin infections.

Conclusion
Among this population, the barriers to abscess care and resultant self-care strategies are the product of perceived and real fears based on negative experiences in the healthcare system. In order to optimize outcomes, healthcare providers and hospital policies should address issues of inadequate pain control, management of withdrawal, and eliminate mistreatment of people who inject drugs. Additionally outreach and education efforts should target these issues and acceptable, low-threshold resources should be made available by providing appropriate healthcare in the context of safe injection facilities and other harm reduction agencies.