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Scientific Publications

General Sequence Injection Sequence Paraphernalia Topics Year, Country & WebLink Short Summary Conclusion Recommendation
Before Administration Preparing Hands Alcohol Swab Injecting Behaviors and Bacterial Infection Risks from Skin

We performed a comprehensive review of bacterial infections in people who use drugs.

Most of the bacterial infections in people who inject drugs were a result of: 
  • germs that are on the surface of their own skin, 
  • use of dirty needles, 
  • failing to clean skin before injecting, 
  • as well as “booting” (flushing and pulling back during injecting), which may increase risk of abscess formation.
 
Harm Reduction programs should provide skin cleaning paraphernalia and educate.
Before Administration Preparing Hands Liquid Disinfectant Impact of Hand Cleanliness and Type of Solutions
page 24,
  • Chapter 2.43: 60% of IDUs produced average finger dab counts between 20 and 50 CFUs. There was no difference between homeless and housed IDUs contamination levels.
  • Chapter 2.45: This study showed alcohol hand rub reduced contamination on IDUs fingers in 23 out of 25 cases. 
  • The 70% alcohol hand rub gave a greater reduction overall in number of colony forming units than the soap and water, but this was not statistically different with the numbers in this study. It also did not on any occasion cause an increase in contamination. 
  • Hand rub may potentially be more convenient as it does not require access to a sink.
  • Attempts to promote hand cleansing should be targeted at all IDUs not just homeless ones.
  • Hand cleansing by either soap and water or alcohol hand rub prior to injecting reduced the amount of contamination on their finger tips
  • The 70% alcohol hand rub gave a greater reduction overall in number of colony forming units than the soap and water.
  • Washing hands before starting injection should be promoted. 
  • 70% alcohol hand rub should be preferred to soap and water as more conveniant and more effective. 
Before Administration Adding Acidifier Citric/Ascorbic Acid Citric/Ascorbic Acidifiers, Dosage, and Vein Risk

Starting at p.26
The experiments performed investigated relative irritancy of prepared injections by measuring osmolality and pH. The pH data can be used to predict the minimum amount of acid needed. A series of heroin injections were prepared and various quantities of either citric acid or ascorbic acid BP from sterile sachets. 

Citric acid is anecdotally reported by IDUs to cause more pain on injection than ascorbic acid, suggesting that irritation of the vein due to the hydrogen ion content is more significant than cell bursting, in causing pain. The results support the advice that small quantities of acid should be used and injections should be administered slowly. When smaller quantities of citric and ascorbic acid (35mg and 70mg respectively) were added, not all the drug was seen to dissolve. Hence the minimum quantities used were increased to 50mg and 135mg, which were deemed approximately to be ‘small pinches’. In theory 99.99% of heroin base will dissolve at pH 4, at which the solubility is 120mg/ml. However, this data relates to pure heroin base and the effects of other compounds present in street heroin cannot be accounted for.

The results show advantages and disadvantages for both citric and ascorbic acids and favour small quantities added stepwise. 
Which sterile acid presents the least theoretical risk to veins?
  • Ascorbic acid may be less irritant to vein lining due the injections being less acidic. 
  • However, it needs to be administered slowly to avoid any osmotic effects. 
  • Citric acid produced theoretically more ‘osmotically compatible’ injections
  • But it was shown that small amounts in excess of what is needed reduce pH a lot and hence causing burning, pain and irritation
  • Citric acid allows less ‘margin for error’ as smaller amounts compared to ascorbic acid produce similar pH changes.
What minimum quantities of acid dissolve heroin? 
  • Less than half a sachet of either acid was sufficient for a £10 bag equivalent of the heroin.
  • The results show the importance of administering injections slowly. 
  • The diluting effects of blood are important to reduce irritation by the acid. 
  • Citric acid is cheaper than ascorbic acid, and for this reason services may be more able to fund citric acid supply. 

Acidifier should be added in small quantities such as 'small pinches' and needs to be administered slowly.

Before Administration Adding Acidifier Citric/Ascorbic Acid Acidifier Introduction and Impact on IDU Attendance

We examined whether the introduction of citrate in SEPs has altered the number of heroin/crack injectors accessing SEPs, the frequency at which heroin/crack injectors visited SEPs and the number of syringes dispensed. Neither new (first seen in either six months period) nor established clients visited SEPs more frequently post citrate.

The introduction of citrate did not negatively affect SEP attendance. Longitudinal attenders' visited SEPs more frequently post citrate, providing staff with greater opportunity for intervention and referral.

Introduction of acidifier increase clients’ frequency visit.

Before Administration Filtering All Filters Crushed Tablets and Filters Performance
Injections of mixtures prepared from crushed tablets contain insoluble particles which can cause embolisms and other complications. Although many particles can be removed by filtration, many injecting drug users do not filter due to availability, cost or performance of filters, and also due to concerns that some of the dose will be lost. Injection solutions were prepared from slow-release morphine tablets (MS Contin®) replicating methods used by injecting drug users.
  • Tablet extracts contained tens of millions of particles with a range in sizes from < 5 μm to > 400 μm. 
  • Cigarette filters removed most of the larger particles (> 50 μm) but the smaller particles remained. 
  • Commercial syringe filters (0.45 and 0.22 μm) produced a dramatic reduction in particles but tended to block unless used after a cigarette filter.
  • Morphine was retained by all filters but could be recovered by following the filtration with one or two 1 ml washes. 
  • The combined use of a cigarette filter then 0.22 μm filter, with rinses, enabled recovery of 90% of the extracted morphine in a solution which was essentially free of tablet-derived particles.
  • The 0.22 μm filter is to be preferred, as it can remove the organisms (e.g. Staphylococcus aureus, Candida) which commonly produce cutaneous and systemic infections in injecting drug users.
  • Harm can be substantially reduced by passing the injection through a (0.22 μm) filter.
  • To prevent the filter from blocking, a preliminary coarse filter (such as a cigarette filter) should be used first. 
  • The filters retain some of the dose, but this can be recovered by following filtration with one or two rinses with 1 ml water. 
  • This remains an unsafe practice due to skin and environmental contamination by particles and microorganisms, and bloodborne infections.
Before Administration Choosing Needle Syringe Needle Licking Prevalence and Potential Germ Risk

IDUs with poor hygiene practices are at risk for infection with their commensal flora. One example of a poor hygiene practice is licking the needle prior to injecting the drug. There are few published reports addressing the proportion of IDUs who lick their needles prior to injection and no prior studies evaluating the reasons for this practice.

We conducted face-to-face interviews with 40 IDUs. We collected data regarding whether the subject licked the needle before injecting drugs, whether the subject licked the injection site before or after injecting drugs, and the reasons they report for doing so.
 
32.5% of IDUs reported licking their needles prior to injecting. Reasons included ritualistic practices, cleaning the needle, enjoying the taste of the drug, checking the "quality" of the drug, and checking that the needle was in usable condition. In our study, approximately one-third of IDUs licked their needles prior to injecting. More data are needed to demonstrate whether the practice of needle licking significantly increases a person's risk for infection with oropharyngeal flora. 

Medical providers should ask patients about specific practices surrounding injection drug use, and educate drug users about avoiding unhygienic injection practices.

Before Administration Choosing Syringe Syringe Syringe Re-use Behavior and Housing

Systematic reviews and meta-analyses show that needle exchange programs reduce HIV and HCV transmission for IDUs but far less is known about the injection practices of IDUs enrolled in these programs. This study adopts a mixed methods approach to quantify high-risk injection practice patterns among IDUs enrolled in a needle exchange program and gather qualitative data to understand underlying injection behaviour rationales and patterns.

Univariate analysis showed all respondents reporting at least one high-risk practice within the past month. Multivariate logistic regression analysis using input from the clientele confirmed the importance of housing status as a determinant of injection practices.

The importance of housing status points to the need to combine needle exchange and appropriate housing.

Before Administration Choosing Syringe Low Dead Space Syringe Factors Affecting Needle and Syringe Preference, Gender

IDUs, a group at elevated risk for HIV transmission, use syringes manufactured in two styles, one of which (the integral cannula type) retains substantially less blood after intravenous use than the other (the detachable needle type). In this report, we examine some of the factors associated with use of syringes with detachable needles among 500 IDUs in San Antonio, Texas, using data from epidemiological surveys, ethnographic studies, and historical observations.
 

Ethnographic data suggested the following perceived benefits with detachable needle syringes :
  • Removing the needle while preparing and drawing up the drug reduces the probability of dulling it by accidentally jamming it into the spoon or cooker. 
  • A drug solution can be drawn into a syringe more rapidly through the larger opening of the cannula than through the much smaller opening of a needle. 
  • If a needle clogs during an injection, it can be replaced easily on a syringe with a detachable needle. In an integral cannula syringe, the plunger must be removed and the solution must be dumped back into a cooker before the needle can be unclogged.
  • Integral cannula syringes were used when they started injecting, 
  • The smaller dead space used substantially less drug. 
  • Overwise, many drug users preferred not to booting because it increases the risk of losing the vein and missing the injection (accidentally moving the tip of the needle out of the vein and injecting some of the solution into tissue), which results in bruising and  possible abcess. 
Needle gauge is another factor that influences. Many IDUs, particularly those who began injecting more recently and still have good veins, prefer the smaller 28 gauge needles because they tend to be less painful to use and do less damage to veins. 
 
Conversely, some IDUs who have been injecting longer and have poor veins may prefer the larger 25 gauge needles because they do not clog as easily, and they can penetrate thick scar tissue without bending. 
In cities where syringes are difficult to obtain prefer the larger gauge needles because they are more durable. Fluid can be drawn into larger gauge needles and expelled much more rapidly than from smaller gauge needles.

Males reported detachable needle use more commonly (43%, OR=1.37) than females (26%).

Harm reductsion programs should take these factors into consideration while selecting paraphernelia to be distributed and promoting low dead space syringes.

During Administration Selecting Injection Site Syringe Femoral Injection Damage and Syringe Specification
Clinical and behavioural markers of severe femoral vein (FV) damage among groin injectors (GI) by comparison of 67 GIs with severely damaged FV and 86 GIs with minimal/moderate damage.
The majority were men (69.3%) and the mean age was 36.2 years with mean duration of injecting drug use of 13.3 years. There were no significant between-group differences in age, gender or duration of IDU. 
Severe FV damage was associated with longer duration of groin injecting, use of thick needles (blue-hub, 23G; or green-hub, 21G), benzodiazepine injection, history of deep vein thrombosis, and recurrent deep vein thrombosis, presence of depressed groin scar, and chronic venous disease.
Logistic regression analysis revealed needle size and deep vein thrombosis as the main predictors of severe FV damage.

Needle and syringe exchange services should consider only supplying appropriate lengths of orange-hub needle (25G) on request from GIs.
Early cessation of GI, avoidance of benzodiazepine injection and prompt diagnosis and treatment of deep vein thrombosis might also reduce the prevalence of severe FV damage.
Routine examination of injecting sites should include an assessment of severity of venous disease in each leg.

During Administration Selecting Injection Site Syringe Jugular Injections Prevalence among IDUs, Gender

Jugular injection of drugs has been reported, although little is known about the prevalence of and risk factors associated with this behaviour. We evaluated factors associated with jugular injection among a cohort of IDU in Vancouver, Canada. 780 IDU were followed up and 25% reported jugular injection in the previous 6 months. 

In multivariate analyses, factors associated independently with jugular injection included:
  • being of the female gender, 
  • daily heroin use,
  • daily cocaine use,
  • requiring help injecting,
  • and involvement in the sex-trade.
 
Reporting a history of jugular injecting was alarmingly high in the cohort and was associated with several identifiable demographic and drug-using characteristics. 

Given previous reports demonstrating the risk of infection and vascular trauma due to this behaviour, these populations should be considered seriously as a target for safer injecting education.

During Administration Selecting Injection Site Syringe Femoral Injection Prevalence among IDUs
Injecting in the femoral vein (FV), often called 'groin injecting', is a serious cause of risk and harm. This study aimed to examine femoral injecting sites and assess venous health, with the intention of developing improved responses.

A total of 160 groin scans were performed in 84 GIs.

  • FV damage at the injecting site in the right groin was graded as minimal in 20 patients (25%), moderate in 27 (34%), severe in 16 (20%) and very-severe in 17 (21%).
  • Corresponding figures for left FV were 24 (30%), 22 (27%), 18 (22%) and 16 (20%). Wide variation was observed in the time to the development of these grades of FV damage.

These findings should further alert clinicians, policy-makers and patients to the urgent need for effective harm reduction responses to groin injecting behaviour.

During Administration Administrating Alcohol Swab Skin-Popping and Abscesses and Cellulitis

The prevalence of and risk factors for abscesses and cellulitis were investigated among a community sample of IDUs. Participants were interviewed, and those with symptoms were examined. Of 169 IDUs, 32% had abscesses, cellulitis (n=5), or both (n=14); 27% had lanced their own abscesses; and 16% had self-treated with antibiotics they purchased on the street. 

IDUs who skin-popped (injected subcutaneously or intramuscularly) were more likely to have an abscess or cellulitis than those who had injected only intravenously. The likelihood of abscesses and cellulitis increased with frequency of skin-popping and decreased with increasing duration of injection drug use. Abscesses are extremely prevalent among IDUs in San Francisco. Skin-popping is a major risk factor, and self-treatment is common.

Education about safe and sterile injection techniques could help IDUs preserve access to their veins and reduce the risk of infections associated with skin-popping.
 
For the prevention of abscesses and cellulitis, alcohol prep pads alone may not be sufficient to clean injection sites. Alcohol lacks the sustained residual antimicrobial activity of chlorhexidine and iodophors, and prep pads are small. Other antiseptic products and techniques should be explored.
During Administration Administrating Syringe Injecting Behaviors and Bacterial Infection Risks

We performed a comprehensive review of bacterial infections in people who use drugs.

Most of the bacterial infections in people who inject drugs were a result of: 
  • germs that are on the surface of their own skin, 
  • use of dirty needles, 
  • failing to clean skin before injecting, 
  • as well as “booting” (flushing and pulling back during injecting), which may increase risk of abscess formation.
A number of other factors have been linked to soft tissue infection and infection in other parts of the body including
  • lack of injecting experience, 
  • skin popping (subcutaneous or intramuscular injection), 
  • repeated injection into soft tissue,
  • use of tap water and saliva for mixing drugs, 
  • injection of speedballs, 
  • higher frequency of injecting, 
  • and needle licking which may double the risk of cellulitis or abscess formation.

Harm Reduction programs should provide skin cleaning paraphernalia, educate IDUs about the risks of “booting”, skin popping, use of tap water and saliva and needle licking.

During Administration Administrating Syringe Women and Injecting-Related Injuries
The process of drug injection may give rise to vascular and soft tissue injuries and infections. The social and physical environments in which drugs are injected play a significant role in these and other morbidities.
As in previous research, women were more likely to report injecting-related injury and disease. There are several possible explanations for this finding: 
  • Women may be more likely than men to perceive and disclose health symptoms.
  • Some commentators have suggested that women have less visible surface veins leading to greater injecting difficulty.
  • Women are more likely to ‘go second’ during an injecting episode, thus injecting with used or blunt needles 
  • Female IDUs are also more likely to be injected by, or need assistance from, others,increasing their risk of exposure to contaminants.
Although a report is often cited as evidence that women have smaller veins, this qualitative study provides limited anatomical evidence. Indeed, gender differences in vein size are debated in the broader medical literature.

Findings support the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes.

During Administration Administrating Syringe IDUs, Gender, and Prevalence of Injecting-Related Problems, Injury, and Disease

The process of drug injection may injure and infect vascular and soft tissue. The social and physical environments in which drugs are injected play a significant role in these and other morbidities. We estimate lifetime prevalence of injecting-related problems, injury and disease and explore the socio-demographic and behavioral characteristics associated with the more serious complications of self-report data from 9552 IDUs.

Lifetime history of either injecting-related problems (IRP) or injecting-related injury and disease (IRID) was reported by 29% of the 9552 IDUs; 
  • 26% reported ever experiencing IRP and 10% (n=972) reported IRID. 
  • Prevalence of IRP included difficulties finding a vein (18%), prominent scarring or bruising (14%) and swelling of hands or feet (7%). 
  • Prevalence of IRID included abscesses or skin infection (6%), thrombosis (4%), septicaemia (2%) and endocarditis (1%).
  • Females were more likely to report lifetime IRID. 
  • Frequency and duration of injecting, recent public injecting, and sharing of needles and/or syringes were also independently associated with IRID.
 
Findings support:
  • the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes, 
  • safer injecting techniques and wound care through provision of hygienic environments and advice on venous access,
  • a specific emphasis on care for women IDUs.
After Administration Cleaning Equipment Bleach Concentrations of bleach on in vivo tissue inflammation and HIV-1 replication

The use of bleach (hypochlorite) as a disinfectant for drug injection equipment in the intravenous-drug-using population was recommended early in the HIV-1/AIDS epidemic. Epidemiological studies have challenged the use of bleach as an effective measure to prevent HIV-1 transmission. However, in vitro HIV-1 coculture studies have shown that a high concentration of bleach is an effective cytotoxic and potentially virucidal agent. Low concentrations of oxidants have been shown to enhance tissue inflammation, in vivo, as well as HIV-1 replication in vitro.

The likelihood of an injection drug user contracting HIV-1 through the sharing of a bleach-cleaned blood-contaminated syringe may be increased by the cotransmission of residual bleach and its localized tissue-inflammatory effects; however, this has not been statistically proven in epidemiological studies

Bleach migh enhence tissue inflammation.

After Administration Caring for Soft Tissue Ointment IDUs, Gender, and Prevalence of Injecting-Related Problems, Injury, and Disease

The process of drug injection may injure and infect vascular and soft tissue. The social and physical environments in which drugs are injected play a significant role in these and other morbidities. We estimate lifetime prevalence of injecting-related problems, injury and disease and explore the socio-demographic and behavioral characteristics associated with the more serious complications of self-report data from 9,552 IDUs.

 
Lifetime history of either injecting-related problems (IRP) or injecting-related injury and disease (IRID) was reported by 29% of the 9552 IDUs; 
  • 26% reported ever experiencing IRP and 10% reported IRID. 
  • Prevalence of IRP included difficulties finding a vein (18%), prominent scarring or bruising (14%) and swelling of hands or feet (7%). 
  • Prevalence of IRID included abscesses or skin infection (6%), thrombosis (4%), septicaemia (2%) and endocarditis (1%).
  • Females were more likely to report lifetime IRID. 
  • Frequency and duration of injecting, recent public injecting, and sharing of needles and/or syringes were also independently associated with IRID.

IRPs and IRIDs were common. Findings support:

  • the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes, 
  • safer injecting techniques and wound care through provision of hygienic environments and advice on venous access,
  • a specific emphasis on care for women IDUs.