Drug Abuse 1

synthetic stimulant and hallucinogen with a chemical structure similar to methamphetamine. MDMA causes a reduction in the concentration of serotonin transporters (SERTs) within the brain2, and brain damage caused by heavy, prolonged use of MDMA may be long-lasting3. High doses can cause malignant hyperthermia, leading to rhabdomyolysis, renal failure and cardiovascular collapse. A staple at raves and PNP (“party and play”) parties because of the associated increase in energy and reduction of sexual inhibition, crystallized methamphetamine and MDMA have been associated with unprotected, promiscuous sexual activity and especially high risk of contracting sexually transmitted diseases. More recently, “bath salts” (e.g. “Ivory Wave”, “Cloud 9”, “Vanilla Sky”) that contain mephedrone, methylenedioxypyrovalerone (MDPV), or other cathinone or ampthetamine type stimulants have become popular and they can be injected, snorted, smoked or ingested orally.

BenzodiazepinesBenzodiazepines are among the most frequently prescribed medications in the US, as they are in the UK, where surveys indicate that approxi-mately 10% of the population take benzodiazepine sedatives regularly. Although they are only mild euphoriants, benzodiazepines are com-monly misused by polydrug addicts (especially temazepam and fluni-trazepam [Rohypnol®; “roofies”]), alcoholics and recreational drug users. Benzodiazepines are ingested (often with alcohol), snorted or, occasionally, injected. The most common side effects of benzodi-azepines are related to their sedating and muscle-relaxing properties, e.g. decreased alertness and concentration and lack of coordination, respectively. Other side effects include depression, disinhibition, blurred vision and confusion, and with intravenous use, hypotension and hypoventilation.

CannabisCannabis (“marijuana”, “pot”, “herb”, “weed”, “ganja”, “Mary Jane”) is the most frequently self-administered illicit drug. It is a mixture of dried shredded leaves and flowers of the Cannabis sativa plant, which con-tains the chemical delta-9-tetrahydrocannabinol (THC), and is usually smoked as a cigarette or through a pipe or bong. Marijuana cigarettes may be laced with other drugs, such as crack or heroin. The minimal amount of THC required to produce a perceptible psychoactive effect is ~10 mcg/kg body weight. A subjective change in perception may be accompanied by an impairment of concentration, psychomotor coordi-nation and/or short-term memory. Arteritis has also been reported4, and it may represent a particular form of Buerger’s disease, with can-nabis acting as a co-factor in young smokers. In a number of countries, there has been an increase in the use of synthetic cannabinoids (“Spice”).

CocaineCocaine (“coke”, “blow”, “toot”, “flake”, “snow”) is an alkaloid stimu-lant and topical anesthetic which is extracted from the leaves of the Erythroxylon coca shrub. Crack (“base”, “rock”, “hubba”, “gravel”), a freebase form of cocaine, is more addictive than heroin. It is produced by dissolving cocaine in water and baking soda and then heating the mixture until it crystallizes. Cocaine is injected or snorted, while crack is smoked.

In addition to Raynaud’s phenomenon, cocaine use has been associ-ated with small vessel vasculitis (leukocytoclastic vasculitis), necro-tizing granulomatous vasculitis, acute generalized exanthematous pustulosis, and Stevens-Johnson syndrome5,5a. Its use can also lead to a number of cardiovascular side effects – Buerger’s disease, hypertensive crisis, myocardial or cerebral infarction, and ventricular arrhythmias.

INTRODUCTIONAccording to the Diagnostic and Statistical Manual of Mental Disorders (DSM-4), drug abuse is a non-conforming pattern of drug practice in a manner that deviates from medically recommended or socially accepted standards. Repeated drug abuse can progress to drug addiction, the result of drug-induced central nervous system (CNS) changes that lead to maladaptive alterations in spontaneous behavior and in the behav-ioral response to subsequent exposures to the drug. Physical depend-ence is associated with drug addiction, which denotes a constellation of cognitive, behavioral and physiologic symptoms manifested by com-pulsive drug use, tolerance, and withdrawal symptoms upon discon-tinuation of a drug (Table 89.1).

Drug abuse is a global problem and is directly responsible for minor to life-threatening and fatal illnesses and injuries, as well as adverse sociologic consequences (loss of occupational productivity and higher rates of poverty, crime, prison occupancy, domestic violence, child abuse or neglect) which increase the risk of infirmity and disability. According to the Office of National Drug Control Policy, the overall economic cost of drug abuse to American society during 2007 was estimated to be $193 billion.

Illicit drug use may be suspected or diagnosed on the basis of cutane-ous findings. In fact, the skin is the tissue most evidently affected by intravenous drug addiction1. The wide spectrum of complications result from local or systemic effects (including toxic or allergic) of the drug itself, adulterants or infectious agents. Polydrug use, especially involv-ing the consumption of alcohol and drugs, is common among drug addicts1.

AmphetaminesAmphetamines were initially sold as a non-prescription appetite sup-pressant and rapidly became a favorite street drug (“pep pills”, “Bennies”). Crystallized methamphetamine (“ice”, “crystal”, “glass”, “tina”), an addictive stimulant with a high potential for abuse and dependence, produces an even stronger “rush” or “flash” when injected intravenously or inhaled. Oral ingestion of tablets (“speed”, “meth”, “chalk”) or snorting powder merely produces a profound sense of euphoria. Smoking the base form (“snot”) extends the duration of the “high” for up to 24 hours. Amphetamines can lead to reduced appetite, restlessness, insomnia and increased or distorted sensations; on physi-cal examination, there may tachypnea, tachycardia and hypertension as well as flushing, sweating and even uncontrollable movements or shaking. Speed freaks (high-intensity abusers) progressively use the drug to remain euphoric, and with high doses or chronic use, xerosto-mia, xerosis, pruritus, acne excoriée and formication can occur, along with dental caries and loss of teeth (“meth mouth”). “Tweaking”, con-tinuous drug use without sleep for 3 to 15 days, is often associated with irritability, paranoia, violence and frustration due to inability to recreate the euphoric high.

Methylenedioxymethamphetamine (MDMA), also known as “ecstasy”, “Adam”, “XTC”, “hug”, “beans”, or “love drug”, is a

Table 89.1  Features of drug dependence.

FEATURES OF DRUG DEPENDENCE

•  Recurrent and excessive drug use which may result in tolerance and withdrawal

•  Recurrent social, occupational, psychological or physical problems as a result of excessive drug use

•  Failed attempts to control substance use

89 DISORDERS DUE TO PHYSICAL AGENTS SECTION 13

Signs of Drug AbuseJosep L Genebriera de Lamo, Mark R Pittelkow and Miguel Sanchez

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PATHOPHYSIOLOGY OF ADDICTIONAdministration of addictive drugs, directly or indirectly, leads to an increase in dopamine activity within the mesolimbic system (reward circuit) as well as the frontal cortex, anterior cingulate and hippocam-pus. This is thought to play a role in incentive salience and craving. In addition, MRI studies have documented progressive loss of frontal lobe volume in both cocaine- and heroin-dependent addicts and this may lead to unrestricted behaviors.

EPIDEMIOLOGYApproximately 5% of the world’s population (i.e. 200 million people) uses illicit drugs and approximately 14 million of them inject drugs6. Drug abuse is a problem is both high- and low-income countries (Table 89.2; Fig. 89.1), and in 2009–2010, the United Nations Office of Drugs and Crime estimated that 2.8–4.5% of the global population (ages 15–64 years) misused cannabis, followed by amphetamines (0.3–1.3%)

More recently, cocaine adulterated with levamisole has been associated with the development of neutropenia and ischemic vasculopathy with necrotizing purpura and ulceration (see below).

Gamma-HydroxybutyrateGamma-hydroxybutyrate (GHB; “liquid ecstasy”, “liquid X”, “liquid G”, “fantasy”), a “party drug”, is a rapid-acting CNS depressant popular among revelers for its relaxant, euphoric and purported aphrodisiac properties. GHB can mentally and physically paralyze a person as well as induce memory loss, and it is used more often than flunitrazepam as a “rape drug”. Because it reportedly promotes muscle mass and has been shown to elevate human growth hormone in vivo, GHB is com-monly misused by bodybuilders.

Lysergic Acid DiethylamideLysergic acid diethylamide (“LSD”, “acid”), an hallucinogen, is manu-factured from the lysergic acid found in ergot, a fungus that grows on rye and other grains. It is often sold in single-dose (20 to 80 mcg) squares of blotter paper. LSD causes an altered experience of time, senses and memories, usually within 30–90 minutes after ingestion. Changes in auditory and visual perception (e.g. moving geometric pat-terns) are typical. In addition to pupil dilation and tachycardia, patients may develop sweating, sialorrhea, piloerection and a strong metallic taste.

OpiatesAlso known as diacetylmorphine, heroin (“junk”, “smack”, “horse”, “scag”), the fastest acting of all opiates, is three times more potent than morphine and still accounts for much of the illicit opiate abuse in the US. Because of its increased lipid solubility, it crosses the blood–brain barrier more rapidly, prompting a “rush” within 7 to 8 seconds after intravenous injection or 10–15 minutes after being snorted or smoked. There has been a growing tendency to sniff, snort (“shabbang”) or smoke (“chase the dragon”) heroin rather than inject it intravenously (“shoot up”) or subcutaneously (“skin pop”). Opiate addicts may alter-nate injections of heroin and cocaine (crisscrossing) or inject highly addictive “speedballs” of the two drugs together. Methadone, an oral synthetic opioid with a half-life between 24 and 48 hours, is widely used as a substitute for heroin in narcotic treatment programs and for chronic pain.

Opiates remain the leading cause of fatal overdoses, with methadone, which is increasingly being obtained via the Internet, becoming a sig-nificant problem. Fentanyl, a narcotic analgesic that is 50 to 100 times more potent than morphine, is particularly prone to overdosing. Buprenorphine, a more potent and longer-lasting analgesic than mor-phine, appears to act as a partial agonist of µ and κ opioid receptors, but tolerance with chronic use may not develop, presumably due to the lack of δ-agonist activity.

Pentazocine is an oral benzomorphan opiate antagonist with a lower risk of drug dependence than opiates, but ingestion of pentazocine may precipitate withdrawal symptoms in persons physically dependent on opiates. However, when tablets are crushed, diluted and then injected in combination with the antihistamine tripelennamine (Pyribenzamine®), the euphoric effects are similar to those produced by heroin. The side effects are similar to those of morphine, but pen-tazocine may be associated with a greater risk of hallucinations. Severe necrosis and secondary infection of the skin and subcutaneous tissue, including underlying muscle, may develop at repeated injection sites of pentazocine.

Anabolic SteroidsAnabolic steroids promote the growth of skeletal muscle and the devel-opment of male sexual characteristics. They are ingested (oxandrolone, oxymetholone, stanozolol) or injected (nandrolone, testosterone, bold-enone) intramuscularly by bodybuilders to increase muscle mass and by athletes to boost physical performance. Physical and psychological dependence can develop after habitual use. Higher risks for cardiovas-cular disease, hepatic disorders (e.g. peliosis hepatis, hepatic adeno-mas), infectious diseases (due to needle sharing) and perhaps mood disorders are among the long-term complications of anabolic steroid misuse. The cutaneous side effects are outlined in Table 89.3.

Table 89.2  Self-reported alcohol and illicit drug use among high school seniors in the US (2008). From the US Department of Justice, Bureau of Justice Statistics (http://bjs.ojp.usdoj.gov/content/dcf/du.cfm).

SELF-REPORTED ALCOHOL AND ILLICIT DRUG USE AMONG HIGH SCHOOL SENIORS IN THE US (2008)

Drug Use within the past year (%)

Alcohol 65

Marijuana 32

Opiates (other than heroin) 9

Stimulants 7

Tranquilizers 6

Hallucinogens 6

Sedatives 6

Cocaine 4

Inhalants 4

Anabolic steroids 1.5

Heroin 0.7

Fig. 89.1  Dependence on or abuse of specific illicit drugs during the past year (US data for 2009). Estimates in those 12 years of age or older. Hallucinogens include ectasy, lysergic acid (LSD) and phencyclidine (PCP). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings, U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Office of Applied Studies. www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9results.htm. 

0 1,000 2,000 3,000 4,000 5,000

Numbers in Thousands

Sedatives 147

Inhalants 164

Hallucinogens 371

Stimulants 371

Heroin 399

Tranquilizers 481

Cocaine 1,120

Pain relievers 1,854

Marijuana 4,299

DEPENDENCE ON OR ABUSE OF SPECIFIC ILLICIT DRUGS (US DATA FOR 2009)

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Fig. 89.2  Injection sites (“skin tracks”) in an intravenous drug user. There is overlying hyperpigmentation and scarring of veins due to inflammation from repeated non-sterile injections as well as injections of irritating drugs and adulterants. 

and opioids (0.5–0.8%)3. According to the National Survey on Drug Use and Health, in 2009, an estimated 21.8 million Americans 12 years of age or older were current (during the past month) illicit drug users.

CLINICAL FEATURES

ScarsIntravenous drug users have a number of recognizable stigmata, which identify their habit to anyone with experience in illicit drug use7. The most prominent of these are “skin tracks”, which represent overlying hyperpigmentation and scarring of veins due to inflammation from repeated non-sterile injections as well as injections of irritating drugs and adulterants (Fig. 89.2). Early lesions in intravenous drug users consist of trails of punctures, crusted lesions and ecchymoses along the veins of an extremity5. Usually, the veins of the arms are initially used for injection, and when these become scarred, drug is injected into the vessels of the hand, digits, wrist, lower extremities, neck, axillae and eventually into any visible vein or palpable artery7. Increasingly, parenteral drug users are injecting themselves in the legs, feet and groin in order to avoid the presence of scars on exposed parts of the body which can persist for years.

Tissue injury also occurs from intradermal or subcutaneous injec-tions and from accidental extravasation after intended injection into veins5. Drugs are injected subcutaneously and intradermally when patent vessels cannot be found. The resulting “skin popping” scars are depressed, irregular, circular and often dyschromic (Fig. 89.3). In some users, indurated, hypertrophic or keloidal scars form at these sites7. Drug users who cannot find intact veins may also rub powdered drugs into lacerations created with razor blades or knives.

Adulterants such as lactose, mannitol, dextrose, baking soda and flour are used to dilute (“cut”) heroin and other powder drugs7. Many adulterants, especially quinine and dextrose, are highly sclerosing and more damaging to tissue than pure heroin1. Quinine is a popular adul-terant because it has a bitter taste similar to heroin and it accentuates the narcotic euphoria. It is destructive to lymphatics and repeated injec-tions can lead to chronic, non-pitting hand edema. More recently, levamisole-adulterated cocaine has been associated with the develop-ment of retiform purpura and cutaneous necrosis (see below).

The risk of thrombophlebitis and skin necrosis from injections of propoxyphene is so high that even the most determined addict ceases use of the drug after only a few weeks (Table 89.3)5. Highly vasocon-strictive, cocaine produces tissue ischemia, especially when extrava-sated. In fact, skin and muscle infarction have developed after inhalation of freebase cocaine. Due to their alkalinity, barbiturates, when injected into the skin, cause tender, erythematous, indurated plaques, which

Fig. 89.3  “Skin popping” scars. A–C Multiple circular depressed scars,  some with rims of postinflammatory hyperpigmentation, admixed with circular hemorrhagic crusts overlying ulcerations. Cocaine was injected into the thighs. 

A

B

C

break down into deep ulcers and frequently become infected. Injection of the antihistamine tripelennamine, usually injected in combination with pentazocine or another opioid, also induces tissue necrosis and ulceration. Pentazocine injection may cause brawny, sclerodermatous skin thickening and large, irregularly shaped, deeply penetrating ulcers that may extend to muscle and then heal with significant atrophy (Fig. 89.4)8. Pentazocine-related cutaneous sclerosis develops more com-monly in addicts with diabetes mellitus8.

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Table 89.3  Cutaneous signs of drug abuse. IM, intramuscular; IV, intravenous; MDMA, methylenedioxymethamphetamine; sc, subcutaneous.

CUTANEOUS SIGNS OF DRUG ABUSE

Lesion type Route(s)/associated drug(s) Other associated signs

Skin tracks IV Lymphedema

Skin popping scars sc or dermal Lymphedema

Ulcerations IV/propoxypheneIV/cocainesc/barbituratessc, IM/pentazocine (± tripelennamine)

Circumferential pigmented bands (IV administration)

Retiform purpura with ulceration Snorting, IV/cocaine adulterated with levamisoleSmoking/crack cocaine adulterated with levamisole

Neutropenia

Sclerosis sc, IM/pentazocinesc/barbituratessc/cocaine

Palmar and digital hyperkeratosis Smoking/crack cocaine MadarosisLinear and circular black plaques on the fingers and palmsCuts and blisters on the lips

Nasal verrucae Snorting/cocaine or heroin Nasal irritationSeptal perforation

Pseudoaneurysm Arterial injection Petechiae/purpuraReduced peripheral pulses

Cellulitis IV, sc, intradermal Osteomyelitis and pyogenic arthritis

Cutaneous Pseudomonas infection IV, sc, intradermal/heroinsc/pentazocine ± tripelennamine

Folliculitis

Wound botulism (Clostridium botulinum, especially type A)

IM, sc/black tar heroin or quinine-adulterated heroin LymphedemaSkin popping scars

Excoriations & self-induced ulcers Methamphetamine Dry leathery skinRed dry noseDental caries/loss of teethWeight lossParanoia

Formication or delusions of parasitosis CocaineMethamphetamine

Pruritus HeroinCocaine (chronic)Methamphetamine

With heroin:FlushingPseudoacanthosis nigricans

Papulopustular acneiform eruption MDMA (ecstasy)

Acne vulgaris Anabolic steroids Coarse skinHirsutismMale and female pattern alopeciaIncreased hair growth in womenGynecomastia (in men)Testicular atrophyClitoral enlargement

MethamphetamineMarijuana

Excoriations

Perinasal and perioral irritant dermatitis

Sniffing of volatile solvents and inhalants

Fibrous myopathy, joint restriction, muscle contractures, brachial plexus neuropathy, inflexible ankylosis and suppurative tenosynovitis are musculoskeletal and neurologic complications from intracutaneous and intravenous injections1.

Bacterial InfectionsUnless they participate in needle exchange programs, hardcore parenteral drug users rarely use sterile techniques and they may share needles, which predisposes them to frequent infections (Table 89.4). Skin and soft tissue infections are the most common diseases for which drug addicts seek healthcare or are hospitalized9–11. Among 127 intra-venous drug users, 41% developed cellulitis, 32% an abscess with cel-lulitis, 16% an abscess alone, 10% infected skin ulcers, 7% necrotizing fasciitis and 5.5% septic phlebitis with cellulitis11. The most common presentation of cellulitis is an erythematous, tender, warm, edematous, indurated plaque (Fig. 89.5); however, only tenderness and edema may be apparent initially, and in more darkly pigmented skin, erythema may

be difficult to appreciate. In contrast to the general population, cellulitis more frequently involves the upper extremity.

Lymphangitis associated with skin infection is common. In addition, underlying osteomyelitis and septic arthritis should be considered in cutaneous infections associated with injections. In some reports, up to one-third of hospitalized addicts with skin and soft tissue infections have an associated culture-proven bacteremia7,11. In a smaller subset, bacterial endocarditis develops, which is the most common systemic bacterial infection in intravenous drug users and accounts for 5% to 8% of hospitalizations12 (see the discussion below).

The flora spectrum of street heroin does not correlate with the spec-trum of bacteria causing infections in intravenous drug users13. Cel-lulitis is most frequently caused by Staphylococcus aureus and less often by streptococci (commensal flora)11,12. However, bacterial cultures and sensitivity testing are indicated in order to identify those cutaneous infections due to methicillin-resistant Staphylococcus aureus (MRSA), Gram-negative bacteria, anaerobes or unusual organisms and to deter-mine the most effective antibiotic regimen13. The combination of

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Fig. 89.4  Atrophic depressions of the thighs and extensive calcification from multiple pentazocine injections. 

Table 89.4  Infectious complications of drug abuse.

INFECTIOUS COMPLICATIONS OF DRUG ABUSE

Type of infection Organisms and/or associated features

BACTERIAL

Abscesses and cellulitis •  Staphylococcus aureus > Streptococcus spp. > Gram-negative bacilli, anaerobes

•  Often polymicrobial•  Lymphangitis is common•  Clostridium infection (e.g. C. botulinum type A) 

with adulterated heroin (e.g. black tar skin popping)

•  Pseudomonas aeruginosa with pentazocine ± tripelennamine or heroin injections

•  Eikenella corrodens with methylphenidate injections (esp. into the femoral triangle)

Necrotizing fasciitis •  Polymicrobial in 60–85% of cases•  Includes anaerobes in ~10%

Pyomyositis

Septic thrombophlebitis •  Associated with endocarditis or pulmonary emboli

Septic arthritis •  Increased likelihood of Gram-negative bacilli (esp. Pseudomonas spp.)

Osteomyelitis •  In Pott’s puffy tumor, frontal sinusitis leads to frontal bone osteomyelitis and a subgaleal abscess; may be complicated by an epidural abscess

Endocarditis •  S. aureus > Streptococcus viridans > Gram-negative (esp. Pseudomonas spp.), polymicrobial

•  Often right-sided (e.g. tricuspid valve)

FUNGAL

Candidiasis •  Disseminated candidiasis with pustular folliculitis; associated with injections of brown heroin

•  Septic arthritis, osteomyelitis, endocarditis (C. parapsilosis, C. tropicalis), septicemia (“fungemia syndrome”)

Aspergillosis •  Pulmonary infections from contaminated marijuana

•  Dissemination and endocarditis may occur

Zygomycosis •  Cellulitic plaques or necrotic abscesses

VIRAL

Hepatitis •  Hepatitis B viral infection may be associated with immune complex disease (e.g. arthritis, urticarial vasculitis) during the period of antigenemia

•  Syringe/needle sharing accounts for more than half of new cases of hepatitis C in the US

HIV

Fig. 89.5  Cellulitis of the lower extremity in an intravenous drug user. 

descending and symmetric, flaccid paralysis with ophthalmoplegia, ptosis or other cranial nerve dysfunction. The diagnosis is supported by conventional electromyography. Treatment consists of high-dose penicillin, antitoxin and respiratory support.

In addition to injecting frequently and using non-sterile techniques (e.g. dirty needles), there are additional risk factors for the development of abscesses, including “skin popping”, injecting speedballs (a mixture of cocaine and heroin that can induce ischemia within soft tissues)18, HIV infection and “booting” (repeatedly flushing and pulling back during injection)18a,18b. Abscesses from subcutaneous drug injection are often multilobulated, deep and have extensive necrosis, requiring explo-ration and debridement. Superficial abscesses often rupture spontane-ously, leaving punched-out ulcers. A single pathogen is cultured in over 50% of cases, and more than one organism is present in 33% to 45%11. Fever and leukocytosis are not particularly reliable measures of severity, as they are absent in 50% and 57% of cases, respectively11. Any type of bacteria may be cultured from these abscesses, but the more common are Staphylococcus aureus (20–60%), Streptococcus spp. (25%) and Gram-negative bacilli (up to 25%). Anaerobic bacteria are common as well, especially in polymicrobial infections. In one study, anaerobic bacteria were recovered from two-thirds of abscesses, and in one-third of these, they were the only cultured organism19. Eikenella corrodens,

tripelennamine and pentazocine may promote the selective survival of Pseudomonas aeruginosa, and the use of quinine to adulterate heroin appears to predispose to Clostridium infection.

Wound botulism due to Clostridium botulinum type A occurs almost exclusively in drug addicts14. This particular infection is associated with parenteral injection, especially skin popping of black tar heroin, a form that derives its color from impurities during its manufacture and from adulterants. Black tar heroin is very hygroscopic and has a high water content, which supports the growth of organisms15. C. sordelli infection can present as toxic shock syndrome and C. novyi type A was respon-sible for an outbreak of severe infection with a high mortality rate in drug users who injected heroin extravascularly16,17.

The spores of C. botulinum are not destroyed by heating the con-taminated heroin and are inoculated into the subcutaneous tissue, where they germinate and produce toxin15. In the early stages, there is usually pain, tenderness and swelling, but a cellulitis or abscess may not be apparent. In cocaine snorters, the intranasal septum or paranasal sinuses may become infected. Botulism causes acute, usually

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an oral flora bacterium, has been cultured from some abscesses caused by injections of methylphenidate. Curiously, some abscesses develop months after a patient has ceased use of drugs.

Abscesses may be contiguous with underlying bone in the setting of associated osteomyelitis. In intravenous drug users, acute or chronic osteomyelitis develops from contiguous infection in surrounding soft tissue, hematogenous seeding of bacteria, or direct penetrating trauma from needles. The presence of osteomyelitis should be considered in anyone with continued pain after treatment of a soft tissue infection or with soft tissue infections that recur or respond slowly to appropriate treatment with antibiotics. Occasionally, septic arthritis can develop via these same mechanisms and may involve more unusual sites, e.g. the sternoclavicular joint in those who “shoot the pocket” (jugular vein)20,20a.

Cervical abscesses usually occur in the anterior cervical triangle, and may cause life-threatening complications such as mediastinitis, pneu-momediastinum, airway obstruction, internal jugular vein thrombosis, and extension into the carotid sheath. Abscesses in the groin may present with only tenderness and edema. These abscesses can be deep and extensive, especially if they originate in the femoral triangle. In general, the degree of pain usually exceeds that anticipated from the clinical findings.

MRI is superior to CT imaging in detecting the presence of fluid and purulent collections in skin, joints or tendon sheaths, but both are valuable in confirming the presence of deep and groin abscesses21. Sinography can be employed to delineate the extent of an abscess cavity or fistula. It is crucial to be aware that necrotizing fasciitis with or without myositis can present as erythema (77%), fluctuance (20%), edema (20%) or induration (43%), clinically resembling a non-fluctuant abscess yet requiring extensive subfascial debridement22. Fever and leukocytosis are often present. In some cases, only swelling or subtle cellulitis is apparent. However, severe pain, disproportionate to the physical findings, is present in 94% of cases23. If this complaint is disregarded or misinterpreted as a request for narcotics, the outcome can be devastating.

Notably, the classic cutaneous findings of necrotizing fasciitis, such as bullae (noted in 3% of patients), tissue crepitance (3%) and skin necrosis (10%), are usually absent, and only present in a small minority of patients22. For this reason, surgical exploration is mandatory in any parenteral drug user with cellulitis and unexplained severe pain24. Any necrotic tissue should be debrided surgically (Fig. 89.6), as the infection will progress in 75% of patients treated with only parenteral antibiot-ics24. Multiple organisms are cultured in 60% to 85% of cases, including anaerobes in 12% of patients. The presence of gas is not pathognomonic for Clostridium infection, as gas gangrene can also (but infrequently) be caused by other bacteria (e.g. usually mixed infections with Entero-coccus faecalis, Escherichia coli, group G Streptococcus, Klebsiella pneumoniae, Proteus vulgaris, Citrobacter diversus, Bacteroides bivius, Peptostreptococcus asaccharolyticus or Morganella morganii).

Fungal InfectionsDermatophytosis is very common in addicts. Disseminated candidiasis associated with injections of brown heroin was reported in the 1980s and found to be caused by an overgrowth of yeast in the lemon juice used to dissolve the heroin25. Initially, patients developed high fevers, rigors, headaches, myalgias and occasionally jaundice, but, at this stage, blood and urine cultures rarely demonstrated organisms. Usually after a week or so, up to 90% of the patients developed pustular folliculitis and painful nodules in hair-bearing areas (scalp, moustache and beard)25. The lesions resembled bacterial folliculitis but potassium hydroxide examination and lesional biopsy specimens demonstrated the presence of yeast. Other complications included ocular disease (chorioretinitis, uveitis, endophthalmitis, episcleritis), monoarthritis, painful costal osteochondritis and pleuritis25.

Intravenous drug use is also a predisposing factor for zygomycosis. The characteristic cutaneous lesion is a cellulitic plaque or abscess with extensive necrotic tissue.

GranulomasInjection of hydrous magnesium silicate (talc) or starch can produce granulomatous responses (Fig. 89.7) in the walls of veins as well as in the deep dermis and subcutaneous tissue, resulting in the formation of

Fig. 89.6  Necrotizing fasciitis of the upper extremity with extensive tissue necrosis in an intravenous drug user. Surgical debridement has been performed. 

Fig. 89.7  Foreign body granuloma formation leading to papules at the sites of injection of adulterated heroin. 

firm, movable cutaneous nodules26 (see Ch. 94). Talc is the main ingre-dient in some of the narcotic tablets that are crushed, diluted in liquid, and then injected. Talc granulomas may also develop in the lungs, liver, lymph nodes, spleen and bone marrow. Granulomas may not appear for up to 50 years after subcutaneous injection, because it is the conver-sion of silica to its colloidal form that stimulates the formation of granulomas26. When the inflammatory nodules ulcerate, they can heal with epidermal pigmentary changes, woody induration of the dermis and subcutaneous tissue, and retracted cicatrices.

Mucous Membrane LesionsSnorting cocaine causes erythema of the nasal mucosa, nasal irritation, anosmia and rhinitis, and may lead to epistaxis, perforation of the nasal

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Fig. 89.8  Tooth decay is a common physical finding in hardcore drug addicts (arrow). The term “meth mouth” is applied to those who abuse methamphetamines. 

exhausted, drug users may attempt to inexorably maintain the granula-tion tissue of the ulcer (with its rich vascular network of capillaries) for injection of heroin or other drugs, resulting in chronic non-healing ulcers called “shooter’s patches”27.

FormicationProlonged use of cocaine may lead to the development of formication, tactile hallucinations during which the patients sense that insects are crawling on or under their skin (“coke bugs”)5. Repetitive, stereotypical skin picking leading to excoriations and disfiguring skin ulcers on the face and extremities is a common finding in methamphetamine abusers. Not uncommonly, these individuals also feel that bugs are crawling under their skin, and cocaine or crystal methamphetamine use should be considered in anyone who presents with delusions of parasitosis as well as neurotic excoriations (Fig. 89.9). Other signs of methampheta-mine abuse are dry skin, pruritus with lichenification, unpleasant body odor, a red dry nose, sweating, premature aging, rotting teeth, aggressive behavior and paranoia. Acne, especially the excoriée type, has been described.

septum and osteolytic sinusitis. Nasal verrucae (snorters’ warts) can also erupt in cocaine users. Less often, sniffing heroin causes these findings. A complex consisting of nasal collapse, septal perforation, palatal retraction and pharyngeal wall ulceration has been described in cocaine snorters. Cuts and blisters on the lips from glass or metal smoking pipes have been noted in addicts who smoke crack cocaine, while ageusia, halitosis and repeated lip smacking are additional signs of cocaine abuse. The labial mucosa may become dry in heroin or amphetamine users7 and amphetamine use may also cause dysgeusia and xerostomia. There are reports of men applying cocaine powder on their glans penis to postpone ejaculation and of women rubbing cocaine on their genitals to enhance pleasure. These practices can lead to pria-pism, irritant dermatitis and even ulcerations. Penile ulcers have also developed after injections of heroin into the shaft veins.

Hardcore drug users frequently have marked dental and gingival disease due to poor hygiene (Fig. 89.8). Betel palm seeds (betel nuts) contain a narcotic stimulant and habitual chewing of these nuts, a practice in some areas of Southeast Asia, stains the teeth and is associ-ated with the development of oral leukoplakia and submucosal fibrosis. The addictive habit of chewing Catha edulis tree leaves, which contain the narcotic Qat, is popular in several African and Middle Eastern countries and produces oral keratotic white plaques in approximately 20% of users.

Red or “bloodshot” eyes due to conjunctival vascular injection occurs with marijuana and sometimes with cocaine or phencyclidine (PCP) use. Repeated sniffing of volatile solvents and inhalants, such as butane gas, paint thinner, aerosol sprays, cleaning fluids and glues, can cause nasal, labial, perioral and perinasal irritant dermatitis (sniffer ’s rash). The skin lesions may be discrete papules or erosions that are often confused with acne.

BurnsBurns are common in addicts with an altered state of mind, including burns from lit matches, cigarettes, paraphernalia, and contact with fire during cooking. Cigarette burns typically occur on the digits and sternum as the cigarette was being held or smoked prior to loss of consciousness7. The necklace sign is produced by cigarette ashes, which fall on the neck when the smoking addict falls asleep. Singeing of the eyelashes and eyebrows, resulting in madarosis, may be caused by rising hot vapors during the smoking of crack cocaine. Crack addicts may also have linear or circular black plaques on the fingers and palms.

UlcersAs has been previously described, ulcers can be caused by direct drug-related cutaneous, deep tissue or vascular injury, by accidental or inci-dental trauma, or by infection. When other venous accesses have been

Fig. 89.9  Multiple excoriations in a cocaine addict. The patient felt “crawling” of his skin. 

A

B

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Fig. 89.10  Coma bulla. Large bulla with subsequent erosion on the medial ankle due to prolonged coma from barbiturate overdose. 

Table 89.5  Drug-induced cutaneous reactions.

DRUG-INDUCED CUTANEOUS REACTIONS

Opiates Barbiturates Amphetamines Cocaine Marijuana

Morbilliform eruption ✓ ✓ ✓ ✓

Bullous eruption ✓ ✓ ✓

Fixed drug eruption ✓ ✓ ✓

Small vessel vasculitis ✓ ✓ ✓ ✓

Stevens–Johnson syndrome

✓ ✓ ✓

Toxic epidermal necrolysis

✓ ✓

Urticaria ✓ ✓ ✓ ✓ ✓

Acute generalized exanthematous pustulosis

✓* ✓* ✓*

Vasculopathy with retiform purpura

✓†

*Isolated case reports.†Levamisole-adulterated.

Additional Cutaneous FindingsCircumferential, pigmented bands due to pressure from tourniquets are common in intravenous drug users with darkly pigmented skin. “Soot tattoos” are produced by injections of residual carbon on the needle after flaming5. Self-induced tattoos have been considered a sign of drug abuse; however, the current popularity of tattoos and their pervasive presence in persons with present or past connections to street gangs have diminished the reliability of this sign5. Hyperkeratosis of the fingers and palms is common in heavy users of crack cocaine. Trau-matic bullae at the site of injection are occasionally observed. Pressure erythema, bullae and ulcers develop in comatose patients after an over-dose with barbiturates or other sedative drugs (Fig. 89.10) (see Ch. 35).

The combination of chronic cocaine use coupled with marijuana inhalation often leads to very pruritic skin. Also, the feeling of euphoria induced by heroin is frequently accompanied by skin flushing and itching, as well as a dry mouth, watery eyes and rhinorrhea. General-ized or focal, especially genital, itching during the euphoric stage fol-lowing heroin administration has been named “high pruritus”.

Hyperhidrosis is a common adverse effect of amphetamines or LSD. Within 30 to 90 minutes of LSD ingestion, the user feels a wide range of emotions, accompanied by sweating, increased body temperature, dry mouth, tremors and dilated pupils. Piloerection, paresthesias and flushing are manifestations of the somatic phase of LSD intoxication, while pseudohallucinations and synesthesias occur during the percep-tual phase. Delusions and visual hallucinations occur at higher doses. Hypoesthesia is a common manifestation of low-dose exposure to PCP.

There have been scattered reports in habitual MDMA (ecstasy) users of a papulopustular (acneiform) facial eruption, which may indicate a higher risk of severe adverse effects, such as hepatic damage. In some cases, the eruption responded to topical metronidazole28. Acne and other skin eruptions are anecdotally worsened by cannabis. Acne ranging from mild to cystic, especially on the trunk, is common among users of anabolic steroids. Other cutaneous effects of anabolic steroid abuse include oily hair and skin, male and female pattern alopecia, hirsutism in women and coarse skin (see Table 89.3). Most are revers-ible if the abuser stops taking the drugs, but some are permanent.

Drug-Induced ReactionsAs expected, hypersensitivity reactions to drugs, especially morbilliform eruptions, urticaria (opiates, barbiturates, amphetamines, marijuana), bullous eruptions, fixed drug reactions, small vessel vasculitis, Stevens–Johnson syndrome and toxic epidermal necrolysis occur more fre-quently in illicit drug users than in the general population (Table 89.5). In one study, dermatographism was found in a quarter of patients comatose from a drug overdose. Angioedema due to barbiturates and heroin can cause eyelid as well as labial edema. Pigmented circular patches on the skin and mucous membranes may be extensive in addicts with fixed drug eruptions.

Vascular LesionsThe most common vascular lesions are ecchymoses and even hemato-mas over injected vessels. Petechiae may form distal to the placement of a tourniquet. Vascular compromise of the hands is common and is characterized by discoloration, edema and a cold temperature. Intense burning pain is often experienced after self-administered intra-arterial injection of drugs. This is followed within hours by edema of the affected limb. Although the peripheral pulses usually remain strong, cyanosis and patches of livedo reticularis can develop followed by distal ischemia and even necrosis. Ischemia and ulceration can appear after intra-arterial injection of a number of drugs, including temazepam (as high as 100% when injected into the radial artery), barbiturates, cocaine, heroin, pentazocine, diazepam, amphetamine and sodium thiopental13. Other manifestations reported after accidental or intentional drug

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injections into the radial artery include purpuric and pustular nodules, presumably as a result of embolization, as well as palmar cyanosis and edema with or without ulceration.

Septic thrombophlebitis results in tender, swollen extremities with or without erythema. A tender cord may be present when the affected vein is superficial, but deep vein thrombophlebitis is easily misdiag-nosed as cellulitis or an abscess, either of which may be an associated complication. Deep vein thromboses are diagnosed via Doppler ultrasonography.

Pseudoaneurysms result from infected injuries to arteries (arterial wall or perivascular tissue) during intra-arterial injection of drugs (“hitting the pinkie”). They are most commonly seen in the groin, fol-lowed by the extremities, with the close proximity of the femoral artery to the femoral vein one possible explanation for those arterial injections that are inadvertent29. The typical lesion is a tender, diffusely indurated, pulsatile mass with an associated bruit (50–60% of cases) and decreased peripheral pulses (25%). Local suppuration and petechiae and purpura are often present. Half will resolve with antibiotics alone, but expanding lesions require proximal ligation of the vessel, resection of the pseu-doaneurysm, and appropriate drainage. Otherwise, there is a risk of rupture due to necrosis. Mycotic aneurysms also occur in 15–25% of patients with infective endocarditis, most frequently in the femoral artery.

Infective endocarditis should be excluded in all injection-drug users with bacteremia. It is most commonly due to S. aureus and the tricuspid valve is involved in 70% of patients. Symptoms may include cough, dyspnea, fever and pleuritic chest pain. The mortality rate is <5%, but can be higher in HIV-infected individuals30,31. When left-sided, compli-cations include brain and splenic abscesses due to septic emboli. Infec-tive endocarditis associated with injection-drug use is also one of the rare settings in which polymicrobial endocarditis is encountered20,30,31.

In addition to arterial disease (see above), cocaine can produce super-ficial or deep venous thromboses. Treatment consists of parenterally administered antibiotics, bed rest, elevation of any involved extremity, and anticoagulation; however, care must be taken to exclude a mycotic aneurysm, which can bleed, especially in the setting of anticoagulation. Distal thrombosis with extensive infarctive thigh lesions and associated hepatitis and glomerulonephritis has been reported with cocaine use, as has aortic thrombosis or dissection, acute arterial insufficiency and intestinal ischemia29. Most recently, levamisole-adulterated cocaine has been associated with the development of neutropenia and retiform purpura that can become necrotic (Fig. 89.11)32–34. Histologic examina-tion demonstrates microvascular thromboses within the dermis, some-times accompanied by leukocytoclastic vasculitis. Patients may also have antineutrophil cytoplasmic antibodies, decreased levels of protein C and S, or anti-phospholipid antibodies. Of note, levamisole can be detected in the serum, urine or crack pipes.

Arteriovenous fistula-associated angiomatoid nodules (pseudo-Kaposi sarcoma) in a patient with hepatitis B viral infection was reported as a possible complication of heroin use35. In addition, palpable purpura and tender nodules may appear as cutaneous manifestations of small and medium-sized vessel vasculitis due to hepatitis B or C viral infections or specific drugs. Repeated vascular injury and infection of the digits can cause irreversible contractures (camptodactyly) that resemble Dupuytren’s disease.

Systemic ComplicationsDrug abuse may indirectly contribute to congenital cutaneous malfor-mations and domestic violence (see Ch. 90). The estimated incidence of infective endocarditis (see above), a major cause of mortality in this population, is 1.5 to 3.3 cases per 1000 injection-drug users per year20. Several cutaneous signs (arterial emboli, conjunctival hemorrhages, splinter hemorrhages, Janeway lesions and Osler nodes) may be present. The prevalence of HIV infection among intravenous drug users with infectious endocarditis is very high, ranging from 45% to 90%. The US Centers for Disease Control and Prevention estimates that 55–60% of AIDS cases among women and one-third of overall AIDS cases in the US are linked to injection-drug use or sex with partners who inject drugs.

Parenteral drug users are also at high risk for contracting other blood-borne viruses such as hepatitis B and C and human T-lymphotrophic virus types 1 and 2 (HTLV-1, HTLV-2). Approximately 60% of all new

Fig. 89.11  Retiform purpura due to levamisole-adulterated cocaine. A, B The earlobe is a common site of involvement and purpuric lesions of the earlobe had been described previously as a side effect of levamisole. Up to 70% of the cocaine in the US at the time of writing contained levamisole but <3% of the heroin supply. Courtesy, Jeffrey Callen, MD. A

B

cases of hepatitis C infections in the US are attributed to syringe and needle sharing with an infected individual. In some user populations, transmission of hepatitis C occurs so rapidly that within 6 months of beginning drug use, one-third of users are infected, and within 2 years, up to 90% have contracted the infection36.

Drug addicts have high prevalences of all sexually transmitted dis-eases, due to multiple partners, prostitution and failure to use condoms. However, narcotic abuse is a common cause of false-positive non-treponemal syphilis screening tests (e.g. VDRL, RPR). In these cases, treponemal tests (e.g. MHA-TP, FTA-ABS) will be non-reactive. In addicts who have had syphilis, both types of tests will be positive, but the titers of the non-treponemal test may not decrease rapidly after treatment.

Cocaine may initiate scleroderma in susceptible individuals or unmask it at an earlier age in those with subclinical disease. However, the localized cutaneous induration induced by cocaine injections is reversible. Cases of Henoch–Schönlein purpura, polyarteritis nodosa and necrotizing angiitis with renal and pulmonary disease have been associated with the use of heroin. Nephrotic syndrome from amyloido-sis has been reported in heroin skin poppers and intravenous drug users with chronically draining skin lesions37.

TREATMENTA detailed discussion of the management of drug addiction is beyond the scope of this chapter. Approaches are summarized in Table 89.6 and discussed elsewhere in the literature38. When providing care to persons suspected of drug addiction, it should be remembered that even admission of illicit drug use is difficult, as patients risk disapproval and overt or concealed rejection even from medical professionals.

The selection of antibiotics to treat skin infections should be guided by antibiotic sensitivities of the cultured organisms. With the emer-gence of community acquired MRSA, appropriate cultures of lesions and wounds have become more imperative than ever. Broad-spectrum antibiotic regimens that cover S. aureus should be prescribed until antibiotic sensitivity results are available. Treatment of cellulitis con-sists of splinting, limb elevation and intravenous antibiotics. Inclusion of vancomycin or linezolid (for MRSA) and clindamycin (for anaer-obes) in the antibiotic regimen has been recommended for hand

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3.  Wareing M, Fisk JE, Murphy PN. Working memory deficits in current and previous users of MDMA (‘ecstasy’). Br J Psychol. 2000;91:181–8.

4.  Ducasse E, Chevalier J, Dasnoy D, et al. Popliteal artery entrapment associated with cannabis arteritis. Eur J Vasc Endovasc Surg. 2004;27:327–32.

5.  Sim MG, Hulse G, Khong E. Injecting drug use and skin lesions. Aust Fam Phys. 2004;33:519–522.

5a.  Brewer JD, Meves A, Bostwick JM, et al. Cocaine  abuse: dermatologic manifestations and  therapeutic approaches. J Am Acad Dermatol. 2008;59:483–7.

6.  World Drug Report 2011. United Nations Office on Drugs and Crime. www.unodc.org/unodc/en/data-and-analysis/WDR-2011.html.

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complications revisited. J Am Acad Dermatol. 1990;22:694–695.

9.  Orangio GR, Pitlick SD, Della Latta P, et al. Soft tissue infections in parenteral drug abusers. Ann Surg. 1984;199:97–100.

10.  White AG. Medical disorders in drug addicts: 200 consecutive admissions. J Am Med Assoc. 1973;223: 1469–1471.

11.  Hasan SB, Albu E, Gerst PH. Infectious complications in IV drug abusers. Infect Surg. 1988;7:218–232.

12.  Tuazon CU, Sheagren JN. Staphylococcal endocarditis in parenteral drug abusers: source of the organism. Ann Intern Med. 1975;82:788–790.

13.  Smith DJ Jr, Busuito MJ, Velanovich V, et al. Drug injection injuries of the upper extremity. Ann Plast Surg. 1989;22:19–24.

14.  MacDonald KL, Cohen ML, Blake PA. The changing epidemiology of adult botulism in the United States. Am J Epidemiol. 1986;124:794–799.

15.  Centers for Disease Control and Prevention (CDC). Wound botulism – California, 1995. MMWR Morb Mortal Wkly Rep. 1995;44:889–892.

16.  Kimura AC, Higa JI, Levin RM, et al. Outbreak of necrotizing fasciitis due to Clostridium sordelli among black-tar heroin users. Clin Infect Dis. 2004;38:e87–91.

17.  Update: Clostridium novyi and unexplained illness and death among injecting-drug users – Scotland, Ireland, and England. MMWR Morb Mortal Wkly Rep. 2000;49:543–5.

18.  Murphy EL, DeVita D, Liu H, et al. Risk factors for skin and soft-tissue abscesses among injection drug users: a case-control study. Clin Infect Dis. 2001;33:35–40.

18a. Spijkerman IJ, van Ameijden EJ, Mientjes GH, et al. Human immunodeficiency virus infection and other risk factors for skin abscesses and endocarditis among injection drug users. J Clin Epidemiol. 1996;49:1149–54.

18b. Murphy EL, DeVita D, Liu H, et al. Risk factors for skin and soft-tissue abscesses among injection drug users: a case-control study. Clin Infect Dis. 2001;33:35–40.

19.  Webb D, Thadepalli H. Skin and soft tissue polymicrobial infections from intravenous abuse of drugs. Western J Med. 1979;130:200–204.

20.  Gordon RJ, Lowy FD. Bacterial infections in drug users.  N Engl J Med. 2005;253:1945–1954.

20a. Stein MD. Medical complications of intravenous drug use. J Gen Intern Med. 1990;5:249–57.

21.  Johnston C, Leogan MT. Imaging features of soft-tissue infections and other complications in drug users after direct subcutaneous infection (“skin popping”). AJR Am J Roentgenol. 2005;182:1195–1202.

22.  Callahan TE, Schecter WP, Horn JK. Necrotizing soft tissue infection masquerading as cutaneous abscess following illicit drug injection. Arch Surg. 1998;133:812–818.

23.  Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg. 1987;206:661–665.

24.  Clark DD. Surgical management of infections and other complications resulting from drug abuse. Arch Surg. 1970;101:619–623.

25.  Dupont B, Drouhet E. Cutaneous, ocular, and osteoarticular candidiasis in heroin addicts: new clinical and therapeutic aspects in 38 patients. J Infect Dis. 1985;152:577–591.

26.  Posner DI, Guill MA III. Cutaneous foreign body granulomas associated with intravenous drug abuse.  J Am Acad Dermatol. 1985;13:869–872.

27.  Tice AD. An unusual, non-healing ulcer on the forearm. N Engl J Med. 2002;347:1725–1726.

28.  Wollina U, Kammler HJ, Hasselbarth N, et al. Ecstasy pimples – a new facial dermatosis. Dermatology. 1998;197:171–173.

29.  Coughlin PA, Mavor AL. Arterial consequences of recreational drug use. Eur J Vasc Endovasc Surg. 2006;32:389–96.

30.  Hecht SR, Berger M. Right-sided endocarditis  in intravenous drug users: prognostic features  in 102 episodes. Ann Intern Med. 1992;117: 560–6.

31.  Levine DP, Crane LR, Zervos MJ. Bacteremia in narcotic addicts at the Detroit Medical Center. II. Infectious endocarditis: a prospective comparative study. Rev Infect Dis. 1986;8:374–96.

32.  Waller JM, Feramisco JD, Alberta-Wszolek L, et al. Cocaine-associated retiform purpura and neutropenia: is levamisole the culprit? J Am Acad Dermatol. 2010;63:530–535.

33.  Bradford M, Rosenberg B, Moreno J, Dumyati G. Bilateral necrosis of earlobes and cheeks: another complication of cocaine contaminated with levamisole. Ann Intern Med. 2010;152:758–759.

34.  Walsh NM, Green PJ, Burlingame RW, et al. Cocaine-related retiform purpura: evidence to incriminate the adulterant, levamisole. J Cutan Pathol. 2010;37:1212–1219.

35.  Fimiani M, Miracco C, Bianciardi S, Andreassi L. Pseudo-Kaposi’s sarcoma in a drug addict. Int J Dermatol. 1986;25:651–652.

36.  Garfein RS, Vlahov D, Galai N, et al. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health. 1996;86:655–661.

37.  Neugarten J, Gallo GR, Buxbaum J, et al. Amyloidosis in subcutaneous heroin abusers (“skin poppers’ amyloidosis”). Am J Med. 1986;81:635–640.

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infections and should also be considered in infections that may result in loss of limb or life13. Hand infections must be aggressively treated, recognizing that amputation of the digits or the hand occurs in 10% of patients13.

Even with surgical plus aggressive medical treatment, the mortality rate of necrotizing fasciitis in drug addicts is approximately 20% and limb amputation is necessary in another 18%22. A decrease in mortal-ity from 27% to 7% was reported with a protocol consisting of aggressive diagnosis, intense intravenous broad-spectrum antimicro-bial therapy, supportive care, early subfascial debridement, and follow-up debridement of the wound in 8 to 12 hours until no further necrotic tissue had formed. Between two and four debridements were required23.

Skin grafting of large ulcers may be necessary when healing does not occur with compression and appropriate dressings. Some substance abusers may deliberately sabotage the skin graft by injecting through it or into the vacuum (VAC) dressing tubing39. Recovered parenteral drug users often wear long-sleeved shirts and other garments to hide the stigmata of their past addiction and may seek help in diminishing the appearance of these signs. Hypertrophic scars improve with intrale-sional injections of corticosteroids and pulsed dye laser treatments (see Ch. 98). Hyperpigmented scars require the use of pigment-specific lasers and bleaching agents, including hydroquinone. Tissue augmenta-tion with hyaluronic acid or fat can improve the appearance of depressed scars. Such scars may also respond to low-fluency treatments with visible light lasers, which stimulate fibroblast proliferation.

Table 89.6  Treatment of drug addiction. GABA, gamma-aminobutyric acid.

TREATMENT OF DRUG ADDICTION

Drug Treatments

Opiates •  Drug detoxification– Office-based– Inpatient– Ultra-rapid under general anesthesia using naltrexone 

(plus clonidine, benzodiazepines and antiemetics)•  Maintenance therapy

– Agonist (methadone, levomethadyl*)– Partial agonist (long-acting buprenorphine)– Antagonist (naltrexone)

•  Pharmacologic therapy for withdrawal (e.g. clonidine, lofexidine, guanfacine)

•  Additional measures (counseling, psychotherapy, acupuncture)

Cocaine •  Drug rehabilitation•  Anticonvulsants (e.g. topiramate, tiagabine), dopamine 

agonists/reuptake inhibitors† (e.g. amantadine, bromocriptine, pergolide, vanoxerine), antidepressants (e.g. bupropion), CNS stimulants (e.g. modafinil), GABAB receptor agonists (e.g. baclofen), N-acetylcysteine

Amphetamines •  Drug rehabilitation•  Antidepressants (e.g. fluoxetine, imipramine, desipramine, 

mirtazapine), modafinil, antipsychotics (e.g. chlorpromazine, haloperidol, thioridazine)

*Withdrawn from the US market due to risk of cardiac arrhythmias.†To date, no statistical evidence of benefit for dopamine agonists.