Harm Reduction ⫸CASE STUDIES - It could happen to YOU!⫷
- Thread starter djsim
- Start date
Sentimental
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When you smoke fentanyl, you only smoke the gel, and you can't smoke Mylans, because there is no gel.
Mandatory17
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great thread, as someone else said above, it really does make you think about things we may have been contemplating.... it made me think, I prefer solid evidence over opinions. thanks. 
InvisibleEye
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As many other posters have said already, this post is absolutely necessary - thanks a million for it.
Wish I had across such a resource when I was experimenting with IV as a teen. Now I can see how misinformed I was about the risks involved. Thanks again. I hope to find something useful to contribute to this thread in the future.
Wish I had across such a resource when I was experimenting with IV as a teen. Now I can see how misinformed I was about the risks involved. Thanks again. I hope to find something useful to contribute to this thread in the future.
barnstable84
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This thread is fantastic. It's nice to be able to read actual case studies of things that have actually happened instead of just being told that all illegal drugs are bad and will kill you straight away.
Has anyone with access to such case studies seen anything about the side effects of promethazine? I'm extremely interested in seeing anything about it for my own safety reasons and I turn up nothing when I search online myself.
Big thanks to djsim, you're doing a brilliant thing. I know it sounds corny, but knowledge truly is power and the more knowledge we have, the safer we can all be.
Has anyone with access to such case studies seen anything about the side effects of promethazine? I'm extremely interested in seeing anything about it for my own safety reasons and I turn up nothing when I search online myself.
Big thanks to djsim, you're doing a brilliant thing. I know it sounds corny, but knowledge truly is power and the more knowledge we have, the safer we can all be.
Captain.Heroin
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Most of the posts in here involve injections of some sort.
If you're talking about the oral ingestion of promethazine, I would have to say too much (hundreds to thousands of milligrams) might render you in a delirium. However, anything short of way too much, and you should be fine.
I am not familiar with promethazine though, so I can't tell you too much about that. Just my gut instinct.
InvisibleEye
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Promethazine
@ barnstable84: here's some info on promethazine (on ScienceDirect)
The Dangers of Intravenous Promethazine Administration
Susan Paparella RN
Huntingdon Valley, Pa
Available online 6 December 2006.
Article Outline
How Does Promethazine Cause Harm?
Adverse events associated with intravenous promethazine administration have been reported in the literature for several years. For example, a professional guitar player, suffering from a migraine headache, went to an emergency department where she received an accidental arterial administration of Phenergan (promethazine), intended for intravenous administration. She developed circulatory problems at the site of injection, which lead to progressive gangrene and amputation of her arm in stages. In 2004, she was awarded $2.4 million for her past and future medical expenses and $5 million for pain and suffering.1
In another case, a patient received a dose of promethazine (12.5 mg) intravenously into an access site in the hand. During the injection, the patient complained of extreme burning, but the nurse continued administering the medication. The patient developed a 1modifier letter double prime × 1.5modifier letter double prime area of necrosis and pain, and eventually required long-term follow-up, including skin grafting and physical rehabilitation.1
In 2006, a 19-year-old woman presented to the emergency department with flu-like symptoms and received Phenergan intravenously. During the injection, the pain was so intense that that patient stated that she wanted to “take the IV line out” herself. After the injection, the patient complained that her arm was still significantly painful and that she felt “something was wrong.” The nurse reassured the patient but the patient's arm and fingers became increasingly discolored after the nurse left the room. During the next 30 days the patient remained in the hospital and watched her previously healthy fingers turn black and shrivel. As a result, her thumb, index finger, and top of her middle finger required amputation (Figure). She has since settled her claim with the hospital for an undisclosed amount of money.2
In 2006, another ED patient with nausea and vomiting was treated with promethazine (12.5 mg) intravenously. His symptoms resolved and he was discharged home. About 2 weeks later, the patient returned to the emergency department with pain and swelling in his left forearm. This was the previous administration site for the intravenous promethazine. A Doppler study showed a thrombus in the cephalic vein, from the antecubital area to the wrist. The patient was treated with an antibiotic and analgesics and given instructions to rest the arm, apply heat, and wear an arm sling. The patient returned to the ED less than 2 weeks later with ongoing symptoms. A repeat Doppler study showed additional thrombi in other veins in his left arm. He was admitted to the hospital for full anticoagulation and discharged home on long-term warfarin therapy.3
...complications appear most often when this drug is administered via the intravenous route (or by inadvertent intra-arterial or subcutaneous administration).
The practice of direct injection of undiluted promethazine is not as uncommon as one may think, as Susan Hohenhaus MA, RN, FAEN, mentioned in her October 2005 Clinical Forum Column in the Journal of Emergency Nursing. Susan observed that nurses were “casual” about how they delivered promethazine intravenous, most often as a direct push through a peripheral IV access line or saline lock because of their familiarity with this drug.4
How Does Promethazine Cause Harm?
Promethazine (Phenergan) is a medication used commonly that possesses antihistamine, sedative, antiemetic, and anticholinergic effects. It is extremely effective when used appropriately and is considered a cost effective alternative to other anti-emetic agents. Promethazine, in the injectable form, with a pH between 4 and 5.5, and is highly caustic to the intima of blood vessels and surrounding tissues. According to the product labeling, this medication may be given by slow intravenous push (recommended no faster than 25 mg/minute), although deep intramuscular injection is the preferred route of administration.5
Chemical irritation and resulting tissue damage can occur with this drug regardless of the route of administration; however, in reports submitted to the Institute for Safe Medication Practices (ISMP) through the USP/ISMP Medication Error reporting program (USP-ISMP MERP) and the Pennsylvania Patient Safety Reporting System (PA-PRSR), complications appear most often when this drug is administered via the intravenous route (or by inadvertent intra-arterial or subcutaneous administration).2. and 3. Adverse symptoms typically include burning, pain, erythema, and swelling at the site, severe spasm of distal vessels, thrombophlebitis, venous thrombosis, phlebitis, abscess, tissue necrosis, nerve damage, paralysis, and gangrene. In some cases, surgical intervention is required, including fasciotomy, skin graft, and even amputation.
- Figure. Gangrene caused by promethazine extravasation. (Photo courtesy of the Daily World, Aberdeen, Wash):
@ barnstable84: here's some info on promethazine (on ScienceDirect)
The Dangers of Intravenous Promethazine Administration
Susan Paparella RN
Huntingdon Valley, Pa
Available online 6 December 2006.
Article Outline
How Does Promethazine Cause Harm?
Adverse events associated with intravenous promethazine administration have been reported in the literature for several years. For example, a professional guitar player, suffering from a migraine headache, went to an emergency department where she received an accidental arterial administration of Phenergan (promethazine), intended for intravenous administration. She developed circulatory problems at the site of injection, which lead to progressive gangrene and amputation of her arm in stages. In 2004, she was awarded $2.4 million for her past and future medical expenses and $5 million for pain and suffering.1
In another case, a patient received a dose of promethazine (12.5 mg) intravenously into an access site in the hand. During the injection, the patient complained of extreme burning, but the nurse continued administering the medication. The patient developed a 1modifier letter double prime × 1.5modifier letter double prime area of necrosis and pain, and eventually required long-term follow-up, including skin grafting and physical rehabilitation.1
In 2006, a 19-year-old woman presented to the emergency department with flu-like symptoms and received Phenergan intravenously. During the injection, the pain was so intense that that patient stated that she wanted to “take the IV line out” herself. After the injection, the patient complained that her arm was still significantly painful and that she felt “something was wrong.” The nurse reassured the patient but the patient's arm and fingers became increasingly discolored after the nurse left the room. During the next 30 days the patient remained in the hospital and watched her previously healthy fingers turn black and shrivel. As a result, her thumb, index finger, and top of her middle finger required amputation (Figure). She has since settled her claim with the hospital for an undisclosed amount of money.2
In 2006, another ED patient with nausea and vomiting was treated with promethazine (12.5 mg) intravenously. His symptoms resolved and he was discharged home. About 2 weeks later, the patient returned to the emergency department with pain and swelling in his left forearm. This was the previous administration site for the intravenous promethazine. A Doppler study showed a thrombus in the cephalic vein, from the antecubital area to the wrist. The patient was treated with an antibiotic and analgesics and given instructions to rest the arm, apply heat, and wear an arm sling. The patient returned to the ED less than 2 weeks later with ongoing symptoms. A repeat Doppler study showed additional thrombi in other veins in his left arm. He was admitted to the hospital for full anticoagulation and discharged home on long-term warfarin therapy.3
...complications appear most often when this drug is administered via the intravenous route (or by inadvertent intra-arterial or subcutaneous administration).
The practice of direct injection of undiluted promethazine is not as uncommon as one may think, as Susan Hohenhaus MA, RN, FAEN, mentioned in her October 2005 Clinical Forum Column in the Journal of Emergency Nursing. Susan observed that nurses were “casual” about how they delivered promethazine intravenous, most often as a direct push through a peripheral IV access line or saline lock because of their familiarity with this drug.4
How Does Promethazine Cause Harm?
Promethazine (Phenergan) is a medication used commonly that possesses antihistamine, sedative, antiemetic, and anticholinergic effects. It is extremely effective when used appropriately and is considered a cost effective alternative to other anti-emetic agents. Promethazine, in the injectable form, with a pH between 4 and 5.5, and is highly caustic to the intima of blood vessels and surrounding tissues. According to the product labeling, this medication may be given by slow intravenous push (recommended no faster than 25 mg/minute), although deep intramuscular injection is the preferred route of administration.5
Chemical irritation and resulting tissue damage can occur with this drug regardless of the route of administration; however, in reports submitted to the Institute for Safe Medication Practices (ISMP) through the USP/ISMP Medication Error reporting program (USP-ISMP MERP) and the Pennsylvania Patient Safety Reporting System (PA-PRSR), complications appear most often when this drug is administered via the intravenous route (or by inadvertent intra-arterial or subcutaneous administration).2. and 3. Adverse symptoms typically include burning, pain, erythema, and swelling at the site, severe spasm of distal vessels, thrombophlebitis, venous thrombosis, phlebitis, abscess, tissue necrosis, nerve damage, paralysis, and gangrene. In some cases, surgical intervention is required, including fasciotomy, skin graft, and even amputation.
- Figure. Gangrene caused by promethazine extravasation. (Photo courtesy of the Daily World, Aberdeen, Wash):
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InvisibleEye
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Here's an example of non-IV complication...
Midfacial Complications of Prolonged Cocaine Snort
Peter D. Villa, DDS, FRCD(C)
ABSTRACT
Acute and chronic ingestion of cocaine predisposes the abuser to a wide range of local and systemic complications. This article describes the case of a 38-year-old man whose chronic cocaine snorting resulted in the erosion of the midfacial anatomy and recurrent sinus infections. Previously published case reports specific to this problem are presented, as are the oral, systemic and behavioural effects of cocaine abuse.
© J Can Dent Assoc 1999; 65:218-23reindeer poop scooper
This article has been peer reviewed.
Case Report
On February 3, 1998, a 38-year-old man was seen for evaluation of an oral-nasal communication after having been referred by his family dentist. The patient described how problems began to manifest themselves as nosebleeds in July 1997 and how, during the following months, those symptoms progressed to recurrent sinus infections. He first noticed a "pinhole" in his palate in late November 1997, after a soft drink he consumed ran out his nose. The opening became larger over the next two months, stabilizing in size to the diameter of his little finger. The patient discovered that a thick layer of bubble gum could be used to cover the defect, normalize his speech, and prevent food stuffs from being displaced into his nose.
The patient’s medical history indicated years of repeated cocaine snorting and a smoking habit of one-half pack of cigarettes per day. He was employed as a labourer, renovating the interior of commercial buildings.
The patient displayed a saddlenose deformity, characterized by a broad, flat nose (Fig. 1). There was no facial swelling, cervical lymphadenopathy, intraoral swelling, or trismus. Primary tooth 53 was deeply decayed and permanent cuspid tooth 13 was erupting palatally. A 10 x 12 mm oval fistula was apparent through the roof of his palate, just left of the midline, in the first molar area. No drainage or exophytic lesions were apparent.
Fig. 1: Saddlenose deformity, front and side views.
Midline Lethal Granuloma, Wegener’s Granulomatosis, nasal lymphoma, and tertiary syphilis can all present with these clinical findings.10-12 The patient’s workup therefore included a biopsy of the palatal mucosa, computed tomography (CT) scans, ear, nose and throat (ENT) evaluation, complete blood count (CBC), sedimentation rate, antinuclear antibody test (ANA), venereal disease test (VDRL), chest x-ray, and urinalysis. After consultation with specialists in other disciplines, results of these tests increased our confidence that we were dealing only with the local effects of cocaine abuse. Figure 2a is a CT scan of the patient’s nasopalatal defect, while Fig. 2b shows a CT scan of a normal midfacial anatomy.
Fig. 2a: CT scan showing palatal perforation, loss of nasal septum and turbinates, and thickening of the maxillary sinus membranes.
The biopsy of soft tissue, taken from the palatal margin of the oral-nasal opening, revealed a non-specific ulcer and chronic inflammation with some eosinophils. The presence of eosinophils has been noted in pathologists’ findings, as reported in Armstrong and Shikani10 and Schweitzer.13
Management was predicated on complete cessation of the drug. The patient was informed of the consequences of continued cocaine use, and how to get help in quitting. He was also advised to smoke less, and to use a proper filtration mask while at work. Appropriate management of recurrent sinus infections was coordinated with his family physician. After basic oral hygiene and restorative procedures were provided, a removable obturator was constructed (Fig. 3a, 3b and 3c). The patient will be re-evaluated for possible surgical closure of the oral-nasal fistula at a later date.
Fig. 3a: Nasopalatal defect.
Fig. 3b: Obturator removed
Fig. 3c: Obturator inserted.
Midfacial Complications of Prolonged Cocaine Snort
Peter D. Villa, DDS, FRCD(C)
ABSTRACT
Acute and chronic ingestion of cocaine predisposes the abuser to a wide range of local and systemic complications. This article describes the case of a 38-year-old man whose chronic cocaine snorting resulted in the erosion of the midfacial anatomy and recurrent sinus infections. Previously published case reports specific to this problem are presented, as are the oral, systemic and behavioural effects of cocaine abuse.
© J Can Dent Assoc 1999; 65:218-23reindeer poop scooper
This article has been peer reviewed.
Case Report
On February 3, 1998, a 38-year-old man was seen for evaluation of an oral-nasal communication after having been referred by his family dentist. The patient described how problems began to manifest themselves as nosebleeds in July 1997 and how, during the following months, those symptoms progressed to recurrent sinus infections. He first noticed a "pinhole" in his palate in late November 1997, after a soft drink he consumed ran out his nose. The opening became larger over the next two months, stabilizing in size to the diameter of his little finger. The patient discovered that a thick layer of bubble gum could be used to cover the defect, normalize his speech, and prevent food stuffs from being displaced into his nose.
The patient’s medical history indicated years of repeated cocaine snorting and a smoking habit of one-half pack of cigarettes per day. He was employed as a labourer, renovating the interior of commercial buildings.
The patient displayed a saddlenose deformity, characterized by a broad, flat nose (Fig. 1). There was no facial swelling, cervical lymphadenopathy, intraoral swelling, or trismus. Primary tooth 53 was deeply decayed and permanent cuspid tooth 13 was erupting palatally. A 10 x 12 mm oval fistula was apparent through the roof of his palate, just left of the midline, in the first molar area. No drainage or exophytic lesions were apparent.
Fig. 1: Saddlenose deformity, front and side views.
Midline Lethal Granuloma, Wegener’s Granulomatosis, nasal lymphoma, and tertiary syphilis can all present with these clinical findings.10-12 The patient’s workup therefore included a biopsy of the palatal mucosa, computed tomography (CT) scans, ear, nose and throat (ENT) evaluation, complete blood count (CBC), sedimentation rate, antinuclear antibody test (ANA), venereal disease test (VDRL), chest x-ray, and urinalysis. After consultation with specialists in other disciplines, results of these tests increased our confidence that we were dealing only with the local effects of cocaine abuse. Figure 2a is a CT scan of the patient’s nasopalatal defect, while Fig. 2b shows a CT scan of a normal midfacial anatomy.
Fig. 2a: CT scan showing palatal perforation, loss of nasal septum and turbinates, and thickening of the maxillary sinus membranes.
The biopsy of soft tissue, taken from the palatal margin of the oral-nasal opening, revealed a non-specific ulcer and chronic inflammation with some eosinophils. The presence of eosinophils has been noted in pathologists’ findings, as reported in Armstrong and Shikani10 and Schweitzer.13
Management was predicated on complete cessation of the drug. The patient was informed of the consequences of continued cocaine use, and how to get help in quitting. He was also advised to smoke less, and to use a proper filtration mask while at work. Appropriate management of recurrent sinus infections was coordinated with his family physician. After basic oral hygiene and restorative procedures were provided, a removable obturator was constructed (Fig. 3a, 3b and 3c). The patient will be re-evaluated for possible surgical closure of the oral-nasal fistula at a later date.
Fig. 3a: Nasopalatal defect.
Fig. 3b: Obturator removed
Fig. 3c: Obturator inserted.
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InvisibleEye
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Outcome after Injections of Crushed
Tablets in Intravenous Drug Abusers in the
Helsinki University Central Hospital
T.A. Partanen, P. Vikatmaa, E. Tukiainen, M. Lepantalo, J. Vuolaa
Helsinki University Central Hospital, Finland
Submitted 7 October 2008; accepted 24 January 2009
Available online 26 March 2009
Methods: The hospital discharge registers were used to identify the patients admitted in
different clinics in Helsinki University Central Hospital during 2000 - 2005. The patient demographics
and social background were clarified. The type of the crushed drugs, the injection
route and the timing of administration were registered. Medical interventions, examinations and surgical procedures were recorded.
Results: Between January 2000 and December 2005, 24 patients had been treated on 30 occasions
for manifestations caused by injecting crushed tablets. The main types of manifestations were acute limb ischaemia (16 patients) and infection (eight patients), and eight cases led to distal or proximal amputations. Men (19 of 24) were affected more frequently than were women (5 of 24). Their ages ranged between 20 and 39 years (mean: 26 years). All the patients had a previous history of intravenous drug abuse, and they lived in Greater Helsinki region. The incidence of seropositivity for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency
virus (HIV) was 33% (n=8), 88% (n=21) and 4% (n=1), respectively. The time between injection and presentation to the Emergency Department varied between 3 h and 10 days (mean: 62 h). Buprenorphine was the most commonly used drug in 10 of the 24 patients, and benzodiazepine derivatives were also used in 11 of the 24 patients.
It has been predicted by the International Narcotics Control
Board (INCB) that prescription drugs will replace illicit drugs in the developed countries before 2010. If the estimated trend is kept, both vascular and infectious problems with crushed tablets will increase in the future. Administration of the prescription drugs is usually oral, but when higher bioavailability is pursued, abusers crush or pulverise the tablets and dissolve them in water. The spectrum of
vascular complications that the drug abuse may result in is wide: cutaneous manifestations, pseudo-aneurysms,
infected deep vein thrombosis and tissue ischaemia (skin necrosis, muscle necrosis and nerve injury).
Accidental, unintentional, intra-arterial (IA) injections do occur, although infrequently, in normal clinical work.5
Iatrogenic IA injections of barbiturates and benzodiazepines have been shown to lead to permanent injuries in
spite of being dilute solutions and their administration in monitored environment.6 The complex IA process that is
possibly caused by a diluted crushed tablet is accelerated by contaminants such as microbes, powder-filling
substances and drug crystals.7 Even though the injection drug users (IDUs) are young
and have no underlying vascular disease (atherosclerosis or diabetes), previous intravenous (IV) drug abuse might have
affected peripheral veins that would have become sclerosed. 4 In addition, the previous damage to collateral arteries due to infections and intimal trauma may increase the risk of tissue necrosis after IA crushed-tablet injections.
Results
All 24 patients, with ages ranging 20-39 years (mean: 26 years) and in a 4:1 male-to-female ratio, come from
Greater Helsinki area (population around 1.2 million). One patient was a Russian immigrant and the rest of them were
native Finns. All patients had previous history of intravenous drug abuse. Eight of them had an earlier sentence of
imprisonment.
Somatically, the patients were quite healthy even though they had a significant amount of viral infections
typical for drug abusers. The incidence of hepatitis B virus (HBV) seropositivity was 33% (eight patients), and 88% of
the patients (21 patients) tested positive for hepatitis C virus (HCV). One female was a human immunodeficiency
virus (HIV) carrier. Previously, 24% of them had recorded infection in their medical files due to drug abuse. One male
was on medication for cardiac insufficiency and arrhythmia. One patient was queuing for the maintenance treatment
for opiate addiction. Twelve out of 24 patients were on maintenance treatment: six of them on methadone and the
other six on buprenorphine. Mental health diagnoses were reported in eight patients.
The crushed tablets were dissolved in water, usually tap water which was sometimes boiled. There was only one record on using filters before administration of the drug.
Majority of the patients (n=19) injected crushed tablets in the non-dominant upper extremity. Five patients were
treated due to a second similar incidence on an average of 1 year 5 months (range: 1 monthe3 years 2 months) after
the first incidence. Buprenorphine was the most commonly used drug in 10 of
the 24 patients, and benzodiazepine derivatives were also used in 11 of the 24 patients. Two IDUs had concomitant
injection of other psychotropics in addition to buprenorphine. A combination of buprenorphine, dextroproxyphene
and heroin was observed in one case. There were 16 arterial injections (Table 2), 2 venous injections and 10 soft-tissue
injections (Table 1). The injection time was reported in 67% of the cases. The time between injection and presentation
to the Emergency Department varied between 3 h and 10 days (mean: 62 h).
Patients who had injected crushed tablets were hospitalised mainly due to acute limb ischaemia (n=16) and
secondly due to infection (n=8). Many times, infection cooccurred with ischaemia. Septic symptoms, high temperature
and reduced general condition led to hospitalisation in seven patients. However, only two out of eight blood
cultures were positive (Streptococcus constellatus, Bacillus Cereus). Staphylococcus epidermidis (n=5), Staphylococcus
aureus (n=3), Streptococcus pyogenes (n=3) and Streptococcus anginosus (n=3) were the most common
pathogens cultured from the wound bed. Femoral osteomyelitis was the most serious infectious complication.
Embolectomy was performed in three cases in which the flow obstruction was shown by ultrasound or angiography.
In spite of the invasive procedures, these cases ended up in amputations and/or permanent disabilities such as functional
hand deficits (n=3), muscle weakness, rigidity (n=1) and numbness of the finger tips (n=1) or hyperaesthesia
(n=1). In one case, injection of crushed alprazolam to femoral artery caused the loss of the peroneal function and muscular necrosis in the anterior compartment (Fig. 1A-C). The IA injections led to severe problems: finger amputations (n=5), toe amputations (n=1), cubital exarticulation (n=1) and upper arm amputation (n=1).
Figure 1 (A) A typical clinical manifestation of micro-emboli found in the skin as purpuric lesions after injection of crushed
alprazolam in the femoral artery. (B) Cutaneous and muscle necrosis corresponding to the territory of the tibial anterior artery 14
days later. (C). The same leg 9 months later. A permanent peroneus cast/support was acquired. The patient could not continue his
work as a driver.
Tablets in Intravenous Drug Abusers in the
Helsinki University Central Hospital
T.A. Partanen, P. Vikatmaa, E. Tukiainen, M. Lepantalo, J. Vuolaa
Helsinki University Central Hospital, Finland
Submitted 7 October 2008; accepted 24 January 2009
Available online 26 March 2009
Methods: The hospital discharge registers were used to identify the patients admitted in
different clinics in Helsinki University Central Hospital during 2000 - 2005. The patient demographics
and social background were clarified. The type of the crushed drugs, the injection
route and the timing of administration were registered. Medical interventions, examinations and surgical procedures were recorded.
Results: Between January 2000 and December 2005, 24 patients had been treated on 30 occasions
for manifestations caused by injecting crushed tablets. The main types of manifestations were acute limb ischaemia (16 patients) and infection (eight patients), and eight cases led to distal or proximal amputations. Men (19 of 24) were affected more frequently than were women (5 of 24). Their ages ranged between 20 and 39 years (mean: 26 years). All the patients had a previous history of intravenous drug abuse, and they lived in Greater Helsinki region. The incidence of seropositivity for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency
virus (HIV) was 33% (n=8), 88% (n=21) and 4% (n=1), respectively. The time between injection and presentation to the Emergency Department varied between 3 h and 10 days (mean: 62 h). Buprenorphine was the most commonly used drug in 10 of the 24 patients, and benzodiazepine derivatives were also used in 11 of the 24 patients.
It has been predicted by the International Narcotics Control
Board (INCB) that prescription drugs will replace illicit drugs in the developed countries before 2010. If the estimated trend is kept, both vascular and infectious problems with crushed tablets will increase in the future. Administration of the prescription drugs is usually oral, but when higher bioavailability is pursued, abusers crush or pulverise the tablets and dissolve them in water. The spectrum of
vascular complications that the drug abuse may result in is wide: cutaneous manifestations, pseudo-aneurysms,
infected deep vein thrombosis and tissue ischaemia (skin necrosis, muscle necrosis and nerve injury).
Accidental, unintentional, intra-arterial (IA) injections do occur, although infrequently, in normal clinical work.5
Iatrogenic IA injections of barbiturates and benzodiazepines have been shown to lead to permanent injuries in
spite of being dilute solutions and their administration in monitored environment.6 The complex IA process that is
possibly caused by a diluted crushed tablet is accelerated by contaminants such as microbes, powder-filling
substances and drug crystals.7 Even though the injection drug users (IDUs) are young
and have no underlying vascular disease (atherosclerosis or diabetes), previous intravenous (IV) drug abuse might have
affected peripheral veins that would have become sclerosed. 4 In addition, the previous damage to collateral arteries due to infections and intimal trauma may increase the risk of tissue necrosis after IA crushed-tablet injections.
Results
All 24 patients, with ages ranging 20-39 years (mean: 26 years) and in a 4:1 male-to-female ratio, come from
Greater Helsinki area (population around 1.2 million). One patient was a Russian immigrant and the rest of them were
native Finns. All patients had previous history of intravenous drug abuse. Eight of them had an earlier sentence of
imprisonment.
Somatically, the patients were quite healthy even though they had a significant amount of viral infections
typical for drug abusers. The incidence of hepatitis B virus (HBV) seropositivity was 33% (eight patients), and 88% of
the patients (21 patients) tested positive for hepatitis C virus (HCV). One female was a human immunodeficiency
virus (HIV) carrier. Previously, 24% of them had recorded infection in their medical files due to drug abuse. One male
was on medication for cardiac insufficiency and arrhythmia. One patient was queuing for the maintenance treatment
for opiate addiction. Twelve out of 24 patients were on maintenance treatment: six of them on methadone and the
other six on buprenorphine. Mental health diagnoses were reported in eight patients.
The crushed tablets were dissolved in water, usually tap water which was sometimes boiled. There was only one record on using filters before administration of the drug.
Majority of the patients (n=19) injected crushed tablets in the non-dominant upper extremity. Five patients were
treated due to a second similar incidence on an average of 1 year 5 months (range: 1 monthe3 years 2 months) after
the first incidence. Buprenorphine was the most commonly used drug in 10 of
the 24 patients, and benzodiazepine derivatives were also used in 11 of the 24 patients. Two IDUs had concomitant
injection of other psychotropics in addition to buprenorphine. A combination of buprenorphine, dextroproxyphene
and heroin was observed in one case. There were 16 arterial injections (Table 2), 2 venous injections and 10 soft-tissue
injections (Table 1). The injection time was reported in 67% of the cases. The time between injection and presentation
to the Emergency Department varied between 3 h and 10 days (mean: 62 h).
Patients who had injected crushed tablets were hospitalised mainly due to acute limb ischaemia (n=16) and
secondly due to infection (n=8). Many times, infection cooccurred with ischaemia. Septic symptoms, high temperature
and reduced general condition led to hospitalisation in seven patients. However, only two out of eight blood
cultures were positive (Streptococcus constellatus, Bacillus Cereus). Staphylococcus epidermidis (n=5), Staphylococcus
aureus (n=3), Streptococcus pyogenes (n=3) and Streptococcus anginosus (n=3) were the most common
pathogens cultured from the wound bed. Femoral osteomyelitis was the most serious infectious complication.
Embolectomy was performed in three cases in which the flow obstruction was shown by ultrasound or angiography.
In spite of the invasive procedures, these cases ended up in amputations and/or permanent disabilities such as functional
hand deficits (n=3), muscle weakness, rigidity (n=1) and numbness of the finger tips (n=1) or hyperaesthesia
(n=1). In one case, injection of crushed alprazolam to femoral artery caused the loss of the peroneal function and muscular necrosis in the anterior compartment (Fig. 1A-C). The IA injections led to severe problems: finger amputations (n=5), toe amputations (n=1), cubital exarticulation (n=1) and upper arm amputation (n=1).
Figure 1 (A) A typical clinical manifestation of micro-emboli found in the skin as purpuric lesions after injection of crushed
alprazolam in the femoral artery. (B) Cutaneous and muscle necrosis corresponding to the territory of the tibial anterior artery 14
days later. (C). The same leg 9 months later. A permanent peroneus cast/support was acquired. The patient could not continue his
work as a driver.
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Captain.Heroin
Bluelight Crew
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Thank you for the contributions, InvisibleEye! Those were some gruesome stories and photos! 
Traumadoll
Bluelighter
- Joined
- Nov 17, 2008
- Messages
- 79
Yeah- Keep 'em coming! These are SO fascinating and very eye-opening. That leg is tragic- be SAFE everyone!
Love,
TD
Love,
TD
This is an excellent, much needed thread; as previously stated, anecdotal "evidence" is one thing, empirical evidence is another and much harder to ignore. I also believe this is in the spirit of harm reduction; that is, I'm a strong advocate of harm reduction not simply b/c it "suits my needs," but b/c the empirical evidence backs it as the most viable approach. Needless to say, I'm not a fan of scare tactics (10 year follow ups on DARE found it not only to be an abysmal failure, but to have potentially increased usage among DARE "educated" vs. non-DARE participants! caveat: correlational not causal, but still ). Anyway, yes, they are gruesome pictures/stories, but in this context, and presented to this audience in particular, it is, as I said, in the spirit of harm reduction. As someone else already said, not to sound corny, but knowledge is power!
Reading about all of these amputations due to injecting in arteries/etc. also makes me want to give a great big hug to the BL community. I used to faint every time I had blood drawn, thus IV use was always something I just *knew* I wouldn't do. Yet, in my experience as well as I'm sure countless others, addiction and/or that incessant, never-ending search for a greater high (or at least the high we *first* got) can lead us to do things we swore we'd never do. I started with IM- prior to so doing, I found as much info on the internet as I could, including this site. I'm fortunate in that I never suffered any complications from IM injection. I then learned that, contrary to my intuition, *proper* IV use can actually be safer than IM due to the risk of abscesses, etc. and for that matter SC due to the risk of bacterial infections (Please, PLEASE correct me if this is misinformation, I certainly don't want to spread dangerous mistruths nor am I encouraging people to IV). Thus, I learned all I could about IV use, including using this site A LOT, and switched ROAs, at least as far as needle use was concerned.
(I realize this almost sounds bizarre, "Hey, thanks for turning me on to IV use! However, there's much stigma surrounding IV use and I feel as if I picked the lesser of two evils- hey, sounds like harm reduction! And on a side note, I'm fortunately not a regular needle user anymore, I was on Suboxone maintenance for six months, then off it for a mere 6 weeks b/f an IV coke spree (and downers are my DOC to boot!), and now have been back on it for the last 2 months- I've shoot midazolam once, but my life now is nothing like it was before So, thank you BlueLight for helping to keep me safe enough that I was not only able to live through my more reckless use, but do so with all my limbs).
). Anyway, yes, they are gruesome pictures/stories, but in this context, and presented to this audience in particular, it is, as I said, in the spirit of harm reduction. As someone else already said, not to sound corny, but knowledge is power!Reading about all of these amputations due to injecting in arteries/etc. also makes me want to give a great big hug to the BL community. I used to faint every time I had blood drawn, thus IV use was always something I just *knew* I wouldn't do. Yet, in my experience as well as I'm sure countless others, addiction and/or that incessant, never-ending search for a greater high (or at least the high we *first* got) can lead us to do things we swore we'd never do. I started with IM- prior to so doing, I found as much info on the internet as I could, including this site. I'm fortunate in that I never suffered any complications from IM injection. I then learned that, contrary to my intuition, *proper* IV use can actually be safer than IM due to the risk of abscesses, etc. and for that matter SC due to the risk of bacterial infections (Please, PLEASE correct me if this is misinformation, I certainly don't want to spread dangerous mistruths nor am I encouraging people to IV). Thus, I learned all I could about IV use, including using this site A LOT, and switched ROAs, at least as far as needle use was concerned.
(I realize this almost sounds bizarre, "Hey, thanks for turning me on to IV use! However, there's much stigma surrounding IV use and I feel as if I picked the lesser of two evils- hey, sounds like harm reduction! And on a side note, I'm fortunately not a regular needle user anymore, I was on Suboxone maintenance for six months, then off it for a mere 6 weeks b/f an IV coke spree (and downers are my DOC to boot!), and now have been back on it for the last 2 months- I've shoot midazolam once, but my life now is nothing like it was before
So, thank you BlueLight for helping to keep me safe enough that I was not only able to live through my more reckless use, but do so with all my limbs).
Captain.Heroin
Bluelight Crew
- Joined
- Nov 3, 2008
- Messages
- 94,868
Unless you have something that's meant for IM/SC use (or, possibly even in this scenario), IV is really the best. There's some drugs you have to IM (not that would be preferable to IM, like ketamine, but that you have to, like most steroids.) IVing is much safer than intra muscular or subcutaneous injection.
InvisibleEye
Bluelighter
- Joined
- Jan 18, 2010
- Messages
- 734
A fatal case of pontine hemorrhage related to methamphetamine abuse
Tomoko Miyashitaa, et al. Department of Forensic Medicine, Wakayama Medical University, Japan
1. Introduction
The sympathomimetic effects of methamphetamine include an elevation of pulse rate and blood pressure, increased alertness, decreased fatigue, and suppression of appetite. Methamphetamine abuse causes hyperthermia, arrhythmia and fugitive hypertension, occasionally resulting in a fatal outcome. In particular, several previous reports stated that methamphetamine abuse increased the risk of cerebral vascular accidents such as hemorrhagic or ischemic stroke, and subarachnoid hemorrhage even in young persons aged less than 20 years. In this report, we describe a fatal case of pontine hemorrhage, presumably due to intravenous self-administration of methamphetamine.
2. Case profile
A 54-year-old male visited his parents’ house at 11:00 PM. At that time, he was nauseous with mild numbness of the extremities, but went to sleep without any medication. Next day, at 4:25 PM, his mother tried to wake him but he did not reply, and she found his body in a prone position. According to the police investigation, no criminal activity was identified. Thus, a forensic autopsy was performed to clarify the cause of his death at our department.
3. Autopsy findings
The deceased was 162cm tall and weighed 51kg. Postmortem rigidity remained slightly in the joints of the jaw, neck and fingers, and moderately in the other joints. Livor mortis, dark red in color, was found on the back and the upper part of the chest. When pressed, it did not disappear. Dark green putrefactive discoloration was slightly observed on the abdomen. Although the face was moderately congested, there were no apparent petechial hemorrhages in the palpebral conjunctivae. The diameter of both pupils was 6mm. An injection mark-like injury with subcutaneous hemorrhage was observed in the left cubital fossa. However, there were no severe injuries leading to death. Internally, there was 10ml of light red fluid in the pericardiac cavity, and intracardiac blood with no soft hemocoagula was dark-red in color (250ml). The heart weighed 390g, showing moderate cardiomegaly, and myocardial fibrosis could be faintly observed at the anterior wall of the left ventricle. However, there were no pathological changes leading him to the death. The left and right lungs were edematous and weighed 550 and 580g, respectively. The brain, weighing 1330g, was remarkably edematous. In sections of the brain, the center of the pons was almost filled with hematoma (Fig. 1). The stomach contained 40ml of reddish brown viscous fluid. The bladder contained 280ml of slightly yellowish urine. The other organs showed no remarkable pathological findings.
Histopathologically, necrotizing angiitis, characterized by fibrinoid necrosis of the intima and media with cell infiltration, was observed in many arteries of the pons and cerebrum. Necrotic lesions showed the absence of nuclei, atrophy with increased eosinophilic smooth muscle, and decreased medial thickness (Fig. 2). In consistent with macroscopic view of the heart, cardiomyocytes seemed to be slightly hypertrophic. Moreover, fibrotic changes could be confirmed on the anterior wall of the left ventricle, and moderate stenosis was also recognized in the left anterior descending coronary artery. However, no histopathological changes indicating fresh myocardial infarction could be detected.
Fig. 1. Macroscopic view of the pontine hemorrhages. In sections of the pons, the central portion is almost totally occupied by massive hematoma.
Fig. 2. Histopathological view of the pons. Necrotizing angiitis characterized by fibrinoid necrosis of the intima and media is observed with cell infiltration.
Tomoko Miyashitaa, et al. Department of Forensic Medicine, Wakayama Medical University, Japan
1. Introduction
The sympathomimetic effects of methamphetamine include an elevation of pulse rate and blood pressure, increased alertness, decreased fatigue, and suppression of appetite. Methamphetamine abuse causes hyperthermia, arrhythmia and fugitive hypertension, occasionally resulting in a fatal outcome. In particular, several previous reports stated that methamphetamine abuse increased the risk of cerebral vascular accidents such as hemorrhagic or ischemic stroke, and subarachnoid hemorrhage even in young persons aged less than 20 years. In this report, we describe a fatal case of pontine hemorrhage, presumably due to intravenous self-administration of methamphetamine.
2. Case profile
A 54-year-old male visited his parents’ house at 11:00 PM. At that time, he was nauseous with mild numbness of the extremities, but went to sleep without any medication. Next day, at 4:25 PM, his mother tried to wake him but he did not reply, and she found his body in a prone position. According to the police investigation, no criminal activity was identified. Thus, a forensic autopsy was performed to clarify the cause of his death at our department.
3. Autopsy findings
The deceased was 162cm tall and weighed 51kg. Postmortem rigidity remained slightly in the joints of the jaw, neck and fingers, and moderately in the other joints. Livor mortis, dark red in color, was found on the back and the upper part of the chest. When pressed, it did not disappear. Dark green putrefactive discoloration was slightly observed on the abdomen. Although the face was moderately congested, there were no apparent petechial hemorrhages in the palpebral conjunctivae. The diameter of both pupils was 6mm. An injection mark-like injury with subcutaneous hemorrhage was observed in the left cubital fossa. However, there were no severe injuries leading to death. Internally, there was 10ml of light red fluid in the pericardiac cavity, and intracardiac blood with no soft hemocoagula was dark-red in color (250ml). The heart weighed 390g, showing moderate cardiomegaly, and myocardial fibrosis could be faintly observed at the anterior wall of the left ventricle. However, there were no pathological changes leading him to the death. The left and right lungs were edematous and weighed 550 and 580g, respectively. The brain, weighing 1330g, was remarkably edematous. In sections of the brain, the center of the pons was almost filled with hematoma (Fig. 1). The stomach contained 40ml of reddish brown viscous fluid. The bladder contained 280ml of slightly yellowish urine. The other organs showed no remarkable pathological findings.
Histopathologically, necrotizing angiitis, characterized by fibrinoid necrosis of the intima and media with cell infiltration, was observed in many arteries of the pons and cerebrum. Necrotic lesions showed the absence of nuclei, atrophy with increased eosinophilic smooth muscle, and decreased medial thickness (Fig. 2). In consistent with macroscopic view of the heart, cardiomyocytes seemed to be slightly hypertrophic. Moreover, fibrotic changes could be confirmed on the anterior wall of the left ventricle, and moderate stenosis was also recognized in the left anterior descending coronary artery. However, no histopathological changes indicating fresh myocardial infarction could be detected.
Fig. 1. Macroscopic view of the pontine hemorrhages. In sections of the pons, the central portion is almost totally occupied by massive hematoma.
Fig. 2. Histopathological view of the pons. Necrotizing angiitis characterized by fibrinoid necrosis of the intima and media is observed with cell infiltration.
Attachments
i use to shoot up like every last drop of powder in the spoon from grinding an 80 before i found out the binders and fillers were bad.... ive been having bad stomache pain could my IV pill use for 2 years daily have anything to do with it? how harmful exatcly are binders and fillers in the bloodstream? and how much safer if any at all, is heroin?
i live in the US and the amount of privatized prisons innocent nonviolent drug users in prison is the thing that i hate most...however i do agree that what u mention is still a problem and the reason the US does this is because they dont want any country partaking in a market that is illegal here because then the US would LOOSE MONEY right now wallstreet is benefiting off of the drug war and companies like nyquil and ATF (ATF actually FUNDS ENTIRELY the "my anti drug"; anti drug infomercials and these companies fund lobbyists as well...money runs my government not morals
Captain.Heroin
Bluelight Crew
- Joined
- Nov 3, 2008
- Messages
- 94,868
LOL
I don't mean to think you're ignorant at all...but do you think the Surgeon's General Warning helped deter people from smoking cigarettes?
This kind of shit makes people trigger happier than ever IMO.
Maybe some of you all look at this thread and think "that's why I have yet to, and will never, shoot up" - and that's good for you all for sure.
But I know this kind of shit makes people more likely to try things - a lot of people like things because they're "dangerous" if you will.
Stomach pain can be from a lot of things. However what's happened is talc gets into your lungs this way. You aren't complaining about shortness of breath or anything like that, so I would think you are OK for now. If your stomach pain gets worse I would go see a doctor.
Heroin is a lot safer (typically but not always), mostly due to the fact that whatever cut is in there, it may not be bad for you. Heroin is often cut with the thought in mind that it will be injected, so often dealers will put "safer" cuts in dope, instead of potentially harmful shit in their dope. Plus heroin often gets to be more pure than 33% which is roughly how pure an OC is.