Cotton Fever: Understanding the Hidden Dangers of IV Drug Use

DISCLAIMER: Cotton fever is not a discrete disease but a name coined among illicit drug users for symptoms sometimes associated with intravenous drug use. This condition is not widely supported by the medical community and has not been confirmed by medical science or research. Some studies examining cotton fever do exist, but there is limited information available, and providers must continue to study and understand this condition and its impact on patients.

My medical review does not constitute acceptance or validation of this condition as a discrete disease. I have no opinion regarding the accuracy of the material. I make no recommendations regarding the condition. Intravenous use of illicit drugs or IV misuse of prescribed drugs always carries a significant risk for adverse reactions and complications, including death. – Dr. Coleman

Considering the potentially life-threatening consequences of intravenous (IV) drug use, cotton fever is less concerning. However, when left untreated, this secondary condition can become a serious threat.

Cotton fever is a rapidly developing and potentially dangerous complication associated with intravenous drug use. This condition can strike within hours of your most recent injection, causing a dramatic increase in body temperature and other symptoms.[1] 

Knowing how to recognize and quickly address the signs of cotton fever can make a major difference in preventing serious consequences. If you or anyone you know uses intravenous drugs, safety should be the primary concern. Seek professional treatment support as soon as possible to pursue recovery. 

What Is Cotton Fever?

Cotton fever is an acute illness that occurs after the injection of drugs filtered through cotton or cotton-like materials. The condition gets its name from the cotton balls, cigarette filters, and similar materials used to strain drug solutions before they are injected. Substances are usually dissolved in water first when being prepared for injection. Then, the mixture is passed through cotton or a different material to filter out any adulterants.

Unlike materials used in a sterile environment, cotton or other materials left out in the open harbor dangerous bacteria. The filtration process described above provides an opportunity for these bacteria to enter the drug from the cotton fibers. Reusing cotton filters can increase your chances of developing cotton fever.

Enterobacter agglomerans is the most likely culprit when cotton fever occurs.[2] This bacterium is naturally found on cotton plants and thrives in the warm environment of used cotton filters. 

How Cotton Fever Differs from Other Substance Use Complications

Other substance-use-related complications include endocarditis and abscesses.[3] Endocarditis, or inflammation of the lining of the heart, is potentially life-threatening. Abscesses may not be as immediately life-threatening, but they can cause serious complications when neglected. 

Neither of the above conditions strikes as quickly as cotton fever, which typically begins exerting its effects within fifteen minutes to a few hours after injection.[4] Cotton fever does not discriminate based on the drug being injected. Whether the substance in question is heroin, cocaine, meth, or even a sterile prescription drug, cotton fever can still occur. 

Added Consequences of Reusing or Sharing Cotton

Cotton fever isn’t the only potential health risk associated with reusing or sharing cotton. Hepatitis C virus can be spread amongst people who share cotton balls.[5] Unlike cotton fever, hepatitis C does not resolve within a few hours, though it is curable with the proper medication.

Sharing “drug preparation equipment,” as this study found, is a strong predictor of HIV infection risk as well.[6] The study clarifies that all equipment, not just syringes, increases this risk, implying a greater need for initiatives targeting both syringe and equipment sharing.

What Are the Symptoms of Cotton Fever?

The telltale sign of cotton fever is a rapidly elevated body temperature. The fever can reach temperatures of 102°F or higher, and is often extremely distressing.[7] 

Along with the fever itself comes a wide variety of potential symptoms, including the following:[8]

• Violent chills: Sometimes, the chills are so powerful that they cause muscle spasms or chattering teeth. Heavy sweating, another familiar fever-related issue, will soon follow as the body strains to control temperature. 
• Elevated heart rate (tachycardia): The heart may beat as fast as 100 beats per minute or more as the body struggles to respond to this bacterial infection.
• Powerful headaches: Cotton fever headaches are sometimes described by those experiencing them as more powerful than a severe migraine. 
• Muscle aches: Deep, throbbing joint pain and muscle pain are frequently reported by cotton fever patients. These issues often do not let up with more conservative treatments.
• Nausea and vomiting: For many, the nausea and vomiting are so intense that they become severely dehydrated. Abdominal cramping may accompany these unpleasant stomach issues.
• Breathing difficulties: Shortness of breath is a common complaint among cotton fever sufferers. You may feel like you can’t get enough air, and a persistent cough may develop.
• Psychological effects: Terror, confusion, and high anxiety are commonly observed and reported by cotton fever sufferers. 

Despite all of these potentially debilitating symptoms, cotton fever typically “runs its course” within 24 hours.[9] Cotton fever is sometimes mistaken for an overdose or withdrawal symptoms, which is why professional diagnosis is key.

Even though cotton fever usually resolves on its own, seeking out treatment is still essential. Vulnerable patients (immunocompromised, elderly, etc.) and healthy patients can develop potentially life-threatening complications that require urgent action by a trained healthcare professional.

How Is Cotton Fever Recognized and Treated?

There is no specific test currently available that can clearly differentiate cotton fever from similar conditions. Blood tests will likely show increased white blood cell counts, but this is only a general indicator of the body’s response to one of many bacterial toxins.

Medical professionals rely mostly on patient history and a careful evaluation of symptoms to make a diagnosis. They may ask a series of screening questions relating to the patient’s drug use, including whether or not they draw their drugs through reused cotton filters.

Considering the intensity and short duration of this condition, understanding the timeline is vital to effective symptom management and recovery. A rapid onset of symptoms within a few hours of your most recent injection offers healthcare providers a significant clue. 

Responsive Treatment Is Crucial

Once your healthcare provider has determined that you have cotton fever, they will begin (or continue) carefully monitoring your body temperature and other vital signs. Effective treatment emphasizes symptom management and quick, supportive responses to new or worsened developments.

Cotton fever is not the type of infection that is dramatically improved by antibiotics. It’s unlikely you will be given any as you undergo treatment. Fever reduction is the primary focus. Medications like acetaminophen or ibuprofen may help to control body temperature while alleviating some discomfort, but the medical provider will make the final call.

If you’re vomiting and dehydrated, you may be given intravenous fluids. Whether you are given opioid pain medication for severe headaches is a judgment call for your care provider and may depend on your substance use history. 

Anti-nausea medications can help reduce the vomiting, perhaps to the point where you will tolerate taking in fluids and other medications orally. While most patients recover completely within a full day, treatment is still essential. Cotton fever can cause body temperatures to climb over 105°F in some cases, which requires emergency intervention. Sepsis may also develop, which can be fatal when left untreated.

You Don’t Have to Fight Alone

Cotton fever is just one of many serious health issues associated with IV drug use. Every injection is a gamble with potentially life-threatening health concerns. But it’s never too late to find hope, healing, and all the other tools you need to make a complete recovery. 

Rehab professionals use evidence-based therapies to address addiction far beyond the superficial level. Recovery is possible, regardless of how long you’ve struggled with substance use problems. Reach out for help today and find a real, sustainable solution.