Substance Abuse SUBSTANCE ABUSE
Figure 2 The left inguinal region of a man showing a localized depression and fissure resulting from repeated use of the femoral vein for intrave- nous injection.
renal3 and metabolic4 complications. The complications of newer recreational drugs have been reviewed.5
Contaminants
Some complications of abuse result from deliberate addition of substances (e.g. quinine, talc) to dilute (‘cut’) the drug before it is sold.6 In other cases, contaminants are introduced when the drug is prepared for injection (e.g. passage through cigarette filters or cotton wool). Particulate contaminants cause long-term, progressive granulomatous pulmonary lesions.6 Other contami- nants, particularly quinine, may be responsible for some of the more acute toxic phenomena seen, and possibly even death.7
Other hazards
Other hazards of substance abuse include: infection with hepatitis B, C and D virus and HIV8
injection site abscess caused by infection or leakage of drug into the tissues
bacterial infections, including anthrax9 and tetanus10 candidiasis
inadvertent intra-arterial injection, leading to digital gangrene (Figures 4 and 5).
Figure 4 A gangrenous forefoot resulting from intra-arterial injection of drugs.
Body packing and stuffing
Body ‘packers’ (sometimes called ‘mules’ or ‘swallowers’) are those who swallow a substantial number of packages containing illicit drugs for the purpose of smuggling.11 Heroin used to be the drug of choice but this has been superseded by cocaine,12 though most deaths at least in New York are opiate-induced.13 Accom- plices have been known to remove packets after death.14 Four different types of packaging have been described,15
though packets are now usually machine manufactured result- ing in uniformity in size and weight. Although each package contains a potentially lethal amount of drug current materials usually do not leak. Body packers may ingest up to 100e200 packages. In the case of cocaine, packages contain approximately 5e12 g. Body packers sometimes ingest anticholinergics such as diphenoxylate/atropine to inhibit intestinal motility, thus reducing potential defecation during the journey and subsequent loss of drugs or discovery en route. The packages can cause gastrointestinal obstruction and this complication can arise regardless of the ingested agent and in the absence of package leak. The use of constipating agents increases the risk of obstruction.
Figure 3 Metallic mercury injected after heroin. MEDICINE 40:2 July 2012 75
Figure 5 Ischaemic hand and fingers resulting from intra-arterial injection of an opioid. The tourniquet had been placed around the palm of the hand, excluding the thumb. The injection was made into one of the digital arteries, under such pressure that the injected material was flushed back into the palmar arch, from where it was distributed to all the digits.
2011 Published by Elsevier Ltd. Africa Health 47
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