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Ischemic Hand Complications from Intra-arterial Injection of Sublingual Buprenorphine/Naloxone Among Patients with Opioid Dependency
Ryan M. Wilson, MD; Shady Elmaraghi, BS; Brian Rinker, MD
University of Kentucky, Lexington, KY

Introduction: Sublingual buprenorphine/naloxone is a common treatment for opioid dependence. The buprenorphine component is a partial agonist of the mu opioid receptor and reduces the symptoms of opiate withdrawal. Naloxone produces an antagonistic effect when administered parentally, reducing the potential for abuse. Despite its design, the medication is still sometimes abused. A common misuse of the medication is to dissolve the gelatin strip and inject the medication intravenously. Inadvertent intra-arterial injection of buprenorphine/naloxone can produce acute ischemic insult to the hand due to gelatin embolism. Our purpose was to review a series of these patients in order to describe the clinical entity, review the outcomes, and propose a rational treatment algorithm.
Materials and Methods: A review was performed of all patients evaluated by the hand surgery team with ischemia of part or all of the hand following buprenorphine/naloxone injection between 2011 and 2015. Clinical records were reviewed. Demographic data, co-morbidities, smoking status, medical and surgical treatments, complications, and amount of tissue loss were recorded. Those patients presenting within 48 hours of the injection were treated with intravenous heparin and warming for 5 days, after which they were maintained on oral aspirin and clopidogrel for 30 days. Those presenting after 48 hours were treated with aspirin and clopidogrel only. Average follow up time was 13 weeks.
Results: A total of 10 patients presented during the review period. Eight patients had ischemia of the radial hand or digits, one had ischemia of the ulnar hand/digits, and one had both. Three patients presented within 48 hours of the injection and were treated with intravenous heparin. Five patients were treated with oral agents. Two patients presented over 30 days after injection with dry gangrene and did not receive anticoagulation. All patients experienced tissue loss, and there was no difference seen in outcome regardless of type of anticoagulation administered. Four patients required surgical intervention for debridement and reconstruction.
Conclusions: With the increasing use of sublingual buprenorphine/naloxone in opioid dependency, ischemic hand injuries from inadvertent intra-arterial injection will be seen with greater frequency. It is important for prescribers of this medication to inform their patients of the potential risks of attempted intravenous abuse. Whereas outcomes did not vary with treatment modality in this series, further study is needed to determine the most effective treatment of these injuries.

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