Opioids are among the most misused substances globally, both for analgesic and recreational purposes. As the opioid crisis persists, it is essential to recognize the diverse complications of substance misuse, including opioid-induced myelopathy. We report a novel case of myelopathy in a young adult following intranasal use of crushed oxycodone, whose underlying pathophysiology remains unclear but may involve vasculopathy, direct neurotoxicity, or immune-mediated inflammation.

A 22-year-old male with a history of polysubstance abuse presented with decreased consciousness and quadriplegia. He spent the night with friends and subsequently became drowsy when driving home, falling asleep in his car. Upon waking four hours later, he had weakness of all extremities and reported significant sensory loss. He admitted to inhaling crushed oxycodone and smoking marijuana several hours prior to falling asleep.

On the initial examination, he had quadriplegia (MRC 0/5), decreased pinprick sensation with preserved vibration and proprioception, absent deep tendon reflexes, and mute bilateral plantar responses. Urine study was positive for amphetamines, benzodiazepines, cannabinoids, and opiates. Cervical spine MRI revealed longitudinally extensive T2 hyperintensity from C1 to T3 without diffusion restriction or contrast enhancement. CSF analysis showed a WBC count of 7/cmm (neutrophil predominant), protein level of 84 mg/dL, and negative results for infectious, demyelinating, autoimmune, and paraneoplastic workups. Vitamin levels and heavy metal screening were within normal limits. 

He was initially treated with five-day course of 1 gram IV methylprednisolone daily, followed by five cycles of plasma exchange due to concern for an immune-mediated process. However, there was no significant improvement, aside from partial recovery of upper extremity (MRC 4/5). He was subsequently discharged to an acute rehabilitation facility.

Opioids, particularly intranasal heroin, have been associated with myelopathy; however, snorting crushed analgesic, oxycodone, also carries a significant risk of serious neurotoxicity, with limited neurological recovery despite aggressive treatment.