03 April 2009

Regional variations

I miss China White.

That may seem to be a weird thing to say, but there it is.   I did my residency training back in Baltimore.   Baltimore was at that time in the grips of a terrible heroin epidemic (still is, as far as I know).   The form of the drug distributed there was the highly purified stuff called China White, and its use was incredibly widespread.   It was easily soluble and thus ideal for intravenous use, and we saw the consequences of IV injection constantly -- accidental overdoses, HIV infection, endocarditis, and, most commonly, pyogenic abscesses.

Oh, the abscesses we saw!   They were magnificent things!   Hot and red, exquisitely painful, immediately subcutaneous, often massive and under tension, ready to spurt liters of pus as soon as you touched the scalpel blade to skin.   There was a trick to lancing them with a minimum of fuss -- bringing the yankauer suction in right along with the knife, making a tiny stab wound just big enough for the tip and immediately plunging the sucker into the abscess to evacuate all the pus without creating a huge mess (or a huge stink).   Incredibly satisfying, both in terms of the sheer volume of pus you could get out, and the patients' abject relief and gratitude for the decompression and resolution of pain.  And they healed rapidly enough that the patient could be injecting back into the same site within a week or two.

Amusingly, the anethetic was almost always the worst part of the whole procedure.   They would writhe and holler and weep at the mere approach of the needle.   I recall one man flinching away from the syringe, saying, "I'm afraid of needles."  Incredulous, I asked him, "How on earth can you be afraid of needles?  You inject heroin every single day of your life?"   He responded, in a moment of clarity, "Mostly I'm afraid of needles that don't have heroin in them."

I could write for hours about the bizarre complications we saw of the IV drug use.  The guys who used to shoot centrally -- in their groins and necks.  The x-rays with fifty broken-off needles in the neck (this was caused by patients shooting in the IJ, and nodding before withdrawing the needle, which would then snap off).   The guys who would escape from the hospital with central lines in place and come back with three different organisms growing out of their bloodstream.  The guy who dropped his lung trying to shoot subclavian, and then came back a week later having done it again.

My personal favorite was a young man who came in complaining of headaches.   They had been occurring daily for a week or two, and they sounded migrainous in their nature, but he had never had migraines before.   He freely admitted using IV heroin and cocaine -- speedballing them, which was kind of unusual in that region.   As so many other "shooters" had, he too was out of peripheral veins and had taken to shooting into his jugular.  
"You know the funny thing, doc," he told me, "is that lately, I have had real trouble getting that vein, too, so I've been shooting into the pulse vein in my neck."
I was staggered.   "You've been shooting heroin and cocaine together into the pulse vein?  You mean the carotid artery?"
"Yeah, I guess that's what you call it."
"How long have you been doing this?"
"About two weeks."
"And how long have you been having the headaches again?"
"Now that you mention it, about two weeks."
"OK, I have an idea for you -- it may sound a little crazy but hear me out -- why don't you stop shooting heroin and cocaine into the pulse vein in your neck?  I think that might fix your headaches."
"I dunno, doc," he responded with a straight face, "I was hoping you could just give me a pill for the headaches."

But on the West Coast, they apparently can't get the China White.  Instead, they get an inferior grade of less-pure heroin generally referred to as "Black tar."   Black tar is viscous and difficult to inject.  IV use is quite uncommon -- at least long-term IV use is, since the black tar scleroses the veins rapidly.   The good news is that needle sharing (and thus HIV) is apparently less common out here.   The bad news is that the consequences of intramuscular injection are just nasty.

Instead of the easy and satisfying subcutaneous abscesses, there are these deep abscesses in the muscle bellies.   If the abscess manages to track to the fascial planes, then it travels up and down the affected extremity.  The whole limb gets hot and swollen and tense.   I have seen compartment syndrome from this, though uncommonly.  More often, it needs to be opened and drained in the operating room.   The depth requires the limb to be filleted open, compared to the smaller incisions for the subcu abscesses, and the fact that the muscle bellies need to be opened up guarantees a bloody, messy procedure, which takes a long time to heal.

Worse, the IM injections predispose to necrotizing fasciitis and other bizarre infections.  We've seen several cases of honest-to-goodness botulism over the last few years.   Freaky stuff, and not for the faint of heart.   At least the complications of the China White were well-known, simple to spot, and easy to manage.

Seriously, there've got to be some entrepreneurial distributors out there who can bring China White to the West Coast, right?  Get to work on it!

That's a joke (I think).   Fortunately, heroin use isn't real common out here at all -- in fact, it's quite rare.   This region's drugs of choice have got to be an easy split between methamphetamines and oxycontin.

This is getting a little long, so I'll contrast those drugs tomorrow.


  1. thanks sf! best post ever.

  2. I think this is the only post of yours that I have read completely in about 6 months.

    Great synopsis, you need to write like this more often.

  3. One time I saw a couple of teenagers on the bus holding a small black chunk of who-knows-what and talking about it. You'd've thought it was chocolate, they were so keen about it. When I got to the office and mentioned this I was informed it must've been black tar.

    West Coast example.

  4. You would have loved one free-wheeling gentleman who used to show up at the facility I worked for from time to time. His nickname was 'Crazy Larry' and for a shooter, he was pretty rational. Unless he went cold turkey due to lack of supply, and then he'd try to shoot all sorts of remarkable things.

    Two of his favorites were cream of wheat and creamy peanut butter...

  5. Great post. Thank you.


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