Cutaneous Complications of Intravenous Drug Abuse

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 (Subutex^TM) 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