Monday, February 15, 2010

Black tar heroin coming to white people near you

Graph: Black tar heroin vs powder heroin, and HIV among injection drug users vs HIV among men who have sex with men, in a map of the US and Canada from Ciccarone and Bourgois 2003--click on the graph for a full-size picture.

Black tar heroin is moving east, says the LA Times, in this first part of a three part article I'll be reading over the next days, being moved by folks from Xalisco, Mexico. The strategy described in the LA Times article involves low-profile low-weaponry low-volume operations targeting white people who've been using prescription opiates, and moving small cheap quantities of black tar heroin as an alternative to Oxycontin and Percocet.

What will this mean for clinicians on the East Coast if the Xalisco teams and their ilk manage to continue moving black tar heroin eastward? UCSF researchers have hypothesized that the properties of black tar heroin itself contributed to less spread of HIV among West Coast heroin users because black tar heroin has to be boiled more; and remaining bits of gooey leftovers in syringes caused users to rinse their works more thoroughly, and to switch out needles more frequently. But black tar heroin also most likely means more bacterial soft tissue infections.

When I started as a pre-med in San Francisco, I volunteered on a healthcare for the homeless medical van. The van would stop and I would circle the surrounding blocks, telling everyone who looked homeless, "Outreach van, down there" and sending them to the nurse and the medical resident who were in the van. In addition to handing out socks and vitamins, a lot of what we did was abscess care. It seems kind of crazy and unthinkable in Boston, but almost inevitable in San Francisco at the time, that medical residents would be lancing and draining small abscesses in the back of an Econoline van. Better that than let some not entirely well-organized heroin addict wait for the bacteria to build up to bigger balls of pus (and attendant complications) until finally winding up in the San Francisco General Hospital emergency department.

At one point, the San Francisco Department of Public Health startedwhat became known as "the abscess task force" to try to deal with the huge number of soft tissue infections, most dramatically abscesses, but also necrotizing fasciitis, botulism, and other soft tissue badness. These problems can be linked to black tar heroin through greater amounts of intramuscular and subcutaneous injection. Black tar heroin users seem to do more shooting into muscle and skin-popping because black tar heroin users sclerose their veins faster. And the boiling of the tar (which Ciccone and Bourgois posit helps kill HIV virions) does not kill the spores of Clostridium species. That seems to mean greater vulnerability to tetanus, botulism, and gangrenous skin infections when the spores of C. tetani, C. botulinum, or C. pefringens get embedded in the tar and then shot into soft tissue.

As far as I can find, there has not been a direct comparison of bacterial infection rates among injection drug users by geography--but it looks like there is a natural experiment in the making, if someone is ready to track it. And, an opportunity to set up systems for early detection and treatment of soft tissue infections, before they begin to swamp new cities' healthcare systems the way they did in San Francisco.

Ciccarone D and Bourgois P, Explaining the geographical variation of HIV among injection drug users in the United States. Subst Use and Misuse 2003 December; 38(14): 2049–2063.

Sunday, February 7, 2010

There'll always be a Texas: nurses prosecuted for reporting improper behavior by a physician

It's certainly possible that nurses might report a doctor to bosses or regulators just to be spiteful. But the system has to make reporting easy, and safe, to make sure that quality issues don't get missed. That's what makes it such a travesty to criminally prosecute nurses for reporting concerns about a doctor's conduct. It would be a travesty even if the nurses' concerns ultimately weren't legitimate. But it's especially egregious when what's being reported is, in fact, bad behavior--stuff like emailing patients to promote his own herbal supplements that he was selling on the side.

New York Times covers the case.
Texas Nurses Association offers updates and legal defense fund information.

And as a bonus, because the Internet is full of glory, and for your edification, are Amazon reviews submitted by the doctor in question, which may singlehandedly convince you that these nurses were truly noble fighters for healthcare quality.

Google is specifically full of glory, and yea, noble also, for it teaches that this same doctor donated $968 to Ron Paul, and is a Facebook fan of "Ladies of Liberty" which is an organization for libertarian ladies to get other ladies involved in libertarianism, and also is a fan of Leviticus diet tips; and that he also appears in a program on "God's Learning Channel" as a doctor who treats patients with Morgellon's Disease...