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CASE REPORT Table of Contents  
Ahead of print publication
Complications as through presentation in pentazocine dependence among the healthcare personnel: A case series from consultation-liaison addiction psychiatry


1 Associate Professor, Department of Psychiatry, ESIC Medical College and Hospital, Hyderabad, Telangana, India
2 Senior Resident, Department of Psychiatry, ESIC Medical College and Hospital, Hyderabad, Telangana, India

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Date of Submission04-Dec-2021
Date of Acceptance18-Jan-2022
Date of Web Publication17-May-2022
 

  Abstract 


Pentazocine is a synthetic, narcotic analgesic, indicated for various moderate-to-severe pain conditions. Its use and dependence on health care personnel pose unique challenges that make them difficult in seeking help. Complications due to parenteral pentazocine injection resulted in significant impairment for day-to-day functioning and contribute to disability. Hence, we present a case series on pentazocine dependence in health care personnel along with chronic nonhealing ulcers, myofibrosis, inflammatory compartmental syndromes like puffy hand syndrome and highlighting the integrative management of it.

Keywords: Health care professional, myofibrosis, pentazocine, puffy hand syndrome, ulcers


How to cite this URL:
Dhagudu NK, Attili S. Complications as through presentation in pentazocine dependence among the healthcare personnel: A case series from consultation-liaison addiction psychiatry. Arch Ment Health [Epub ahead of print] [cited 2022 Nov 29]. Available from: https://www.amhonline.org/preprintarticle.asp?id=345400





  Introduction Top


Pentazocine is a synthetic opioid, narcotic analgesic, commonly used for moderate to severe pain secondary to various conditions. Complications due to parenteral pentazocine misuse like localized ulceration, abscess, induration, sclerosis, and myofibrosis are well-documented.[1] Apart from pentazocine, other narcotics are also reported like butorphanol, propoxyphene, heroin, piritramide, methadone, and meperidine. There are only a few reports on secondary pentazocine-induced complications, especially in health care personnel, about soft tissue infection as a compartmental syndrome called puffy hand syndrome and its myofibrotic changes.[2] After taking informed consent, we report a case series who were presented with pentazocine dependence among the doctors and its severe induced or secondary surgical complications of inflammatory swellings, ulcers, and myofibrotic changes of all peripheries.


  Case Series Top


Case 1

We present the case of a 30-year-old right-handed man, who presented as consultation and liaison referral from the general surgery department, for his multiple time presentation for swollen peripheries with multiple surgical drainage intervention scars and hypopigmented and hyperpigmented healed and nonhealed ulcers along with myofibrotic changes. He had significant impairment of his daily activities including the lifting of arms, holding the things, walking and some extent bending also [forward, backward, and sideways] and so on. The impairment was to the extent that he needed assistance in taking food and for other needs. Due to the involvement of pelvic girdle muscles, his gait had become short-stepping. Furthermore, he could not abduct his thighs more than 40°, contributing to significant gait and daily functioning disability.

While in addiction psychiatry specialty evaluation, he started to report his pentazocine use from the time, i.e., 6 years before, when he was working as a private medical practitioner in a private hospital at his native place. He used to inject his pentazocine use daily with 1 ampoule along with his girlfriend and for that reason he claimed that bonding between them increased and turned out to be a love relationship. Initial few days he used to inject with the help of his girlfriend, later he used himself. Within 6 months later, he escalated the quantity to 150 mg to 300 mg per day intravenous route. The hospital chief physician inquired about his swellings and abscess on forearms, for that he revealed his pentazocine misuse; subsequently, he got terminated from work for the inadvertent use of pentazocine. After this work-related loss, as a relief choice, he further escalated his pentazocine requirement from 900 to 1200 mg for the adjustment problems after separation from that loving relationship and in jobless distress states. Later, he selected a physician job at the chemical factory where he found that nobody knows his pentazocine injecting use. However, his injecting-related nonhealing, painless ulcers and swellings become problematic and hampering to do work. Meanwhile, in the last 3 years, he did not do any work and needed to consult the surgery department frequently for incision and drainage of swellings and the wounds care of one over other limb involved.

On examination, he had difficulty in flexing both upper limbs. Wasting of the left arm was there, along-with hyper fibrotic swelling and multiple hypo-pigmented scars in the left forearm and hand [Figure 1]. On right upper limb forearm had multiple 4 cm × 5 cm sized punched out ulcers with irregular in shaped, hyperpigmented to violaceous margins along with gangrenous swelling of the hand [Figure 2]. Both lower limbs had multiple healed atrophic linear distribution scars at the site of injections [Figure 3]. No venous access was found and all lower limb veins thickened and fibrosis. Furthermore, he had a gait disability that resulted in form of short stepping and difficulty rising from the supine position and bending from a standing position. Other systemic examinations revealed no abnormality.
Figure 1: Hypopigmented scar marks with fibrosis

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Figure 2: Puffy hand syndrome

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Figure 3: Multiple healed atrophic linear scars

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On investigation, complete hemogram, liver and renal function tests, and serum creatinine were within the normal limits and HIV testing turns negative. He got diagnosed with opioid dependence syndrome for his pentazocine use for the features of craving, tolerance, withdrawals and using despite physical harms. As a treatment, he was on buprenorphine maintenance for the last 1 year and was adherent to follow-ups for the same period. We consider weekly dispensing for him because of the multiple and frequent necessity of surgical consultations and admissions.

Case 2

A 68-year-old married male, a physician, who belongs to a semi-urban area came with a history of 30 years of pentazocine use, in a dependence pattern presented through a consultation-liaison referral from the cardiology department having complaints of shortness of breath, abnormal sensations in the peripheries. The reasons for referring the subject have presented with opioid withdrawals such as restlessness, anxiety and abnormal pain sensation which does not corroborate with the routine investigations.

As part of a detailed assessment, the subject reveals their intravenous use of pentazocine 90 mg/day for the last 30 years in a dependant pattern which was started from 30 mg/day as pain relief from their routine work as well as for getting pleasure from that. Eventually, the person started to get local complications at intravenous sites like healed ulcers, hyperpigmentation's later on mobility restrictions on areas both upper limbs and lower limbs.

Hence, he had significant impairment of his daily routine activities such as lifting arms, walking in straight, forward bending, broad-based gait, apparently limping while walking. He couldn't abduct his thighs not more than 50°. He did not reveal his intravenous pentazocine use to other health-care givers wherever he requires to consult them for various health reasons because of perceived stigma and discrimination for his substance use. He had the motivation to stop his intravenous pentazocine use due to progressive restriction of accessible areas to inject and frequent ulcers at injection sites. However, he always had feared to stop for his imminent sickness caused by his opioid withdrawals especially, which were going to peak at 1-week interval. Hence, for that reason, he was unable to sustain his abstinence for not more than 10 days. He completely relied on substance use on Family members to procure it despite frequent criticism from them.

On physical examination, he had difficulty in flexing both upper limbs and lower limbs and also noted wasting of the left arm along with multiple hyper and hypopigmented scars in the left forearm along with unequal hyper fibrotic changes in the arm area [Figure 4]. On the left thigh area, he had multiple 2–4 cm × 2–5 cm size punched out healing ulcers which are irregular in shape, hyperpigmented, hyper fibrotic swelling are noted [Figure 5]. In both limbs had multiple healed atrophic linear distribution of scars noted at the site of injections.
Figure 4: Hyper pigmented and hyper fibrotic scars

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Figure 5: Hyper pigmented punched out healing ulcers in left thigh

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On investigation, it was found that decreased hemoglobin levels (8 g), raised liver enzyme levels 1–2 times, having serum creatinine 1.8 mg/dl, 2D-echo has shown that ejection fraction was 40%–50% and diagnosed with infective endocarditis by cardiology team and pyelonephritis by nephrology team as they were noted as systemic complications of intravenous pentazocine use. As part of consultation-liaison management, he was diagnosed with opioid dependence syndrome as per International Classification of Diseases-10 criteria, for the first time for his features of tolerance, withdrawals, use despite local and systemic complications and craving. Psychoeducation was given to the patient and patient attendants regarding the nature of opioid-dependant syndrome and discussion with other medical teams regarding the patients' opioid-dependant syndrome and its complications along with management strategies in a collaborative manner. Importantly asserted that need for long-term care of his opioid dependence syndrome with anti-craving medicine (buprenorphine) along with psychosocial support.


  Discussion Top


The rate of overall substance misuse in physicians or health care personnel is similar to that of the general population, but opiates are more because of easy access to them and having knowledge about its effects. Although the diagnosis of pentazocine induced ulcers easy by its characteristic presentations like “skin popping” called for pentazocine injection resulted punched out irregular shaped deep ulcers with black eschar and woody induration of surrounding inflammation, a halo of hyperpigmentation around the ulcer, trails like linear, multiple, needle marks and other destructive cutaneous manifestations including dermal fibrosis, granulomatous inflammation, and vascular thrombosis, puffy hand syndrome and myofibrosis are well described in the literature.[2] However, this is not the case in all because of social stigma, especially among the health care professionals who presented to other medical specialties for their comorbid conditions and perceived alienation and threat of job loss.[3] Hence, a high index of suspicion is required in health care personnel who present with ulcers with its unique characteristics to identify parenteral opiate users and its dependence in early stages before reaching severe devastating complications like woody indurate ulcers with punched out margins, thrombophlebitis, myofibrosis, and its resulted compartmental syndrome and cellulitis or gangrenous changes called “puffy hand syndrome.”[4] Another reason is painless nature of these ulcers makes the discomfort disproportionately less than the extent of ulcer involvement.[5] Hence, here in this case series of the above two, as they presented for treatment to seek help only after the experiencing of these above said secondary complications due to parenteral pentazocine dependent use.

Pentazocine-induced ulcers are known for not responding with conservative treatment, therefore for better recovery early surgical intervention in form of incision and drainage for swellings, abscess, and its secondary compartmental syndrome. Surgical excision and grafting for early healing of ulcer required.[6],[7],[8],[9],[10] Comprehensive collaborative management is required particularly in consultation-liaison with other medical specialties and as well person-centered medical considerations are essential to limit their disability.

Although pentazocine injection is common to see in an addiction psychiatry setting it is worthy to mention the magnanimity of progression of complications and disability in the course of parenteral pentazocine dependence in a health care personnel perspective. Hence this case series highlights the worth of integrative collaborative care that has not commonly seen among the physicians/doctors who is encountered by other physicians in developing countries, it deserves to mention the need for understanding.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parks DL, Perry HO, Muller SA. Cutaneous complications of pentazocine injections. Arch Dermatol 1971;104:231-5.  Back to cited text no. 1
    
2.
Schlicher JE, Zuehlke RL, Lynch PJ. Local changes at the site of pentazocine injection. Arch Dermatol 1971;104:90-1.  Back to cited text no. 2
    
3.
Domino KB, Hornbein TF, Polissar NL, Renner G, Johnson J, Alberti S, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005;293:1453-60.  Back to cited text no. 3
    
4.
Neviaser RJ, Butterfield WC, Wieche DR. The puffy hand of drug addiction: A study of the pathogenesis. J Bone Joint Surg Am 1972;54:629-33.  Back to cited text no. 4
    
5.
Prasad H, Khaitan BK, Ramam M, Sharma VK, Pandhi RK, Agarwal S, et al. Diagnostic clinical features of pentazocine-induced ulcers. Int J Dermatol 2005;44:910-5.  Back to cited text no. 5
    
6.
Oh SJ, Rollins JL, Lewis I. Pentazocine-induced fibrous myopathy. JAMA 1975;231:271-3.  Back to cited text no. 6
    
7.
Goyal V, Chawla JM, Balhara YP, Shukla G, Singh S, Behari M. Calcific myofibrosis due to pentazocine abuse: A case report. J Med Case Rep 2008;2:160.  Back to cited text no. 7
    
8.
Agashe VM, Patil H, Gundavda MK. Multiple skin abscesses and myofibrosis of bilateral lower limbs following repeated intramuscular injection of pentazocine with concomitant tuberculous infection. J Orthop Case Rep 2015;5:15-8.  Back to cited text no. 8
    
9.
Roberson JR, Dimon JH 3rd. Myofibrosis and joint contractures caused by injections of pentazocine. A case report. J Bone Joint Surg Am 1983;65:1007-9.  Back to cited text no. 9
    
10.
Jain A, Bhattacharya SN, Singal A, Baruah MC, Bhatia A. Pentazocine induced widespread cutaneous and myo-fibrosis. J Dermatol 1999;26:368-70.  Back to cited text no. 10
    

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Correspondence Address:
Naveen Kumar Dhagudu,
Associate Professor, Department of Psychiatry, ESIC Medical College and Hospital, Hyderabad
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amh.amh_180_21



    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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