I suspect I have seen more opioid overdoses than any other imminently life-threatening condition. On the hottest days and coldest nights during my residency in Camden, NJ, patients in respiratory arrest or recovering from law enforcement-delivered naloxone would arrive as fast as we could pull another stretcher into the hallway.
More often than not, management consisted solely of a brief period of observation before the patients were sent on their way. Later, the hospital would lead the charge in ED-based addiction medicine, with comprehensive outpatient resources, buprenorphine bridging, and more, but my evaluation, management, and disposition of opioid use disorder, at least in the first few years of my training, were limited to helping the patient recover from his overdose.
The opportunities I missed to make a difference are staggering.
Our knowledge and understanding of the many facets of opioid use disorder over the past decade have grown, matured, and evolved. Buprenorphine induction, substance abuse counseling, and ubiquitously-available naloxone are widespread, yet comprehensive care could—and should—have started long ago with simple but revolutionary additions to bedside practice. Asking patients about injection practices and informing them about safe ones are brief but important harm-reduction maneuvers that can make a tremendous difference.
Nearly one-third of patients in one survey of injection drug users admitted to an academic hospital reported licking their needles prior to injection. These patients reported reasons for the practice ranging from the ritualistic (“This is the way I was taught”) to more objectively surreal excuses: They were cleaning the needle, ensuring its readiness for injection, or tasting the drug for quality. (Int J Drug Policy. 2008;19:342.)
It's clear that such a practice poses unique microbial risks beyond those typically encountered in injection drug use. Oral flora introduced into the subcutaneous tissue or bloodstream can lead to anaerobic skin and soft tissue infections, which may be more virulent than common pathogens and should prompt consideration of antibiotics active against anaerobes for cellulitis or abscess.
Importantly, patients who lick their needles before injection can develop infectious endocarditis, not just from the common and expected Staphylococcus species but also from Eikenella corrodens, a facultative anaerobe best known for its inclusion in the HACEK group of culture-negative endocarditis organisms. In the midst of flu season where blood cultures can be used to satisfy the classic Duke criteria for diagnosing endocarditis, asking, “Do you lick your needles?” may make the difference between a diagnosis missed and a life saved.
Most heroin in the United States is white heroin, or heroin hydrochloride, the drug in its salt form. It is water-soluble, and typical practice for injection involves dissolving the powder in water, ideally using a sterile stirrer (or the sterile inside of the syringe plunger in a pinch). Needle-exchange sites across the country distribute sterile water for injection, yet nonsterile diluents abound in places where these programs are not available or utilized.
Though a terrible myth once propagated in the Philadelphia area claimed that water from the top of the toilet was sterile, using bottled, tap, or otherwise nonsterile water skyrockets the risk of fastidious gram-negative invasion, a hazard highlighted by the rise of Pseudomonas implicated in epidural abscesses and septic arthritis diagnoses. (Spine. 2015;40:E949.) The possibility of infection is mitigated by boiling the water, but decreased with counseling to avoid nonsterile sources and nearly eliminated when sterile diluents are provided. A handful of sterile flushes given in the ED may save thousands in downstream health care costs and prevent the devastating complications of a rapidly progressive virulent infection.
So ask your patients, “What do you use to mix your heroin (or fentanyl)?”
Black tar, or acetylated heroin, is more commonly found in Europe and the southwestern United States, but it has steadily crept across the country. It is a freebase form that requires an acidic diluent to prepare for injection, ideally sterile citric acid, provided by the local exchange or even obtained at a well-equipped pharmacy or grocery store.
Where these works are unavailable, patients may often turn to more available forms of acid, usually vinegar or fruit juice. Using juice for injection continues to propagate, with the technique seeping ritualistically into the heroin salt community and adopted by those using heroin/cocaine or heroin/crack cocaine (speedball).
Unfortunately, these methods pose yet another unique microbial risk. A simple painful red eye may have once been dismissed as a minor complaint, but it may actually be the first presentation of endogenous fungal endophthalmitis in a patient using nonsterile acidic diluents for injection. (JAMA Ophthalmol. 2017;135:534; http://bit.ly/2WDNWe3.) Idle acidic sources can serve as a fertile feeding ground for fungal spores, so consider the risk of invasive fungal infections and discuss it with patients before the risk becomes reality.
These simple questions can make a profound difference in diagnosis and prevention and demonstrate to patients our familiarity with their disease and our willingness to help, opening the door to comprehensive and ongoing care.
Dr. Pescatoreis the director of emergency medicine research for the Crozer-Keystone Health System in Chester, PA. He is also the founder and medical director of Mullica Hill Advanced Therapies, a private medical clinic, and the host with Ali Raja, MD, of our podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.