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 Canadian
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Unintended subcutaneous and intramuscular injection by drug users
There was a recent epidemic of unexplained illness and death among injection drug users in Scotland, Ireland and England. The syndrome-based case definition was soft-tissue inflammation (abscess, cellulitis, fasciitis or myositis) at an injection site and either severe systemic toxicity (sustained systolic blood pressure < 90 mm Hg despite volume replacement and total peripheral white blood cell count > 30.0 × 109 cells/L) or postmortem evidence of a diffuse toxic or infectious process including pleural effusions and soft-tissue edema and necrosis.1 For a significant number of cases that met the case definition, there was laboratory evidence of clostridial infection, which suggests that the drugs or other materials used by the injection drug user were contaminated with soil or feces.2 Aside from proximity in time, the common risk factor for all cases was subcutaneous or intramuscular injection rather than intravenous injection of heroin.3 Public health authorities advised physicians to urgently report cases meeting the case definition and recommended that injection drug users with a serious inflammation seek medical attention rapidly. Injection drug users were cautioned to smoke rather than inject heroin; if they did inject, they were advised to avoid injecting into muscle or tissue outside a vein. To better define the size of the population at risk in our city, we surveyed 153 injection drug users attending Montreal needle exchange programs about their injection practices. No one reported intentional subcutaneous (skin popping) or intramuscular (muscle popping) injections. However, 72 (47.1%) reported unplanned injections; of 17 554 injections in the previous month, 2308 (13.1%) were subcutaneous and 667 (3.8%) were intramuscular as a result of injection error. There was a significant association between these unintended injections and higher age (p = 0.01) and female sex (p = 0.02). Length of injecting career and choice of drug were not associated with an inadvertent injection. These findings suggest that a significant number of injection drug users in Montreal, particularly women and older users, are at risk for toxin-mediated fatal infections if contaminated heroin enters the market, even if only intravenous injections are planned. Because smoking is a less cost-effective route of heroin administration than injection, many users are unlikely to follow the advice to switch to smoking. Serious consideration should be given to encouraging physicians to prescribe sterile injection equipment,4 to increasing treatment slots, to setting up injection rooms staffed by nurses who can provide advice on safe injection techniques, to conducting clinical trials of medical-quality heroin in people for whom methadone substitution has failed and to instituting strictly supervised heroin, diamorphine or buprenorphine prescription programs for long-term injectors.5 This would reduce the risk of life-threatening infection from nonsterilized drugs, prevent overdose from heroin of unknown purity, break the link between drug use and criminal activity to acquire drugs and decrease the number of injections in public places.
Catherine Hankins References
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