The health consequences of injecting tablet preparations: foreign body pulmonary embolization and pulmonary hypertension among deceased injecting drug users.

AIMS: To determine: (1) the characteristics of cases presenting to the Department of Forensic Medicine Sydney (1997-2013) with foreign body pulmonary embolization; (2) the extent and locations of embolization; and (3) the relationship between extent, and use of other injection sites, with pathology.

DESIGN

Analysis of consecutive case presentations with foreign body pulmonary embolization.

SETTING/

PARTICIPANTS

Sydney, Australia, with a total of 373 cases (271 males, 102 females).

MEASUREMENTS: Full autopsy reports, microscopy of tissue samples, and full toxicology. The extent and locations of embolization, inflammatory responses, clinical signs of pulmonary hypertension and signs of right-sided heart failure were examined.

FINDINGS: Cases increased from three (1997) to 58 (2013). In 43.4%, foreign particles were moderate-abundant in extent. Cases with moderate-abundant emboli were more likely to have injection sites other than the cubital fossa [odds ratio (OR) = 2.4]. In 6.9% of cases emboli were also found in other organs. A foreign body inflammatory response was present in 45.3%, vascular scarring in 8.0%, signs of pulmonary hypertension in 10.2% and signs of right-sided heart pathology in 5.4%. Cases with moderate-abundant deposition were more likely to have emboli in other organs (OR = 7.9), a foreign body inflammatory response (OR = 5.3), vascular scarring (OR = 3.4), signs of pulmonary hypertension (OR = 5.4) and right-sided heart pathology (OR = 5.3).

CONCLUSIONS

Cases of foreign body pulmonary embolization (resulting from injecting crushed tablets meant for oral use, such as benzodiazepines and pharmaceutical opioids) in Sydney, Australia increased markedly from 1997 to 2013. In a large proportion there were clinical consequences. More extensive embolization was associated with higher levels of pulmonary hypertension and right-sided heart pathology.