Self-injecting non-prescribed substances into vascular access devices: a case study of one health system’s ongoing journey from clinical concern to practice and policy response

Abstract

Background Overdose-associated deaths and morbidity related to substance use is a global public health emergency with devastating social and economic costs. Complications of substance use are most pronounced among people who inject drugs (PWID), particularly infections, resulting in increased risk of hospitalization. PWID often require intravenous access for medical treatments such as antibiotics; however, vascular access may be limited due to the impacts of long-term self-venipuncture. While vascular access devices including peripherally inserted central catheters (PICCs) allow reliable and sustained routes of administration for indicated therapies, the use of PICCs among PWID presents unique challenges. The incidence and risks associated with self-injecting non-prescribed substances into vascular access devices (SIVAD) is one such concern for which there is limited evidence and absence of formal practice guidance. Case presentation We report the experience of a multidisciplinary team at a health organization in Vancouver, Canada, working to characterize the incidence, patient and healthcare provider perspectives, and overall impact of SIVAD. The case study of SIVAD begins with a patient’s perspective, including patient rationale for SIVAD, understanding of risks and the varying responses given by healthcare providers following disclosure of SIVAD. Using the limited literature available on the subject, we summarize the intersection of SIVAD and substance use and outline known and anticipated health risks. The case study is further contextualized by experience from a Vancouver in-hospital Overdose Prevention Site (OPS), where 37% of all individual visits involve SIVAD. The case study concludes by describing the systematic process by which local clinical guidance for SIVAD harm reduction was developed with stakeholder engagement, medical ethics consultation, expert consensus guideline development and implementation with staff education and planned research evaluation. Conclusion SIVAD is encountered with enough frequency in an urban healthcare setting in Vancouver, Canada, to warrant an organizational approach. This case study aims to enhance appreciation of SIVAD as a common and complex clinical issue with anticipated health risks. The authors conclude that using a harm reduction lens for SIVAD policy and research can provide benefit to clinicians and patients by offering a clear and a consistent healthcare response to this common issue.

Development of a Medical Device in Response to a Fatal Self-Injection of Non-prescribed Opioids: A Case Report

“…This case highlights the conundrum that healthcare providers face when caring for PWID. Patients are at increased risk of infection, overdose, and death while adding to the duration cost of their healthcare [ 6 , 7 ]. Despite precautions taken, the patient found an opportunity to use her own VAD, which caused a fatal overdose.…”

“…A literature review on the topic found a lack of publications on the prevalence and statistics regarding the frequency of SIVAD at the time of this case. Recent studies show an increasing acknowledgment of the need for formal management [ 6 , 7 ]. There was a lack of comprehensive protocols defining the management of patients in the hospital and outpatient settings [ 7 ].…”

“…Recent studies show an increasing acknowledgment of the need for formal management [ 6 , 7 ]. There was a lack of comprehensive protocols defining the management of patients in the hospital and outpatient settings [ 7 ]. Current methods in use were direct supervision, video surveillance detection tape, and protective caps that needed to be removed for therapy.…”

“…This poses a dilemma for both the patient and the provider. PWID have a higher risk of self-injecting during a time when they may be experiencing withdrawal or cravings [ 4 , 7 , 10 ]. Medical providers must balance the risks of VAD and the risk of SIVAD by the patient leading to additional complications [ 7 ].…”

“…PWID have a higher risk of self-injecting during a time when they may be experiencing withdrawal or cravings [ 4 , 7 , 10 ]. Medical providers must balance the risks of VAD and the risk of SIVAD by the patient leading to additional complications [ 7 ]. Nurses must endure the cognitive burden of managing at-risk patients with unprotected VADs while providing the parental therapy necessary for appropriate treatment [ 10 ].…”