Introduction: Extended-release subcutaneous buprenorphine injection is a relatively new formulation and clinicians are still gaining experience with its use. There is sparse literature available on adverse events. We describe a case of skin necrosis associated with the injection site of extended-release buprenorphine. Case Report: A 35-year-old reported immediate swelling and eventual skin breakdown near his buprenorphine injection site. He was found to have ulceration down to the subcutis with no evidence of infection. The patient followed up with dermatology and underwent debridement of the site. The injection site healed with scar formation. Discussion: Although mild to moderate adverse events related to the injection site have been reported in Phase 3 studies of extendedrelease buprenorphine injection, this is a rare case of skin necrosis requiring surgical intervention and excision of the depot. Conclusions: This case highlights the potential complication of skin necrosis after inadvertent dermal of extended-release buprenorphine and reviews proper administration techniques.

Introduction: Kratom (Mitragyna speciosa) is a popular plantbased extract that has dose-dependent stimulatory and sedative effects. It has been used for self-treatment of opioid withdrawal and can result in seizures, hepatotoxicity, and infectious complications from bacterial contamination. Reports of morbidity and mortality associated with Kratom may be confounded by coingestants. We report a case of severe rhabdomyolysis and pressure necrosis leading to fasciotomy in a patient who was using Kratom. Case report: A 31-year-old male with substance use presented to the emergency department after loss of consciousness for 6 hours after smoking Kratom. He was found to have rhabdomyolysis, acute renal and hepatic injury, and electrolyte disturbances. No ethanol was detected, and urine drug screen was negative. Over the next 3 hours, the patient developed signs of compartment syndrome and he was transferred to the operating room for fasciotomy. He required continuous renal replacement therapy for 48 hours and his labs and clinical status improved. He was discharged 18 days later. A serum and urine sample from the first day of presentation were analyzed for mitragynine and 7-hydroxymitragynine using an Ultra Performance Liquid Chromatography-Tandem Mass Spectrometer (UPLC-MSMS) method. The serum mitragynine was 5 ng/mL and the urine mitragynine 6 ng/mL. Conclusions: Although there are numerous reports of opioids resulting in prolonged periods of immobilization and rhabdomyolysis, this is not commonly reported in Kratom overdoses. This case report highlights the profound sedative effect of Kratom and the potential of pressure necrosis injury resulting in rhabdomyolysis and compartment syndrome requiring fasciotomy.