DRUG POINTS Death from pulmonary microembolisation after intravenous injection of temazepam

Dr E J VELLA (Pathology Laboratory, Lakin Road, Warwick CV34 5BJ) and Dr C W EDWARDS (Departme9e of Pathology, East Birmingham Hospital, Birmingham B9 5ST) write: A 31 year old female drug misuser presented with pain in her right leg. She told the casualty doctor that a few hours previously she had crushed a few 10 mg tablets of temazepam, dissolved them in water, and injected the solution intravenously into her right groin. No abnormality was found on examination. She was given paracetamol for the pain and sent home, where she died about 38 hours later. At necropsy there was no arterial or venous thrombosis in the leg. Histologically, small pulmonary vessels contained basophilic fibrillary foreign material, which was also present in small vessels in the right groin. Postmortem blood samples showed temazepam (286 ,ug/l) and methadone (120 ,ug/l), plus traces of diazepam, desmethyldiazepam, and a breakdown product of chlormethiazole. These results showed no evidence of drug overdose, and death was attributed to pulmonary microembolisation of material injected intravenously into the right groin. The severe morbidity associated with intra-arterial injection of temazepam has been well described,' but the dangers of intravenous injection are not well recognised. The present case appears to be the first recorded death associated with intravenous temazepam injection, and the pulmonary microemboli have not to our knowledge been described. The nature of the foreign material in the small vessels of the lungs and groin is uncertain. It might represent contaminants introduced during crude filtration by the abuser before injection; cigarette filters are often used for this purpose (J Drake, personal communication). If so, this material could be responsible for the vascular blockages and rhabdomyolysis which have been described after intra-arterial injection of temazepam gel.2 Other possibilities include excipients of temazepam tablets such as crospovidone, which is a hygroscopic, plastic like material commonly used to carry water insoluble drugs. It has been suggested that temazepam tablets are less "abusable" than the capsules and should be prescribed in preference.34 This case shows that determined abusers of temazepam will devise methods of injecting the tablets, and that this can lead to death. We thank Amanda Fellows, drug information pharmacist at South Warwickshire Hospital, for providing information about temazepam formulations.