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

Holy shit, sorry to hear that man. What'd the docs have to say about it?

They said my walking will always be impeded (I walk with a limp and need a cane) and that I have nerve damage in my legs. Unfortunately my GP withdrew my prescription for gabapentin due to my history of substance misuse.

Thankfully I think canes look really cool, like on the series House, so I don't mind using one that much. At least I don't have to use a zimmer frame or something rediculous like that.
 
I absolutely love this thread.

Almost needs to be a sub-forum for case studies. That way discussion can be kept separate per each study.

Nice reading, either way.
 
Eerr.... femoral injection ISN'T injecting in the penis.

Mistake was corrected. Pointed out by another poster in a different thread, did not realize I had mentioned it in this thread too. A couple foreign Harm Reduction websites use the term 'groin' when describing femerol injecting, often in conjunction with articles about Diconal addicts injecting in the penis, and in threads dealing with unconventional injection/vein sites on BL- so I just hopped on assumption bandwagon.
 
Cutaneous complications of intravenous drug abuse
P. Del Giudice - 10.1111/j.1365-2133.2004.05607.x

Injection drug abuse is a world-wide problem responsible for numerous minor to life-threatening and fatal complications. The skin is the tissue most evidently affected by intravenous drug addiction. 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 or becoming the site of toxigenic infections. Between 1996 and 2001, in our institution in south-eastern France, we observed cutaneous complications after crushed buprenorphine tablet injections in 13 patients. This paper reviews and classifies adverse effects of parenteral drug abuse on the skin.

NSFW:
The drugs
When illicit narcotics sold on the street, such as heroin or cocaine, reach the consumer, they have been diluted ('cut') several times by 50-99%.4,5 The list of substances used to dilute the drug is long and includes quinine, lactose, lidocaine, caffeine, inositol, dextrose, sucrose, procaine, starch, magnesium silicate (talc), mannitol and other substances.6–9 The drug, usually in the form of a powder, may contain soil, dust and pathogens introduced during manufacturing or storage.6–10

Most drug addicts use several drugs. Heroin has long been the most common, followed by cocaine.2 Cocaine has direct cytotoxic effects and acts as a powerful adrenergic agent, thus its use results in vasoconstriction.11,12 The list of the different drugs injected is long (Table 1). Tablets normally intended for oral administration may be crushed, dissolved and injected.

Between 1996 and 2001, in our institution in south-eastern France, cutaneous complications after injections of crushed buprenorphine tablets were observed. Buprenorphine (SubutexTM) is a semisynthetic partial opioid agonist used in Europe as oral treatment for opioid dependence. The complications observed in 13 patients are summarized in Table 2.


The technique of injection
The narcotic is prepared for injection by mixing with water, lemon juice or other liquid. The solution is heated in a spoon or another recipient until the powder dissolves and is then filtered through a cotton wool ball or a cigarette filter into a syringe.4–13 The ritual surrounding the injection may include the use of unsterile supplies, the sharing of equipment and lack of skin antisepsis.6–17 The normal injection route is intravenous. Darke et al.18 observed that there was a time-dependent progression regarding the injection sites. The cubital fossa is the starting point followed, after 3·5 years, by the upper arms, and, after 4 years of addiction, the hands. Injection in the neck, foot and leg occurs after 6 years, and injection in the groin, toes and fingers after 10 years. When peripheral veins are sclerosed the addict, unable to access a peripheral vein, injects by mistake or deliberately, in subcutaneous tissue and muscle. Deliberate subcutaneous injection ('skin popping') is also used to avoid 'track marks' which represent stigmata of drug addiction.19 Sometimes major vessels such as neck, groin or upper limb arteries are used.14


Local cutaneous complications

Local complications occur at the site or in the area of injection. Two types are described: acute complications occurring within a few hours to 48–72 h after injection, and delayed complications.


Acute complications

Injection marks. Recent injection marks at the site of injection are present in all IDUs.20,21

Cutaneous infections. Cutaneous infections are common in IDUs.16 Abscesses and cellulitis occur in 22–65% of addicts (Figs 1 and 2).22–24 Vishov et al.17 reported that 11% of IDUs interviewed had had at least one abscess in the past 6 months and Spijkerman et al.25 found an incidence of skin abscesses of 33 per 100 person-years. A combination of factors favours cutaneous infection. Tuazon et al.26 found that 68% of street heroin samples and 89% of the material for injection confiscated in Washington DC were contaminated with various single or multiple pathogens including Clostridium sp., Gram-negative bacteria and fungi. Moustoukas et al.27 in Chicago, found similar results with 61% of heroin samples contaminated with 1·6 × 102 to 3·7 × 104 organisms per gram. Other risk factors include intradermal injection,28,29 absence of skin asepsis,6,28,29 unsterile equipment, poor hygiene,19 adulterants acting as irritant substances and foreign bodies, and the combination of heroin and cocaine.28 Spijkerman et al.25 found that HIV infection, female gender, prostitution, foreign nationality, combined injection of heroin and cocaine, a high frequency of injecting, and obtaining syringes through the needle exchange programme were independently and positively associated with skin abscesses. In addition, the pharmacological properties of the drugs such as the vasoconstrictive effect of cocaine may contribute to infections.30 The use of alcohol to clean the skin before injection may protect against cutaneous infections.17,28,29

A wide range of pathogens including almost all bacteria and fungi have been isolated in these infections. Single or multiple pathogens may be isolated. Gram-positive cocci are the bacteria most frequently seen. The three most common are Staphylococcus aureus, group A ß-haemolytic Streptococcus and other Streptococci.2,30–35 Anaerobes are the second most common group of bacteria to be isolated, and include Clostridium sp., usually associated with aerobic bacteria. Gram-negative bacteria are less commonly isolated. The source of the pathogens is variable but most originate from the flora of the skin and oropharynx. Indeed some IDUs lick needles, use saliva to clean the skin, to moisten the cotton wool or to dilute the drug.28–30 Irritant substances cause sterile chemical cellulitis and abscesses. Management of abscesses includes incision, drainage and antibiotics active against Staph. aureus, Streptococci and anaerobes.35


Necrotizing fasciitis. This is a rare but severe and life-threatening manifestation with a high rate of mortality and amputation.36–38 Necrotizing fasciitis occurs mainly after subcutaneous injection. The use of black tar heroin has been associated with epidemics of abscesses, cellulitis and necrotizing fasciitis.38 Recent severe cutaneous infections, myonecrosis and sepsis with a high mortality rate have been reported in the U.K. and San Francisco caused by Clostridium novyi, C. perfingens and other Clostridium sp.39,40 Other local infections include lymphangitis, thrombophlebitis, pyoderma, ecthyma gangrenosum41 and gas gangrene.42,43

The impact of opiate maintenance programmes on the rate of cutaneous infections is an important issue. Bassetti et al.44 reported no beneficial effect of an injected opiate maintenance programme on the incidence of hospitalization because of current infections, including cutaneous infections. However, Conrad et al.45 observed a significant decline of cutaneous infections over 18 months of heroin-supported treatment, and Batki et al.46 a reduction of hospital admissions for abscesses and cellulitis. A reduction of abscesses resulted from a needle and educational programme in IDUs in Bangladesh.47


Necrotizing ulcers. Cutaneous necrosis and necrotizing ulcers may develop as a result of several combined factors mainly 'skin popping', toxicity and the irritant properties of the drug and adulterants, vascular thrombosis and infection (Fig. 3).31,48–54 For example, quinine used as an adulterant has caustic effects. In addition some drugs such as cocaine have potent vasoconstrictive and thrombotic effects.11,12 Although bacteria may be cultivated from necrotic ulcers, most authors consider the mechanism to be related not to an infection but to a direct effect of the drug or adulterants. However, in some cases infection may contribute to the formation of ulcerated lesions even though it is difficult to demonstrate the respective contribution of each factor.53 Indeed Hoeger et al.55 reported a synergistic cocaine and streptococcal cutaneous necrosis. Some bullous lesions, nodules and chemical cellulitis and abscesses share identical physiopathology and may precede necrosis and ulceration.3,4,53,56

Cutaneous necrosis also results from arterial thrombosis after direct intra-arterial injection such as scrotal skin necrosis after pudendal artery injection.41


False aneurysm and mycotic aneurysms. False aneurysm and mycotic aneurysm are rare but serious complications. The lesion manifests as a pulsatile mass located in the area of major arteries. In some case it may present as a non-pulsatile inflammatory mass and may be mistaken for a cutaneous abscess.16,57–59 Inappropriate incision is disastrous. False aneurysm is caused by vascular injuries after drug injection. Staph. aureus is the main pathogen in mycotic aneurysms. Most cases involve the femoral artery following groin injection but other locations such as the upper limbs have been described.57,60 The treatment is difficult, and is based on ligation and surgical excision of the aneurysm.61–65


Thrombophlebitis. Injecting drug use is considered a risk factor for deep vein thrombosis.66 The repeated trauma of venepuncture, local infections and the irritating qualities of the drugs and adulterants are the main cause of superficial and deep venous thrombosis.14,67,68 Septic thrombosis is responsible for bacteraemia, with Staph. aureus as the most frequent pathogen.69 High-risk locations include iliofemoral and upper limb deep thrombosis.59,69–72


Intra-arterial injections. Inadvertent or deliberate direct intra-arterial injection of drugs may cause severe tissue ischaemia and necrosis.58,73–80 Immediately after injection, the patient feels intense pain and burning; within a few hours a marked oedema appears, followed by cyanosis in the territory of the artery (Fig. 4).73–80 In the most severe cases necrosis occurs, leading to amputation. Several mechanisms have been suggested to explain the vascular injury. A direct vasoconstriction may be caused by cocaine or amphetamines. The local chemical toxicity of drugs or adulterants cause chemical endarteritis resulting in vasospasm and thrombosis. Finally the mixture may contain microparticles that act as emboli. This is particularly the case when oral drug formulations such as crushed tablets are injected. The result is a peripheral ischaemia, oedema and compartment syndrome, which worsen the ischaemia.73–80

The management of intra-arterial drug injection is difficult. Most authors suggest an elevation of the limb, analgesia and heparinization. In the case of compartment syndrome, urgent surgical decompression is indicated. Many treatments have been used including vasodilators, anticoagulants, corticosteroids, prostaglandin inhibitors, and others.73–80



Delayed complications

Hyperpigmentation. Weidman and Fellner3 found that hyperpigmentation at the site of injection was the most common cutaneous finding, present in 54% of subjects it is related to scars and tracks along the injected veins (Fig. 5). Hyperpigmentation results from a postinflammatory process following the various skin injuries.

Scarring. Scars and, in particular, needle tracks are the main stigmata of narcotic abuse (Figs 1, 5 and 6).19,21,56 Horowitz81 found that 76% of 74 IDUs examined had scars along a vascular distribution, mainly the ante-cubital area and the dorsum of the hand. The presence of scarring was related to the duration of drug abuse.81 Fifty-three per cent of the subjects who had stopped injection for more than 5 years still had scarring.81 Repeated injections along a superficial vein result in venous thrombosis and subsequent fibrosis to form linear cord-like hypopigmented or hyperpigmented scars ('railroad tracks') pathognomonic of intravenous drug addiction.6'Pop scars' form irreversible irregular round or oval hypopigmented or hyperpigmented, atrophic or hypertrophic scars, or keloids, 0·5–3 cm in diameter (Fig. 5).4,8 Other scars result from various skin injuries from trauma, infections, necrosis, burns, suicide scars, etc.

'Shooting tattoos.' These result from the 'cooking' of the drug, flaming of needles and soot deposition or the introduction of foreign materials in the dermis.19,81,82 Common tattoos are a means of disguising scars.


Chronic venous insufficiency and ulcers. Pieper et al.67,68,83 found that 88% of people with a history of injection drug abuse had clinical evidence of chronic venous insufficiency. Risk factors for the development of venous insufficiency include vein trauma, necrotic ulcers, superficial and deep vein thrombosis and blockage of the lymphatic system by repeated infections and the sclerosing effects of adulterants.67,68,83 Both lymphatic blockage and venous impairment contribute to chronic oedema of the lower extremities. Delayed leg ulcers occur at sites of past subcutaneous injection as a result of lymphatic and venous vessel damage.67,68,83


Cutaneous nodules, panniculitis, sclerosis and ulcers. The drug and adulterants can cause a dermal inflammatory reaction which may be a foreign body granuloma or a nonspecific nongranulomatous inflammation with or without detectable foreign bodies. Cutaneous nodules, panniculitis and dermal sclerosis result from the chronic dermal inflammatory process.7,82 Hahn et al.76 demonstrated starch or talc granuloma in five of nine skin nodules. The lesions may break down and ulcerate, producing chronic ulcers.84,85 Chronic infections, such as underlying osteitis, may be associated.86 The vascularized granulation tissue in and around the ulcer may used as a site for drug injection.85–87

In some instances chronic dermal inflammation evolves into a severe dermal fibrosis. Pentazocine abuse was responsible for extensive 'woody' cutaneous fibrosis.48–51

Histopathological analysis and examination of tissues under polarized light can show the presence of birefringent material, such as starch, talc and other foreign particles.7,82,86


Raynaud's phenomenon and peripheral ischaemia. Heng and Haberfeld84 reported multiple large skin ulcers with kidney and liver injury after intravenous cocaine injection and suggested that the multiple infarcted lesions were caused by the vasoconstrictive and thrombotic effects of the cocaine. Cocaine has been associated with vascular disorders such as Raynaud's phenomenon and digital necrosis.88,89



Complications related to the site of injection
No area of the skin is spared by addicts. Specific locations of injection become the sites of particular complications.


Hands. These are a common site of injection, mainly the dorsum of the hand and the digits (Figs 3 and 6).15,31,34,90–92 Infection may affect all the anatomical structures of the hand causing abscesses, cellulitis, necrotizing fasciitis, tenosynovitis, arthritis, osteitis and osteomyelitis. Destruction of the articular cartilage causes finger deformities.92 Volkman's ischaemia and bullae may occur following coma. Radial or brachial intra-arterial injections may cause hand ischaemia and digital necrosis.

With repeated injections, the hands become chronically swollen. This phenomenon, called 'puffy hand' syndrome by Abeles,93 seems to be specific to addiction.13,94 The 'puffy hand' syndrome is a form of lymphoedema caused by the sclerosing action of the drugs.92–94 Neviaser et al.94 demonstrated that the cause of 'puffy hand' was a lymphatic obstruction. The swelling persists even after the addict stops injections.


Penis. Penile veins are used for injection, particularly the dorsal vein of the penis, resulting in penile necrotizing ulcers (Fig. 1).95,96


Neck. Jugular vein injection may be complicated by descending cervical cellulitis and mediastinitis with a high rate of mortality.97,98


Groin. Direct pudendal artery injections cause penile and scrotal necrotizing ulcers.41,77,78 Abscesses, false and mycotic femoral aneurysms and iliofemoral venous thrombosis complicate groin injections.21,60,69



Hypersensitivity reactions

Opiates can cause itching because of histamine release. The pruritus starts almost immediately after heroin injection and can last 10 min to 24 h.3 Although various hypersensitivity reactions have been reported, they remain surprisingly rare given the number and variety of adulterants and drugs. Urticaria was reported in 4% of addicts by Weidman and Fellner3 following heroin injection. Urticaria started about an hour after injection and lasted for several hours to days.4 Severe angio-oedema and urticaria with bronchospasm have been reported.99 A serum sickness-like reaction with amphetamine,3 rare morbilliform and fixed drug eruptions with heroin and a case of Lyell's syndrome with heroin have been reported.4,9,100 The various adulterants are likely to be responsible for most of these reactions.

A few cases of leucocytoclastic vasculitis have been reported but it is unclear whether the vasculitis was linked to the drug or to other factors such as cryoglobulinaemia and viral infections.4,9,101,102


Cutaneous manifestations of systemic infections

These include bacteraemia, endocarditis, osteoarthritis and systemic candidosis. Bacteraemia is a life-threatening complication of drug injection. Fifty per cent of the bacteraemia in drug addicts is caused by Staph. aureus.103 Cutaneous infections, septic thrombophlebitis and endocarditis are the main sources of bacteraemia.2,5,103 Endocarditis is more frequently a right-sided endocarditis.1,2,103–106Staph. aureus bacteraemia and endocarditis may present with purpura, pustules and limb ischaemia caused by peripheral embolism and septic vasculitis.104,107 Bacteraemia can cause secondary septic arthritis. The costochondral articulations are usually involved in IDUs.2,108,109

Systemic candidosis is the most common fungal systemic infection in IDUs. After 1980 a syndrome including cutaneous, ocular (chorioretinitis or uveitis) and osteoarticular involvement (mainly costochondral) was described in subjects injecting brown heroin diluted with lemon juice.109–111 Typical cutaneous manifestations included painful nodules and pustules mainly located on the scalp and hair-bearing area.109–111 Costochondral involvement may present as a mass or a tumour in the anterior region of the thorax usually without inflammatory signs.


Toxigenic infections

Skin is an important focus for toxin-related bacterial infections. Tetanus is a rare but regularly reported complication in IDUs.1,112–114 Anaerobic infections, repeated septic needle injuries, chronic wounds and under-immunization render IDUs at risk for tetanus.112 In Italy injection drug use is the main risk factor among young individuals.113 Systematic vaccination is recommended for IDUs.

Wound botulism has been reported in IDUs both in the U.S.A. and Europe.115–117 A recent epidemic occurred in California associated with the subcutaneous or intramuscular injection of 'black tar' heroin.115–117

A recent case of cutaneous anthrax complicated by meningitis in a heroin skin-popper has been reported in Norway.118 Exceptional cases of toxic shock syndrome attributed to the direct intravenous inoculation of Staph. aureus toxin at the time of heroin injection, and staphylococcal scalded skin syndrome have been reported.119–121


Miscellaneous complications

Other cutaneous manifestations have been reported where the causal relationship with drug use is not clear, including cases of polyarteritis nodosa122,123 and scleroderma.124–126 Needle fragment foreign bodies after needle breakage are occasionally found in the skin.13,58,127


Conclusions

The skin is the tissue most evidently affected by intravenous drug addiction. Indirect skin manifestations caused by injection abuse cannot be reported in detail in this review. They would include those related to blood-borne pathogens such as HIV, viral hepatitis and other pathogens; cutaneous stigmata of drug-induced coma; and various traumatic injuries: those related to psychological troubles (suicide scars), social deficiency, alcohol, violence and accidents.128 The spectrum of cutaneous manifestations is increasing as much as the number of drugs available for abuse increases. It is important to develop and evaluate drug substitution and educational programmes in order to reduce these complications.



Figure 1. Multiple sites of group A ß-haemolytic Streptococcus A localized necrotizing cellulitis (after surgical excision of necrotizing tissues). Multiple scars of past injection and abscesses. Injection scars over the penis.

Figure 2. Cutaneous abscess of the thigh after 'skin popping'

Figure 3. Necrotizing ulcer after morphine sulphate tablet injection.

Figure 4. Livedoid purpuric feature after direct intra-arterial buprenorphine tablets injection of the brachial artery.

Figure 5. Pigmented 'pop scars' of the leg following cocaine injection.

Figure 6. Digits show cocaine injection scars and beginning of digit retraction.
 

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^ The above isn't really a case study per se, but it makes for good reading. Extended text under NSFW tag
 
^ The above isn't really a case study per se, but it makes for good reading. Extended text under NSFW tag

Indeed.

The intra-arterial picture of buprenorphine was interesting to look at...it should be stressed to all IV drug users the difference between hitting a vein and an artery.
 
^ And figure 3 is a good reason why people should never IV MS Contin
 
^ And figure 3 is a good reason why people should never IV MS Contin

If that isn't the truth. There have been MANY cases of major complications when IVing MS Contin tablets yet people still seem to think this is safe and commonly accepted practice. It is so far from it. You should know the second you add water to MS Contin and it turns into that tell tale gel substance that any further attempts to make this into an IV'able solution is probably going to warrant a very risky, limb/life threatening, choice.

Although someones going to chime in with "I've shot MS Contins 1000 times and they totally work when you shoot them yada yada yada" You gotta love that. Of course if you get it in your vein and jam that dirty solution into your blood it will "work" as morphine is water soluble. But it doesn't mean that you aren't going to end up as the next leg/arm/hand etc. in the case studies thread. It's sad that more people can't be deferred until after something happens to them. I do my best on this site to try and discourage people from having to come through the ER as the next major complication I see from IV complications.

Thank you for posting this thread djsim. I really think it's going to help a lot of people even if it's mildly a scare tactic. IT SHOULD BE. Scare tactics are amazingly helpful to me as long as it's not falsified or lieing. It's great information. Thank you.
 
You should know the second you add water to MS Contin and it turns into that tell tale gel substance that any further attempts to make this into an IV'able solution is probably going to warrant a very risky, limb/life threatening, choice.

.

Thats why people that know what they are doing DESTROY the gel substance, and turn it into a crispy plastic ball - before putting it through a micron filter.
 
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Wow...some people are incredibly desperate.

It's not desperation. it is called addiction...My ex had one of the first reported cases of WB in September 1991, he was in the hospital for 4 months, he couldn't move, he couldnt even open his eyes, and he stayed that way for months. So if anyone thinks "This happens to other people" think again. My ex was on deaths door and his doctor to this day has no idea how he survived. His doctor is one of the doctors who was mentioned in that report..WB is no joke man, it is a killer, and with this black tar crap, well all I can say is thank God for methadone..I mutilated my body because once the veins are gone, I just stuck the needle anywhere, in my forarm, my butt, my legs. I had so many absesses that I am surprized I didn't lose an arm or a leg..I have scars all over my body, and that sucks. I am not saying this to brag, I am saying this because if it means one person won't put that needle in their arm for the first time tonight, everything I said is worth it. I am 54 years old and most of my friends are dead or in prison, please guys, if you are thinking about picking up a rig, think it through...Think what your life will be one year from today..I don't wish my nightmare on my worst enemy..I love to party, just no more stuff and no needles.....

LillyF40
 
I like this thread. It exposes all the bullshit and dangers associated with addiction.
 
I like this thread. It exposes all the bullshit and dangers associated with addiction.

Not so much addictioj, but reckless addiction. Addiction is a compulsion to use, but it's always in ones power to eat or plug an mscontin rather than IV or IM(!) it
 
Thats why people that know what they are doing DESTROY the gel substance, and turn it into a crispy plastic ball - before putting it through a micron filter.

Ok I understand this in other threads, but promoting the safety of IV'ing MS Contins in the CASE STUDIES thread blatantly showing the possible outcome of doing so is beyond ridiculous. Geez remove that post somebody or edit it before someone goes "Ohhh that happened because they didn't crisp it first" please stop this crap. IV'ing MS Contin anyway is BAD. Doing it with methods of getting rid of the gel and running it through a micron filter are better. But still BAD news and asking for problems.
 
ugh, this thread is like watching bizarre foods, except with junkies.
 
Not so much addictioj, but reckless addiction. Addiction is a compulsion to use, but it's always in ones power to eat or plug an mscontin rather than IV or IM(!) it

I agree. I am never reckless, I always take the time to do it right.
 
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