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HR ⫸CASE STUDIES - It could happen to YOU!⫷

djsim

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I'm going to start posting these "case studies" so everyone can see that what BL preaches is not urban myth. So if it drives the message home even thru heurism availability then it's still serving it's purpose.

I'll start with this one, then will consolidate everything into a sticky sometime in the future.
 
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djsim

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Case Studies

Necrotising myositis after intravenous methylphenidat (Ritalin) injection

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

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'medicine cabinet'

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Wow a softball sized abcess, that thing had to of hurt like crazy
 

Tchort

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Excellent idea. I can think of two examples, if you don't mind me adding them to your thread :)
From the Center For Disease Control (CDC):

Wound Botulism Among Black Tar Heroin Users --- Washington, 2003

During August 22--26, 2003, four injection-drug users (IDUs) in Yakima County, Washington, sought medical care at the same hospital with complaints of several days of weakness, drooping eyelids, blurred vision, and difficulty speaking and swallowing. All four were regular, nonintravenous injectors of black tar heroin (BTH), and one also snorted BTH. This report summarizes the investigation of these cases, which implicated wound botulism (WB) as the cause of illness.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5237a3.htm

New England Journal Of Medicine:

Aluminum Toxicity Due to Intravenous Injection of Boiled Methadone [Methadone syrup / oral concentrate / take home doses-T]

A 42-year-old man who was in rehabilitation for intravenous substance abuse presented with a three-month history of seizures and incoordination. Other symptoms included dysarthria, a hesitant pattern of speech, myoclonic jerks, postural tremor, emotional lability, and fluctuating short-term memory. On questioning he admitted that for four years he had been concentrating his methadone preparation, which was diluted with a grape-flavored drink, by heating it in an uncoated aluminum pot. He would then reconstitute the residue for intravenous injection. His serum aluminum level was 6650 nmol per liter (reference interval, <400).
http://content.nejm.org/cgi/content/short/354/11/1210
 

monstanoodle

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Very, very good thread idea. I'm still pretty certain that a great deal of people will continue to ask such questions and will still get answers that stem from the "I know a bloke who___ so it's fine". =D
 

Cane2theLeft

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Very, very good thread idea. I'm still pretty certain that a great deal of people will continue to ask such questions and will still get answers that stem from the "I know a bloke who___ so it's fine". =D
I see this all the time and I can't believe people but I guess they rationalize what they want to be doing. I think its so ridiculous but at least we have people here calling them out.
 

Kaelfi

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Thank you for this thread. It makes me re-think a few things I was contemplating. Getting high is one thing, destroying your body is another!

Thanks again, hope to see more (wake-up calls for me) in the future.
 

djsim

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Great thread djsim. Am I to understand this is from professional expirience?
I'm just posting some relevant journal articles at the moment. I could share some of my experiences -- like the junky who robbed the pharmacy and was found dead later in the day with 5+ durogesics on his arm -- but at the end of the day it's just another 2nd hand experience which people can easily dismiss as being irrelevant. It's harder to do so when the facts (and more importanly the pictures in this case) are staring you in the face. Any addict can see truths in some of these studies, and it should be made easily accessable to everyone, not just those with the initiative to finds journal article etc
I'll add some more when my exams are done
 

djsim

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Severe Upper Limb Complications from Parenteral Abuse of Subutex®

Case 1
A 55-year-old male presented with a large thenar abscess. His entire thenar eminence was intensely swollen, extremely tender, red and warm. There were 3 other indurated subcutaneous swellings on his forearm along the line of his cephalic vein (Fig. 1). During surgical debridement, a large, multiloculated abscess was found within the thenar muscles, which were gangrenous and required complete excision. Cultures grew Staphylococcus aureus, and he was treated with intravenous cloxacillin followed by oral augmentin. He initially denied, but later admitted to being a chronic intravenous drug abuser, and having injected Subutex® into his left thenar eminence. As all his thenar muscles were excised, he has lost palmar abduction and opposition of the thumb, impairing his ability to pinch and grasp. He declined further reconstructive surgery.

Case 2
A 48-year-old male on an opiate cessation programme injected Subutex® twice into his radial artery at the right wrist. He presented 12 hours later with an intensely swollen, ischaemic hand (Fig. 2). There were injection marks at the right wrist overlying the radial artery. The radial pulse was palpable proximal to the wrist crease but not beyond. The ulnar pulse was palpable, but Allen’s test showed markedly delayed capillary refill from both radial and ulnar arteries. He was treated with intravenous dextran, oral pentoxifylline, nifedipine and aspirin. An axillary brachial plexus block with marcain was given for vasodilation and pain relief. The thenar and first dorsal interosseous muscle compartments were decompressed with fasciotomies. The colour and capillary return of the hand initially improved over 3 days and he was discharged on oral medications. However, his thumb, index, middle and ring fingers gradually turned gangrenous over the next month (Fig. 3). These were amputated once the gangrene had fully demarcated – the fingers at the proximal interphalangeal joint and the thumb at the interphalangeal joint.

Case 3
A 23-year-old male presented initially with severe unilateral left upper limb oedema with no history of trauma. he was treated with warfarin. He presented 2 months later with ischaemia distal to the mid-forearm and dry gangrene of all the digits of the left hand (Fig. 4). He admitted to having injected a Subutex® solution into his brachial artery because he could not find a vein. He initially refused amputation and absconded, but presented again 3 months later with sepsis and wet gangrene of the digits. All digits on his left hand were amputated at the level of the proximal phalanx. Following this, he again injected Subutex® into his left brachial artery, resulting in worsening ischaemia from the level of the mid-forearm distally. He was given intravenous iloprostol and prophylactic antibiotics, but his forearm turned gangrenous, requiring a below-elbow amputation.

Case 4
A 22-year-old male with a history of intravenous heroin abuse presented a month after attempting to inject dissolved Subutex® into a volar vein in his left wrist. He had burning pain, paraesthesia and numbness of the thumb, index and middle fingers. He later developed paralysis of the thenar muscles. Examination showed a complete loss of sensation of the thumb, index and middle fingers and severe atrophy of the thenar muscles. Nerve conduction studies and electromyography showed denervation of the thenar muscles and no conduction across the median nerve at the wrist and carpal tunnel. He had not recovered sensation or thenar motor function after 2 months. Surgical exploration revealed scarring of the median nerve proximal to the carpal tunnel. One month after undergoing microsurgical neurolysis, he continues to have neuralgic pain, numbness and thenar weakness.

Discussion (abridged):
  • Upper limb complications from parenteral abuse of intravenous or oral formulations of drugs such as heroin, benzodiazepines and methadone are well documented in the literature. These consist of infections of varying severity,7 vascular complications including superficial thrombophlebitis, deep venous thrombosis and critical limb ischaemia8 and compartment syndrome.9 In previously reported series, patients tended to be chronic intravenous drug abusers, usually in their 20s to 30s. In this series, patients were also chronic intravenous drug abusers, but on average were older, with 2 patients above 45 years old.
  • Limb ischaemia occurs when a large artery is injected, either deliberately or inadvertently. The drug itself or other constituents of the tablet causes inflammation, severe vasospasm, and thrombosis. Incompletely dissolved constituents form micro-emboli, which lodge in the microcirculation, causing widespread scattered end-organ ischaemia. Venospasm and venous thrombosis result in outflow obstruction and acute compartment syndrome.9 Intermittent decrease in the arterial vasospasm and opening of collateral vessels may result in reperfusion injury, which can also cause significant swelling and compartment syndrome. Treatment with antiplatelet agents, vasodilators, anticoagulation, corticosteroids, intravenous dextran-40,8 intravenous iloprost (a prostaglandin analog),10,11 thrombolysis,12,13 thrombectomy, and hyperbaric oxygen therapy14 have all been tried. A fasciotomy may be required to relieve compartment pressure. There is a high failure rate of about 25% in one large series.8 However, numerous individual case reports or small case series have documented successful revascularisation with more aggressive methods including thrombolysis and thrombectomy.10-13 Reasons for failure may include delayed presentation and widespread damage to the microcirculation from micro-emboli. In the absence of infection, amputation should be delayed until the level of dry gangrene is fully demarcated. Onset of infection (wet gangrene) requires immediate amputation to a level above the infection.
  • Inadvertent damage to the median nerve is a rare complication of parenteral drug abuse that has not been previously reported. This may be due to direct trauma or extravasation of the injected solution. Varying degrees of nerve injury ranging from temporary neuropraxia to fibrosis or destruction of nerve fibres may potentially occur. In the case described, there was total loss of nerve function due to perineurial and intraneurial scarring. This was probably caused by an inflammatory reaction to Subutex® injected around and into the nerve. In the absence of recovery on close follow-up with serial clinical examination and neurophysiological studies, surgical exploration and neurolysis may be required, as in the case described. Reconstruction with nerve grafts may be required if there is no recovery following neurolysis, or in the presence of more severe nerve injury.
 

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djsim

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IV Buprenorphine

Subutex® abuse presenting to the emergency department: a case series
Chew, HC Hong Kong j. emerg. med. Vol. 14(3) Jul 2007

A case series of four patients who presented to the emergency department following complications of Subutex? abuse. Local complications included deep venous thrombosis, limb ischaemia, and abscess over injection sites. Systemic complications involved epidural abscess and osteomyelitis of the spine.

Patient 1
A 30-year-old Malay female presented in February 2006 with sudden onset of left lower limb swelling with pain and fever (Figure 1). Clinically, she had evidence of deep venous thrombosis which was confirmed on duplex ultrasonography. She admitted injecting Subutex? into her left femoral vein. She was commenced on anticoagulation but subsequently she defaulted follow-up.

Patient 2
A 35-year-old Chinese male developed left hand pain and numbness after injecting his radial artery with Subutex? in May 2006. Clinically, he had developed left hand ischaemia with absent pulses up to the brachial artery (Figures 2 & 3). Duplex ultrasonography confirmed acute thrombosis of the brachial artery. He underwent successful thrombolysis but subsequently discharged himself against medical advice and defaulted follow-up.

Patient 3
A 40-year-old Malay male presented in May 2006 with complaints of fever and lower back pain. He initially denied any intravenous drug use but needle marks were seen over both his arms. Clinically he had a positive straight leg raising test. No neurological deficit was detected. He was admitted for a presumed diagnosis of epidural abscess which was confirmed on magnetic resonance imaging (MRI) of the spine (Figure 4). This was surgically drained and the patient was treated with a prolonged course of intravenous antibiotics.

Patient 4
A 60-year-old Indian male complained of multiple painful skin lesions over both arms and legs in June 2006 (Figures 5a & 5b). Clinically, he had multiple abscesses over the upper limbs and popliteal fossa with needle marks over the areas. He was admitted for incision and drainage of these abscesses but he discharged himself against medical advice the following day.

Discussion (abridged):

...common features of cellulitis, non-healing wounds as well as vascular complications. These are proposed to be a result of the excipients in the preparation of Subutex?, which is meant to be administered sublingually, causing chemical irritation to the vessel wall resulting in poor healing and increased infective and thrombosis rates. The effect of Subutex on the vessel wall has not been studied but the excipients which act as binders to buprenorphine are likely to precipitate local inflammation causing thrombosis or intimal weakening, leading to either vessel occlusion or pseudoaneurysm formation after several injections. This effect can be aggravated by hot or warm injections as a result of the preparation methods as well as inadequate sterility techniques of injection. Local infections result from the use of contaminated preparations and needles. Common bacteria involved are skin organisms such as Staphylococcus and Streptococcus. These infections present in a myriad of ways from simple cellulitis to necrotising fasciitis, which can be life threatening. Delayed presentation may result in increased severity of the infection.7-12 Treatment of such infections usually requires extensive debridement and may result in loss of tissues and poor functional outcome. Complex reconstructive procedures may be required to restore function, and amputation is occasionally required to control the infection. Limb ischaemia or venous thrombosis occurs when a large vessel is injected, either deliberately or inadvertently. The drug itself or other constituents of the tablet cause inflammation, vasospasm and thrombosis. Incompletely dissolved constituents form micro-emboli, which lodge in the microcirculation, causing widespread end-organ ischaemia. Venospasm and venous thrombosis result in outflow obstruction and may cause the acute compartment syndrome. Intermittent decrease in the arterial vasospasm and opening of collateral vessels can precipitate a reperfusion injury, which translates to significant swelling and compartment syndrome. Treatments with antiplatelet drugs, vasodilators, anticoagulation, corticosteroids, thrombolysis, thrombectomy and hyperbaric oxygen therapy have all been tried. Fasciotomy may be required to relieve compartmental pressure. Failure to salvage limbs is frequently attributed to delayed presentation for fear of prosecution and widespread damage to the microcirculation from micro-emboli.7,8 Pulmonary complications of injection drug abuse include pulmonary infections, interstitial pneumonia, pulmonary vascular diseases, septic embolisation and pneumothorax, among others.

Epidural abscess of the spine threatens the spinal cord by both physical compression as well as vascular infarction of the spinal cord. Complications such as motor dysfunction and sensory problems or even paralysis may occur if this is left untreated. The diagnosis is frequently delayed as the initial presentation may be back pain alone or radicular symptoms. The clinical triad of fever, back pain and neurologic deficit is not present in most patients. Early presentations are usually subtle and atypical presentations are not unusual. Intravenous drug abusers belong to a high risk group and hence this medical emergency, which may require urgent surgical decompression and drainage of the abscess as well as intravenous antibiotics, must be suspected in such patients when they present with fever and back pain.


Figure 1. Left lower limb swelling extending to upper thigh caused by deep venous thrombosis of the femoral vein.

Figure 2. Needle marks as a result of intravenous drug use.

Figure 3. Left hand digital ischemia from brachial artery thrombosis following accidental intraarterial injection.

Figure 4. MRI spine showing osteomyelitis of the lumbar spine with epidural abscess over the L5-S1 region.

Figure 5. Abscess formation seen over the skin of both right and left biceps region following injection with contaminated needles.
 

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Artificial Emotion

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I used to inject the 10mg/ml concentrated methadose solution IM. Is the main danger caused by aluminium contamination over the long term?
 

Captain.Heroin

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Life has no meaning, yet I keep searching...
I used to inject the 10mg/ml concentrated methadose solution IM. Is the main danger caused by aluminium contamination over the long term?
If you're using the exact same method as the person in the case study, then it would be one of the main dangers.
 

Artificial Emotion

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What if you use stainless steel pots to reduce it down? What then would be the main risks? I can't find any ingredient that is particularly badly suited to IV injection in small quantities.
 

Tchort

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What if you use stainless steel pots to reduce it down? What then would be the main risks? I can't find any ingredient that is particularly badly suited to IV injection in small quantities.
A stainless steel pot doesn't have aluminum. . .

Methadose concentrated oral solution (10mg/ml) is not fit for injection.

Other ingredients of Methadose Oral Concentrate: Artificial cherry flavor, citric acid anhydrous
USP, FD&C Red No 40, D&C Red No 33, methylparaben NF, polaxamer 407 NF, propylene
glycol USP, propylparaben NF, purified water USP, sodium citrate dihydrate USP, sucrose NF.
The above ingredients are what constitute the red, cherry liquid syrup used at most American MMT clinics. I cringe when thinking about an IV injection of that shit. I've listed in other threads what each of the ingredients in most injected oral concentrates do when IV'd, so I won't do so again here. No, it is not even relatively safe to IV Methadose oral concentrate in small amounts, ever.

This article covors the basics well. Though it is specifically describing the Methadone syrup available in Austrailia, some of the same ingredients apply, as do the warnings.

INJECTING METHADONE
We can’t stress enough that methadone was made to be taken orally, never injected. It’s not sterile, it has some seriously nasty ingredients for veins and organs, you might end up hanging out, and many users don’t get a rush anyway. This guide is only for those who insist on injecting their methadone, to make sure they can reduce the many risks involved.

Possible health problems
Methadone syrup was never designed for injection. Each millilitre contains 5 mg of methadone hydrochloride, sodium benzoate, ethanol, sorbitol solution, glycerol, caramel and finally, flavour pharmaceutical 503.978/A. These can have the following effects when injected:

Methadone hydrochloride: respiratory depression
Sodium benzoate: Hypersensitivity and allergic reactions. Respiratory reactions have occurred in people susceptible to aspirin-induced asthma.
Ethanol: Central nervous system depression, which can lead to stopping breathing and coma
Sorbitol solution: effects can be similar to a ‘dirty hit’: facial flushing, abdominal pain, nausea, vomiting and sweating. High levels may lead to kidney failure or kidney stones.
Glycerol, caramel and flavour pharmaceutical 503.978/A:
effects unknown.

Some of these ingredients can cause allergic reactions, respiratory reactions, and damage your heart, kidney, veins and liver if injected. Talk to your NSP workers or methadone prescriber about the differences between pure methadone and methadone with additives.

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.
Methadone is not a sterile fluid so blood diseases can arise from injection. A large volume of injected fluid can also cause vein damage, especially if injected quickly. Always go slow and steady.

Injecting methadone will lessen the amount of time it will stay in the body, so withdrawal symptoms will usually come on earlier than usual. Some users state there is no rush from injecting methadone anyway and it is just a needle fixation. In any case, weigh up the high risks of injection carefully against the perceived benefit.
http://www.saferinjecting.net/injecting-methadone.htm
 
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