A 42 y.o. male IV fentanyl and cocaine user comes to the ED with a wound on the L arm

The pt reports he has been injecting cocaine mixed with kool-aid and noted increased drainage of the wound.

why does he mix cocaine with Kool-aid?

Kool-Aid is a brand of flavored drink mix invented in 1927 by Edwin Perkins. The brand is owned by Kraft Heinz based in Chicago.  It contains  sugar, fructose, artificial color and flavor but most important if you want to use it for drug injection: citric acid.

Acid is necessary to prepare brown heroin and crack cocaine for injection as they are in a base form and poorly soluble in water.

While the citric acid improves the high from the drug; overuse of the acidifier is common which is associated with skin and soft tissue infections by causing increased sclerosis of veins. In a study in London where citric acid is available to IV drug users since 2003,  many used more that the recommended amount.  (27 mg or two pinches of citric acid or 67 mg of vitamin C is sufficient to dissolve the 140 mg of dimorphine base present in a 250mg heroin sample)  Where lemon juice is used to acidify the cocaine, outbreaks of Candida endopthalmitis have been reported.

fungal endophthalmitis with Candida

Historically, IV drug use probably began after the invention of the hypodermic needle in the late 1800’s.  Widespread morphine addiction was documented after the Civil War and the Franco-Prussian War in Europe. According to CDC data in 2014 27 million people have tried IV drugs in the last year. A few of the complications of IV drug use are listed below.

Endocarditis is found in 8.5% of IV drug users with fever.

A patient from Monday found at the side of the road unresponsive with a fentanyl OD. Differential here includes aspiration, pneumonia or noncardiogenic pulmonary edema.

FUN FACT:

Acidity of heroin varies by the source.  Colombian –sourced heroin is in a salt form and dissolves easily without acidification.  Afghani heroin on the other hand requires acidification and the average pH at injection is 2.6. Our patient signed out AMA.

Harris M, Scott J, Wright T, et al. Injecting-related health harms and overuse of acidifiers among people who inject heroin and crack cocaine in London: a mixed-methods study. Harm Reduction Journal 2019;16:6- doi.org/10.1186/s12954-019-0330-6

Scott J, et al. Laboratory study of the effects of citric and ascorbic acids on injections prepared with brown heroin. Int J Drug Policy 2000;11(6)417-22.

Garden J, et al. Evaluation of the provision of single use citric acid sachets to injecting drug users. Edinburgh Effective Interventions Unit. Scottish Executive Drug Misuse Research Programme, University of Paisley;2003.