Safer injection

One of the best ways for injection drug users to avoid infection by blood-borne diseases like hepatitis C is to use sterile, unused drug-use equipment every time. This means not reusing needles, cookers, filters, tourniquets, water, swabs and other materials used by someone else. Reusing means anything like borrowing, lending, passing on, buying, selling, sharing, receiving or taking any equipment that was used by someone else. Some people do not identify risk with the word “sharing” or when reusing involves a close sexual partner (like a boyfriend or girlfriend). 

The hepatitis C virus may be able to survive outside the body for a long period of time. Although the exact length of time is still under debate, some people believe that the virus can live outside the body for at least four days. The amount of blood needed to pass on an infection is so small that people don’t have to see the blood for it to be infectious. These microscopic amounts of blood could be on the surface where the drugs and equipment are set up or on any one of the pieces of equipment. 

The harm reduction information that follows is offered as a public health service. Its purpose is not to encourage or condone the use or possession of illegal drugs. It is to help people make safer choices in their use of drugs that will reduce the spread of Hep C and HIV.

Steps to Safer Injection

People who use injection drugs can take steps to reduce the chances that they will either contract Hep C or pass it on to others if they are already infected. The injection steps shown below can be divided into four distinct stages: Preparation, Mixing, Injecting and Cleaning Up. The equipment distributed in safer-injection kits can be obtained from local needle exchange programs.

Preparation

1. Choosing a safe place is preferable—one that is well lit and has running water so people can wash their hands thoroughly with soap and hot running water. This will help to reduce the chance of infections. 

• Hands can also be wiped with an alcohol swab included in the injection kit. Wiping in one direction can clean the hands effectively. Wiping in circles or back and forth can simply move bacteria around.

2. The work surface should also be cleaned with soap and water.

• A new piece of newspaper can also be spread out to create a clean work area to set out the drug-use equipment. The equipment should be new and unused. This prevents the spread of blood-borne viruses and also infections like abscesses.

3. All the equipment is kept within reach. In a group, each individual must have his or her own equipment. People can mark their own equipment so it can be told apart from others to reduce accidental sharing. Safer drug-use equipment distributed by many needle exchange programs includes:

• sterile, unused needles 
• sterile water 
• cookers 
• filters
• tourniquet
• ascorbic acid (vitamin C powder)
• alcohol swabs 

According to mandatory program and service guidelines developed by the Ontario Ministry of Health and Long-Term Care, each board of health in the province is responsible for ensuring access to syringes and needles as a harm reduction strategy in communities where drug use is recognized as a problem. The Ontario Harm Reduction Distribution Program provides other harm reduction materials, such as sterile water, cookers, tourniquets, vitamin C (acidifier) and alcohol swabs to Ontario’s needle exchange and harm reduction programs. For more information on these supplies, visit OHRDP's Product Information page.

Mixing

1. When injecting, the drug is fully dissolved to prevent insoluble particles from entering the bloodstream and causing health problems like chalk lung. Adding sterile water from the ampoule to the cooker will dissolve the drug. 

• If a person is trying a new drug, using again after a long break or has recently switched dealers, taking half a hit or half a dose to test the potency of the drug can help prevent overdose. 
• If a person is injecting a pill, it must be crushed as finely as possible with a sterile crushing tool (two spoons or a pill crusher) to reduce the chances of injecting undissolved particles. If it has a coating, the coating has to be removed because it will not dissolve and can cause vein damage if it enters the bloodstream. Clean fingers, a clean cloth or paper and sterile water are the best tools to use to remove the coating—saliva, dirty fingers, or dirty clothes can lead to bacterial infections. 
• Cool water that has been boiled beforehand can also be used to dissolve the drug. The syringe can be used to transfer water from the cup of cooled boiled water to the cooker, but if a person draws up water with a used syringe, both the water and the cup have been contaminated, which then need to be replaced before someone else uses them.
• A pinch of vitamin C about one-quarter the size of the rock is used to help dissolve brown heroin and crack. Too much vitamin C will make the solution too acidic and can cause vein problems. Vinegar and lemon juice are not recommended as they can cause fungal infections and damage veins.

2. Applying heat can help drugs dissolve more completely and reduce the complications that come with injecting undissolved particles.

• Some drugs will clump when heated, so a test can be done first by dissolving a small sample. Others, such as cocaine, do not need to be heated at all.
• If the cooker touches the flame, soot may get into the solution.

3. A new sterile filter is added to the cooker and the liquid is drawn into a new syringe through the filter. This further reduces the amount of undissolved particles that could make it into the bloodstream.

• People should be encouraged to use new needles every time. In cases where there is no access to needle exchange programs, like prison, needles can be cleaned between each use and not shared between people. Cleaning means rinsing the syringe twice with clean water, twice with bleach, and then twice with new water for 30 seconds at a time.
• Frontloading or backloading must always be done with a new, unused syringe, if people are using a syringe to divide the hit. If the syringe has been used by another person, then it has been contaminated and could easily contaminate the other equipment.

4. Removing air bubbles from the syringe will prevent air embolisms, which are rare medical complications that happen when gas or air gets into the bloodstream. Air bubbles can be removed from a syringe by:

• pointing the needle skywards
• flicking gently on the side
• pushing the plunger up slowly to push out any air bubbles and until a small droplet of liquid appears on the tip of the needle

Injecting

1. The injection site must be cleaned using an alcohol wipe or soap and water so that bacteria, dirt, or other germs on the skin do not get pushed into the veins by the needle.

• People can plan ahead so they don’t have to touch the site once it’s clean which can transfer bacteria back to the injection site. For example, they can consider cleaning more than one site in case they miss the vein the first time around.
• Wiping in only one direction will push the dirt and bacteria off the injection site. A circular motion will just move the germs and dirt around and they will stay on the skin.

2. Finding a vein to inject into is the next step and will prevent abscesses that can occur when the drug is injected into tissue, instead of the vein.

• Some techniques for finding a vein include:
  • using a thin, pliable tourniquet that is easy to release
  • running warm water over the site
  • tightening the shirt sleeve on the upper arm
  • making a pumping action with the fist
  • swinging the arm in a circle

3. With the needle bevel up (the opening of the needle facing up), the needle is slowly inserted into the vein. The needle should be at about a 35-degree angle and inserted in the direction of the heart (the direction of blood flow) to reduce vein damage.

• Using the needle to “fish around” for a vein will cause bruising and damage the veins. Instead, it is recommended to remove the needle and try again. The site may need to be cleaned again if it was touched by anything but the needle.

4. Flagging will ensure that the needle is in the vein. Flagging involves pulling the plunger back slowly until a little blood flows into the syringe. When people miss the vein during injection, they can cause abscesses or may not get high from the drug, depending on which substance is used.

• When flagging, if the blood is frothy, a brighter red than usual, or the plunger is pushed back by pressure from the blood, the needle has likely hit an artery. This can result in serious blood loss. The needle must be removed slowly and pressure applied to the spot to stop the bleeding. Raising the limb can help too. If bleeding continues and there is swelling or pain after 10 minutes, medical attention is needed.

5. Once the person is sure that the syringe is in the vein, he or she releases the tourniquet and slowly pushes the plunger in to inject the drug.

• If the person cannot release the tourniquet before injecting, it should be done as quickly after injection as possible as injecting into a tied-off vein can cause pressure in the vein and lead to vein ruptures.
• When injecting into veins properly, there should not be a lot of pain. If there is too much pain, it’s likely the syringe has hit an artery and should be removed immediately. Injecting into arteries will cause intense pain and excessive swelling in the limbs and has the potential to cause excessive blood loss and waste the drug and its desired effects.

6. The needle is slowly removed at the same angle as it was inserted, to reduce vein damage. Pressure is applied on the spot for a few minutes with a clean, dry gauze, tissue or cotton ball to stop the bleeding. Using an alcohol swab for this will actually cause more bleeding because the alcohol prevents the blood from clotting.

Cleaning Up

1. Disposing of the used needle in a sharps container is important so other people do not come in contact with contaminated supplies and risk transmitting blood-borne infections.

• Sharps containers are available from most needle exchange programs. The used needle can also be put in an empty plastic bottle that has a tight-fitting lid (like a bleach bottle or pop bottle).
• Used filters should also be disposed of as hepatitis C can be present and bacteria and fungus can grow in used filters. Clean filters that were never touched can be kept for the future.

2. It is important to dispose of all the other equipment in the sharps container. None of the equipment should be re-used or shared because of the risk of transmitting hepatitis C from blood-to-blood contact between people and because used equipment can cause more abscesses and other infections than new sterile equipment. 

3. Because HCV can live on surfaces for up to 4 days or more, the final step is to wash both the work surface and hands with soap and water and dispose of any newsprint or paper that was used during injection.

• Hands can also be wiped with a new alcohol swab.