31 March 2011

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).


Originally published April 2009


  1. That's really interesting. In these cases is the ER obligated in any way to offer or encourage drug rehab? What are the worst-cast complications, especially if the user doesn't wait for the wound to heal before injecting again?

  2. I meant to add that I can't fathom being addicted to something so badly that I'd essentially let me flesh rot just to get high. Yuck!

  3. Or, we could just legalize and regulate it. Pharma-grade, sterile, and cheap.

  4. It's funny, I've been working with drug users for 4 years, and I've never actually seen China White! Black tar only once.
    Here in Vancouver we get a sort of hybrid that is powdery, and light brown. It dissolves easily in water and mixes to a slightly yellowish/brown clear fluid.
    With that, we are lucky enough to see the kind of abcesses you are waxing poetic about ;) Except where I work we aren't able to lance, so we let the magic of Mesalt do it's thing!

  5. I, too, trained on the East Coast and have been transplanted to the west coast. I miss simple heroin and cocaine. Weird stuff out here with the black tar, and meth, well 'nuff said.

  6. *completely inappropriate fake resurrect*

    I once got a guy with one-sided necrotizing fasciitis of the neck and face from injecting black tar into the neck. I still get the urge to facepalm when recalling it.


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