Posts Tagged ‘injecting buprenorphine’

Injecting Buprenorphine (Suboxone, Subutex)


I know why addicts inject buprenorphine (Subutex): they think it saves them money. Over the long run, however, I doubt that’s true, given the hidden costs of addiction.

Buprenorphine has a relatively low bioavailability, at around 30%, when taken sublingually (under the tongue). This means only 30% of the total dose reaches the blood stream. If the pH of the mouth is lowered, bioavailability is reduced even further. This is why we recommend patients on buprenorphine avoid eating or drinking anything acidic for about twenty minutes prior to taking their dose.

By definition, when a drug in injected, it has 100% bioavailability. Therefore, some people inject their prescribed buprenorphine in order to get the desired blood level with a lower dose of buprenorphine. If they are prescribed 8mg per day, perhaps they use 4mg intravenously and sell the rest of their dose, or stockpile it.

People who misuse buprenorphine in this way may be blinded by their addiction to the multiple dangers of injecting drugs.

Anytime humans inject drugs into their bodies that weren’t meant to be injected, problems will occur. All sorts of medical complications can arise, which can cause exorbitant medical bills for drug users…and tax payers.

Skin: These pills weren’t meant to be injected, so they are not sterile. Buprenorphine does come in a sterile ampule to be used intravenously in healthcare settings, but I doubt that form would be found on the street for sale. The sublingual pills and film have bacteria in them, and we all have bacteria on our skin. Inevitably, some bacteria “go along for the ride” when pill matter is injected. This can cause skin and soft tissue infection of varying severity. Patients who inject can get anything from a mild cellulitis, which is an infection of the skin and soft tissues underneath, to life-threatening sepsis, which is a blood infection from bacteria. Many patients get abscesses, which are localized pockets of pus which must be drained in order to resolve.

The worst skin infection is called necrotizing fasciitis, which is a rapidly progressive infection that kills tissue. It’s also known as “flesh eating” bacteria. Often, surgeons have to remove whole infected areas of this dead tissue in order to save the patient’s life.

Scars and track marks are probably the most common skin manifestation of intravenous drug use. These can be minimized by also using a new needle, and not re-using needles.

As an aside, please don’t try to treat your own skin infections by yourself. I’ve seen horrible complications when patients try to drain abscesses on their own. And that leftover antibiotic you have on the shelf at home may not be a good choice to treat skin infections, particularly not the newer resistant bacteria.

Cardiovascular system: The tablets aren’t pure buprenorphine. The manufacturer’s website lists corn starch as another main ingredient. I don’t know for sure what that does to veins, but I know I use it in the kitchen to thicken a concoction if it’s too liquid. I imagine it does the same thing to blood in the veins. Even if the addict uses something to filter what he is injecting, some particles can still get through to the veins. Risks can be minimized by using a micron filter.

Again, bacteria can cause problems in the cardiovascular system. Sepsis, an overwhelming blood infection, can lead to endocarditis. This is a serious and life-threatening infection of heart valves. If the infection destroys a heart valve, heart surgery with valve replacement may be necessary.

Thrombophlebitis is a condition where the veins become clotting and possibly infected, usually at the injection site but sometimes further “downstream” in the vein. If this occurs in the deep veins pieces can break off and go to the lungs, causing pulmonary emboli.

If a drug is accidently injected into an artery instead of a vein, catastrophic complications can occur, including loss of limb below the level of injection. The artery becomes damaged which causes inflammation and clotting. The patient usually feels intense pain and burning immediately after injecting. Some sources suggest this can be treated with elevation of the limb and blood thinners, so go to your local emergency room if this happens to you.

Pulmonary: Corn starch and other particles like talc can cause clots and inflammation, creating structures called granulomata. As more granulomata are created, oxygen exchange in the lungs becomes more difficult, causing low oxygen levels in the patient.

Pulmonary emboli are clots from the venous blood system that break off and travel to the pulmonary arteries. When these clots are large enough, they can kill rapidly. The patient may have sharp chest pain, feel short of breath, and have a fast heart rate with low blood pressure. Blood can’t travel through the lungs to get oxygen, and the patient dies from lack of oxygenated blood. Even small clots can cause serious problems, particularly if they are also infected with bacteria.

This list isn’t complete – many other medical problems occur with intravenous drug use. Of course the most common may be transmission of the Hepatitis C or B viruses if needle/syringes/injection works are shared, as well as HIV. There are weird things like endophthalmitis, and infection of the internal eye, and other medical problems too numerous to list.

Opioid addicts using intravenously can get addicted to the process of injection. The brain repeatedly associates the ritual of injection with a rush of pleasure, and so the whole act of injecting can be difficult to stop. I’ve had patients on methadone and buprenorphine who continue to inject saline with no drugs just to feel the rush from using a needle. This can be overcome with time and counseling, but some patients have enormous difficulty with this.

So if you are reading this and considering injecting your buprenorphine in order to save money, please don’t do it. You will likely end up paying much more in the long run, and I don’t necessarily mean in a financial sense.

Complications of Intravenous Buprenorphine (Suboxone, Subutex) Abuse

Endophthalmitis from IV drug use















Since I started this blog, some of my readers have educated me about how frequently addicts use Suboxone and Subutex intravenously. I think some of these addicts have become blasé about the reality of complications that can occur from injecting a medication that’s not meant to be injected.

Like oral opioids, Suboxone and Subutex tablets and films aren’t sterile. Bacteria live everywhere, including inside an on oral medication. Since the medication is meant to be taken by mouth, these bacteria don’t harm the user when swallowed or used sublingually as intended. But when injected, these bacteria have the potential to cause catastrophic illness, depending on the nature of the bacteria.

Skin and bloodstream infections, endocarditis

Most commonly, we see cellulitis, a soft tissue infection, around the site of the injection. Sometimes the infection walls off and forms an abscess that usually must be drained. The infection can spread to the walls of the vein, causing angiitis. These infections can spread to the rest of the body, and can lodge in special areas that cause big problems. For example, endocarditis, an infection of one of the heart valves, occurs more commonly in IV drug users. It’s difficult to treat endocarditis, and requires lengthy antibiotic treatments. Sometimes this infection can destroy the heart valve and the patient may require surgical replacement of the valve. People can die from this serious infection.

Some of Singapore’s large population of intravenous heroin users switched to buprenorphine when it became available, but with that availability came an increase in complications from addicts who injected buprenorphine rather than use it as intended.

Researchers studied a series of one-hundred and thirty intravenous buprenorphine addicts that came to a Singapore hospital for treatment for infections. Of those, 31% had cellulitis. In nearly half of those patients, skin and blood cultures were positive for bacteria, most for Staph aureus. Twenty-four percent of the patients with skin infections eventually required surgical procedures, and the average length of stay in the hospital was eight days. (1)

A different study, also done in Singapore, looked at twelve consecutive patients admitted to the hospital with infective endocarditis from using buprenorphine intravenously. Eleven of the twelve patients had Staph aureus in their bloodstream, and five of them died. The average length of stay was 48 days, and multiple medical complications were noted. Three patients required open heart surgery. (2)

Fungal Endophthalmitis

Bacteria aren’t the only unwelcome travelers hitching a ride on a buprenorphine tablet. Fungal endophthalmitis is rare in people who have not had eye surgery, yet it is seen in intravenous addicts in general, and now specifically in addicts injecting sublingual tablets. At least four cases of endophthalmitis in intravenous users of buprenorphine tablets occurred within a year at one Australian hospital. These serious inner eye infections developed due to a type of Candida fungus usually found in the mouth. One of the patients admitted injecting a tablet that had been in her friend’s mouth for a short time, prior to diversion of the tablet to the patient. The oral candida species likely contaminated the buprenorphine tablet through this method.

In the 1980’s, a series of cases of candida endophthalmitis was seen in users of brown heroin. At that time, scientists thought the Candida came from lemon juice used to break down the heroin for injection. However, none of these four intravenous buprenorphine abusers used lemon juice. (3)

It is possible we will see more cases of fungal infections in patients who inject buprenorphine that has partially dissolved in another person’s mouth, due to the oral contamination of the pill.

Talc Granulomatosis

Tablets meant to be taken by mouth or sublingually (under the tongue) often contain talc as a filler. Heroin is sometimes cut with talc, to make more product to sell on the street. When these substances are injected, they can cause talc granulomatosis. Many addicts don’t get regular check-ups and most are reluctant to tell doctors about their IV drug use, even during serious medical problems. This condition is likely under-recognized because on the chest X-ray, talc granulomatosis looks like other interstitial lung diseases. The talc crystals lodge in the lungs, and cause an immunologic response. This in turn causes trouble breathing, dry cough, and low oxygen levels. Respiratory failure and death can occur in the worst cases, since there are no definite effective treatments. In some studies, patients with talc granulomatosis have improved when given corticosteroids, but tend to get worse again as soon as the medication is stopped.

Tablets meant to be used under the tongue aren’t sterile and aren’t suitable to be injected. Tablets diverted from patients who partially dissolve them in their mouths may be particularly hazardous due to contamination with mouth bacteria.  Addicts who inject tablets meant for orally use risk catastrophic health problems beyond overdose.

If you are an intravenous drug user, don’t fool yourself into thinking you’re safe because you use new needles and “works” each time. New needles do reduce the risk of contracting hepatitis and HIV, but oral pills still contain substances that were never meant to be injected.

  1. Ho et al., “Cutaneous complications among i.v. buprenorphine users,” Journal of Dermatology, 2009, Jan;36(1) pp22-
  2. Chong, “Infective Endocarditis due to intravenous Subutex abuse,” Singapore Medical Journal, 2009 Jan;50(1):34-42.
  3. Alboltins et. al., letter to the editor, Medical Journal of Australia, April 18, 2005, Vol 182(8) p.427.

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