Alison F Coull

The experience of an increase in the injection of ethylphenidate in Lothian April 2014–March 2015

Background and aims New psychoactive substances are causing increasing harm across the UK but the use of new psychoactive substance by injecting has become a significant problem within Lothian since the beginning of 2014. Data indicate a rapid rise in the number of existing drug injectors, particularly heroin injectors, moving to new psychoactive substance injecting. This paper reports the experiences within Lothian of a sudden increase in injecting of ethylphenidate over one year. A temporary class drug order was placed on ethylphenidate on 10 April 2015, and as yet the effects of this are unknown. Methods Data specifically relating to new psychoactive substance recorded during injecting equipment provision transactions conducted by the NHS are reported. A survey was utilised to gather more detailed data from new psychoactive substance injectors. Results Injection of new psychoactive substance, including ethylphenidate has had significant adverse effects on physical and mental health. Risky behaviour such as sharing of equipment is known, and there are risks of transmission of infections. Conclusion The rapid increase in injecting ethylphenidate has had a major impact on injecting equipment provision services, health services and public health. More work is required to identify routes to recovery.

Education programmes preparing independent prescribers in Scotland: An evaluation

BACKGROUND Nurse prescribing (NP) is part of the modernisation of the health care workforce and contributes to patient care by improving access to quality services and medication, through utilisation of advanced professional skills. Nurses and midwives need to complete additional education in order to prescribe. This paper explores pedagogical issues relevant to professional training programmes. OBJECTIVES To assess if programmes of education for nurse prescribing in Scotland were fit for purpose, from both the student and educator perspective with recommendations for future educational delivery. DESIGN Data were collected using several methods: a questionnaire to all course members on prescribing programmes followed by focus-groups; and interviews with programme providers. RESULTS Nurses and midwives training as prescribers work in a wide range of healthcare settings, in different geographic environments. They tended to be experienced, educated to degree level and most are over forty years of age. Most undertook the course to develop professionally and to improve patient care. Existing provision of education for prescribing is deemed appropriate and fit for purpose. The NP programme greatly enhances pharmacological knowledge building on existing clinical experience. The nature of these programmes works well and should be retained. However, whilst the educational programmes were centrally funded, less than half of students were provided with any allocated study time from their employers preventing nurses from maximising the gain from the educational preparation for prescribing. CONCLUSIONS Nurse and midwife generic preparation for independent nurse prescribing in Scotland greatly increases professional expertise and is appropriate and fit for purpose. As other countries beyond Scotland and the UK seek to further progress nursing roles, learning from this controlled and structured development of prescribing underpinned by evidence could be of significant benefit.

Prevalence of skin problems and leg ulceration in a sample of young injecting drug users.

BackgroundDrug users suffer harm from the injecting process, and clinical services are reporting increasing numbers presenting with skin-related problems such as abscesses and leg ulcers. Skin breakdown can lead to long-term health problems and increased service costs and is often the first indication of serious systemic ill health. The extent of skin problems in injecting drug users has not previously been quantified empirically, and there is a dearth of robust topical literature. Where skin problems have been reported, this is often without clear definition and generic terms such as ‘soft tissue infection’ are used which lack specificity. The aim of this study was to identify the range and extent of skin problems including leg ulceration in a sample of injecting drug users. Definitions of skin problems were developed and applied to descriptions from drug users to improve rigour.MethodsData were collected in needle exchanges and methadone clinics across Glasgow, Scotland, from both current and former drug injectors using face-to-face interviews.ResultsTwo hundred participants were recruited, of which 74% (n = 148) were males and 26% (n = 52) were females. The age range was 21–44 years (mean 35 years). Just under two thirds (64%, n = 127) were currently injecting or had injected within the last 6 months, and 36% (n = 73) had previously injected and had not injected for more than 6 months.Sixty per cent (n = 120) of the sample had experienced a skin problem, and the majority reported more than one problem. Most common were abscesses, lumps, track marks and leg ulcers. Fifteen per cent (n = 30) of all participants reported having had a leg ulcer.ConclusionsThis is an original empirical study which demonstrated unique findings of a high prevalence of skin disease (60%) and surprisingly high rates of leg ulceration (15%). Skin disease in injecting drug users is clearly widespread. Leg ulceration in particular is a chronic recurring condition that is costly to treat and has long-term implications for drug users and services caring for current or former injectors long after illicit drug use has ceased.

The role of intravenous drug use in venous leg ulceration

V enous leg ulceration is thought to be a disease of old age and prevalence is around 1% of the adult population. However, as many as 46% of sufferers may develop their ulceration before the age of 50 (Mackenzie et al, 2003) and, increasingly, venous leg ulcers are occurring in younger people as a result of intravenous injecting. A recent study showed a high leg-ulcer prevalence of 15% in a sample of 200 people (aged under 44) who had injected drugs (Coull et al, 2014). The assessment process is important in the care of patients with leg ulceration. However, many leg ulcer assessments do not include a question about intravenous (IV) drug use, and IV drug use is rarely mentioned as a risk factor in literature about venous leg ulceration. Chronic venous disorders (CVDs) are classified in a staging system that ranges from no visible or palpable signs of venous disease through the signs of chronic venous insufficiency (CVI), varicose veins, oedema, skin changes, to ulceration as end-stage venous disease (EklOf et al, 2004). CVI commonly occurs in the sixth or seventh decade of life, but occurs in the third or fourth decade for people who inject drugs (PWID) (Pieper, 1996). It is important to recognise that prevalence is higher than expected, and be aware of key contributing factors that might cause leg ulceration in PWID, especially as ulceration may occur long after injecting has ceased (Pieper, 1996). Most significant is injecting in the femoral vein or the legs, and the presence of deep vein thrombosis (DVT). PWID may use the femoral vein as a site to inject into (groin injecting). This site can be used for many years and is associated with a lack of alternative access, easier technique, improved drug effect, and the fact that the site is easily hidden (Williams and Abbey, 2006). Femoral injecting is risky, with many reported problems. Repeated puncturing of the femoral vein may result in a noticeable dimples in the skin and eventually a sinus may form in some individuals (Maliphant and Scott, 2005). Swellings or aneurysms can occur in the groin area and there is a risk of inadvertent arterial injection, venous insufficiency, infection and pain (Gan et al, 2000; Senbajo et al, 2012). Scarring or thickening of the femoral vein can occur causing difficulty with injecting, such as needle breakage and a requirement to use longer, thicker needles. Swelling or thickening can lead to a narrowing of the lumen causing a slowing in venous blood flow, resultant back pressure and venous hypertension. Consequently, as the blood flow becomes sluggish, a DVT may form (MacKenzie et al, 2000). Injecting directly into the legs increases the likelihood of skin breakdown and ulceration. This is partly owing to the venous damage inflicted by repeated needle punctures and increased risk of infection and DVT in the lower legs (Pieper et al, 2009). DVT is a risk factor in the development of venous ulceration, and, although DVT is relatively common in PWID, there is a lack of awareness of the long-term consequences on the lower limb (Williams and Abbey, 2006). A clot in the leg, especially proximal to the knee, also increases the likelihood of post–thrombotic syndrome (PTS), which is characterised by signs of venous insufficiency with limb swelling, pain, skin changes, difficulty in walking and venous ulceration (Kahn and Ginsberg, 2004). PTS has been known about for many years (Linton, 1953) but little is known about the risk factors or why it occurs in some and not others. Despite this, it is possible that the PTS sequelae, including ulceration that follows DVT, could be prevented in up to 50% of sufferers by using compression hosiery (Prandoni et al, 2004). However, a study by Kahn et al (2014) contradicted earlier results and showed elastic compression stockings did not prevent PTS. Further trials are needed, but hosiery may offer symptomatic relief and would be advised for those with a proximal DVT at or above the popliteal vein (Arumugaswamy and Tran, 2014). Other guidelines suggest that those with PTS should wear compression hosiery constantly and forever, to minimise the extension of disease and venous ulcer formation (Robson et al, 2008). Compression can also have a dramatic effect on reducing pain (Ettridge, 2011). Health professionals caring for PWID should be aware of the high prevalence of leg ulceration in this group, and consider their role in the prevention of ulceration following DVT and in PTS. Early recognition of PTS may help reduce the prevalence of leg ulceration. Educating this group about the long-term consequences is also worthy of consideration. BJN