Subutex abuse presenting to the emergency department: a case series

Introduction: Subutex (sublingual buprenorphine hydrochloride) tablets are prescribed to alleviate symptoms of opiate withdrawal in addicts undergoing a cessation programme. Although Subutex is safe and effective, parenteral abuse is an emerging phenomenon. A variety of complications may present due to the different areas that patients inject themselves. Aim: We present a case series of four patients who presented to the emergency department following complications of Subutex abuse. The complications included deep venous thrombosis, limb ischaemia and epidural abscess with osteomyelitis of the spine. Discussion: Sublingual buprenorphine was launched in Singapore in 2002. It is currently the preferred alternative to methadone for treating opiate dependency locally. Despite safeguards, instances of abuse of buprenorphine exist. These medications can be passed or sold to others not on a cessation programme. Two of the 4 patients in this series obtained Subutex illegally. Parenteral abuse of Subutex is of grave concern. In Australia and France, between 23-37% of Subutex users have abused it in this fashion. Conclusion: Subutex abuse is not uncommon in Singapore. Complications especially from parenteral use can occur and may result in serious morbidity. A high index of suspicion among physicians must be maintained in patients with unusual limb infections, ischaemia or venous thrombosis. Tighter regulations on prescription and consumption of Subutex may be useful in preventing these complications, in addition to increasing public awareness and education of the risks of parenteral abuse for patients on cessation programme. (Hong Kong j.emerg.med. 2007;14:163168)