Wound Botulism Associated With Black Tar Heroin Among Injecting Drug Users

• Published in: JAMA : the journal of the American Medical Association Vol. 279; no. 11; pp. 859 - 863
• Main Authors: Passaro, Douglas J, Werner, S. Benson, McGee, Jim, Mac Kenzie, William R, Vugia, Duc J
• Format: Journal Article
• Language: English
• Published: Chicago, IL American Medical Association 18.03.1998
• Subjects: Adult; Aged; Biological and medical sciences; Botulism; Botulism - epidemiology; Botulism - etiology; California - epidemiology; Case-Control Studies; Drug addictions; Female; Health risk assessment; Heroin; Humans; Injuries; Likelihood Functions; Male; Medical sciences; Middle Aged; Multivariate Analysis; Regression Analysis; Risk Factors; Statistics, Nonparametric; Studies; Substance Abuse, Intravenous - complications; Toxicology; Wound Infection - epidemiology; Wound Infection - etiology; California; United States; North America; America; Human; Drug addiction; Intravenous administration; Toxicity; Epidemiology; Wound; Infection; Botulism; Risk factor; Bacteriosis; Complication; Heroin; Public health
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.279.11.859

CONTEXT.— Wound botulism (WB) is a potentially lethal, descending, flaccid, paralysis that results when spores of Clostridium botulinum germinate in a wound and elaborate neurotoxin. Since 1988, California has experienced a dramatic increase in WB associated with injecting "black tar" heroin (BTH), a dark, tarry form of the drug. OBJECTIVE.— To identify risk factors for WB among injecting drug users (IDUs). DESIGN.— Case-control study based on data from in-person and telephone interviews. PARTICIPANTS.— Case patients (n=26) were IDUs who developed WB from January 1994 through February 1996. Controls (n=110) were IDUs newly enrolled in methadone detoxification programs in 4 counties. MAIN OUTCOME MEASURES.— Factors associated with the development of WB. RESULTS.— Among the 26 patients, the median age was 41.5 years, 15 (58%) were women, 14 (54%) were non-Hispanic white, 11 (42%) were Hispanic, and none were positive for the human immunodeficiency virus. Nearly all participants (96% of patients and 97% of controls) injected BTH, and the mean cumulative dose of BTH used per month was similar for patients and controls (27 g and 31 g, respectively; P=.6). Patients were more likely than controls to inject drugs subcutaneously or intramuscularly (92% vs 44%, P<.001) and used this route of drug administration more times per month (mean, 67 vs 24, P<.001), with a greater cumulative monthly dose of BTH (22.3 g vs 6.3 g, P<.001). A dose-response relationship was observed between the monthly cumulative dose of BTH injected subcutaneously or intramuscularly and the development of WB (χ2 for linear trend, 26.5; P<.001). In the final regression model, subcutaneous or intramuscular injection of BTH was the only behavior associated with WB among IDUs (odds ratio, 13.7; 95% confidence interval, 3.0-63.0). The risk for development of WB was not affected by cleaning the skin, cleaning injection paraphernalia, or sharing needles. CONCLUSIONS.— Injection of BTH intramuscularly or subcutaneously is the primary risk factor for the development of WB. Physicians in the western United States, where BTH is widely used, should be aware of the potential for WB to occur among IDUs.