Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 56-60

The surgical complications of pentazoine addiction among health workers in the Ladoke Akintola University of Technology Teaching Hospitals


1 Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria
2 Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Oyo State, Nigeria

Date of Web Publication20-Apr-2018

Correspondence Address:
Dr. Ganiyu O Oseni
Department of Surgery, College of Health Sciences, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_13_17

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  Abstract 

Objective: To present some of the hazards prevalent because of the usage of pentazocine injection and create awareness for the prevention and early detection of its resulting complications to reduce morbidity and mortality in our environment.
Design: A retrospective cohort study.
Setting: The Ladoke Akintola University of Technology Teaching Hospital, Osogbo and Ogbomoso centers.
Patients and Methods: The surgical management of 11 health workers with complications because of pentazocine injection between December 2013 and November 2014.
Results: Eleven health workers presented with complications, which needed surgical intervention, because of pentazocine injection. Among the health workers, five were females and six were males, with four medical doctors, three nurses, three attendants, and one medical student.
Conclusion: A lack of knowledge regarding the risks because of pentazocine addiction and the easy availability of this drug over the counter have contributed immensely to the insurgence of its surgical complications. Health education should be directed toward prevention, early diagnosis, and management to abolish or reduce morbidity associated with these complications.

Keywords: Addiction, complications, health workers, myopathy, narcotic drugs, pentazocine


How to cite this article:
Oseni GO, Olaitan PB, Olakulehin OA, Akanbi OO, Adebayo KO, Oyewole AO, Onilede DA. The surgical complications of pentazoine addiction among health workers in the Ladoke Akintola University of Technology Teaching Hospitals. Nigerian J Plast Surg 2017;13:56-60

How to cite this URL:
Oseni GO, Olaitan PB, Olakulehin OA, Akanbi OO, Adebayo KO, Oyewole AO, Onilede DA. The surgical complications of pentazoine addiction among health workers in the Ladoke Akintola University of Technology Teaching Hospitals. Nigerian J Plast Surg [serial online] 2017 [cited 2018 Sep 19];13:56-60. Available from: http://www.njps.org/text.asp?2017/13/2/56/230800


  Introduction Top


Pentazocine addiction is becoming a serious health issue in Nigeria because of its associated complications and socioeconomic impact on the community. It is a mixed agonist–antagonist synthetic narcotic analgesic derived from benzomorphan. It was approved by the Food and Drug Administration in 1967[1] and is used to treat moderate to severe pain. Many of its complications such as deep irregular ulcer, induration, and myopathy have been reported in the literature.[1],[2],[3] Although a narcotic drug, its addictive and dependency potential have not been well recognized. Its addiction is more common among health workers.[1] The abuse potential of a drug is usually not known until it has been used for some periods. Therefore, henceforth, a constant monitoring of all suspected drugs is needed to prevent any unwanted and dangerous effect.

This report presents a case series of health workers who presented in the plastic surgery unit with musculocutaneous complications following the abuse of pentazocine. All of them presented with varying musculoskeletal complications necessitating surgical procedures. The complications as well as the management of these complications are documented in this article [Figure 1].
Figure 1: Multiple scars on the buttock and arms following repeated pentazocine injection

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  Patients and methods Top


This is a retrospective study of 11 health workers with varying complications associated with addiction to pentazocine, which needed surgical interventions. The case notes of the patients were the source of information from which age, sex, occupation, the duration of addiction, complications, as well as treatment given were documented. The information was descriptively analyzed [Table 1].
Table 1: Detailed summary of all the health workers addicted to pentazocine

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  Results Top


Eleven health workers were managed between December 2013 and November 2014 with a female-to-male ratio of 5:6. Their ages ranged between 21 and 62 years. There were four medical doctors (two surgeons and two medical officers), three nurses, three health attendants, and one medical student.

The health workers had their first experience with the injection usually through a prescription by their physicians for medical problems including postoperative pain (5; 45.4%), trauma (2; 18.2%), sickle cell crisis (2; 18.5%), abdominal pain (1; 9.1%), and tooth ache (1; 9.1%). The route of administration of pentazocine injection by all the patients was intramuscular, however, two of the physicians sometimes used intravenous route in addition to intramuscular route [Figure 1]. The sites of injection were usually the gluteal region, thighs, forearm, arm, deltoid region, and anterior abdominal wall in that order.

All of them took at least eight ampoules (240 mg) of pentazocine per day. The most common presenting complaints were discharging sinuses (10; 90.9%), lower limb edema (4; 36.4%), ulcers (3; 27.3%), hip and knee contractures (2; 18.2%), skin fibrosis (6; 54.5%), and scarring(4; 36.4%). Two (18.2%) patients presented with septicemia out of which one was a physician and died of overwhelming sepsis. 1 (9.1%) patient presented with convulsion and depression. One of the patients died from overwhelming sepsis [Table 2].
Table 2: Complications observed among the health workers

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  Discussion Top


The abuse of the prescription of opioids such as pentazocine is on the rise in Nigeria. This drug was not known in Nigeria in the seventies when its usage was mainly confined to the USA.[4],[5] However, in recent times, pentazocine injection has become rampart in all cadres of health institutions in Nigeria for the treatment of postoperative and other forms of pain. The use of pentazocine has risen due to the nonavailability of other opioids such as pethidine and morphine. The intramuscular use of pentazocine, which is the most common route in this environment, can give rise to dermal vascular thrombosis, granulomatous inflammation, and fibrosis,[6],[7],[8] leading to dermal necrosis and ulceration [Figure 1]. Focal myopathy and fibrosis[9],[10] as a result of the use of pentazocine have also been described [Figure 2]. The frequent use of this drug as regularly as seen in these patients, therefore, predisposes the patients in this study to these complications. Fibromyositis is a rare side effect because of intramuscular opioid use. The pathogenesis of these complications is not known. However, it may be that the acidic pentazocine crystallizes in the neutral or slightly alkaline medium of extracellular fluid,[7],[8],[9],[10] which then causes chronic inflammatory response and subsequent fibrosis. The fibrosis formed causes obstruction of the lymphatic vessels, lymph stasis, and a subsequent superimposed infection of the subcutaneous tissue and the edema of the affected limb. The role of infection in the development of fibrosis because of drug abuse has not been documented in the literature. However, a superimposed infection of the chronic irritation by the pentazocine crystals may lead to chronic abscess that is finally discharged through the skin [Figure 2]. This is supported by the operative findings in some of our patients, in whom the sinuses were confined to the subcutaneous fatty layer and rarely spread beyond the deep fascia with the deeper tissues being spared [Figure 3]. Bony calcifications in the muscles involved as well as the subcutaneous tissues were observed in four of the patients. These may be a result of the crystals of pentazocine being secondarily infected on a chronic basis. These also helped to perpetuate myositis, cellulitis, and some sepsis as noted in the patients in this study. A frequent and repeated debridement of the sinuses, myositis, and necrotic wounds was not only common but also necessary as a result of repeated infections and sepsis. Soft tissue necrosis and skin loss were seen in a few of the patients who had to have local tissue management and flap cover [Figure 4].
Figure 2: Myositis, myopathy, and sinuses on the gluteal region and thigh from repeated injections

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Figure 3: Intraoperative findings and soft tissue deficiency following debridement

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Figure 4: Skin loss, contracted hip, and gluteal skin contracture from repeated skin necrosis

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There are only a few publications on narcotic addiction and dependence in Nigeria, probably due to the fact that they are not readily accessible without prescription by the doctors. However, a strong analgesic effect of pentazocine along with its tolerance and availability without prescription may be responsible for the increasing complications of the drug in the developing countries. Health workers, who have free access to this drug, are, therefore, the most affected by the addiction.

The management of pentazocine addiction in Nigeria is always challenging, most especially, when it involves health workers who have free access to the drug in view of their profession and in a society where stigmatization is a major issue. The management of pentazocine addiction, which involves the treatment of dependency as well as surgical complications, is always difficult to enforce on the affected individuals because of the risk of job loss in the process of management and stigmatization. This is reflected in this study by poor treatment compliance of these patients and loss to follow-up. These patients were comanaged with psychiatrists and psychologists, but they were all lost to follow-up after the wound healed.


  Conclusion Top


Physicians as well as other health workers, developing focal muscle induration and a restriction of movements especially in the quadriceps or glutei, need to be asked for a history of intramuscular drug abuse especially for pentazocine in our environment. It should be noted that most of the patients in this study freely confessed to their addiction and had a desire to quit. However, they all found this extremely difficult in spite of the complications. A lack of standardized treatment protocol for substance abuse has, thus, resulted in limited follow-up visits by the patients, as well as increasing the chances of relapse. This has also led to recurrent wounds, sinuses, ulcers, scarring, and contractures, and they are hardly ever free from wounds.

The history regarding drug use should be taken during the evaluation of multiple cutaneous ulcers or discharging sinuses on the thighs and upper limbs, with atypical form of myopathy with contractures.[8],[9],[10] Treatment methods need to focus on the skin infection, myopathy, as well as detoxification and abstinence from drug.[4] Health education of the health workers, as well as of the populace, on the possible complications of parenteral pentazocine would go a long way in reducing these complications. There should be a law restricting the sale of pentazocine over the counter in Nigeria, because this will reduce the free access to this drug by health workers as well as other members of the community. Research has shown that providing treatment in different settings results in fragmented and ultimately ineffective care.[11] Therefore, there is need to establish addiction centers in the tertiary health facilities or revamp addiction services, which are usually set up to handle addiction primarily as an acute or transitory problem and to treat it as a self-contained illness.

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.
Agarwal S, Trivedi M. Cutaneous complications of pentazocine abuse. Indian J Dermatol Venereol Leprol 2007;73:280.  Back to cited text no. 1
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2.
De D, Dogra S, Kanwar AJ. Pentazocine-induced leg ulcers and fibrous papules. Indian J Dermatol Venereol Leprol 2007;73:112-3.  Back to cited text no. 2
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3.
Schlicher JE, Zuehlke RL, Lynch PJ. Local changes at site of pentazocine injection. Arch Dermatol 1971;104:90-1.  Back to cited text no. 3
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4.
Mudrick C, Isaacs J, Frankenhoff J. Case report: Injectable pentazocine abuse leading to necrotizing soft tissue infection and florid osteomyelitis. Hand (N Y) 2011;6:457-9.  Back to cited text no. 4
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5.
Oh SJ, Rollins JL, Lewis I. Pentazocine induced fibrous myopathy. JAMA 1975;231:271-3.  Back to cited text no. 5
[PUBMED]    
6.
Palestine RF, Millns JL, Spigel GT, Schroeter AL. Skin manifestations of pentazocine abuse. J Am Acad Dermatol 1980;2:47-55.  Back to cited text no. 6
[PUBMED]    
7.
Schlicher JE, Zuchlke RL, Lynch PJ. Local changes at the site of pentazocine injection. Arch Dermatol 1971;104:90-1.  Back to cited text no. 7
    
8.
Winfield JB, Greer K. Cutaneous complications of parenterally administered pentazocine. JAMA 1973;226:189-90.  Back to cited text no. 8
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9.
Das CP, Thussu A, Prabhakar S, Banerjee AK. Pentazocine induced fibromyositis and contracture. Postgrad Med J 1999;75:361-2.  Back to cited text no. 9
[PUBMED]    
10.
Silva MC, Singh P, Murthy P. Fibromyositis after intramuscular pentazocine abuse. J Postgrad Med 2002;48:239.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Fleury MJ, Brochu S. Addictions with co-occurring problems: Statistics and challenges. J Addict Res Ther 2014;S10:e001.  Back to cited text no. 11
    


    Figures

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

  [Table 1], [Table 2]



 

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