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Effective Interventions Unit
Examining the injecting practices of injecting drug users in Scotland

Chapter 3: Results

The results will be presented in two ways. This chapter will provide a detailed description of the injecting process and the frequencies with which each element occurs. The following chapter will present case studies chosen to illustrate the variation that exists in injecting practices.

Study group characteristics

The study group consisted of 30 injectors aged between 21 and 42 years of age. The mean age of participants was 31.7 years. The majority of the group were male (n=22). Eight of the participants were in a current relationship with another IDU. The majority of respondents (n=25) lived in their own home or that of a sexual partner or family member. The remaining five were "skippering" (sleeping rough), living in emergency accommodation or staying with family or friends through necessity rather than choice. Only four (4/30) of the group reported having some form of employment. This employment was in all cases part-time, occasional and ended during the study. Roughly half (16/30) of the respondents did not know their HCV sero-status. Six participants reported that they were HCV positive and eight said they had tested HCV negative. Half (n=15) of the study group were not in treatment during the data collection period, 14 respondents were receiving methadone treatment and one participant had a short stay in a residential detoxification unit.

Drug use & injecting habits

Injecting careers in the group ranged from just two weeks to 21 years, with seven (7/30) group members injecting for less than two years. A small minority (3/30) considered themselves to be occasional IDUs. For the rest, injecting represented an everyday occurrence subject to available funds.

The majority (n=26) of respondents injected heroin only. Two IDUs injected both heroin and cocaine and two injected cocaine only.

Just over two-thirds of the group (n=21) practised regular self-injection with the remainder (n=9) preferring to entrust the administration of their injection to a fellow IDU. Of this latter group, six (6/9) individuals displayed total reliance on another IDU for the intravenous delivery of their drugs. The remaining three were observed both self-injecting and, on some occasions, trusting another IDU to give them their injection. The request to be injected by another arose either because the vein they proposed to use posed great challenges to the self-injector or because their confidence in their own ability had waned for some reason.

Overview of observed events

In total the research team observed members of the study group injecting on 53 separate occasions. Forty-eight of these events were recorded on video; only these 48 recorded events were used in the analysis. Each of the 48 recorded events are detailed in Appendix 1.

Eighteen events (18/48) involved an IDU injecting alone; in two of these events another IDU was present to assist with administration of the injection but did not inject themselves. Five of those observed injecting alone were also seen injecting in the company of others on other occasions. The majority of observed events (22/48) involved groups of two IDUs injecting together. Less common were groups of three (7/48) and the observation of a group of four IDUs occurred once (Table 1). Group injecting events usually involved cohabiting partners (16/30) either by themselves or in conjunction with family members, friends or acquaintances. A further 12 group injecting events involved acquaintances and/or friends and the remaining two involved "grafting partners" (IDUs who generate habit supporting income together).

The injecting process

The entire injecting process can be split into three distinct parts. These are the preparation episode, the administration episode and the post administration episode (Carruthers, 2003).

During the 48 recorded events, 65 preparation episodes were observed. This stage was defined as the transformation of purchased powdered drugs into a liquid form suitable for injecting (Carruthers, 2003).

The researchers also observed 103 administration episodes. The administration episode starts when the IDU begins to locate a vein for injection and finishes when the needle is removed after successful intravenous delivery. Three of these injecting episodes involved the direct injection of the contents of a temazepam capsule by one IDU and therefore did not require preparation.

The final stage of the injecting process is the post administration stage that occurs once the needle has been removed from the vein.

The three parts of the injecting process provide a useful model to analyse the results. Using this model, recorded observations were examined for the equipment used, the techniques employed and for specific risk incidents which had the potential to transmit hepatitis C infection.

The preparation, administration and post administration stages of the injecting process are now described in detail below.

Preparation

The purpose of the preparation stage is to transform the drug into a liquid form appropriate for injection - a process known as 'cooking'. All 65 observed preparation episodes involved heroin or cocaine in powder form; 56 episodes involved heroin and nine involved cocaine. In only one observation was poly-drug injecting observed. On this occasion the participant injected both cocaine and temazepam.

• Equipment used in the preparation stage

There are several pieces of equipment required for preparing drugs for injection. Firstly, a preparation surface is required for the drug user to place their equipment upon. The powdered drug is then put into a heat resistant container (a "cooker"). Depending on the type of drug being prepared, an acidifier may be necessary to help dissolve the drug. Heroin, in the form in which it is available in Scotland, requires an acidifier whereas cocaine does not. Water is required to mix the drug and liquefy it for injection. Some form of heat source needs to be available to heat and dissolve the drug solution. Once the drug is dissolved a filter is submersed in the solution in the cooker. The tip of the needle is placed on the filter and the solution drawn up through it; the purpose of the filter is to strain out impurities in the solution.

The types of equipment used by participants at each stage are described in detail below.

• Surface

In 21 (21/65) preparation episodes, participants prepared upon a fairly restricted area. Examples of such preparation surfaces included a wooden board, a magazine, a book, tissue paper, a swab and a tin lid. In the remaining 44 episodes participants placed their equipment upon a larger surface such as a table.

On no occasion was the preparation surface wiped before use and on 15 (15/65) the surface was visibly unclean. The remainder (50/65) appeared clean to the researchers.

• Cookers

A spoon was used as a cooker in the majority (60/65) of preparation episodes; in the remaining five episodes the bottom of an aluminium drinks can was used. On one occasion the aluminium can was picked up from the pavement. The majority of cookers (46/65) were unclean (Table 2). This was noticeable as there were traces of residual drug liquid left over from a previous episode. Twenty-five (25/46) of these episodes involved two or more participants sharing the same previously used cooker (Table 3). Only 13 (13/65) episodes involved a cooker which was cleaned in front of the researchers; five (5/13) of these were then shared. In two episodes the cooker was visibly clean from the outset and shared between two participants. In four cases the cleanliness of the cooker could not be discerned.

• Acidifier

Within the 56 episodes in which heroin was prepared, 26 involved sachets of citric acid from a Pharmacy/Needle Exchange, 25 episodes involved catering citric obtained from either a local shop or a 'Home Brew' supplier, and in three episodes the same participant used 'Jif' lemon juice. On two occasions the type of acidifier was unknown. The seven remaining episodes involved cocaine which does not require an acidifier.

• Preparation water

In 32 (32/65) episodes fresh tap water was used; in 14 episodes freshly boiled tap water was used and in three episodes participants used newly opened bottled water. In seven episodes the tap water was not fresh. On these seven occasions the water used to prepare had been used previously to clean needles; this is known as 'flush water'. In two episodes previously opened bottled water was used and in four episodes the source of the water was unknown. In three episodes the participant used no water, the drug was dissolved using 'Jif' lemon alone (Table 4).

• Heating and dissolving

The majority of episodes (44/65) involved the use of a cigarette lighter to heat the solution. Other sources included a cooker hob, a burning medi-swab and a burning candle. In the majority of cases the powder was dissolved with the aid of a stirrer. On 26 (26/65) occasions, participants used the cap from a needle/syringe, and on 20 occasions the plunger end of a 1ml syringe was used. A penknife was used on four occasions, the front end of a 2ml syringe was utilised on three occasions, a nail file and a paperclip were each used once. On five occasions the solution was not stirred and in another five observations the type of stirrer was unknown.

• Filters

The filter from a cigarette was used in the majority of episodes (33/65). In 12 episodes cotton wool or a cotton bud was used, and a piece torn from a medi-swab was used once. In 18 episodes, the filter material was unknown. On one occasion, no filter was used. Most (41/64) filters were new, 13 had previously been used and the status of 10 filters was unknown.

• Drawing solution into needle/syringe

At the end of the preparation stage, the drug is ready to be drawn up into the needle/syringe. In 38 of the 47 preparation episodes involving more than one IDU, a single prepared drug solute was divided between the group (Table 5). There are multiple ways of ensuring an even divide of the drug solution in these circumstances (Grund et al, 1996). One method involves frontloading and backloading. These are terms used to describe the process of transferring liquid from one needle/syringe to another. Frontloading involves squirting the drug solute from one syringe through the needle attachment aperture on another syringe, the plunger of which has been drawn back to leave a void. Backloading is the practice of transferring the solution from one needle/syringe to another by removing the plunger from one syringe and squirting the solution through the needle attachment of another into the back of that syringe. Another method involves drawing the whole amount into a syringe to measure the total volume of liquid in the cooker and then squirting an agreed portion back on to the cooker to allow the other user(s) to draw up their portion into their needle/syringe (Koester et al. 2003). Within the study group, however, the preferred method was to pre-measure the water before adding it to the cooker. Once this had been done, and the drug dissolved, participants drew up their portion of the solution and checked the syringes to ensure each had the same amount. Each individual's share could be drawn up into his or her syringe consecutively or simultaneously.

Consecutive drawing up was the most commonly observed practice. In 27 out of the 38 group preparations the solution was drawn up in this fashion. A previously used needle drew the solution up first in more than half (14/27) of these occasions. Also common was for one or more injectors to place their needle/syringe back onto the filter after all or most of the solution had been drawn up.

• Overview of sharing of filters, cookers, water

In 44 of the 47 preparation episodes involving more than one IDU, cookers, filters and water were shared among participants. On 38 occasions, a single batch of drug solute was prepared on one cooker, using one filter for division among the group; the other six episodes involved separate preparations using the same cooker and filter (See again Table 5).

• Preparation hygiene

There was a general lack of hygiene throughout the preparation stage. No preparation surface was wiped prior to preparation. In only one (1/103) episode did a participant wash their hands prior to preparation, and in only 20 (20/103) episodes was a swab used to clean the injection site prior to injection.

Administration

The administration stage involves choosing a needle and syringe with which to inject and choosing the location in which to inject.

• Needles/syringes

Out of 103 administration episodes the majority (n=88) involved the use of a 1ml insulin needle and syringe. Fourteen injections were administered with a 2ml syringe with detachable needle. Needles are colour coded depending on their thickness. Of these 14 administration episodes, five involved a green needle (0.8mm), five a blue needle (0.6mm) and four an orange needle (0.5mm). In one episode involving a 2ml syringe, the gauge of the needle was unknown.

In five episodes participants transferred the solution from one needle and syringe to another. This usually occurred because the needle in the first set was blunt or the needle and syringe became blocked. In four of these episodes, the original and transfer sets belonged to the same IDU. One one occasion, however, a participant backloaded the solution from their own used needle to another's used needle and then injected themselves with it. This was the only observed example of 'direct' needle sharing throughout the study.

Of the 103 administration episodes, 54 involved a sterile needle/syringe and 49 involved a pre-used needle/syringe (Table 6). Participants involved in 48 (48/49) of these incidents reported that the needle/syringe had been used only by themselves. However some participants admitted that they may have used another's needle by mistake. The reason given was the difficulty in distinguishing one needle/syringe from another in situations in which IDUs were using the same size of syringe and gauge of needle. As participant 101 explained:

"the other day the guy across the road was rattling and I said "I've got a bit come on over and I will square you up"…. and I went into the toilet to make it up and he put the kettle on and he's getting his tools and I've put mine down. Obviously they have not been marked. I made the hit up and I picked mine up and I have sooked half of it up and I have picked up his half of it up and when I have been doing that I've went "whose is whose?" And I was positive his was on my left hand side so I gave him the ones that have been on my left hand side. I'm 99.5% positive that I was right but there is always that 0.5% chance that I did mix it up" (Participant 101, interview)

*some participants were unsure if their needle/syringe had been pre-used by someone else - see text.

Cohabitants and IDUs sharing the same accommodation also acknowledged that there is a potential mix-up of needles/syringes when they are stored loose in the same place. From the 47 preparation observations involving two or more participants, only 11 (11/47) involved the participants using different methods to distinguish their needles. These methods included burning the plunger end of the syringe, scraping the units on the side of the syringe and pulling the plunger down.

After drawing the drug solution into the needle/syringe and prior to inserting it into a vein, participants often wiped the tip of the needle in some fashion. On 23 (23/103) occasions participants were witnessed wiping their needle tip between their fingers. Needles were also wiped in other ways. They were wiped with a swab 10 times (on one of these incidents the swab had already been used as a heat source), with a tissue three times, twice on a pair of jeans and once on an injector's bare thigh. Licking the needle tip was observed on 12 occasions. When asked why they did this, one IDU replied:

"It's a habit. I don't know why I do it. It removes dirt so I don't have a dirty hit." (Participant 117, audio recording)

• Injecting sites

The 103 recorded administration episodes included 38 injections into the arm, 35 into the groin, 11 into the leg, nine into hands, seven into the neck, two into the 'blood bank' (under the upper arm) and one into the stomach. Six of the 30 participants injected into more than one area. One individual injected into her arm, hand, leg and stomach over five observations.

• Methods of raising veins

When injecting into the arm the IDU usually needs something to 'tie off' to restrict the blood flow. This causes the veins to bulge out making them more accessible for injection. For all 38 injections into the arm a tourniquet was used. Other methods used to raise veins included sitting in front of a fire, clenching fists and rubbing the injection site.

Two injectors used their neck as their injecting site on seven different occasions. Both relied on other IDUs to administer their injection. The first participant chose to lie upside down on a couch to raise the neck veins. The second lay on a bed. In both cases the individuals held their breath in a controlled manner. This practice helped to make their veins more visible. Close co-operation between injector and recipient was essential in this process.

• Inserting the needle into a vein

Once the location has been chosen the needle is then inserted into the vein. To check the needle is properly inserted into the vein the participant will pull back the plunger and check if blood is visible in the chamber. This is the visual confirmation that the drugs contained in the syringe can be delivered intravenously. However it must not be assumed that once an IDU pierces their skin with a needle/syringe that a vein has been successfully located. Researchers witnessed 79 unsuccessful attempts to locate a vein. This occurred when a participant inserted their needle/syringe, pulled back the plunger, saw no blood in their syringe and removed the needle/syringe. Failed attempts occurred when participants were injecting into their arms, hands and legs. All injections into the groin area were administered at first attempt.

• Administering the drug

When the blood has entered the syringe, the plunger is depressed to administer the drug. Once the drug had been administered into the bloodstream it was common for 'flushing' to take place. This practice occured after the drug had entered the vein. Before withdrawing the needle the participant would pull back the plunger until blood was again visible in the chamber and then depressed it. During the observation sessions this happened between one and five times per administration depending on the user. This is believed by many drug users to 'flush' the drug round the system. However, although this practice was commonplace, many users thought this was a fallacy and believed that it ruins the quality of their veins.

Twenty-two (22/103) administration episodes involved a participant being injected by someone else. Eleven (11/22) were injected by sexual partners, five by acquaintances and six by close friends. Three episodes involved two participants attempting to inject the same participant. On nine separate occasions an IDU touched their injecting site with their hand and then, without washing, injected another IDU and touched that person's injection site with the same hand.

The amount of time required for administration varied. Success depended on the location of a vein. One participant took 15 seconds and the longest time observed was 19 minutes 24 seconds.

One individual was observed injecting nine times on six occasions. One time it took two minutes to locate a vein and administer his injection in one attempt. Another time he took fifteen minutes and injected in eight different sites on both his hands and arms. During this last administration episode this individual talked about a 'race against time' once blood has entered the syringe. He was referring to time pressure created by avoiding blood congealing in the syringe on occasions when blood had entered the needle/syringe from a non-viable vein.

Post-administration

The post administration stage includes all events which occur once the needle has been removed from the vein. Typical events might include stemming the blood flow from the injection site, the cleaning of syringes, disposal of equipment and the storage of the injecting paraphernalia.

• Stemming blood

Once the needle was removed it was common for the participant to wipe their injection site to stem the blood flow. The most common method was to wipe the injection site with fingers (30/103); on only two occasions (2/30) did participants wash their hands afterwards. A swab was used 29 times and a tissue on 28 occasions. On 4 (4/57) of these occasions these bloody swabs and tissues were left lying on a surface without proper disposal. The injection site was licked six times, and wiped with clothing three times. A tourniquet was used once to stop blood flowing. On six occasions nothing was used to wipe the injection site as there was no noticeable blood flow (Table 7).

• Cleaning needles/syringes

Seventy-one of the 103 administration episodes involved participants flushing their syringe with the same water used in the preparation process (Table 8). Forty-nine (49/71) of these episodes involved two or more participants sharing the same flush water. On only 10 occasions did participants clean their needles/syringes using fresh running tap water from the kitchen or bathroom. On no occasion was bleach used to clean the needles/syringes. It was not known how, or if, needles/syringes were cleaned on 22 occasions. After flush water was drawn into the needle/syringe, on most occasions (93/103) the water was sprayed into a bin, into a plastic bag or down the sink, in the other 10 episodes, flush water was sprayed out of windows and onto carpets.

• Storage of equipment

A total of 82 needles were used in the 103 injections episodes observed (some participants re-used their needle/syringe in more than one episode). Twenty-five (25/82) of these needles/syringes were disposed into a cin bin, obtained from a needle/pharmacy exchange. However, it must not be assumed that cin bin disposal means that the needle/syringe will not be used again; the research team witnessed participants re-using needles/syringes from cin bins on a number of occasions. Ten needles were placed into a plastic bag from the pharmacy, 10 into a drawer, seven into a spectacles case, four into a wallet, two into a rubbish bin, two into a cupboard and two into a plastic box. Twenty needles were not disposed of during the time that the researchers were there, but were left lying loose on the preparation surface (Table 9).

Catering citric acid, used by some injectors to dissolve their drugs was purchased in large amounts and used for weeks if not months. Storage was mainly within a closed container, a plastic bag or within its original packaging.

Participants also stored filters for use at a later date. This storage served two purposes. The first was to use the filter again in the preparation process. The second was known as a 'boil up'. It was common for IDUs to collect filters so that they could heat them with water to extract the excess drug from them. This was useful when they had no money for drugs or early in the morning before they were able to buy more. In the 65 preparation episodes a total of 57 filters were used. Nineteen (19/57) of these filters were kept on the spoon for later use, 12 were kept in a drawer, eight in a closed container, six in a cup, and one in a cupboard. The storage place of 11 filters was unknown. On no occasion did the researchers witness a filter being thrown away (Table 10).

• Participants living with children

IDUs living with children generally took greater care in the storage of their paraphernalia during the post-administration stage. They were more likely to display a more systematic approach to tidying up the equipment immediately after administration. This usually meant making sure that all the equipment was stored in a confined space hidden and out of reach of children. Such storage environments included kitchen drawers, the back of a bathroom drawer, the top shelf in cupboards and cardboard boxes placed at the back of a bedroom cupboard.

Impact of harm reduction advice

During the taped interviews, participants were asked about their knowledge of HCV and risk behaviours.

Every member of the study group showed a basic awareness of at least a few safer injecting principles. All of them understood that the practice of sharing needles/syringes was a risky one. This risk was more often associated with contracting HIV than HCV.

Most displayed a basic awareness of a hierarchy of risk; they knew that some injecting practices were riskier than others. Most understood that the sharing of cooker, water, and filters represented a risk but also knew if they used clean needles/syringes as well as a clean cooker, water and new filter that they could share these items, fairly secure in the knowledge that transmission risk would be minimal.

Many IDUs talked of their risk awareness as being a response to visual stimulus. If blood was visible on injecting paraphernalia then IDUs knew that using that item of paraphernalia was something to be avoided.

A fatalistic attitude to taking risks was often observed particularly among IDUs who quoted extremely high levels of HCV prevalence. Phrases like, "90% of junkies have got it anyway" were commonly heard from study participants when talking about HCV.

Crucial to understanding why risky behaviours are continuing despite safer injection messages is that, for most IDUs, harm reduction is only one competing factor amongst many other considerations that contribute to an individual's decision-making process at any one injecting event. Contracting a blood borne virus (BBV) is considered serious but is also viewed by many as a long-term risk and one which may diminish in significance as a contributing factor in the decision-making process especially when that individual has more pressing short-term concerns. Examples of such concerns will be illustrated in Chapter 4.

Most participants maintained that despite greater awareness of the consequences of unsafe injecting they would still engage in risky practices in certain scenarios. Many said they would use or consider using another IDU's previously used needle/syringe if: a) they were experiencing severe withdrawals or b) they did not have a needle/syringe of their own. Other factors shaping an individual's injecting practices include naivety, bereavement, laziness, tendency towards short-term thinking and homelessness. Homelessness could lead to the practice of outdoor injecting. Those who inject outdoors have no access to running water, cannot stock up on sterile injecting equipment, and do not have the luxury of being able to take their time in the preparation process.

In summary, harm reduction messages have to compete with other often more pressing concerns.

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