Description
A 53-year-old man, a health professional from a Middle Eastern country, was admitted with parenteral overuse of pentazocine. He had first used pentazocine in the First Persian Gulf War for migraine. He began to abuse pentazocine, which he scaled up to 20 ampules per day and continued using for >15 years. Since 2006, because of political regulations in the healthcare system in his country, he obtained the drug from illegal sources instead of from pharmacies. He was abstinent for 9 months after a treatment programme. He suffered from musculoskeletal pain, diarrhoea and insomnia during early withdrawal.
He was using 10 30 mg pentazocine ampules intramuscularly in his left inguinal region for 6 months before admission. He had a wound in his left inguinal region that contained necrotic and infectious tissue (figure 1); he had been dressing this wound himself for months. He experienced guilty thoughts and was in a depressive mood.
Figure 1.
Necrotic and infectious tissue in the inguinal region caused by chronic opioid injection.
He completed our 12-step therapy and was on quetiapine (200 mg), bupropion (150 mg) and naltrexone (50 mg) treatment after inpatient detoxification. He has been in follow-up in our outpatient clinic for 13 months and remains abstinent. He is functional in his occupation and social domains. After multiple surgeries in Turkey, his wound has healed.
Repeated intramuscular injections of pentazocine, which is known to be abused, may cause soft tissue induration, fibrosis or ulceration, hyperpigmentation and myopathy.1 2 It is important to consider opioid injection in patients with a chronic wound, in the differential diagnosis. Although the rate of overall substance abuse is similar to that of the general population, abuse of opiates is more common in physicians. With appropriate treatment, many physicians with substance abuse disorders achieve long-term recovery and sobriety.3
Learning points.
Repeated injections of pentazocine may cause irregular ulcers with surrounding induration or hyperpigmentation. Pentazocine-induced ulcers can be an under-recognised cause of chronic non-healing ulcers.
Rates of substance abuse among physicians are similar to those of the general population; physicians have no immunity to substance abuse disorders.
The treatment outcomes for physicians with substance abuse disorders, when receiving appropriate assessment and treatment, can be considerably better than for the general population.
Footnotes
Twitter: Follow Onur Noyan at @iasonur
Contributors: AED and SN conceived the idea for the manuscript and selected appropriate images. AED and OCN drafted the text. ND revised the text for important intellectual content. All the authors approved the final submitted version.
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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