Sharp Increase in Wound Botulism Is Reported Among Drug Users in State

Injection drug users in California are suffering a “dramatic increase” in wound botulism, a serious, often fatal infection caused by spores from a common soil bacterium, researchers reported this week.

Also being seen among the same population are smaller, but still noticeable, increases in tetanus and necrotizing fasciitis, the latter caused by the so-called flesh-eating bacteria.

In all these cases, the illness is associated with the common technique of “skin-popping” black tar heroin, a crudely prepared form of the drug whose Southland supply is produced in Mexico.

Although the numbers of discovered cases are small, health authorities fear that the deaths of some victims have been attributed to drug overdoses and other causes.

Researchers from Stanford University and the California Department of Health Services reported in Wednesday’s issue of the Journal of the American Medical Assn. that they identified 49 cases of wound botulism in California from 1988 through 1995, compared to an average of one case every other year during the preceding three decades. An additional 31 cases were observed in the state in 1996 and 1997, according to Dr. Duc J. Vugia of the department’s division of communicable disease control.

Only two cases were reported in the rest of the country during 1996 and 1997, both in Arizona.

A March 8 report from the Centers for Disease Control and Prevention cited six cases of tetanus among drug users in California during 1997, compared to one in 1987.

No figures are available on necrotizing fasciitis because such cases do not have to be reported to the state, Vugia said, but there are anecdotal accounts of increased numbers among drug users.

The researchers believe that the problems may be caused by unusual substances used to “cut,” or dilute, the heroin, such as ground paper fiber soaked in black shoe polish and even, according to some anecdotal evidence, dirt.

“This is obviously a potentially huge problem for the drug-using population,” said Dr. Douglas J. Passaro, who was with the health department when the study was conducted but is now at Stanford. “I think the problem is directly proportional to the amount of black tar heroin being used and the safety of that supply.”

Heroin from Asia is highly refined, yielding a fine white powder that is typically cut with lactose or sugars to keep users from getting an overdose and to provide dealers with more profit.

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But black tar heroin, as its name implies, is crudely refined and dark-colored, allowing distributors to cut it with a much broader variety of substances. Apparently, many of those are contaminated with dirt, which can contain the spores of lethal bacteria, including those that cause the three illnesses. As much as 95% of the heroin sold in California is now of the black tar variety, and it is the predominant form sold west of the Mississippi, according to federal authorities.

“I’ve had many users tell me that when they filter the liquefied heroin through a cotton ball, they are seeing increasing amounts of grit left on the cotton,” Passaro said.

If the heroin were injected into the bloodstream, which has a lot of oxygen to kill the anaerobic bacteria, there would not be a problem. But many users now inject the drug just under the skin or into muscles in hopes of leaving fewer needle tracks. The airless environment at those sites provides a fertile breeding ground for the bacteria that cause the three ailments, Vugia said. The toxins produced by the bacteria are among the most lethal known.

The initial symptoms of wound botulism include droopy eyelids, a thick, dry tongue, difficulty speaking, double vision and weakness of the neck muscles--all of which can be confused with the signs of a drug high, particularly by practitioners who do not encounter botulism often. Left alone, the symptoms progress to generalized weakness, difficulty in breathing and, eventually, paralysis.

The toxin can be neutralized with an anti-botulism immunoglobulin and the bacteria killed with penicillin, but long-term problems may persist. Passaro said one victim has been on a ventilator for a year.

The state health department has contacted all local health departments to warn of the danger, but would like to see the message spread more widely. “We want to get the message out there to everyone,” Vugia said.