Intravenous Drug Abuse
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.[6,7,8,9] The drug, usually in the form of a powder, may contain soil, dust and pathogens introduced during manufacturing or storage.[6,7,8,9,10]
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.[4,5,6,7,8,9,10,11,12,13] The ritual surrounding the injection may include the use of unsterile supplies, the sharing of equipment and lack of skin antisepsis.[6,7,8,9,10,11,12,13,14,15,16,17] 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]
The British Journal of Dermatology. 2004;150(1) © 2004 Blackwell Publishing
Cite this: Cutaneous Complications of Intravenous Drug Abuse - Medscape - Jan 01, 2004.
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