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Effective Interventions Unit
Examining the injecting practices of injecting drug users in Scotland
Chapter 5: Discussion and Conclusions
This study is the first ever in the UK to combine ethnographic methodology with video recording to investigate the details of the drug injecting process. A recent study in Australia (Carruthers, 2003) also filmed injecting practices but it is not clear the extent to which respondents were recorded in their own natural settings.
The main objective of the study was to examine the mechanics of injecting in order to determine any ways, as yet not fully understood, in which HCV can be transmitted between IDUs. Other objectives were to contextualize these practices and to gain some understanding of IDUs knowledge of HCV transmission risks and harm reduction techniques.
A total of 30 IDUs were recruited to the study. The aim was to recruit injectors with varying lengths of injecting career and from different life situations. Among the 30 participants, injecting careers ranged from two weeks to 21 years; five were homeless.
As with any qualitative study, the sample size is small and the results may not be generalisable to other injecting populations. Moreover, in addition to this usual caveat for qualitative work, there were other issues raised by this study which should be noted by those who may want to undertake similar research in the future:
Firstly, ethical approval was difficult to obtain and it took a considerable length of time for approval to be granted.
Secondly, insufficient time was allowed in the original proposal for analysis. It was difficult at the outset to predict how much time would be required for analysis as no previous video studies of injecting practices have been undertaken previously. Rather than the original three months with one researcher which was originally proposed, the time taken to analyse the data sufficiently was four months with two researchers and input from audio-visual analysis experts.
Thirdly, a longer period of fieldwork would have yielded both a larger sample and more insight into the lifestyles of the participants involved in the study. The issue of bias, or of altering behaviour, by the presence of researchers and a video camera was raised in the chapter on Methodology. Whilst the researchers' impression was that no change in behaviour occurred as a result of their presence, a longer time spent with individual participants or groups of participants would have allowed a greater degree of certainty that the actions depicted on the video were "natural" and not biased by the presence of a research team and camera.
Despite these issues, the results clearly showed that there are multiple ways in which IDUs put themselves at risk of HCV transmission during the injecting process.
To become infected with HCV, the individual must come into contact with the blood of an infected person. The most common route of HCV transmission is injecting drug use (Wodak et al, 1996). The most obvious route of HCV transmission is for an IDU to inject with a needle and syringe previously used by a potentially infected injector. Only one such incident (1/103 injections) of direct sharing occurred in this study. This, together with oral reports from respondents, indicates a high level of awareness by IDUs of the risks involved in sharing needles/syringes with others. An understanding, however, of occasions when indirect sharing of needles/syringes could occur, and the risk this poses, seemed less well understood. Such indirect sharing of potentially infected needles/syringes and the sharing of other potentially infected injecting paraphernalia was more common. These possible routes of transmission will be discussed below along with the implications for harm reduction messages and public health policies.
Participants invariably injected with their own, or what they regarded as their own, needle/syringes. Just over half of the injection episodes (54/103) involved the use of new, sterile, needles/syringes. The potential for transmission arose in the episodes (49/103) in which participants injected with previously used needles/syringes. Apart from the one IDU who was seen to inject with another's needle/syringe, the participants in the other 48 injection episodes believed that their pre-used needles had been used only by themselves. However, some participants admitted that they have may have used another person's needle/syringe by mistake. This could happen in two ways. Firstly, cohabiting IDUs often stored their used needle/syringes next to each other's and then had difficulty in distinguishing one from another. Secondly, needle/syringes could be confused where two or more people were injecting together, put their needle/syringes down next to each other's and then could not tell which was theirs. By far the most common type of needle/syringe used by IDUs in the study was the fixed 1ml insulin needle/syringe. This was used in 85% (88/103) of all injections. On only eleven occasions were these needle/syringes observed as marked in some way that could differentiate them from those belonging to other IDUs.
The utilisation of a pre-used needle/syringe in the preparation of drug solute for more than one injector is another, and perhaps more common way in which needle/syringes can be shared indirectly. Almost two-thirds of the video sessions involved groups of two or more IDUs injecting together. It was common to prepare drugs in one batch for all participants; this being the most efficient way to divide drugs bought with pooled resources (Koester et al, 2003). Pre-used needle/syringes were used to draw up preparation water; inserted into shared filters; used to measure drug solution; and then squirted solution back onto a spoon for injection by another IDU. Although the used needle/syringe does not come into direct contact with another IDU in such circumstances, it potentially could contaminate any or all of the other injecting paraphernalia or drug solution. (Koester et al, 2003).
Flush water, used to rinse out needle syringes after injection, was another potential source of infection if, as was common in the study, the same container of water was used consecutively by different IDUs who later re-used the same needle/syringes. Uncleaned spoons and filters, potentially contaminated in the way described, were commonly stored for re-use.
Blood-to-skin contact is generally regarded as a low transmission risk, but in circumstance where this happens frequently, or where skin is broken, this can increase the risk (Carruthers, 2003). IDUs were seen placing bloody fingers on another's injection site and leaving bloodied tissues or cotton wool on tables and other surfaces.
While the main aim of the study was to identify risk behaviours for HCV, many of the behaviours recorded, particularly those related to hygiene, also have potential for the development of bacterial infections such as abscesses, ulcers, necrotic tissue and inflammation, all of which are common among IDUs.
The level of hygiene was generally low. In only one (1/103) injection administrations did a participant wash their hands prior to injecting. A swab was used to clean the injection site prior to injection in only 20 (20/103) occasions. On no occasion was the preparation surface wiped before use and on 15 (15/65) the surface was visibly unclean. Of the 57 filters used in the preparation episodes, none were disposed of, and eight were kept in closed containers, highly conducive to the development of anaerobic bacteria. The re-use of filters was implicated in the recent outbreak of
clostridium novyi infection among IDUs in Scotland (Taylor et al, unpublished data).
Most of the study participants were aware of BBVs and how they were transmitted. However, the circumstances of their lives and drug habits acted as obstacles to the practice of safe injecting.
IDU populations are not comprised of isolated individuals but small groups of two or more participants whose relationships are promoted and strengthened through the common interest and practice of injecting. They share strategies to procure both the money for drugs and the drugs themselves. As a consequence of the intensity of injecting and their interdependence on one another, blood which might be infected can pass from one to another.
The preparation and injecting of drugs is highly complex. Even for those who fully understand how to prevent contamination of equipment and drug solute from blood, the process of preparation and injecting are riddled with pressures which may result in sub-optimal practices with regard to preventing transmission of BBVs. For example, when IDUs are injecting together the controlling person is usually, although not always, the one who has supplied the drug. Those not in control may need to compromise their desire to inject safely because they do not have the same leverage as the controller in the ways that drugs are prepared and injected. Thus, interdependence and negotiation results in compromise and risky injecting practices with regard to BBVs.
Further pressures around injecting and its accompanying lifestyle add to the difficulties in practising safe injecting. Fear of blood congealing in the syringe imposes time constraints which may result in short-cuts being taken or mistakes being made, all of which may result in risky injecting with regard to infection; fear of insulting people by engaging in safe injecting practices, which suggest that the person is infected, lead to sharing injecting paraphernalia. Following injecting, the need to quickly stem blood with a finger so that the integrity of the vein is maintained, can involve blood-to-skin contact between injectors. The practice of rinsing needle/syringes after injecting, which may remove a potential source of infection, is offset by the desire to preserve residual drug on spoons and in filters and by the storage of these needles/syringes for later use.
What does all this mean in terms of harm reduction?
The messages arising from our findings are clear. Injectors should be warned clearly that they should share none of the parts involved in the preparation of drugs for injecting or in the post-injecting stage. This message should include the sharing of drugs. IDUs should be advised that each individual should make up their own drug solution using new equipment each time. If it is not always possible to use brand new equipment, injectors should ensure that they inject with used equipment that they can guarantee has not been used by anyone else. To ensure that IDUs can comply and implement these harm reduction strategies, they must have the resources to do so.
If a sterile needle/syringe was used at each injection episode it would eradicate the contamination of other paraphernalia such as spoons and filters. Re-use of needles/syringes was common amongst participants in this study. Much of this re-use arose from IDUs not having clean, sterile equipment at the time of need.
It is important that IDUs have the potential to use a sterile needle/syringe for each injecting episode. This has obvious cost implications, especially in light of the new legislation which now allows health boards to provide other injecting paraphernalia. In essence, needles/syringes are central to the injecting process and act as a conduit between contaminated blood and potentially all other items of injecting paraphernalia. Therefore, if health boards have to make a choice between which paraphernalia to provide, the choice, as far as blood borne viruses are concerned, should err on the side of needles/syringes.
The recent increase in number of needle and syringes which can be given to IDUs at any one time will hopefully reduce the need for needle/syringe re-use (Scottish Executive HDL (2002) 90) and an evaluation of this change is currently underway. However, this increase will only be effective if IDUs have access to the facilities which provide needles/syringes. A common complaint from respondents was that, with the exception of one service, all other exchange facilities were not open at convenient times.
Consideration should be given to increasing the number of services providing 24 hour access, or to making clean equipment available through other means such as vending machines.
Despite best efforts, there will still be some IDUs who continue to store needle/syringes for later use.
Consideration should be given to producing the commonly used fixed 1ml set in different colours so that cohabiting IDUs, for example, can distinguish each other's equipment. This goes against the grain of harm reduction messages encouraging the use of only new equipment but may be a pragmatic development given the lifestyles of injectors as described above.
IDUs should also be given the opportunity to learn more about the ways in which injecting paraphernalia can become contaminated at various stages in the injecting process. Injectors are not immune to harm reduction messages, as seen in their knowledge of the risks involved in the direct sharing of others' needles/syringes and their avoidance of this activity. If they understood more about the implications of indirect sharing, this may also have a positive impact on their risk behaviours.
IDUs need more information about the various ways in which different pieces of equipment can become contaminated in the process of drug preparation. This could be achieved through a training video, posters and leaflets demonstrating risk practices.
In addition to the risk behaviours for BBVs, the practice of poor hygiene put IDUs at risk of bacterial infections.
Health promotion materials should be developed which emphasise the need for hygienic practices, particularly the washing of hands before and after injecting, the swabbing of skin prior to injecting, and the cleaning of preparation surfaces. The finding that some IDUs use swabs as a heat source to dissolve drugs makes it imperative that sufficient swabs are made available to IDUs.
Such harm reduction developments would hopefully reduce many of the risk behaviours outlined in this report. However, as the results have shown, there are a myriad of pressures on IDUs which conspire against the practice of safer injecting to protect them from BBVs. Some of these arise from the desire to "beat the clock" to prevent needles becoming blocked by congealing blood, often among those who have been injecting for some time and have poor veins or newer injectors with poor injecting techniques. Others arise from social circumstances, such as homelessness.
Observations supported the notion that IDUs injecting indoors had more opportunity to inject according to safer injecting principles than outdoor injectors. The advantages that indoor injectors have are: a) access to running water; b) the ability to stock up on sterile injecting equipment; and c) the luxury of being able to take their time during the process. In contrast outdoor injectors are faced with circumstances that may lead them to make risky choices. The most pressing obstacle to safer injecting is concerned with the lack of access to running water. Water used in outdoor injecting events is usually contained in a small plastic water bottle either bought from a local shop or filled up in a public toilet. This water is used both to prepare drugs for injecting and rinse out needle/syringes. Keeping bottled water for re-use in subsequent injecting events is commonplace and if shared presents a risk for transmission of HCV. From observations, outdoor injecting events involving large groups of IDUs sharing equipment are probably rare. By definition, congregations of large groups of IDUs within the city centre attract unwanted attention from the police and general public. The main cause for concern with regards to the transmission of HCV amongst outdoor injectors is the lending of core equipment to others in need.
One method of dealing with the harms associated with poor injecting techniques and of injecting outside would be to provide
safe injecting rooms, particularly in the city centre where outdoor injecting is most common. Evaluations of safer injecting rooms indicate that these facilities have improved the health and social functioning of IDUs, risk behaviours for BBVs, and use of drugs in public (Kerr et al, 2003). A study evaluating the potential use of such facilities in Canada found that those who required help with injecting, those who had difficulty in accessing sterile needles/syringes and those who injected in public would be willing to use such a service (Wood et al, 2003).
Many of the pressures experienced and risk behaviours exhibited by IDUs arise from one simple fact: the intensity of desire for drugs to stave off withdrawal symptoms. This intensity is in complete inverse proportion to the desire to practice safe injecting. Many of the risks - preparing drugs communally, storing used filters and spoons - arose out of the need to ensure that they received the maximum amount of drug possible. A minimum of just under half of the sample were receiving methadone at the time of the study. Despite this treatment, the injectors required to "top-up" with heroin. Elsewhere, methadone maintenance therapy has been shown to reduce, but not eliminate, the practice of injecting (Hutchinson et al, 2000; Simeons et al; 2002). Inadequacy of dose may be a factor influencing the continuation of injecting. In the interests of preventing the transmission of BBVs,
harm reduction policy should include the provision to injectors of adequate doses of methadone or other substitute medication which would enable the cessation of injecting.
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 that they would use or consider using another IDU's 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, homelessness, bereavement, laziness, a tendency towards short-term thinking and homelessness. These factors clearly affect the injecting practices of some IDUs more than others. The examples of Mark (103) and Jamie (114) illustrate that some IDUs have taken heed of harm reduction advice and translated it broadly into safe injecting practices which display a form of long term thinking. What is clear is that whilst harm reduction professionals may analyse injecting practices in isolation such distinctions are not made within the mind of an IDU. Rather, harm reduction messages have to compete inside the minds of IDUs with other often more pressing concerns. Safer injecting advice has made some impact and translated into improvements in terms of reducing some risk behaviours but has not eradicated unsafe practices. The findings from this research should enable harm reduction practitioners and policy-makers to address these issues more effectively.
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