JIST

Abstract

A 32 year-old Malay male with prior history of drug abuse, was found dead at home while watching TV. At autopsy, his body showed multiple specific tattoos consistent with known drug groupies, and multiple hypertrophic scars in the groin folds of prior injections, with fresh injection marks in the front of right elbow and right groin fold. Sections of the heart muscle showed a small dull yellow area in the interventricular septal wall, with the lungs showing white, granular, nodular spots throughout the parenchyma. Histology of these lesions confirmed foreign body granulomas filled with bi-refringent crystals, with extensive inflammation around them, also seen focally in other organs. Toxicology screening demonstrated low levels of buprenorphine (Subutex) and midazolam (Dormicum), with high levels of buprenorphine metabolites in the bile and urine, followed by blood.

This case presents a recurrent scenario of sudden death among known or unsuspected addicts seen in Singapore with low or high levels of Subutex, when combined with benzodiazepines, since 2003. Tablets of Subutex were introduced in Singapore to substitute heroin maintenance programmes including methadone maintenance, since it

is administered as a tablet sublingually. The incidence of deaths started surging with increased supply from unscrupulous general practitioners (GP’s), who ran a profitable

black market. The authorities became alarmed at the blatant sale and use of Subutex usually with a benzodiazepine, just outside the clinics of GP’s selling them in residential colonies, and open discarding of used needles around these areas, resulting in an increased needle culture, not seen during the height of heroin addiction in Singapore.

In our study conducted between 2003 and 2005, we found the rate of buprenorphine-related deaths going up nearly twice; a higher incidence of Malay fatalities, compared

to its incidence in the demographically predominant race - Chinese, followed by Indians, and that there was no correlation with the buprenorphine levels and fatality; rather it was its concomitant use with benzodiazepines. The Singapore government’s amendment of the law to bring buprenorphine and its administration under its control, and stricter prosecution of errant GP’s in 2006, has reduced the overt addiction and abuse, but has not significantly curbed these frequent small number of Subutex abuse-related deaths since these tightened measures have been in force for about a year.