Subcutaneous Injection of Percocet: A Case of Severe Soft Tissue Loss

Prescription drug abuse ranks as the second most common class of illicit drug use in the United States, and one mechanism of opiate abuse involves intravenous injection of enteral narcotics such as oxycodone or hydrocodone. The authors describe a patient who sustained significant soft tissue necrosis after intravenously injecting a solution made from crushed enteral narcotics, with a focus on the operative course that resulted due to a delay in initial definitive treatment. The patient’s wounds encompassed 8% total body surface area and covered 247 cm². A 55-year-old female was admitted to the burn unit (West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA) after she initially presented with infection and cellulitis to her bilateral upper extremities 3 weeks after intravenously injecting herself with crushed oxycodone/acetaminophen. She underwent numerous sequential operative repairs including initial debridement, placement of dermal replacement templates, and several split-thickness autografts and xenografts. Her total length of stay was 59 days, broken into an initial 47-day stay, and a subsequent 12-day readmission due to graft failure secondary to poor follow-up. As the number of prescription drug abusers rises, it is possible that an increase in attempts to intravenously abuse enteral narcotics may also rise. As such, burn centers should be prepared for the extent of potential limb necrosis and the operative treatment that may ensue.

Prescription drug abuse ranks as the second most common class of illicit drug use in the United States.¹ The National Institute on Drug Abuse estimates 15.7 million adult and teenage Americans are using a prescription drug for nonmedical purposes, with 6.7 million reporting use within the past month.² In 2012, the nonmedical use of pain relievers had the second largest number of recent initiates (1.9 million) among persons aged 12 years or older.3 While this estimate may fluctuate minimally from recent years (2002-2011),³ emergency department visits for acquisition, abuse, and overdose of prescription-controlled drugs have been steadily rising.⁴ Intravenous drug use is well known to be associated with soft tissue infections; 20%-30% of users experience some, if not recurrent, cellulitis and abscesses.^5-9 One uncommon method of opiate abuse is IV injection of enteral narcotics; there have been some case reports of pulmonary complications^5-9 and soft tissue infection related to this method of use. The authors present a dissimilar outcome from intravenous use of enteral narcotics where injury, while extensive, was confined to the soft tissues at the injection site.

A 55-year-old white female with multiple medical comorbidities, in addition to alcohol abuse and depression, presented to an outlying community hospital with fevers, chills, tachycardia, soft tissue infection, and cellulitis of bilateral upper extremities totaling 8% total body surface area (TBSA). Throughout treatment, the initial cause of the wound remained unknown as the patient refused to provide details as to how the wound started, or a precise timeline of the progression of the wound. After 3 weeks of failed conservative treatment and local wound care with silver sulfadiazine, she was transferred to a burn unit (West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA) for treatment of nonhealing wounds and progression of cellulitis. At the time of admission, the patient admitted to intravenously injecting an undisclosed substance and refused to provide further details. There was approximately 8% TBSA of necrotic eschar and fibrinous tissue involving the extensor surfaces of her arms and forearms, with purulent drainage noted in the right hand (Figure 1). Despite the status of the patient’s wounds, she was afebrile with stable vital signs. She received supportive care, IV anti-infective therapy, local wound care using mafenide acetate, and on hospital day 2 began the first of many serial debridements and negative pressure therapy. One of these procedures resulted in exposure of extensor tendon on the dorsum of the right hand and dermal replacement template (Integra Template, Integra LifeScience, Plainsboro, NJ ) was placed (Figure 2). The dermal replacement template was chosen to provide a graftable foundation given the exposure of tendon and bone during the debridement process. After several trips to the operating room, the patient was eventually grafted with a total of  247 cm² of split-thickness autograft. Topical therapy included bacitracin and oat/beta glucan cream. With adequate healing and no signs of further infection, she was eventually discharged on hospital day 47 (Figure 3).

Of note, the patient remained evasive regarding the cause of her disease, and the care team received varied and conflicting accounts as to the etiology of her infection. She eventually admitted to crushing and injecting an unknown quantity of a combination of oxycodone/acetaminophen several days prior to her initial presentation and denied prior use of IV abuse of prescription medication or illicit drugs including opiates and methamphetamine.

Two weeks after discharge, the patient returned with skin graft failure to the left hand and nonhealing wounds (approximately 2% TBSA). The patient admitted to noncompliance with provided wound care instructions including missed follow-up appointments, failure to adhere to discharge instructions for wound care, and refusal of visiting nurse services (Figure 4). She again underwent serial debridement and subsequent split-thickness skin grafting over the course of 2 weeks of hospitalization. Her total duration of treatment required 59 days of burn-unit care and 8 operative procedures including both the initial management and subsequent readmission (Figure 5). The patient did attend a single outpatient follow-up appointment 1 month after discharge, at which time the grafts were healing well without signs of infection or graft failure (Figure 6). She failed to attend subsequent outpatient appointments and was lost to follow-up.

To the author’s knowledge, this is the first documented case of IV use of oxycodone/acetaminophen causing soft tissue necrosis. Several previous reports have documented severe, at times fatal, pulmonary complications after IV injection of oral narcotics.^10,11 In previous reports, injury has been limited to either the alveolar or pulmonary capillary beds, with expected common findings such as diffuse micronodular infiltrates or cellulose granulomatosis.^12,13 Previous reports show the use of saline or other polar, inorganic solvent after tablet maceration, likely resulting in incomplete dissolution.¹³

The patient described here, however, was absent of lung injury and only sustained upper extremity soft tissue damage. It is unknown how the oxycodone/acetaminophen was prepared for injection and which, if any, solvents were used. Given the extent of the soft tissue injury, and noted absence of systemic complications, it is likely that after injecting the oxycodone/acetaminophen into her hands, extravasation occurred resulting in significant vascular and soft tissue necrosis with resulting eschar. Unlike previous cases, where management was primarily pulmonary, this patient’s presentation and course of treatment was more typical of a full-thickness thermal injury with inadequate early management. The deepness and extent of the necrosis complicated her recovery, especially over the hands where achieving viable tissue required excision to the level of the extensor tendons. Her case was likely complicated by the combination of limited initial management at the outlying hospital, as well as continued denial of the IV injury. Given the uncertainty regarding the solvent used in this case, it is likely that either the solvent directly caused vascular destruction or, at the time of injection, there was infiltration into the surrounding soft tissue. It should be emphasized that at the referring facility, the patient refused to provide details as to the initial cause of her wounds, and at the burn center, the patient initially admitted only to injecting a substance and refused to provide specifics. After a prolonged period of inconsistent answers, the insulting agent was identified. The treatment, therefore, was directed by observable injuries as opposed to a presumed insulting agent. This is something other centers are likely to encounter and the authors suggest clinicians should base treatment on clinical presentation as opposed to history.

While related to the superficial injury seen with the recent increase in IV use of the codeine extract desomorphine (commonly known as krokodil), there is a noted absence of deep structure destruction.¹⁴ Recreational users of desomorphine inject a suspension of desomorphine dissolved in a variety of solvents, such as strong alkalies or organic solvents which, after repeated use, results in thrombophlebitis and subsequent gangrenous necrosis.¹⁴ Although the treating clinicians were uncertain of the solvent used, the extent of soft tissue necrosis in this patient is suggestive of the course of extensive, deep soft tissue injury seen in IV desomorphine abusers. However, due to the extent of soft tissue injury after this patient’s first and, as she proclaimed, only use, and the well-documented pulmonary risks of IV oxycodone/acetaminophen use, it is unlikely she would have developed a chronic dependency likely to cause the level of significant destruction seen with desomorphine—assuming she does, in fact, avoid subsequent IV administration.

In addition to a previously undocumented complication of IV use of oral medication, this case also demonstrates the negative effects limited resources and inadequate follow-up have on outcomes. The patient’s failure to provide an accurate history of the injuries limited the care she received at the outlying hospital; that, combined with a hospital inexperienced in deep-tissue wound care may have contributed to the extent of necrosis seen here. The authors think earlier admission to a burn center would have had a beneficial outcome for this patient given the clincians’ familiarity with deep tissue injuries and heightened comfort in operative repairs.

Additionally, after her initial discharge from the burn center, the patient failed to properly manage her injuries and grafts in the outpatient setting. This was due in part to limited understanding of the importance of continued proper wound care, which resulted in refusal of visiting nurse service and failure to comply with discharge instructions, made more complicated by the patient’s limited geographical access to care. The outpatient wound center was geographically distant from the patient’s primary residence, and local resources were not available for adequate and thorough follow-up. This resulted in her readmission and repeat operative management. At the time of readmission, the patient denied continuing use of IV narcotics and made no statements to indicate otherwise. Even after her second admission, she was lost to follow-up 1 month after discharge and the status of her wound care remains unclear.

While the decision to crush and inject oral medication was the precipitating injury, her course of treatment was significantly complicated by the limitation of local resources and the inability to ensure proper outpatient management.

This case presentation illustrates a previously undocumented complication of IV use of oxycodone/acetaminophen as well as the deleterious effects of resource limitations. As nonprescription abuse of oral narcotic medication becomes increasingly common,1,2 similar presentations may occur. The selection of solvent and subsequent preparation prior to injection may be the determining factor between skin and soft tissue necrosis vs the more commonly seen pulmonary symptomatology. Physicians and other allied health care workers should be cognizant of the severe consequences of IV use of oral narcotics and proactive in discouraging patients who disclose prior IV abuse of oral medications.

Clinicians should also be sensitive to the psychological and physical aspects of drug abuse and the need for the involvement of ancillary services such as case management, rehabilitation, and detoxification admissions.  Failure to acknowledge and address an underlying substance abuse may prolong healing and impede wound treatment. Additionally, for patients whose presentation includes deep tissue involvement, the authors encourage referral to a burn center with experience treating necrotic wounds and deep tissue injuries.

Affiliations: Lake Erie College of Osteopathic Medicine, Erie, PA; University of Pittsburgh School of Medicine, Department of Plastic and Reconstructive Surgery, Pittsburgh, PA; and West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA

Correspondence:
Ariel M. Aballay, MD
West Penn Burn Center
4800 Friendship Avenue
Pittsburgh, PA 15224
AAballay@wpahs.org

Disclosure: The authors disclose no financial or other conflicts of interest.