Psychiatric Bulletin (2006) 30: 263-265. doi: 10.1192/pb.30.7.263
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 263-265
© 2006 The Royal College of Psychiatrists
Knowledge of deep vein thrombosis among intravenous drug misusers
Karen Williams, Consultant Psychiatrist
Addiction Treatment Unit, Gloucester
Emma Abbey, Specialist Registrar
Wotton Lawn Hospital, Horton Road, Gloucester GL13WL, e-mail:
emma.abbey{at}glos.nhs.uk
Declaration of interest.
None.
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Abstract
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AIMS AND METHOD
All patients attending the local supervised drug consumption clinics were
surveyed over a month. They were asked via a questionnaire to list the risks
of injecting drugs, particularly the symptoms and consequences of deep vein
thrombosis (DVT). Of 69 patients surveyed, 46 agreed to take part.
RESULTS
Only 9 patients (20%) had never injected drugs, whereas 16 (43%) of those
injecting had injected into the groin; 10 patients (22%) had experienced a
venous thrombosis themselves, and 35 (76%) knew of someone who had. Only 30
(65%) knew what a clot or thrombosis was. Pain and swelling were the most
commonly reported symptoms, but few drug misusers knew of other symptoms. The
best informed were those who had experienced thrombosis themselves
recently.
CLINICAL IMPLICATIONS
The results indicate an apparent lack of basic knowledge about the risks of
DVT in this sample of drug misusers, and a need for some new initiatives to
address health education in this area for all drug misusers.
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Introduction
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Deep vein thrombosis (DVT) is a complication particularly associated with
groin injecting in intravenous drug misuse
(Roszler et al, 1989;
Baldeweg, 2000;
MacKenzie et al, 2000;
McColl et al, 2001).
There has been an increase in the numbers of drug misusers admitted to general
hospitals in Gloucestershire with DVT, from 3 in 1998 to 20 in 2003. We
suspect that this increase may be owing to an increased incidence of groin
injecting. The large size of the groin vein makes it easy to locate, and it
may be the last vein left when all others are impossible to use. It also has
less of an impact on cosmetic appearance than other injection sites, and some
users report a quicker/better drug effect. Regular use of the groin site leads
to a characteristic ‘dimple’ in the skin over the vein, making
location of the site easier for the drug misuser. No survey or study of this
type has been conducted in Gloucestershire before. Studies on the increased
risk of DVT in the drug misuse population seem to have been mainly published
in radiology or medical journals (Roszler
et al, 1989; Baldeweg,
2000). Studies have focused on the medical outcomes or treatments
available (MacKenzie et al,
2000). The issue of prevention of DVT has not generally been
considered. When the prevention of drug misuse by injection is discussed in
the literature it is most likely to concentrate on the spread of HIV
(Williams et al, 1997)
or other blood-borne viral infections.
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Method
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All patients attending the local supervised drug consumption clinics were
surveyed over 1 month. All patients were opiate misusers currently on a
replacement regime of methadone or buprenorphine requiring daily attendance.
The only exclusion criterion was refusal by the patient. The participants were
asked via a questionnaire to list the risks of injecting, particularly into
the groin. They were asked which sites they had used to inject and how they
had learned their injecting technique. They were also asked to list the
symptoms and consequences of DVT and whether they or anyone they knew had ever
had a thrombosis. The questionnaire was administered verbally so participants
could respond freely and were not prompted to list symptoms.
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Results
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Of 69 patients, 46 agreed to take part: 37 (80%) male and 9 (20%) female;
mean age 31 years 8 months. Twenty-three patients refused to take part, of
whom 14 (61%) were male and the mean age was 29 years 7 months. All patients
were opiate misusers but only 9 (20%) had never injected drugs. Over half had
taught themselves to inject (54%, 21 patients). Among patients who had ever
injected, arms (37, 100%) and hands (35, 95%) were the most common injection
sites but 43% of patients (16) had injected into their groins and 57% into
their necks (21 patients). Use of femoral veins was associated with lack of
alternative venous access (14, 88%), easier technique (3, 19%) and improved
drug effect (2, 13%); no one claimed that it was for cosmetic reasons. Ten
patients (22%) had experienced a venous thrombosis themselves and 35 (76%)
knew of someone else who had.
Although 34 (74%) listed thrombosis as a risk of groin injecting, only 30
(65%) knew what a clot or thrombosis actually was. Thirty-four (74%) correctly
identified that pain and 30 (65%) that swelling were associated symptoms, but
few knew of other symptoms (Table
1). Twenty-seven patients (59%) reported that death could occur as
a result of thrombosis and 23 (50%) thought that amputation of a limb was
likely. Other consequences were reported by less than 30%.
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Discussion
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Femoral veins are frequently used as an injection site by drug misusers in
urban Gloucestershire. There appears to be a lack of basic knowledge about the
risks and symptoms of DVT among drug misusers, despite increased admissions
for treatment of thromboses and the provision of harm reduction leaflets to
all drug misusers in our service
(Gloucestershire Partnership Trust,
2001).
One of the most interesting findings of this survey was the widely
differing level of knowledge between patients interviewed. A small subset of
patients had experienced a DVT within the past few months and had been
referred to the drug misuse service by the general physicians who had treated
them in the local district general hospital. These patients were the best
informed about DVT and its symptoms and consequences. It is possible that
these patients caused the results of this survey to be skewed, with an
over-reporting of the knowledge of DVT. It may also cause an over-reporting of
the numbers of drug misusers who have personally experienced a DVT.
The survey did show that over half the patients interviewed had taught
themselves to inject drugs, including a groin injecting technique. It is
possible that this is one cause of poor injecting technique among drug
misusers and would predispose them to the development of venous
thrombosis.
The results indicate the need for some new initiatives to address health
education in this area for all drug misusers. It is worth considering that
this survey only addresses those patients who are actually on substitute
medication and attending the supervised clinics. It has therefore missed
patients who have not yet reached the stage in their addiction where they wish
to access services. The knowledge of DVT of users not in contact with services
is likely to be much lower than that reported here, and their risks
consequently higher.
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References
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BALDEWEG, S. E. (2000) Injecting drug use is a major
risk factor for deep vein thrombosis. BMJ,
321, 1018.[Free Full Text]GLOUCESTERSHIRE PARTNERSHIP TRUST (2001)
Harm Reduction (Advice About Safer Drug Use).
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LINNELL, M. (2003) Going In The Groin:
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MacKENZIE, A. R., LAING, R. B. S., DOUGLAS, J. G., et al
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McCOLL, M. D., TAIT, R. O., GREER, I. A., et al
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WILLIAMS, P. G., ANSELL, S. M. & MILNE, F. J.
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Abstract
Introduction
