YET ANOTHER REASON TO

STAY AWAY FROM DRUGS

Dr. Heather Tarantino
Dr. Srikanth Nimmagadda
Introduction
Thrombotic thrombocytopenic purpura (TTP)
like illness is a rare but serious blood disorder
characterized by microangiopathic hemolytic
anemia and thrombocytopenia, in the
absence of certain known causes of TTP.
TTP has not been associated previously with
abuse of any opiate.

Inroduction:
This is the first report outside of Tennessee, TTP-
like illness associated with abuse of an opioid
pain reliever by injection.
Our case meets the current case definition by
CDC for IV drug abuse-related TTP, a diagnosis of
TTP since February 1, 2012 in a person who had
used drugs intravenously for nonmedical
reasons.
This case also supports the findings previously
published in the one and only case control study
by Tennessee Department of Health.
Case Report
Patient is a 35 yr Old, Caucasian female,
CC: I have burning epigastric pain
Burning epigastric pain, 15/10 in intensity, since last 3 months,
gradually getting worse, radiating to back, propping up and opana
helps to relieve pain.
Associated with nausea and decreased appetite,
PMH: Hepatitis C, Chronic low back pain
Home Medication: Diclofenac Sodium 50 mg two times a day
PSH: C-Section X 4, D & C X 3,
FH: DM, CVA
Social History: 1 PPD X 24 years, Quit alcohol 7 years ago, IV drug
abuse: Opana ER 20 mg per day, last abuse was 2 days ago, THC
occasional abuse, last time 1-2 months ago

Case Report
Clinical Examination:
Vitals: BP: 130/81, T: 36.6 C, PR: 88, RR: 18, 100%
saturation on RA,
Constitutional: Significant distress with severe pain,
well nourished,
Abdomen: Epigastric and RUQ tenderness, Liver
palpable 2 inches below costal margin, No
splenomegaly, Bowel sounds , soft and present all 4
quadrants
Skin: Multiple needle marks and tracks on fore arm
Case Report
Labs:
CBC: WBC 11.9, Hb 7.4, MCV
100, Platelet count : 41,000
Cr: 1.1(Baseline 0.7-0.8),
GFR:56
Direct coombs: Negative
UDS: Positive for opiates
LDH: 729, Haptoglobin: <20,
T.Bili: 2.5
Hepatitis C: RNA 468 in
08/2012
Peripheral smear:
Thrombocytopenia (37,000),
with anemia Frequent
Schistocytes 5-6 per each
high power field

Case Report
The diagnosis of TTP-AHUS(Atypical
hemolytic uremic syndrome)/TTP like illness
is made on basis of
3

Microangiopathic hemolytic anemia
Thrombocytopenia
Acute renal insufficiency
Ruling out other causes
case definition given by CDC

Hospital course
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
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P
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Time Line
LDH
Hemoglobin
Platelets
Plasmapheresis
Discussion
New formulation of Opana ER was released in Feb,2012, with the intent to inhibit crushing and
dissolving the tablets.
Ingredients: polyethylene oxide (PEO) and polyethylene glycol.
Unclear what component or components of reformulated Opana ER might trigger TTP-like illness
In one study in rats, intravenously injected PEO caused thrombocytopenia.
Onaugust13,2012,a Nephrologist reported to the Tennessee Department of Health(TDH)three
cases of unexplained thrombotic thrombocytopenic purpura (TTP),
By the end of October, a total of 15 such cases had been reported. Fourteen of the 15 patients
reported injecting reformulated Opana ER.
Seven of the 15 were treated for sepsis in addition to TTP-like illness. Twelve patients reported
chronic hepatitis C or had positive test results for anti-HCV antibody.
To test for an association between TTP like illness and injection of reformulated Opana ER, TDH
conducted a case control study.
This study identified a strong association (odds ratio=35.0; 95% confidence interval=3.9-312.1)
between TTP-like illness and injection of reformulated Opana ER.

Clinical implications
The extent of this problem is not clear because there is no requirement to report such cases and
because IV drug use might not be suspected or reported among patients with TTP.
Recommendations from CDC for physicians prescribing Opana ER,
2

A. Clinicians treating patients with TTP of unknown etiology should:
1. Ask patients about intravenous drug use.
a. Patients who report IV drug use should be asked about the specific drugs injected.
2. Perform a urine drug test.
a. A negative drug test is not definitive because the interval between the critical drug use and diagnosis might be
greater than the time during which a drug can be detected in the urine, which is probably not more than 4 days in the
case of opioids.
3. Request a copy of the patients prescriptions for controlled substances from the state prescription drug
monitoring program to determine if any doctor has prescribed the patient Opana ER. This information
might be more accurate than the patients report of drug sources.
B. Clinicians treating patients with TTP who report IV use of Opana ER should:
1. Counsel patients regarding the risks of continued IV drug use, including blood-borne infections, fatal
overdose, and TTP.
2. Refer them to substance abuse treatment programs in their community. A list of substance abuse
treatment facilities is located at: http://www.samhsa.gov/treatment/index.aspx
3. Notify other clinicians who have prescribed the patient Opana ER of the diagnosis of TTP and the
reported association with that drug.
Prompt initiation of treatment on suspicion of diagnosis with plasmapheresis was also advised.

References
1. Morbidity and Mortality Weekly Report (MMWR) January
11, 2013 / 62(01);1-4
2. CDC Health Advisory CDCHAN-00331-2012-26-10-UPD-N
3. Uptodate, Diagnosis of thrombotic thrombocytopenic
purpura-hemolytic uremic syndrome in adults
4. Peripheral smear image: Cleveland Clinic Center for
Continuing Education, Disorders of Platelet Function and
Number