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Wellbutrin injection: a novel pattern of prescription drug abuse
Transcript of Wellbutrin injection: a novel pattern of prescription drug abuse
Last week, on AMC's "The Walking Dead"
50 year old woman, career drug addict. Chronic pain syndrome, has failed outpatient addictions treatment. Gets fentanyl patches from walk-in clinics.
Case 2: Jake the Snake
60 year old man presents to the ER. Claims that one week ago, he got clawed by his cat. Also, claims that he was messing around in a snake cage and got scratched or bit. ALSO claims he fell on both closed fists and bruised his knuckles. Pinpoint scabs in his interdigital webs.
When all else fails, talk to the patient.
• Patients report a sense of mild euphoria
• Some state using it after coming down off a coke high makes withdrawl less
• Some state it makes the high of cocaine "higher"
Case 1: Fallen Angel
30 year old woman presents to the walk-in clinic. Nursing student, past history of depression and insomnia. Requests refill prescription of Wellbutrin and clonazepam. Denies any worsening or side effects.
No problem, right?
You're injecting Wellbutrin?!!
"Gimme a second while I check the records..."
Meditech shows she was discharged from the ICU yesterday.
She was septic, on IV antibiotics and the general surgeon did fasciotomies and a split thickness skin graft on her left antecubital fossa to repair a narsty drug injection abscess with necrosis. Psychiatry says she continues to get prescriptions because she is "angelic looking".
"The needle tears a hole/that unfamiliar sting"
A novel, "viral" pattern of injected prescription drug abuse
"So...wait...you say your landlord is okay with all these animals? Oh...his dog bit you too? And the motel is condemned?"
...until I opened it up...
Well, that doesn't look so bad...
20 cc of thick pus out of each site.
right D2 knuckle, joint capsule eroded away and articular cartilage visible
left D23 extensor mechanism visible, still intact
packed open and admitted on IV antibiotics
That's gonna leave a mark...
Widespread tissue ischemia and necrosis. Admitted for IV antibiotics, surgical debridement, consideration of vacuum dressing and eventual skin grafting.
Cultures positive for Staph Aureus, NOT a resistant strain.
Warning...NSFW advisory on the next photo...
There is no stated outpatient follow-up plan
What is bupropion?
• inhibits reuptake of dopamine and norepinephrine
• has some use in addiction management (nicotine, methamphetamine)
• listed by the FDA as a
So...wait a sec. A "non-abusable" medication which is actually used to TREAT addiction is now being sought out and used by addicts?
for an adrenergic med, this all makes sense...
"...but wait a sec. I thought THIS guy was a
"Don't you read the textbooks? Didn't you pay attention in pharmacology class? Yer doing it wrong! Wellbutrin is a poor choice for you!"
"The street finds its own uses for things..."
- William Gibson
• methadone abuse
• gas huffing
• cutting and branding
maybe it doesn't need to make physiological "sense"
So what's actually happening in here?
It presents a bit like injectable calcium extravasation injuries
? is it just infection
? is is some kind of vasospastic effect
? if so, is it synergistic with co-injected stimulants (coke, meth)
? is it just a direct toxic effect to the tissues
Kids will be kids...whatever... but this is getting dangerous...
What do we DO about it?
ALSO says he is not addicted to the 240mg of morphine he takes daily, is not on methadone despite coming up positive on urine testing, and does NOT inject the Wellbutrin that his family doctor prescribes him.
The "usual care" model (plus improvisation)
IV antibiotics (Not as an outpatient! No PICC lines)
Heparin or other blood thinners?
Nitroglycerine paste and calcium channel blockers? Phentolamine?
Fancy dressing options (Home care, ?vacuum dressings)
Ooooooh. Here's a thought:
discontinuing the offending agent!
Bupropion now appears to be demonstrating a track record of being dangerous in injection abuse. There are replacements available (?duloxetine, which also has a chronic pain indication) that have not demonstrated an abuse trend...yet.
And...is the patient REALLY depressed in the first place?
What "other" ways are there to fix this problem:
"Problems cannot be solved by the same level of thinking that created them."
- Albert Einstein
Admitted in the past for forehead injections of stimulants and opiates, ended up with a discitis of the neck and was in a halo for awhile in 2010.
Now presents with a wound on her chest that needs attention.
First: Is this a known problem? (no need to reinvent the wheel)
• Scattered reported cases of buproprion inhalation abuse or overdose
NO reported cases of
abuse in the literature or on review with colleagues (Kingston, Hamilton, Toronto, San Jose California)
Time to invent a wheel, then, I guess.
Great. So it's a local "innovation" then.
How did this even HAPPEN????
If we believe this is dangerous behaviour, how do we stop it from gaining popularity?
The parable of the 100th monkey
(surgical/antimicrobial "treatment" aside)
How about some ideas from waaaay out in left field?
Do we know the reasons why ideas go "viral"?
How far can we take "harm reduction"?
Should there be a local moratorium on this molecule?
Inform the pharmacies?
What about a counter-marketing campaign?
Can we harness the forces of "viralness" for good?
The parable of the 5th monkey
Stephenson, G. R. (1967). Cultural acquisition of a specific learned response among rhesus monkeys. In: Starek, D., Schneider, R., and Kuhn, H. J. (eds.), Progress in Primatology, Stuttgart: Fischer, pp. 279-288.
Department of Emergency Medicine Rounds Presentation 2013/04/23
Dr. James Truong, North Bay Regional Health Centre
North Bay, Ontario, Canada
(yes, I'm aware it's likely apocryphal...)
Desperate times? Radical solutions
This is what you find when you type "how to inject Wellbutrin" into Google. A complete how-to.
Appendix 3: What you get when you Google how to treat an abscess
Another tip of the huge iceberg that is addiction
- Trent Reznor
Case 4: The Crown Of Thorns
40 year old male, bipolar and long history of injection drug addiction. Has survived longstanding use of cocaine, opiates and methamphetamines, including a broken needle lodged in his right subclavian vein.
Co-injects cocaine and Wellbutrin into what he thinks is his right internal jugular vein. Presents to the ER with dysphoria and progressive, Guillaine–Barré-like migratory weakness of his legs and arms. Is admitted to the ICU.
In retrospect, it wasn't his internal jugular after all. It was probably the preforaminal part of his vertebral artery.
The paralysis doesn't get better...
Emergency MRI shows his brainstem and cord are turning to mush. There is no blood clot or bleeding seen. It has simply infarcted.
He asks to take himself off the ventilator.
But his cerebral cortex is normal. He is AWARE of what is happening.
Absolute contraindications to bupropion Rx:
• previous history of injection drug abuse
• previous history of unexplained soft tissue infections/abscesses
Relative contraindications to bupropion Rx:
• history of street drug or prescription drug addiction
• history of medication "irregularity" (contract as opiates)
• patient asks for the drug BY NAME
Mortatorium on prescriptions altogether?
Fight fire with fire: "viral" information campaign?
What do I suggest?