ABSCESSES PLAGUE ADDICTS, RAVAGE CITY'S HEALTH BUDGET

Germs Enter Body Along With Heroin; Serious Infections Increasingly
Common

Covered in scars, and missing chunks of his buttocks, John Bunkley is
one of thousands of walking examples of what skin abscesses are doing
to San Francisco's heroin addicts.

He is also an example of what they are doing to The City's health care
budget.

Bunkley, 51 and homeless, recently spent eight weeks at San Francisco
General Hospital - his eighth stay there in the past year - being
treated with aggressive antibiotics to clear a bacterial infection
from his bloodstream.

Bunkley, like the vast majority of The City's estimated 17,000
injection drug users, has no medical insurance. One stay alone cost
the financially strapped city Health Department an estimated $56,000,
said Joshua Bamberger, medical director for special projects at the
department.

Not to mention what Bunkley himself has gone through. More than a
year ago, bacteria from an infected abscess got into his bloodstream
and settled on his spine, eating away at the bone. He now suffers
from frequent back pain, and doctors told him he will probably need
surgery to fuse some of his vertebrae.

"Either that, or I'll end up in a wheelchair," he said.

While usually not fatal, abscesses are a painful, gruesome and
frequent side effect of injection drug use, and those who treat them
say they are seeing more than ever.

People with drug-related abscesses are clogging emergency rooms,
filling up hospital beds and draining resources away from other health
problems.

Getting more slots for drug treatment is an obvious part of the
solution. But the failure rate is high and even those enrolled in
methadone maintenance - the most successful type of treatment - often
continue to shoot heroin, and get abscesses.

Now the Health Department wants to station doctors and nurse
practitioners at needle exchange sites and other places where addicts
congregate, to treat soft tissue infections before they get out of
hand. And a special clinic at San Francisco General is being proposed
to handle nothing but abscesses, to keep people out of the already
overcrowded emergency room.

Insurance gap Reliable figures are hard to come by, but Bamberger
estimated that at San Francisco General, where most serious abscesses
are treated, $20 million to $40 million a year is spent on soft tissue
infections related to drug use, most of which is not covered by
insurance. This comes at a time when the hospital is losing $7.5
million a year in federal support and requiring ever-larger subsidies
from The City's general fund.

More than heart attacks, AIDS or strokes, abscesses are the leading
cause of admission to San Francisco General, Bamberger said. More
than 1,000 people were hospitalized after undergoing surgery to drain
abscesses in 1998.

In the operating room, doctors normally see from five to eight
abscesses requiring surgery every day, said William Schecter, chief of
surgery at S.F. General. That doesn't count the number that are
drained and dressed in the emergency room.

"The cost of caring for soft tissue infections related to injection
drug use is astronomical," Schecter said. He estimates that only
about 10 percent of the patients he sees have health insurance.

Abscesses form when users inject under the skin or into muscle - "skin
popping" and "muscling" in street parlance. Most longtime users like
Bunkley resort to those techniques when their veins become so scarred
from repeated injections that they are no longer usable.

Ordinary bacteria from the skin follow the needle into the body. If
they hit a vein, they would probably be carried away and quickly
disarmed by the body's immune system.

But when they hit muscle or fat, they find a welcoming environment in
which to breed.

In fleshy areas like the buttocks, bacteria have lots of room to grow,
and abscesses are frequently the size of a grapefruit or even larger.
Dead cells left over from the immune system's battle with the
infection form a liquid pus that pushes up against the skin, forming a
dome with a soft spot in the center.

Junk masks the pain Many patients don't come in early because they are
high on heroin and don't feel the pain. But when they run out of
money for drugs or the infection becomes so advanced it's
debilitating, they show up at the emergency room, said Alan Gelb,
director of San Francisco General's emergency department.

"A lot of the patients have had multiple abscesses, and after a while
the skin and the soft tissue gets so scarred it's like wood," Gelb
said. "It's harder to completely drain them because the bacteria can
hide in the scar tissue."

The worst cases have involved the so-called "flesh eating bacteria,"
which have killed some injection drug users and severely disfigured
others. But even ordinary bacteria can lead to blood infections,
amputations and deaths.

Schecter, who has been dealing with drug-related abscesses since the
early 1970s, said about one patient per month either dies or spends
weeks in the intensive care unit with gigantic wounds or amputations.
That doesn't count those who are hospitalized in the regular wards
hooked up to intravenous antibiotics.

In the worst cases, Schecter said, the body's immune system kicks into
high gear and doesn't settle down even after surgeons have cut out the
infection.

"The patient's heart rate goes up to 150, their lungs stop working,
their kidneys stop working, the whole body turns into a wound," he
said. "You're standing there and doing everything you can to keep them
alive. It's like watching a patient get sucked down a hole."

One man Schecter treated came to the hospital on average four times a
year for 20 years with soft tissue infections.

"We had to cut away large parts of his body and then skin graft him.
He eventually lost a leg, and then his kidneys failed," Schecter said.
"The tragedy is that this guy was a nice guy, he was an intelligent
man. He just had this habit that basically ruined his life and
mutilated his body."

Most addicts, it seems, know someone who has died or had a limb
amputated from infection. Linda Luevanos, who shot up for 30 years,
said that this summer a friend got an abscess in his leg. He tried to
drain it himself, and then continued shooting in the same leg.
Doctors had to amputate his leg from the knee down, she said.

Another friend died from flesh-eating bacteria and another had one
entire buttock and most of the back of her leg removed after the
infection began eating away at her flesh, Luevanos said.

"It was ugly. You could see every vein and muscle," she
said.

Luevanos has been on methadone for a year and hasn't injected drugs
for four months. This after she got eight abscesses in the past four
years, after going decades without getting a single one.

"They hurt!" she said. "I say to God now, 'Please, I don't want to do
this any more.' "

Epidemic seen Bamberger has treated hundreds of abscesses in his work
with HIV-infected drug users, and is distressed by what he sees as an
epidemic.

"People have been filleted, whole chunks of their buttocks removed,"
Bamberger said. "You can spend all day long in medical textbooks and
you won't see a page or even a paragraph on how to treat soft tissue
infections in injection drug users. There's no research on it because
no one cares."

That's beginning to change. Dan Ciccarone of the Urban Health Study
is one of three UCSF researchers leading studies related to abscesses.
Besides treating patients at a needle exchange in the Haight and at
Hayes Valley's Tom Waddell Clinic, Ciccarone and his colleagues have
interviewed more than 1,000 injection drug users for a large-scale
study.

"It's a hot topic," Ciccarone said. "Hospital administration has
recognized it as a problem from a financial point of view, and that
has created a lot of buzz."

Doctors don't know why abscesses seem to be on the rise in San
Francisco, which appears to see more soft tissue infections per addict
than any other city.

One theory is that it is linked to the type of heroin, called black
tar, sold on the West Coast. But it's been a difficult hypothesis to
prove, since possessing heroin is illegal, and getting research
exemptions is notoriously difficult.

"That's the $100,000 question," Ciccarone said. "Are people getting
abscesses from dirty drugs, or is it from poor injection technique and
hygiene?"

Meanwhile, Bamberger said he hopes to gather a team of doctors and
nurses who enjoy working with the homeless and drug addicted to staff
the proposed hospital clinic and mobile unit that would travel among
needle exchange sites, homeless shelters and other gathering spots for
injection drug users.

Intervention opportunity Ciccarone said that that kind of focused
approach could also provide more chances to talk to people about
getting off drugs.

"Every clinical encounter can be used as an opportunity to see where
people are in the stages of change," he said. "Are they ready for the
next step, maybe detox or recovery? I really would like to be part of
that opportunity."

Bamberger agreed, and said the program, which would cost about $1
million a year, could also theoretically save The City as much as $20
million.

Health Department Director Mitchell Katz said he supports the idea,
but cautioned against expecting it to be a cure for the department's
budget woes.

At San Francisco General's emergency room, where waits can sometimes
stretch to six hours, "The lines will move faster for everybody else,"
Katz said. "But it's a reality of an urban area that if you save money
here, you usually spend it on another unmet need."

Schecter agreed that there are no easy answers, but welcomes the new
effort.

"Surely what we're doing now isn't working," he said. "I'm all in
favor of trying new methods."