- For early treatment, physicians should understand varied uses of additives to suspect and detect local or systemic complications
With the number of people who inject drugs on the rise, for early treatment, it is essential that attending physicians have a thorough understanding of the uses of varied additives in order to suspect and detect resultant local or systemic complications.
These observations were made in a letter to the editors of the Sri Lanka Journal of Medicine on “Pinpointing the additive: A peculiar skin manifestation among intravenous drug injectors” by B.M. Munasinghe (attached to the Mannar District General Hospital’s Anaesthesiology and Intensive Care Department as a Consultant Anaesthetist [Acting]) and S. Pranavan and U. Mayorathan (both attached to the Jaffna Teaching Hospital’s Judicial Medical Officer’s Office), which was published in the said journal’s 32nd volume’s first issue in August 2023.
The world has, as mentioned in the “Global prevalence of injecting drug use, and socio-demographic characteristics and the prevalence of human immunodeficiency virus, the hepatitis B virus, and the hepatitis C virus in people who inject drugs: A multi-stage systematic review” by L. Degenhardt, A. Peacock, S. Colledge, J. Leung, J. Grebely, P. Vickerman, J. Stone, E.B. Cunningham, A. Trickey, K. Dumchev, M. Lynskey, P. Griffiths, R.P. Mattick, M. Hickman, and S. Larney, during the last 15 years, seen a steady rise in people who inject drugs, a significant number of whom are represented by Asian countries. The available Sri Lankan data (the National Dangerous Drugs Control Board’s “Handbook of drug abuse information in Sri Lanka 2017”) show a preference for heroin and cocaine as intravenously injected drugs.
Numerous additives are used by people who inject drugs in order to make these drugs more water soluble, rapid-acting, and with prolonged euphoric effects. Lime juice is one such additive injected with heroin and less commonly with “crack” or unpurified cocaine. As mentioned in H.F. Newton-John, K. Wise, and D.F. Looke’s “Role of the lemon in disseminated candidiasis (Candida is a yeast-like parasitic fungus that can sometimes cause thrush, which is the infection of the mouth and throat and/or genitals, causing whitish patches and/or a whitish discharge) of heroin abusers” and J.B. Page and J.S. Fraile’s “Lemon juice is a solvent for heroin in Spain”, the initial documented cases of the use of lime juice with intravenous illicit drugs were reported in the late 1980s.
These early reports were followed by, as documented in T.A. Albini, R.L. Sun, E.R. Holz, R.N. Khurana, and N.A. Rao’s “Lemon juice and Candida endophthalmitis (a purulent fungal infection involving the intraocular fluids) in crack cocaine misuse”, J.W. Welsh, C. Rodriguez, and J. Suzuki’s “Bilateral upper extremity cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) from injecting crack cocaine dissolved in lemon juice: A case report”, and J. Bisbe, J.M. Miro, X. Latorre, A. Moreno, J. Mallolas, J.M. Gatell, J.P.D.L. Bellacasa, and E. Soriano’s “Disseminated candidiasis in addicts who use brown heroin: Report of 83 cases and review”, a persistent occurrence of additive (lime juice)-associated, localised, and potentially fatal systemic complications including disseminated candidiasis, Candida endophthalmitis, endocarditis (inflammation of the endocardium [the thin, smooth membrane which lines the inside of the chambers of the heart and forms the surface of the valves]), and upper limb cellulitis.
Munasinghe et al. reported two cases of characteristic skin manifestations in heroin injectors who regularly use lime juice as an additive. The two suspected intravenous illicit drug injectors were produced by the Police for forensic pathology. Both were young males, aged 22 and 24 years, respectively. They strongly denied any history or current use of illicit drugs.
On examination, distinct “track marks” were visible on the anterior cubital fossa (an area of transition between the anatomical arm and the forearm which is located in a depression on the anterior surface of the elbow joint). These were longitudinal, purplish lines corresponding to the path of the anterior cubital vein. No abscess formation was noted locally, and the rest of the vital parameters of the suspects were stable.
On further questioning, they admitted to using intravenous heroin for the last three years. To increase the ease of intravenous administration, they had started adding lime juice prepared by themselves a year back. As the euphoric effect was markedly potentiated by lime juice, it was regularly added to heroin, frequently three to four drops per injection. Following this, they noticed the discolouration of the injection site which was covered with long sleeves. Up to this medical visit, they have had several episodes of fever within the year, which were managed at home. They were referred for further investigations to look for any serious infection, which yielded negative results.
The cutaneous manifestations following intravenous illicit use of drugs are multiple. The “track marks” are produced by repeated intravenous injection. The subsequent sclerosis (abnormal hardening of body tissue) of the overlying skin leads to hyperpigmentation. Due to a lack of sclerosing additives, cocaine injections do not lead to track marks in comparison to heroin.
According to M. Harris, J. Scott, T. Wright, R. Brathwaite, D. Ciccarone, and V. Hope’s “Injecting-related health harms and the overuse of acidifiers among people who inject heroin and crack cocaine in London, England: A mixed methods study”, the use of lime or lemon juice is believed to exert additional vascular damage resulting in multiple attempts at injection, skin and soft tissue infection, and the use of inguinal (groin) veins such as the femoral vein (a large blood vessel in the thighs which collects deoxygenated blood from tissues in the lower legs and helps move it to the heart) with the risk of deep vein thrombosis (occurs when a blood clot/thrombus forms in one or more of the deep veins in the body, usually in the legs).
To convert to a water-soluble form for intravenous injection, both heroin and “crack” cocaine need to be mixed with acid. J. Scott, A. Winfield, E. Kennedy, and C. Bond’s “Laboratory study of the effects of citric and ascorbic acids on injections prepared with brown heroin” elaborate that lemon or lime and vinegar are the most commonly used, containing citric and acetic acid, respectively.
There is a potentially disruptive nature of highly concentrated lime or lemon juice on injecting vessels and subsequent vein sclerosis. It is thought that contaminated lemon or lime juice is the source of Candida growth in complicated cases.
The freely available nature and low cost of these additives pose a greater threat to being used in a non-sterile manner and in high concentrations. Similarly, due to the stigma of using visible veins, people nowadays, who inject drugs, have resorted to anatomical locations such as the popliteal (situated in the hollow at the back of the knee) veins and femoral veins, which might not reveal the injection sites and possible local infection related to drug or additive use.