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

[Captain.Heroin]

Five months later he attended the emergency department with a temperature and low back pain. A diagnosis of psoas abscess was made and he was admitted to the acute medical ward. He absconded from the ward before being seen. The blood cultures that had been taken in the emergency department once again grew S aureus. Attempts made to contact the patient failed as he had lost touch with his family, his phone had been disconnected, and he was no longer registered with a general practitioner. It is interesting to note that the card from this attendance was missing from his emergency department notes, and the blood culture report was filed in the hospital notes only. This information was therefore not available to emergency department staff when he next attended.

Damn...what a retard.

Why would you seek medical attention only to disappear? Probably got a call from his dealer. 8)

DISCUSSION (ABRIDGED):

Pyomyositis presents in three stages. Initially there is myositis and muscle oedema but no abscess formation. The patient presents with muscle pain and low grade fever. At this stage the condition may be cured by appropriate antibiotic therapy, but it is difficult to diagnose because of non-specific signs and symptoms.5 The most common stage at presentation is stage two, characterised by abscess formation, muscle pain, fever, tenderness, and leucocytosis. This picture is complicated in stage three disease by systemic toxicity. Treatment in the latter stages requires surgical drainage as well as appropriate antibiotics.

Can I get the unabridged version of the discussion on pyomyositis? I'm actually kind of interested now that you got me reading.

 

[TheDankaholic]

Damn...what a retard.

Why would you seek medical attention only to disappear? Probably got a call from his dealer. 8)

From a RN who works the emergency room, I bet I can tell you what happened. He came in complaining about the abdominal pain, back pain yada yada. Crying in pain which apparently was real. Got a shot of Dilaudid (Hydromorphone) or Morphine & left the hospital shortly after. A VERY VERY common thing to happen in the ER at the hospital. I see people go missing all the time after getting pain shots. That's why people who REALLY need them have a hard time getting them because people like that make you skeptical of everyone. It really sucks that it has to be that way but it is. You start seeing people think ANYONE in pain in the ER is just there for there dope fix to cure there withdrawals or just because they want some of that good Doctor Dope.

 

[kasad]

Come on guys, make this one a sticky already.

 

[Artificial Emotion]

I was just reading one of the case studies where an OD of fentanyl was taken and hypoxia was causing problems. If you're in one of those situations where you're on your own (if you don't know anyone that can look after you) and you know there could be an increased possibility of overdosing (e.g. when trying fentanyl for the first time etc.), could you reduce the negative consequences of respiratory depression e.g. hypoxia by using one of those small portable oxygen tanks with an oxygen mask that is held on to the face so that if you are lying down and OD you might survive?

Also, I heard of a drug called EPO that stimulates the body into producing red blood cells which might help prevent hypoxia. Could this help or is it a stupid idea?

 

[Artificial Emotion]

From a RN who works the emergency room, I bet I can tell you what happened. He came in complaining about the abdominal pain, back pain yada yada. Crying in pain which apparently was real. Got a shot of Dilaudid (Hydromorphone) or Morphine & left the hospital shortly after. A VERY VERY common thing to happen in the ER at the hospital. I see people go missing all the time after getting pain shots. That's why people who REALLY need them have a hard time getting them because people like that make you skeptical of everyone. It really sucks that it has to be that way but it is. You start seeing people think ANYONE in pain in the ER is just there for there dope fix to cure there withdrawals or just because they want some of that good Doctor Dope.

When I was studying pharmacy (which I didn't get to complete unforunately) my lecturer who was a doctor of medicine told me that his tendency to give people the benefit of the doubt (including addicts who he readily treated with large tolerance-beating doses of opioids) was extremely rare. He told me about his colleagues who were good people but felt morally justified in leaving people who might be telling the truth in agonizing pain just to make it more difficult for addicts and to prevent people from getting high courtesy of the NHS.

 

[djsim]

I was just reading one of the case studies where an OD of fentanyl was taken and hypoxia was causing problems. If you're in one of those situations where you're on your own (if you don't know anyone that can look after you) and you know there could be an increased possibility of overdosing (e.g. when trying fentanyl for the first time etc.), could you reduce the negative consequences of respiratory depression e.g. hypoxia by using one of those small portable oxygen tanks with an oxygen mask that is held on to the face so that if you are lying down and OD you might survive?

Also, I heard of a drug called EPO that stimulates the body into producing red blood cells which might help prevent hypoxia. Could this help or is it a stupid idea?

EPO; no.
Oxygen; maybe, but it's still not going to work as you want. Opiate ODs usually require intubation, which is a tube down the throat. But worse ODs (like the doses given with anesthesia for example), you need mechanical ventilation. The mask won't help b/c it doesn't breathe for you, so even if you had 100% O2 (which would kill you), if you're not breathing fast enough it's not going to matter. All you can do is to use with someone else so they can get medical help. You can't do this on your own.
Lesson from this should be never IV/smoke fentanyl patches. I usually don't see the point in making abuse-"proof" meds, but the change to gel-less fentanyl patches has done a lot more good than anyone will know. Everyone who complains about have the Mylan patches may have averted an OD

 

[Tchort]

EPO; no.
Oxygen; maybe, but it's still not going to work as you want. Opiate ODs usually require intubation, which is a tube down the throat. But worse ODs (like the doses given with anesthesia for example), you need mechanical ventilation. The mask won't help b/c it doesn't breathe for you, so even if you had 100% O2 (which would kill you), if you're not breathing fast enough it's not going to matter. All you can do is to use with someone else so they can get medical help. You can't do this on your own.
Lesson from this should be never IV/smoke fentanyl patches. I usually don't see the point in making abuse-"proof" meds, but the change to gel-less fentanyl patches has done a lot more good than anyone will know. Everyone who complains about have the Mylan patches may have averted an OD

The original Fentanyl patches with gel were such a fools errand on the part of Big Pharma. Unevenly spread active ingredient, heat sensitive (don't curl up with that electric blanket while wearing the Duragesic, you may keel over), and so easy to abuse!.

Honestly, what were they thinking? That no one was going to figure out how to get to the Fent? That no one was going to try?

I would love to see Solvets make a come back (tablets meant to be injected via cold shake: dropped in a syringe barrel and shaken to dissolve).

They won't make Solvets, but they are willing to put insanely high amounts of Fentanyl in an unsafe and unstable dosage form openly and stupidly easy to abuse.

 

[garuda]

Young people like me think they're invincible. Or I did until I crippled myself from an OD of pod tea. No more sport for me, EVER. My kidneys failed and I almost died. If you're going to do an opiate with a long half life, lie down on bed if you're on your own. That way if you pass out and are unconscious for many hours, the muscles in your legs won't break down and poison your kidneys and disable you for the rest of your life. Basic harm reduction tip.

Rhabdomyolysis? Why would pod tea have caused this? I can't see anyone nodding not reclining or resting somehow, did you somehow nod in a way that cut off the blood supply to your legs?

 

[Artificial Emotion]

Yes it was rhabdomyolysis. I lay down with my black on a solid floor. I was probably standing up and eventually fell over or something. I just know that I woke up on my back and had numb legs which I couldn't move. I had to crawl to the phone to call an ambulance.

 

[djsim]

Yes it was rhabdomyolysis. I lay down with my black on a solid floor. I was probably standing up and eventually fell over or something. I just know that I woke up on my back and had numb legs which I couldn't move. I had to crawl to the phone to call an ambulance.

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

They won't make Solvets, but they are willing to put insanely high amounts of Fentanyl in an unsafe and unstable dosage form openly and stupidly easy to abuse.

So true. 10mg of fentanyl (equivalent to ~2grams of morphine) in a pouch which is easier to open than a TV dinner... hmmm, wonder what will happen 8) I wonder how the fuck something with so much fentanyl got thru when at the same time junkies were dying from China White? Obviously the FDA knew how strong fent (and analogs) were, and more importantly, that people would inject it to get high. Incredibly stupid.
I haven't seen the gel patches for so long.... what kind of dimensions are we talking (for the biggest one)? ie how many mL of gel in the 100mcg/hr?

 

[djsim]

Intra-arterial self-injection of methadone tablets into the femoral artery
Paul Gramenz MD, David Roberts MD and Laura Schrag MD -- doi:10.1016/j.jemermed.2008.08.003

Case Report
A 34-year-old man presented to the Emergency Department (ED) minutes after he crushed 10 10-mg methadone tablets in cold water and accidentally injected the solution into his right femoral artery instead of the femoral vein. He experienced immediate pain, cyanosis, and numbness of his entire right leg. On arrival, the patient was alert and in marked distress. He had a sinus tachycardia with a rate in the 120s (beats/min), a blood pressure of 156/90 mm Hg, and an oxygen saturation of 100% on room air. The right leg was cool and severely mottled. He was able to plantar and dorsiflex the right ankle but refused to move his knee or hip secondary to pain. The dorsalis pedis pulse was palpable, but the posterior tibial artery was appreciable only by Doppler examination. He denied abdominal, chest, or back pain, and had no nausea, vomiting, fevers, or chills. Laboratory data on presentation included a hemoglobin of 12.6 g/dL, hematocrit of 39.9% white blood cells of 16.6 k/cmm, normal basic metabolic panel, and creatine kinase (CK) of 4208. The patient was given a 60-U/kg bolus of heparin and started on heparin at 12 U/kg/h, low molecular-weight (LMW) dextran, intravenous (i.v.) dexamethasone 0.1 mg/kg, sodium bicarbonate infusion, and i.v. hydromorphone for pain. An angiogram of the lower extremity revealed focal areas of narrowing, suggesting spasm and evidence of distal small-particle embolization. He was admitted to the intensive care unit, where oral nifedipine was added. His CK peaked at 166,000, but his renal function remained normal. Pedal pulses were maintained throughout his hospital stay, and motor and sensory function improved. On hospital day 6, he was discharged with patchy mottling throughout the lower extremity and a CK of 30,000 (Figure 1 and Figure 2). Discharge medications included nifedipine, Coumadin, enoxaparin (for a subtherapeutic international normalized ratio), and an analgesic, with instruction to follow-up with vascular surgery to evaluate the potential need for future amputation. Unfortunately, the patient never returned to clinic for follow-up and has not been seen since in the ED.

Figure 1. Photograph of the patient's leg on the day of discharge.

Figure 2. Photograph of the patient's foot on the day of discharge.

 

[Eight0Eight]

^ You can easily dilute down and fit a 100mcg gel patch in a 1ml pin.

BTW - thats the first time I've ever heard of somebody injecting in the fucking eyeball! That fucking insane.

I thought I had heard pretty much everything regarding IV heroin - but that takes the biscuit.

Surely he must have been mentally unstable?


* Edit - I've accidently shot Heroin into my Femoral artery - it really painful. My whole leg swelled up, especially my knee and it was difficult to walk. I thought I was going to pass out. Since then I've been especially careful to check the colour of the blood when I pull back, and not to be too hasty.

 

[Captain.Heroin]

Unfortunately, the patient never returned to clinic for follow-up and has not been seen since in the ED.

Figure 1. Photograph of the patient's leg on the day of discharge.

Figure 2. Photograph of the patient's foot on the day of discharge.

OMFG!!! Wow. That's all I have to say.

He was going to IV 100mg methadone? wow.

 

[Eight0Eight]

^100mg IV methadone isn't a great deal if you have a serious habit.

 

[memphiseve]

HOLY COW! (this whole thread)

in some cases, methadone is mixed with cordial or fruit juice. Injecting this after it has been in someone’s mouth also means there will be plenty of harmful bacteria entering your bloodstream.

o_o why???

 

[Captain.Heroin]

HOLY COW! (this whole thread)


o_o why???

I think they put that quote in there because there are people who will put a pill in their mouth to spit it out later and try to divert it...totally not safe once it's touched the inside of your mouth.

 

[memphiseve]

TY CapnH.

*gives me the willies*

 

[BadHabbit]

oh man... people are nuts...

 

[djsim]

Right ventricular needle embolus in an injecting drug user: the need for early removal
D L Ngaage,M E Cowen- Emerg Med J 2001;18:500–501

Case report
A 22 year old female injecting drug user was admitted for bilateral VATS decortication. She had staphylococcal pneumonia three months before admission and subsequently, developed bilateral empyema. Two years previously, she fractured two injection needles in her left groin and concealed it. This was complicated by recurrent left groin infections and a deep vein thrombosis (DVT) in the left leg. Six months afterwards, she developed a blood culture positive staphyloccocal endocarditis. Her chest radiograph (fig 1) and transthoracic echocardiography demonstrated a needle lying free in the right ventricle (RV) seeded with vegetations. She refused transvenous removal of the needle embolus, and in the next 18 months she had three episodes of bacterial endocarditis. She is hepatitis C positive, a heavy user of heroine and cocaine, and an ex-convict. She has been admitted and treated numerous times in the accident and emergency department for illicit drug overdose, and on two occasions for organic depression and attempted suicide with paracetamol overdose. On admission, she was dyspneic on minimal exertion with an oxygen saturation of 87%, PO2 of 8.4 Kpa and PCO2 of 6.3 Kpa on air. She was in respiratory distress but not feverish and haemodynamically stable. She had multiple scars at her wrist, antecubital fossa and both groins. A chest radiograph and computed tomography demonstrated a bilateral empyema, and a needle in the RV. Transthoracic and transoesophageal echocardiography showed the needle to be completely embedded in the wall of the RV and not suitable for transvenous retrieval. She refused surgical removal of the needle embolus. The bilateral empyema was treated by VATS drainage and decortication, and she was discharged six days after surgery.

Discussion (abridged):
The retention of injection needles at the site of intravenous drug injection is an unusual occurrence not yet reported in injecting drug users. The repeated use of an injection needle and its manipulation to gain intravenous access at different sites can cause it to fracture.


Figure 1 A plain posteroanterior chest radiograph demonstrating the fractured injection needle in the right ventricle.
(Note, red circle added by me as it is very hard to see)

 

[BadHabbit]

The worst part is, she wouldn't let them remove it... That's going to be the death of this young woman... It's a fucking shame, drugs often times make us do things, that we know are not good for us... Her mind was probably on her next fix, and the fact that she wouldn't be able to get high for a few days, if she had the surgery... Sad, oh so sad, and 22 years old...
Ugh, Thank god for MMT...
Mat