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Harm Reduction ⫸CASE STUDIES - It could happen to YOU!⫷

I can answer your question. After IV"ing heroin for many years, I lost all of my veins. I got clean for a number of years, but I started using again. When I starting using again there was no more "Mexican Brown" It was black tar, and at first I just snorted it, but I couldn't stand the way it made my nose burn, so I picked up a rig again and decided to try and find a vein. That worked a few times, but when my vein was gone, I started to just inject the tar in my arm like a flu shot. I can remember it burning so bad I would be crying and I would have to stop and go somewhere else, but I was sick and I had to get well so I did what I had to do. I don't know what the fuck they put in that black tar but It's poison. I haven't touched a needle since July 1, 2002 and I still have scars all over my arms and butt, and I have huge lumps all over my butt where I shot up. Those lumps hurt for months, and today, if I ever want to pick up a needle, all I have to do is look at the scars and remember the pain. It's called obession I was obsessed with the needle. I don't know how else to desribe it. I never thought when I was growing up that I would one day mutilate my body, but thats where I ended up. When I finally had enough I went on Methadone Maintenance and I haven't had that obsession since..

LillyF40%)

Thanks for sharing Lilly. I'm glad to hear you're on maintenance now and are in control. It's the greatest feeling ever to abstain for a long period of time and know you're better off for doing so. Did you ever have any complications from subcutaneous injections?
 
Necrotising myositis after intravenous methylphenidat (Ritalin) injection

A 30 year old male intravenous drug user was admitted with a swollen painful left thigh after injection of 30 mg methylphenidat (Ritalin). On examination, we found a softball-sized abscess in his left thigh. Striking lab results were a CK of 18 100 U/l, a CRP of 177 mg/l, and a WCC of 20.0x109/l. A CT scan revealed a large abscess that contained multiple pockets of gas, extending from the lesser trochanter to the distal femoral condyle (fig 1). The patient went to theatre and the abscess was excised and drained and an extensive debridement was performed. Macro- and microscopic analysis showed acute necrotising myositis and extensive abscess formation. The patient was re-examined 2 days later and the wound was closed. Thereafter, healing of the wound progressed well. The patient was discharged home 15 days postoperatively.


This is a very informative and frightening thread. It does, however, back up my thoughts on what can, uh, safely be IV'd. I shot dope and coke for years-- other than the occasional miss/small abscess, no physical problems. I have stayed away from shooting pharmaceuticals, crack and other chemicals that should not be IV'd.

Very good read.
 
This is a very informative and frightening thread. It does, however, back up my thoughts on what can, uh, safely be IV'd. I shot dope and coke for years-- other than the occasional miss/small abscess, no physical problems. I have stayed away from shooting pharmaceuticals, crack and other chemicals that should not be IV'd.

Very good read.

Cocaine itself is corrosive to the veins, so I don't think it can be safely shot for a long time. I have IV'd coke a handful of times, didn't find it nearly as desirable as heroin though.

"What can safely be IV'd" -> sterile ampules that were meant for iv.

You "can safely iv" other drugs, but whether you do or not depends on how good you are with a syringe.
 
I can answer your question. After IV"ing heroin for many years, I lost all of my veins. I got clean for a number of years, but I started using again. When I starting using again there was no more "Mexican Brown" It was black tar, and at first I just snorted it, but I couldn't stand the way it made my nose burn, so I picked up a rig again and decided to try and find a vein. That worked a few times, but when my vein was gone, I started to just inject the tar in my arm like a flu shot. I can remember it burning so bad I would be crying and I would have to stop and go somewhere else, but I was sick and I had to get well so I did what I had to do. I don't know what the fuck they put in that black tar but It's poison. I haven't touched a needle since July 1, 2002 and I still have scars all over my arms and butt, and I have huge lumps all over my butt where I shot up. Those lumps hurt for months, and today, if I ever want to pick up a needle, all I have to do is look at the scars and remember the pain. It's called obession I was obsessed with the needle. I don't know how else to desribe it. I never thought when I was growing up that I would one day mutilate my body, but thats where I ended up. When I finally had enough I went on Methadone Maintenance and I haven't had that obsession since..

LillyF40%)

I would rather shoot in my groin, rather than SC.
 
Scalp necrosis and ulceration secondary to heroin injection
Conde-Taboada, A. (2006). International Journal of Dermatology 45(9): 1135-1136.
http://dx.doi.org/10.1111/j.1365-4632.2006.02908.x

Case Study
A 36-year-old man was referred to our Dermatology Department from the penitentiary of estate, because of an ulcer on his scalp. The patient had chronic hepatitis C infection, diagnosed years ago. He had injected heroin on the right side of his neck, and swelling of the whole head and face appeared suddenly. He also lost the vision in his right eye for several minutes. The inflammation of the head slowly decreased after 24 h, leaving a large wound covered by a hard crust. Physical examination revealed a superficial ulceration located on the frontal and parietal zones of the right side of the scalp. It had a sharply marginated border, with some scarring areas (Fig. 1). The right eyebrow was also affected. All the studies performed were normal, including cellular blood count, erythrocyte sedimentation rate, Doppler ultrasonography of the supra-aortic arteries, and ophthalmologic examination. The ulcer was treated with surgical debridement of necrotic tissue and antibiotic ointment. At this point, surgical restoration of the scalp is being evaluated.

Discussion
Scalp necrosis has been reported as an uncommon phenomenon because of the rich blood supply of this area. In some cases, it is related to a giant cell (Horton) arteritis,1,2 and may also be a complication of surgical procedures for meningeal tumors3 or other types of tumor of the central nervous system.4 A wide spectrum of cutaneous complications may occur in intravenous drug users. These include acute or delayed local complications, hypersensitivity reactions, cutaneous manifestations of systemic infections, and sites of toxigenic infections.5
The clinical course of our patient, with transient blindness affecting the right eye and the anatomic distribution of the ulcer (following the course of the frontal branch of the superficial temporal artery), implies an embolic phenomenon, with arterial occlusion. The drug could have been injected in the external carotid artery, leading to ischemia of the area of the distal branches. Inadvertent or deliberate intra-arterial injection of drugs has rarely been reported to cause ischemia and necrosis.6,7 The chemical toxicity of drugs and adulterants can cause endarteritis resulting in vasospasm and thrombosis. Moreover, the mixture may contain microparticles that act as emboli.5

There is a rare entity, named Nicolau syndrome, which results in the development of acute, severe pain and localized eruption during intramuscular injections, leading in a short time to cutaneous, subcutaneous, and even muscular necrosis.8 It is classically described as an immediate pallor with intense pain at the injection site, followed by an erythematous macula evolving into a livedoid patch that becomes hemorrhagic and necrotic.9 The main pathogenic mechanism suggested points to a vascular origin. This entity may be the end result of intraarterial or peri-arterial injection of the offending drug, with subsequent arterial vasospasm and cutaneous necrosis.10 We believe that our patient cannot be classified with this disease, because it is not a local necrosis. Nevertheless, there could be an overlap if Nicolau syndrome is due to local arterial embolism of the drug.

Figure 1 Ulceration located on the right side of the scalp, also affecting the eyebrow
 

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Exogenous ocular candidiasis associated with intravenous heroin abuse
Sorrell, T. C., C. Dunlop, et al. (1984), Br J Ophthalmol 68(11): 841-845. DOI:10.1136/bjo.68.11.841
http://bjo.bmj.com/cgi/content/abstract/68/11/841


Abstract: Seven young men developed disseminated candidiasis within 10 days of a single episode of intravenous heroin abuse. Sequential development of eye and skin lesions was noted in all cases. The bone or costal cartilage was involved in five. Ocular manifestations of candidiasis included episcleritis, chorioretinitis, and endophthalmitis. A presumptive diagnosis of candida chorioretinitis was established rapidly by culture of Candida albicans from involved skin and costal cartilage. Systemic therapy with amphotericin B plus 5-fluorocytosine resulted in cure of the episcleritis, chorioretinitis, osteomyelitis, costochondritis, and skin infection. Pars plana vitrectomy with local instillation of amphotericin B was required to cure chorioretinitis associated with vitreal extension of infection.


Case Reports

CASE 1
The index case was a 26-year-old man who was admitted to hospital with fever, anorexia, and blurred vision. Ten days previously he and eight friends had injected themselves intravenously with heroin. Six hours after injection the patient experienced anorexia, then nausea and vomiting, generalised aches, and abdominal pain. The pain abated after six hours. The anorexia and nausea persisted. Three days after the injection he noted blurring of vision, occasional 'spots' before the eyes, and 'redness' of both eyes, especially the right. Jaundice was also noted on day 3; this increased over two days, then subsided. On the fifth day he first noticed 'pimples' in the scalp and beard area; these subsequently became more numerous and appeared in axillary and pubic hair-bearing areas. On the day of presentation (day 10) the patient complained of pain over the right eighth costal cartilage. He had been well in the past and had abused heroin twice in the 12 months before admission.

On physical examination his temperature was 37-4°C. Multiple pustules and subcutaneous nodules were associated with hair follicles in the scalp and beard area. A few pustules were present in the left axillary and pubic hair-bearing areas. Enlarged, nontender, occipital lymph nodes were present bilaterally. Cardiovascular examination was normal. Asmall area of tenderness and minimal swelling was found at the eighth costochondral junction on the right side. General examination was otherwise normal. The eyes showed bilateral conjunctival injection. On ophthalmoscopy the right vitreous humour appeared hazy. The right macula was obscured by two rounded, white lesions which extended anteriorly into the vitreous humour. The optic disc appeared oedematous. In the left eye, two small areas of chorioretinitis were noted near the fovea. Slit-lamp examination revealed cells in the vitreous humour and anterior chamber of each eye. Visual acuity was 2/60 for the right eye and 6/6 for the left. Investigations showed abnormal liver function with gamma glutamyl transpeptidase 255 U/l (normal 8- 43), alkaline phosphatase 159 U/I (normal 30-115), bilirubin 15 ismol/l (normal 2-21). The creatinine was 73 ,umol/l (normal 60-125), haemoglobin 13-0 g/dl, white cell count 16.3 x 101/l with 70% neutrophils, platelets 328x 109/l, ESR 61 mm/h. The titre of antibody to Candida albicans (indirect haemagglutination) was 10240 (negative if less than or equal to 160), cytomegalovirus titre 4, toxoplasmosis haemagglutination titre 256, toxoplasmosis complement fixation titre less than 4, serum cryptococcal antigen negative, hepatitis B surface antibody positive. Chest x-ray was normal. Microbiological samples were obtained from pubic lesions, facial lesions, and neck and scalp biopsies. Candida albicans was isolated on blood agar and Sabouraud's medium within 48 hours in all cases. Forty-eight hour subcultures from Robertson's cooked meat medium also yielded Candida albicans. The urine contained a trace of protein and 10-1000x 109leucocytes/l. Three blood and urine cultures, including fungal cultures, were negative. A "mtechnetium bone scan demonstrated an area of increased uptake at the medial end of the eighth right rib. Histology of a scalp biopsy showed acute folliculitis. Blastospores and pseudohyphae were present in a few of the most inflamed hair follicles. Pseudohyphae were also identified in hair shafts.

The patient was treated with oral 5-fluorocytosine (150 mg/kg/day) and intravenous amphotericin B (maintenance 0*5 mg/kg/day). The skin lesions, cartilage pain, and hepatitis resolved after 20 days of therapy; the serum creatinine rose to 175 [tmol/l. The areas of chorioretinitis in the left eye remained static for one week, then regressed. The lesions in the right eye progressed on therapy (Figs. 1, 2). A right pars plana vitrectomy was performed seven days after institution of systemic antifungal therapy and amphotericin B, 5[tg, was instilled slowly, anterior to the retina. Material obtained at vitrectomy did not yield Candida albicans on culture of the concentrate, but Gram stain revealed budding yeasts. The postoperative course was complicated by intraocular haemorrhage and uveitis. Vision in the eye was restricted to appreciation of hand movements only. A course of 1016 mg of amphotericin B with concomitant 5-fluorocytosine was completed over 31 days.

On review four months later the patient remained asymptomatic. General physical examination was normal. Two small residual areas of pigmentation were present in the left eye; visual acuity was normal. In the right eye central vision was reduced to appreciation of hand movements and peripheral vision to appreciation of objects. The right retina could not be visualised because of residual vitreous haemorrhage. Slit-lamp examination revealed clearance of cells from the anterior chamber. The serum antibody titre to Candida albicans had fallen to 640.

CASES 2-7
The six other patients had injected themselves with heroin on the night of 26 August 1982. Two different syringes and two samples of heroin, obtained from the same dealer, were used. Juice from the same lemon was used as an additive. None of these materials was available for culture. Symptoms experienced by these patients were similar to those of the index case. Clinical findings are summarised in Table 1.

MANAGEMENT
NSFW:

Therapy with amphotericin B and 5-fluorocytosine was instituted in six of the seven patients. Four patients received approximately 1 g of amphotericin B. Skin, musculoskeletal, and small eye lesions were cured by this therapy. A therapeutic pars plana vitrectomy with local instillation amphotericin B (5 ,ug) was undertaken in two patients after progression of chorioretinal lesions on systemic antifungal therapy. This procedure, although curative of the infection, was complicated by intravitreal haemorrhage and persistence of poor visual acuity in both cases. A further patient, (patient 2, Table 1), who absconded after receiving 300 mg of amphotericin B, returned five weeks later with increased pain and swelling over his sixth left costal cartilage and again refused treatment. The small eye lesions seen initially had resolved. He was then lost to follow-up. The seventh patient presented with mild folliculitis. Eye examination revealed only occasional cells in the vitreous humour. These lesions resolved spontaneously.


DISCUSSION
NSFW:

Characteristic chorioretinal and other eye lesions are an important clinical indicator of disseminated candidiasis.2 Certain eye lesions may be peculiar to heroin abusers-for example, vitreous involvement without chorioretinitis as observed by us and Snip et al.3 and prominent inflammation of the anterior chamber.4 Episcleritis, present in two of our cases, has not been described previously. As Candida albicans was not isolated from conjunctival biopsies obtained from these patients after one week of a fungal therapy, evidence for the aetiological role of this agent in the episcleritis remains circumstantial.

Macronodular or follicular skin lesions confined to hair-bearing areas, and associated with occipital lymphadenopathy, were distinctive clinical features of our cases and may be characteristic of disseminated candidiasis in heroin abusers.5 The diagnosis of candidiasis was made readily by histological examination and culture of material from these skin lesions and supported by high titres of serum haemagglutinating antibody to Candida albicans. In one patient C. albicans was also isolated from an area of costochondritis. Culture of samples obtained from two patients at vitrectomy were negative for C. albicans, despite concentration of the specimens. Other workers have reported improvement in yield of fungal organisms after concentration of samples.4 Previous antifungal therapy may have affected yields from our patients. Serological tests have often been unhelpful in the diagnosis of disseminated candidiasis, particularly in immunosuppressed patient. ' High titres were found at presentation in our cases, all previously normal hosts; titres were substantially lower at the end of therapy, consistent with recent candidal infection.

Optimal regimens of antifungal therapy for endophthalmitis, chorioretinitis, and disseminated candidiasis have not been defined. Small lesions may resolve spontaneously (our case 7). Courses of up to 2 g of amphotericin B have been recommended for deep-seated infection. ' Combinations of amphotericin B and 5-fluorocytosine have been recommended because of potential synergistic activity against Candida albicans and prevention of the emergence of resistance to 5-fluorocytosine by the use of amphotericin B. ' Cure was achieved with 1 g of amphotericin B plus 5-fluorocytosine (150 mg/kg/day) in four of our cases. However, progression of eye lesions occurred during systemic therapy in two patients with marked endophthalmitis. In one case administration of systemic corticosteroids prior to diagnosis may have promoted intravitreal extension of chorioretinitis. Therapeutic vitrectomy plus intravitreal instillation of amphotericin B were curative in both patients. This has been the experience of other workers.46 The value of intravitreal instillation of amphotericin B remains controversial owing to its potential retinal toxicity6-8 and the difficulty of assessing its efficacy. Cure of endophthalmitis has been achieved by vitrectomy in association with systemic antifungal therapy,-9 and intravitreal amphotericif B has been used without resultant retinal toxicity.'"' However, pooling of high concentrations of antifungal drugs in unformed vitreous may result in local toxicity.'2 Uveitis and retinal and preretinal haemorrhages were noted after local instillation of amphotericin B in our two patients who underwent this procedure; these complications may have been caused by local drug toxicity.

The need for surgery to cure vitreal candidiasis reflects in part the poor penetration of amphotericin B into the vitreous humour.'3 Candidal infection confined to the choroid and retina may be cured by systemic therapy alone, as noted by ourselves and others.214 15

Further studies are required to determine the role of amphotericin B and less toxic drugs such as ketoconazole in the management of ocular candidiasis. Cases of failure of ketoconazole therapy in candida endophthalmitis have been reported,16 suggesting that amphotericin B will remain the mainstay of treatment.



Fig. 1 Right eye of the index case immediately prior to initiation of antifungal therapy. A large fluffy exudate (arrow) with surrounding smaller lesions is seen in the macular area. A small haemorrhage is located inferiorly to the optic disc. The nasal margin ofthe optic disc is blurred.

Fig. 2 Right eye ofthe index case on the seventh day of antifungal therapy. The fundus appears blurred due to generalised vitreal haze. The macular exudates have enlarged (arrow) and are extending anteriorly into the vitreous humour.

Fig. 3 Multiple fluffy exudates with vitreal extension are seen in the left fundus. Small haemorrhages are present peripherally. Generalised blurring ofthe optic disc is well demonstrated.

Fig. 4 A single Roth spot (arrow) is seen clearly in the paramacular area ofthe fundus of the left eye.
 

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Keep you rigs in your arm, not your neck!

!8o!8o!

That's some CRAZY stuff. I can't believe someone would even consider shooting heroin into their neck.

Wow.

Thanks, DJSim. That made my day.
 
^ In true desperation I've known people to inject in the neck (not to mention in the penis 8o) so can kinda understand it to an extent. For me there were always a couple of absolute no-go areas when it came to injection sites and the neck was one of them. The penis was most certainly another :D
 
you're very easily shocked, aren't you?

It's the picture...it's like I can almost imagine what that feels like...

I showed my fiancee too she was grossed out.

and yes I get shocked very easily sometimes. When I was in school kids would touch me and I'd *gasp!* :|
 
^ it shocked me too. A lot of us haven't seen some of the really nasty things associated with drug addiction (like IVing saliva etc)
 
!8o!8o!

That's some CRAZY stuff. I can't believe someone would even consider shooting heroin into their neck.

Wow.

Thanks, DJSim. That made my day.

yeah man, it's amazing what some people who are hopelessly addicted will do. a guy, who used to be a best friend of mine, who i used to shoot a fair amount meth, morph and oxy together had perfectly good arms for shooting and turns to me one day while we're about to shoot some meth in his bathroom upstairs and asked me to hold his neck tight while he registered and shot into his neck. it shocked the fuck out of me and i swore to him i'd never do it again no matter what. i told him about all the shit that could arise like instant OD, passing out then falling over, missing the shot etc etc and still he wanted to risk it all for the split second of a quicker and harder rush.

i've actually met a guy who had a track mark along his neck as well. his arms were in terrible fucking shape:|
 
8(

I have no idea what to say to that.

Today I was having a shot in this squat in the high rise commission flats (projects) with two vietnamese guys who were melting unisoms (OTC sleeping gel caps), mixing it with their gear and shooting it into their groins.

Shocking?
 
^ Groin shots is nothing shocking to me - virtually every user I know does it, including myself.

The local needle exchange say that they give out FAR more "groin pins" than regular 1ml insulin needles.

I don't see people mixing gear with sleeping pills very often though.

I *have* seen a couple of people using REALLY large needles, and using them to inject crushed up temazapams. The needle was fat enough to allow the undissolved sludge through.:!

I found that quite upsetting to see.

As far as IV saliva - I've only ever seen that in that movie "Spun". I thought it was pretty much made up. I can't imagine anyone actually doing that shit!
 
Today I was having a shot in this squat in the high rise commission flats (projects) with two vietnamese guys who were melting unisoms (OTC sleeping gel caps), mixing it with their gear and shooting it into their groins.

Shocking?

Urgghh, those fucking Unisoms... I have no idea how any pharmacist can sell the gel caps in good conscience, knowing that 95% of the time they are used for IV by heroin users.

As far as IV saliva - I've only ever seen that in that movie "Spun". I thought it was pretty much made up. I can't imagine anyone actually doing that shit!

Yeh, I agree... sounds like an urban myth. I can't imagine anyone being that stupid/desperate.
 
Wow. 8o

I have never used needles for recreational drug use, but I've always associated a sort mystical glow with heroin IVing. I have wanted to try it for a while, and this thread has opened to the real dangers of injection. I will make sure I educate myself fully before going through with it, and will take precautions to avoid addiction.
 
^ it shocked me too. A lot of us haven't seen some of the really nasty things associated with drug addiction (like IVing saliva etc)



DJ, why would you IV Saliva? Could you find an article about this? I believe you, but that's unique to say the least. HA
 
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