A Case of Acute Opioid Withdrawal after Liposuction Surgery in a Patient on Extended-release Buprenorphine.

BACKGROUND: The US Food and Drug Administration approved the once-monthly injectable extended-release buprenorphine product to treat moderate-to-severe opioid use disorders. The patient in our case report had a liposuction procedure and immediately started having opioid withdrawal symptoms after the procedure. CASE DESCRIPTION: The patient is a 27-year-old African-American woman who injects drugs and has morbid obesity. She enrolled in a medications for addiction treatment program and opted to get treated with extended-release buprenorphine monthly injections. She tolerated them well for a span of 6 months. In one clinic visit, she reported opioid withdrawal symptoms and started purchasing and using sublingual buprenorphine from her acquaintances. On review of history, she underwent liposuction surgery and this triggered the opioid withdrawal symptoms. Examining her abdomen revealed surgical scars at the site of the buprenorphine injection and the residual buprenorphine depot was not palpable.A subcutaneous injection of 300-mg extended release buprenorphine was administered in the right periumbilical area in this clinic visit. The following week, she was doing well and denied any withdrawal symptoms. DISCUSSION: This is a unique case of "iatrogenic opioid withdrawal" after a fairly common surgical procedure. The extended-release buprenorphine formulation solidifies when it comes into contact with bodily fluids forming a depot. The depot and surrounding adipose tissue may have been removed during the patient's liposuction procedure, causing an immediate drop in buprenorphine levels leading to acute opioid withdrawal.This case report highlights the precautions that need to be taken before patients go for a surgical procedure like liposuction.

Hepatitis C Treatment in Persons Who Inject Drugs in a Medication Assisted Treatment Program: A Retrospective Review of an Integrated Model.

BACKGROUND: Hepatitis C virus (HCV) infection is common among persons who inject drugs (PWID), mostly due to needle sharing. The number of new cases in PWID are steadily increasing despite the availability of effective treatments. The objective of this model is to increase uptake and compliance with HCV treatment. We developed a model to treat HCV and opioid use disorder simultaneously in a methadone maintenance program. METHODS: Patients were screened on site for HCV at admission and then annually. Once HCV was positive, the genotypes and fibrosis scores were identified. Patients were enrolled into the treatment program after obtaining written consent. Patients either self-administered the medications at home or utilized a directly observed treatment (DOT). The sustained virologic response (SVR) was tested at 12 weeks posttreatment. We conducted a retrospective review of patients who received treatment and reviewed the demographic data, co-infections, medication administration, and SVR results at the end of study period. RESULTS: One hundred ninety patients were identified as Hepatitis C positive. 88.9% (169 patients) received HCV treatment during the study period. 62.7% (106 patients) were male and 37.3% were female (63 patients). 62.7% of them (106 patients) completed HCV treatment by the end of study period. Out of them, 96.2% (102 patients) achieved SVR. 68.9% (73 patients) utilized DOT for medication administration. CONCLUSIONS: Our model successfully treated HCV in our patient population, who are otherwise deprived of resources and access to health care. Replicating this model is a potential strategy to reduce the disease burden and break the transmission cycle of HCV.

Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA.

Xylazine, an alpha-2 adrenergic receptor agonist typically used as a sedative and analgesic in veterinary medicine, is being illicitly supplied to persons who inject drugs (PWID), especially in Puerto Rico and Philadelphia, Pennsylvania in the USA. There is a high prevalence (up to 78%) of xylazine in fentanyl in these areas and also a steep increase in fatalities from its overdose. In this case report, we discuss a case of xylazine-induced skin ulcers in a PWID in the city of Philadelphia. The patient is a 37-year-old female who was injecting about eight to ten "bags" of "dope" (fentanyl, which is typically mixed with xylazine in Philadelphia) every day. She typically injected into her veins on the hands and sometimes into the legs. She presented with ulcers on her lower extremities extending from the knees to ankles, associated with copious purulent drainage and a foul smell. There was extensive necrosis of the subcutaneous tissues, abscesses, and tibial osteomyelitis. This led to multiple hospitalizations with bacteremia from Strep pyogenes, methicillin-resistant Staphylococcus aureus, methicillin-sensitive S. aureus, Enterococcus faecalis, Escherichia coli, and Proteus requiring intravenous antibiotics. She required debridement of the wounds and topical care to treat them. In the areas with a high prevalence of the use of xylazine mixed with fentanyl or heroin, abscesses, and painful skin ulcers are very often reported. The mechanism is thought to be due to its direct vasoconstricting effect on local blood vessels and the resultant decreased skin perfusion. Prolonged use can lead to decreased perfusion and impaired wound healing, leading to higher chances of infection of these ulcers. In addition to the topical effect of vasoconstriction, xylazine also leads to hypotension, bradycardia, and respiratory depression. A skin ulcer in a PWID, similar to the ones reported in our case, should raise clinical suspicion for the presence of xylazine in opiates and other substances.

Buprenorphine Implant Removal 7 Years Postinsertion: A Case Report.

: A long-acting buprenorphine subdermal implant, Probuphine, was approved by the Food and Drug Administration (FDA) in May 2016, for the maintenance treatment of patients with opioid-use disorder. Long-acting implants offer the potential benefits of improved medication adherence, consistent daily dosing, and reduced risk of medication diversion. Sets of 4 implants are typically inserted for a period of 6 months and then removed. Similar technology has been successfully utilized in implantable formulations of birth control medications; however, there is currently little clinical experience involving buprenorphine implants that have remained in the body for extended periods of time. This is a case report involving an early clinical study subject who had been lost to follow-up at the time of the original study because of incarceration. Despite the protracted duration of time since initial implantation, all 4 implants remained easily palpable, and displayed little physical deterioration or tissue infiltration. All implants were able to be removed using the standard explant technique of midline incision and limited tissue dissection. While extending length of treatment beyond the indicated 6-month period is not being espoused, this case demonstrates that although situations may arise where implants may remain in an individual for longer than the intended dosing period, implants may be removed safely despite remaining implanted for longer than intended.