The Hospital that I work at is a county hospital, meaning that it is primarily funded by the taxpayers and Medicare/Medicaid. In other words, patients pay if they can, but if they can't, that's ok too. The Hospital served nearly 500,000 patients in 2006 (including 81,000 in the ER). Of these, only about one-third were able to pay with commercial or private insurance, and 12% were unable to pay at all. What this means, at least for the ER, is that many of our clients come from severely underserved populations, including the poor, the homeless, and the addicted. These are the folks for whom our Emergency Medicine services are the only kind of primary care they receive.

An interesting case I saw recently was a 29 y/o female who, due to chronic IV drug use, looked like she was about 15 years older. She presented with massive opened abscesses to both arms, which were extremely painful and draining copious amounts of foul-smelling pus, or "purulent discharge," in medical terms. (To see an early-stage closed abscess, click here. To see a later-stage opened abscess, click here.)

I overheard one of the nurses say that the patient used about 6 grams of heroin daily. (Slight tangent: I'm not sure if I believe this. 6 grams daily is a tremendous amount, even for a seasoned junkie. Currently, the purest heroin can cost over $100 per gram.)

Anyway, this case led me to do a little research on the cause and formation of drug abscesses, which typically result from using dirty needles when shooting up. An infection starts brewing under the skin, creating a pocket of pus. Left untreated, the infection will spread, destroying the surrounding tissue, including the overlying skin. At this point, the abscess has opened. Treatment for small or shallow abscesses includes antibiotics, plus a debridement of the abscess itself followed by daily gauze packings and dressing changes. Treatment for large abscesses, like those of the woman I saw, could be amputation.

In my research on this topic, I came across King County's "Harm Reduction" website. (Incidentally, this page is the first that appears if you Google "drug abscess"). If you are not familiar with this, harm reduction is the theory instead of criminalizing a certain behavior, the general population is better served by providing the resources to make that behavior safer. In drug terms, harm reduction programs generally consist of needle exchanges, distribution of clean supplies like new cotton balls, spoons and alcohol pads, and information about the safest ways to use drugs. Naturally, these programs are strongly criticized, as it can appear that they are supporting or condoning drug use.

My position: neither theory is perfect. The government's War on Drugs is problematic, and has been largely unsuccessful in reducing overall drug use (this is a topic for another day). And while harm reduction programs may make IV drug use safer, I believe that it's not the only solution, and emphasis must also be placed on helping addicts get off drugs.

What do you think?