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CHAPTER FOUR: THE FIELD BASED STUDY FINDINGS

The Participants

4.1 A total of 359 participants were recruited to the study and completed the needle exchange short questionnaire ( NESQ) to provide the core quantitative data. Of these, 189 participants were recruited in Aberdeen and 170 in Dundee. The total number approached or number who refused was not recorded.

Demographics and injecting history

4.2 All quantitative data that was found to be normally distributed was compared using t-tests, otherwise a Chi squared test was used. P values of =0.05 indicate a significant difference. A summary of the two groups and comparisons is shown in table 8.

Table 8: Demographic data for Aberdeen and Dundee cohorts and t-test p values

Patterns of drug use

4.3 The main drug used by injection by all but a few in each cohort was heroin (table 9, overleaf). Forty (21.1%) of the Aberdeen cohort sometimes injected a second drug. In 31 cases this was crack cocaine, for 5 this was speed (amphetamine), 3 cocaine powder and one 'other'. Thirty three (19.4%) of the Dundee cohort sometimes injected a second drug. In 13 cases this was speed (amphetamine), for 10 this was 'pills' of various types, 3 crack cocaine, 3 cocaine powder and 2 'other'. Speed and 'pills' were more commonly reported in Dundee while crack cocaine was more commonly reported in Aberdeen. Small numbers in both groups injected a third and sometimes a fourth drug.

Table 9: Main drug used by injection for Aberdeen and Dundee cohorts

4.4 In Aberdeen 155 people (82%) were classed as 'regular users', which was defined as those injecting one or more times every day. In Dundee this figure was 125 (74%). It was not established whether participants were receiving any form of drug treatment at the time of participation (e.g. methadone), which could influence the frequency of injecting.

4.5 Daily amount of heroin used was calculated by multiplying the amount of heroin per injection (which was reported in or converted to monetary value) by the number of injections per day. For example, a person who usually injected a '£10 bag' three times a day had a 'daily amount' value of £30. Table 10 shows this data rounded to the nearest '£5 bag' in order to make the values meaningful. When compared statistically, actual figures were used, not the rounded figures. There was no significant difference between the groups in the average daily amount of heroin used by regular users (p=0.603). It should be highlighted that many people commented that actual amount used varied depending on finances and availability. Therefore these figures will be approximations.

Table 10: Amount of heroin used per day by Aberdeen and Dundee cohorts

Injection sites and administration methods

4.6 Participants were asked in the NESQ to describe their main injecting site, which was defined as the one that they currently most often injected into. The researcher marked this on a diagram on the questionnaire. Table 11 lists the results.

4.7 There were more injectors using their groin (femoral vein) as their main site in Aberdeen (31.2%, n = 59) compared to Dundee (10.5%, n =18). Amongst groin injectors, time since first injection was 10.8 years in Aberdeen ( SD = 6.8) and 6.9 years ( SD =5.5) in Dundee. Classifying injecting sites together, 125 (66.9%) of Aberdeen participants stated their main injecting site was a peripheral vein (all arm, hand, leg and feet sites) and 60 (32.1%) said it was a deep vein (groin or neck). Two (1.1%) said another site (buttock or genitals). In Dundee 149 (87.7%) used a peripheral site as their main site and 20 (11.8%) used a deep vein (groin, neck or clavicle). The proportion of participants using a deep vein as their main site was significantly greater in Aberdeen compared to Dundee (p<0.001).

Table 11: Main site of injection administration currently being used

4.8 As well as their main site, participants were asked to describe all additional sites they regularly used at the moment. The mean number of sites used by the Aberdeen cohort was 4.1 ( SD = 2.8). For Dundee the mean number of sites was 4.0 ( SD =2.6). There was no significant difference in this (p = 0.535).

Breaks in injecting

4.9 This question was considered important in relation to vascular health. It was hypothesised that those who had had breaks from injecting may have had better vascular health than those who had injected continuously. In the Aberdeen group, 161 (85.6%, 1 missing) participants said they had had a break from injecting at some point. In Dundee this figure was 138 (81.2%). There was no significant difference for this between the groups (p = 0.256). However it became clear from the researcher annotations on the questionnaires and through the qualitative interviews that there are complications with this term. The descriptions of breaks varied considerably both in frequency and duration. For example some people mentioned breaks in terms of years and others did so in days. One person reported that they take planned two week breaks four times a year in order to 'let veins recover'. A further person said they often 'stopped for a few days' with no definite pattern. Imprisonment sometimes forced breaks. Although breaks in injecting may be a factor in limiting the extent of vein damage, the significance in this study cannot be confirmed and would be difficult to do so in future work of this kind due to the high number of variables and reliance on recall.

Who prepares the participant's injections?

4.10 In the Aberdeen cohort, 171 (91.0%, 1 missing) participants prepared their own injections. In Dundee this figure was 154 (91.1%, 1 missing) which is not significantly different (p =0.956). In the case of people who did not prepare their own, all but two said the preparer was their partner. In one case it was a brother and one person, who was a new injector, said their preparer varies. There was no relationship between age and whether the person prepared their own injections, but those who prepared their own had been injecting longer than those who did not. Looking at the participants as a whole, 19% of women (n=20, total number of women = 107) did NOT prepare their own injections. For men this figure was 5% (n= 12, total number of men = 248). Women were significantly less likely to prepare their own injections than men (p = <0.001).

Participant Summary

Both groups were predominantly made up of primary heroin users, most of who injected regularly. The Aberdeen group contained more 'regular' injectors defined as injecting one or more times a day (82% vs 74%), although this was not significantly different. The two groups contained similar proportions of men and women and began injecting at similar ages. About half of each group had been roofless, and more of the Dundee group were currently roofless although this was just short of significance. The Aberdeen group were older than the Dundee group, by on average approximately two years and had a significantly longer average time since first injection (8.8 years compared to 5.9 years), which means they may have been exposed to injecting related risks for longer. This is confounded by the very varied frequency of and duration of breaks in injecting identified in both groups. Both groups injected the same average amounts and range of amounts of heroin. 21.1% of the Aberdeen group sometimes injected a second drug, most commonly crack and in Dundee 19.4% sometimes injected a second drug, most commonly speed or pills. Significantly more of the Aberdeen group used a deep vein (femoral and jugular veins) as their main site compared to the Dundee group, a greater proportion of whom used peripheral veins (arms and legs). It is not known how many were receiving drug treatment such as methadone.

Injection preparation equipment used

4.11 Participants in the NESQ were asked to select from lists read out to them, all the injecting equipment that they were currently using. If they said something not on the list, the researcher could select 'other' and describe the item(s).

Needles and syringes

Table 12 (overleaf) shows the syringes that participants reported using. All syringes currently used could be selected, hence the totals exceed 100%.

Table 12: Syringes that participants reported using ( NB Some participants used more than one type).

4.12 Regarding detachable needles, the most commonly used type was 'Blue spikes' used by 56 (29.6%) of the Aberdeen group and 18 (10.6%) of the Dundee group. This corresponds with the greater use of detachable barrels in Aberdeen. Blue spike users were significantly more likely to be main site groin injectors (p<0.001). The type of injecting equipment used to access each site was not specifically asked. Drugs worker advice may be an influencing factor in equipment use. In the qualitative interviews it was noted that those who used insulin syringes for peripheral sites, if also using the groin site, reported selecting larger needles and detachable barrels for this site. It is suggested that the difference in use of the 0.5ml insulin syringes is due to variations in drug worker promotion and availability from pharmacy exchanges in Dundee.

Paraphernalia

4.13 Table 13 summarises the paraphernalia currently used by the two cohorts. All items currently used could be selected hence the totals exceed 100%. Examples of ' other' filter materials were all reported in Aberdeen. These included nappy linings, duvet or pillow fillers, sanitary towel material, socks, sponge, swabs and tampons. Participants could again report more than one of each type of item. 'Currently' was not defined to participants.

4.14 Only one participant in Dundee did not use any of the paraphernalia items supplied. This person was a heroin injector and reported using their own makeshift items instead. This participant was a 35 year old female who had just begun injecting. She did not participate in an interview, so no further information is available on why this was so, but it may be that she was a new contact to the service. 169 (99.4%) of the Dundee cohort reported using one or more of the paraphernalia items supplied by the exchange. The data above shows that in Dundee where paraphernalia was supplied it was used predominantly. However, it also shows that it was not used exclusively. The qualitative interviews provided greater insight and it is discussed later why this was so.

4.15 In Aberdeen a small number had obtained some of the exchange paraphernalia from needle exchanges outside of Aberdeen. However they did not use this exclusively. In both Aberdeen and Dundee a small number described using water ampoules. One participant who took part in an interview described a source of medical supplies. It is unknown what the other sources were.

4.16 As water was not supplied in Dundee it is not surprising to see that the range of different types reported is large and similar to that of Aberdeen. Kitchen tap was the most popular source in both cohorts. The researchers frequently annotated this 'boiled'. This is advocated in safer injecting leaflets in the absence of access to sterile ampoules. The use of bottled water could potentially be of concern, especially if this bottle had also been drunk out of, due to bacterial and fungal infection risks from the mouth. Qualitative data on the sharing of water is further discussed later.

Table 13: Paraphernalia 'currently used' by participants in Aberdeen and Dundee

Injecting equipment summary

In both groups the majority used 1ml insulin syringes. In Aberdeen detachable 1ml syringes and blue needles were more common, probably because of the greater prevalence of groin injecting. A few Aberdeen participants did access supplied paraphernalia elsewhere, but most used makeshift. In Dundee, the supplied paraphernalia was used by all but one participant. The filters supplied in Dundee (Stericup/Sterifilt) were used by less people than the other items supplied (citric acid sachets and cookers). Supplied paraphernalia was not used exclusively in Dundee, makeshift items were still reported. The qualitative interviews gave greater insight into understanding this (see later).

Injecting site complications currently experienced

Data gathered using the NESQ from all participants

4.17 Participants in the NESQ were asked to report any injecting site complications that they had on the day of participation. These were verified by inspection by the researchers wherever possible. Tables 14 and 15 present the data.

Non infected complications

4.18 In Aberdeen the number of sterile abscesses per person ranged from one to 10, with the most common number being one. In Dundee the range was one to 20 with again the most common number being one. Grouping the data together for 'non-infected complications', 142 (75.1%) of the Aberdeen cohort presented with one or more, in Dundee this figure was 123 (71.9%) which was not significantly less (p = 0.491). Using a logistic regression model to adjust for time since first injection (injecting time), also showed no significant difference between the groups (p=0.806).

Table 14: Number of participants experiencing non-infected complications from injecting on day of baseline participation

Skin and soft tissue infections

4.19 In Aberdeen, the number of infected abscesses ranged from one to eight, with one being the most common. In Dundee, again one abscess was the most common but the range went up to 22 (which was annotated as an estimate). In Aberdeen, 14 people had one ulcer and the range went up to five. In Dundee, seven people had one ulcer and the range went up to 30, which was estimated.

4.20 Grouping the data together for 'skin & soft tissue infection', 40 (21.2%) of the Aberdeen cohort and 30 (17.5%) of the Dundee cohort had a current complication within this category, which was not significantly less (p = 0.386). Again, using a logistic regression model to adjust for time since first injection (injecting time), also showed no significant difference between the groups (p=0.454).

Table 15: Number of participants experiencing non-infected complications from injecting on day of baseline participation

Swelling at injecting sites and puffy limbs

4.21 In Aberdeen, 77 (40.7%) participants had swelling at their injecting sites on the day of baseline participation, in Dundee this figure was 53 (31.0%) (p =0.093). Fifty (26.5%) in Aberdeen had puffy limbs or digits compared to 30 (17.5%) in Dundee, which was a significant difference (p = 0.027). When length of time injecting was adjusted for the difference was not significant (p=0.139).

Data on injecting site complications established at the health check

The number of participants who took part in the health check is shown in table 16.

Table 16: Number of participants who took part in the health check

4.22 Injecting complications that they had on the day of the health check were assessed by the researcher using the Injecting Site Injury Rating Scale. This scale gave sizes and descriptive information for each grade of severity for each type of complication to attempt to standardise researcher assessment. A copy can be provided from j.a.scott@bath.ac.uk Where more than one of the same type of injury was seen (e.g. abscess) the researcher was asked to rate the most severe. Date is shown in table 17 combining both injuries seen at baseline and 6 month follow up. The numbers represent the number of participants assessed who had a complication at this grade. The percentage data shows the proportion of participants who's complication was assessed at the stated grade compared to the total number of participants who had this complication. Percentages have been calculated because of the large difference in numbers of participants. However the small number of participants in Dundee also means caution is needed. Data should be interpreted by considering the trends in severity. The data suggests a tendency towards more severe complications in Aberdeen. Caution is needed as interpretation could have varied between the researchers, despite the criteria given on the rating scale. Validation of this rating scale would be necessary in subsequent work to increase robustness of using this tool.

Table 17: Researcher assessed severity of injecting complications seen.

Injecting site complications summary:

'Track marks' were the most common non-infected complication reported by participants on the day of participation in the NESQ. This was also true for those who participated in the health check. 'Track marks' is the common name given to phlebitis, which is inflammation of the veins. Phlebitis is a sign of vein irritation and can lead to peripheral vascular damage such as vein collapse. This prompts IDUs to search for other accessible veins and ultimately the use of deep veins such as the femoral vein ('groin'). Track marks will be worsened by frequent venous access and venous irritation e.g. from the use of too much or harsh acid. Nerve tingling and burning sensations were commonly reported at the NESQ in both groups. These may be caused by the injection of irritant solutions or nerve damage from missing veins with needles. Sterile abscesses are the common name for 'granuloma', which are hard lumps that form around foreign bodies when injected, such as insoluble particles. 142 (75.1%) of the Aberdeen cohort presented with one or more 'non infected complication', in Dundee this figure was 123 (71.9%). Overall there was no statistical difference between participants in the two locations experiencing non-sterile complications on the day of NESQ participation.

Skin and soft tissue infections were less common in both groups than non-infected complications, with 40 (21.2%) of the Aberdeen cohort and 30 (17.5%) of the Dundee cohort being affected on day of participation. There was no significant difference. The number of ulcers, which is associated with poor vascular supply, was close to significance in Aberdeen. Puffy limbs or digits were significantly more common in Aberdeen (n =50, 26.5%) compared to Dundee (n=30, 17.5%), again a sign of poor vascular function, but significance between the results disappeared when length of time injecting was controlled for. The researcher assessment of severity suggests that the complications seen in Aberdeen were worse than those seen in Dundee, although caution is needed due to the number of cases in Dundee and the methodology as discussed.

General health measures established at the baseline health check

4.23 Blood pressure, heart rate, respiration function and limb measurements were taken at the health check and Body Mass Index was calculated. This was done to allow some general health parameters of the two groups to be reported and compared. Table 18 shows the results.

4.24 Two-tailed t-tests found no significant difference in the means for any of the health measures between the two groups. The faster heart rates detected could be due to withdrawal symptoms or anxiety at being assessed. Average respiration rates in both groups were close to normal (15 per min) but the range varied greatly in Aberdeen. Again this could be due to withdrawal. Some low peak flows were identified, although the group averages of around 450 l/min were good. The researchers annotated 'smoker' against the majority of the participants, which may worsen peak flow. The Aberdeen group had slightly larger hands and ankle average circumferences and the presence of limb and digit swelling was shown in the NESQ data to be higher in this group. Prior validation of the technique ensured that the researchers in both sites were making these measures at the same points. Hand measures were taken just below the fingers and ankles were just on the ankle bone. The researcher in Aberdeen made two GP referrals due to health measure concerns. In Dundee no GP referrals were made, but an on site doctor was consulted when required.

Table 18: general health measures established at baseline health checks

General health measures summary:

The two groups had average similar general health status, with average values within normal parameters. Values at either end of the range of results were extreme in some cases, particularly heart rate, respiration rate and obesity.

Self reported injecting equipment sharing practices

4.25 Self reported sharing practices undertaken 'ever' and 'in the past month' were explored in the NESQ. Sharing was first defined to participants before these questions were asked. Sharing was described as 'Pass on after you used or borrow after someone else has used it'. It is therefore thought unlikely that the Dundee participants defined passing on new sterile equipment obtained from the exchange to others as 'sharing' (for example providing another injector with an unopened citric acid sachet).

Sharing practices that have ever been undertaken

Table 19 illustrates the extent of sharing of needles and syringes ever.

Table 19: self reported sharing of needles and syringes EVER

Table 20 shows the extent of sharing of paraphernalia items ever.

Table 20: self reported sharing of paraphernalia EVER

4.26 In the NESQ participants were specifically asked if they had ever used any injecting equipment (needles, syringes or paraphernalia) after someone else had used it. This was to tease out this behaviour from the definition of sharing detailed above. Of the Aberdeen participants, responses were noted for 180 (9 missing). Of these, 142 (78.9%) said they had used injecting equipment after someone else had used it. In Dundee 156 responses were noted (14 missing) and of these 75 (48.1%) said they had, which was significantly lower (p<0.001). The lack of difference in the sharing of cookers was explained in the qualitative interviews, where batch preparation of drugs and subsequent division of this amongst IDUs was identified as a common practice. This is discussed more later.

Sharing practices that have been undertaken in the past month

Participants' sharing practices in the past month only are shown in table 21.

Table 21: Self reported risky sharing practices in the past month only

4.28 Participants were also asked to respond to the statement 'In the past month I have always put my used needles and syringes in a cin-bin (disposal bin)'. In Aberdeen 134 (70.9%) agreed with this statement, in Dundee this figure was 118 (69.4%), with no significant difference (p= 0.758). It is not known if this was interpreted as immediately after use or eventually and could be better explored in future work.

4.29 As said in 3.6, paraphernalia supply began in Dundee in a staged manner. In the 1990's makeshift paraphernalia items such as cigarette filters were supplied from the HRC under local agreement. The HRC also undertook pilot work around the supply of the first commercially available items from Exchange Supplies in the early 2000's. Following the law change in 2003, paraphernalia supply extended across Tayside needle exchange schemes. This means that Dundee participants who had been injecting for longer time periods may have had access to varying levels of paraphernalia availability. Therefore, data on 'past month' sharing was analysed for those who had begun injecting from 2003 onwards, in both Aberdeen and Dundee. This was done to identify if those in Dundee who had always potentially had access to the widest availability of paraphernalia reported lower levels of recent paraphernalia sharing than those in Aberdeen.

4.30 There were 47 in the Aberdeen group who began injecting since 2003 and 96 in the Dundee group. There was no significant difference found between them for the following paraphernalia sharing and risk taking behaviours: 'Has kept needles & syringes for use by others in past month' (12.8% in Aberdeen vs 8.3% in Dundee, p=0.402), 'Has used someone else's needles & syringes in past month' (8.5% in Aberdeen vs 8.3% in Dundee, p=0.971), 'Has kept own filters for use by me in past month' (57.5% in Aberdeen vs. 57.3% in Dundee, p=0.986), 'Has given someone else a used filter in past month' (25.5% in Aberdeen vs. 31.3% in Dundee, p=0.481), 'Has used same acid as someone else in past month' (46.8% in Aberdeen vs. 55.2% in Dundee, p=0.345), 'Has used same water as someone else in past month' 48.9% in Aberdeen vs. 55.2% in Dundee, p=0.480).

4.31 It should be noted that when it came to injecting someone else and being injected by someone else, the differences became significant when analysis was restricted to those who had begun injecting since 2003. Significantly more Dundee newer injectors had engaged in these behaviours in the past month than those in Aberdeen: 'In the past month I have injected someone else' (25.5% in Aberdeen vs. 45.8% in Dundee, p=0.019) and 'Someone else has injected me in the past month' 38.3% n Aberdeen vs. 56.3% in Dundee, p=0.044).

4.32 As shown in tables 18 and 19, the majority of Dundee participants used Sterifilt/Stericup filters and the sachets of acid supplied, although the qualitative interviews showed this not to be on every occasion. Data was extracted to compare filter reuse and sharing and acid sharing between those in Dundee who used both these supplied items with those in Aberdeen who did not. It was hypothesised that use of these supplied items might show a difference in sharing of these items in the past month. However no significant differences in reported behaviour were found: 'I have kept my filters for later use by me' (64.5% Aberdeen vs. 58.9% Dundee; p=0.285), 'I have given someone else one of my used filters' (43.3% Aberdeen vs. 37.0% Dundee, p=0.233) or 'I have used the same acid pot/bag/box as someone else' (67.5% Aberdeen vs. 60.3% Dundee; p=0.165). When this was restricted to those who begun injecting from 2003, again no significant differences were seen: 'I have kept my filters for later use by me' (51.4% Aberdeen vs. 57.9% Dundee; p=0.510), 'I have given someone else one of my used filters' (31.4% Aberdeen vs. 31.6% Dundee, p=0.987) or 'I have used the same acid pot/bag/box as someone else' (51.4% Aberdeen vs. 55.8% Dundee; p=0.685). It should be noted that this data indicates a reduction in the proportions of newer injectors in Aberdeen taking these risks compared to the Aberdeen cohort overall.

Injecting equipment sharing practices summary:

A greater proportion of participants in Aberdeen (51.1%) had ever shared needles and syringes compared to Dundee (37.7%), which was significant (p=0.013). Sharing of needles and syringes in the past month was broken down into two practices: (1) keeping needles and syringes for reuse by others, and (2) using needles and syringes that someone else may have previously used. In both cases, these practices were reported to a greater extent in Aberdeen (12.2% of participants reported each practice) compared to Dundee (7.6% and 10.6%), although overall the numbers were relatively small and not significantly different. In both locations a large majority (around 90%) had not kept needles and syringes for reuse by others or used someone else's needles and syringes in the past month. This is encouraging and suggests the embracing of harm reduction messages in both locations. Less encouraging is the high levels of reuse of own equipment identified in both locations, suggesting levels of equipment supply reaching IDUs in both locations are not adequate. This was further demonstrated in the qualitative interviews (see later).

Sharing of all paraphernalia items ever, was higher in Aberdeen. Participants in Aberdeen were statistically more likely to have ever shared acids, water and filters than those in Dundee. Although not significantly different, the Aberdeen participants reported greater levels of cooker sharing than those in Dundee. Batch preparation, which involves cooker sharing, was shown in the qualitative interviews to be common practice in both areas as a means of pooling resources.

In the past month, in Dundee more participants had kept their own needles and syringes for reuse (70.0% vs 65.1%), injected someone else (50.0% vs 40.7%) or been injected by another (48.8% vs 39.2%), but none were significantly higher Amongst those who had begun injecting since 2003, significantly more in Dundee had injected others or been injected by another in the past month, which suggests a need to focus on these risk practices with newer injectors.

In the past month, a greater percentage of Aberdeen participants had used the same acid container compared to those in Dundee (61.9% versus 55.3%), given someone a used filter (42.3% versus 33.5%) or kept their own filters for reuse (65.6% versus 55.9%). None of these practices tested significantly different, but the latter was close to significance. A similar percentage in Aberdeen (56.1%) and Dundee (54.7%) had shared water containers in the past month. Overall, levels of sharing in the past month were less than sharing 'ever', suggesting participants were taking on board harm reduction messages, but they were not significantly different between the two locations.

There were no significant differences in paraphernalia sharing or filter reuse in the past month amongst those who had begun injecting since 2003, although those in Dundee potentially had access to paraphernalia supply. Similarly the extent of past month filter reuse and passing on or past month acid sharing were not significantly different between those in Dundee who used the supplied acids and filters compared to those in Aberdeen who did not use supplied paraphernalia.

Self reported skin cleansing practices

Participants' hand washing practices prior to preparation of injections are shown in table 22. This data compares with the findings in Bristol in stage one ( Chapter 2).

Table 22: Self reported hand washing prior to preparing

4.33 When data was grouped together to test for differences in whether participants 'always or mostly' washed their hands, there was no significant difference between Dundee (n=85) and Aberdeen (n=82) (p=0.425).

Participants' practice relating to washing/wiping injecting sites before injecting, responses are shown in table 23. (Pre-injection swabs were supplied in both locations.)

Table 23: Self reported site cleaning prior to injecting

4.34 When data was grouped together to test for differences in whether participants 'always or mostly' wiped their injecting sites prior to injecting, significantly more participants in Dundee (n=115) than Aberdeen (n=99) reported site wiping (p=0.004).

4.35 Combining data for both cohorts, those who 'always or mostly' wiped their sites before injecting were significantly less likely to have a skin or soft tissue infection on the day of data collection (p=0.05).

Skin cleansing practices summary:

Hand washing and skin cleansing prior to injecting were reported to be undertaken by the majority, but only on some occasions. There were no statistical differences found in the number in each location who said they 'always or mostly washed their hands prior to injecting. However significantly more participants in Dundee wiped their sites prior to injecting compared to Aberdeen participants. Combining participants from both groups showed that those who always or mostly wiped their sites prior to injecting were statistically less likely to have a skin or soft tissue infection on the day of participation. This concurs with the findings of Vlahov et al (1992) in the USA.

Follow up health check data collected at 6 months

4.36 As shown in table 16 (4.21), in Aberdeen 27.0% (n=51) of participants who underwent a baseline health check were followed up in 6 months. However in Dundee this figure was 7.7% (n=13) and the total number of baseline participants was much less (37 in Dundee versus 106 in Aberdeen). This gave too small a dataset to make meaningful comparisons between the Dundee and Aberdeen participants at 6 months. When those in the Aberdeen group who were followed up at 6 months (n=51), had their baseline and follow up data compared, there was no significant change in the number with skin and soft tissue infections (9 vs 11, p = 0.652). Similarly there was no significant difference in the number with non-infected complications (37 vs 34, p =0.316). No change in care was made in this time. Blood pressure, heart rate, respiration rate and peak flow averages also showed no significant change.

Findings from the qualitative data

4.37 In depth qualitative interviews were undertaken to provide an understanding of participant's views on and experiences of using paraphernalia. They were also undertaken to better understand risk taking behaviours. The findings gave a deeper understanding of the quantitative results of the NESQ. Fifty four in depth interviews provided this data. Of these, 34 were with Aberdeen participants and 20 with Dundee participants. The key findings are reported and illustrated with quotes. The codes used after the quotes relate to Gender (M=male, F = female), Age, location (A = Aberdeen, D = Dundee) and length of time since first injection. So for example, M46D(25) was male, 46 years old, part of the Dundee cohort and had been injecting for 25 years.

4.38 Those who took part in the NESQ but were unwilling to be interviewed were given the opportunity to provide brief qualitative data, on which the researcher made notes. They were asked to describe 'Problems obtaining paraphernalia', 'Problems using paraphernalia', 'Items you would like to have supplied' and to give their thoughts on 'How to reduce sharing, lending and borrowing'. The researcher notes were subject to thematic analysis. In Aberdeen, 39 participants in the NESQ gave additional comments and in Dundee this figure was 99. Findings were largely similar to the interviews, but where additional points were made they have been noted in this section.

Injection preparation and administration practices

The preparation steps used

4.39 Those who participated in the interviews, both in Aberdeen and Dundee, described using a similar heroin injection preparation process. The method reported concurs with the steps identified from analysis of the transcripts of Taylor et al (stage one) and from work in Bristol and Hereford (Ponton & Scott, 2004). The order in which components were added to the spoon did vary occasionally, for example if preparing outside liquid may be added first to avoid powder blowing away. The need for spoons, water, the addition of acid and the use of a filter was considered essential by most interviewees in both locations. Some did report unsuccessfully attempting to prepare injections in the past without some of these items, particularly acid. A few said they could manage without filters or chose not to use them. For most interviewees the use of a tourniquet was also considered necessary, although not all required this.

4.40 Variation was found in the quantity of citric acid reported to be used. This was found both in Dundee and Aberdeen. Some interviewees reported adding citric acid stepwise, checking to see if the liquid went clear (the end point indicator) with each small sprinkle. However, more commonly interviewees reported using the same quantities of acid every time they prepared a set amount of heroin. In Dundee quantities were described in sachet proportions, for example 'half a sachet', 'whole sachet'. Some interviewees reported using excessive amounts when compared with the laboratory findings from part one. For example adding one whole sachet to a £10 bag. Some reported using two whole sachets. Only one Dundee interviewee mentioned that not everything in the drug should be dissolved with citric and that he expected some residue in the cooker. In Aberdeen because citric acid sachets were not supplied, it was harder to judge the reported quantities the interviewees used, as these were usually described in 'pinches'. In both locations, visual judgement was the only means reported of determining how satisfied the interviewee was with the resulting prepared injection. Visual judgement also informed whether a filter was believed to retain drug or not, as discussed later.

How did people learn to prepare and inject?

4.41 All interviewees had learned how to prepare injections by watching someone else. Most described having their first injection prepared for them by another, who often also administered their first injection to them. In some cases this was a particularly trusted person such as a brother or sexual partner. However for others there was no particular trust relationship. Instead, the circumstances had encouraged them to inject and the person who facilitated this was someone present at the time when the opportunity or necessity arose:

'[I learned to inject]… in the homeless unit. I used to do foil…I was on foil for 5 years… in there [the homeless unit] it'd have to go in the pot so if you don't inject you don't get, so I just started injecting...The choice between injecting and rattling -you're gonna inject' M33D(new injector)

4.42 This interviewee was referring to residents pooling finances to buy drugs that are then prepared in a batch and divided. Because he had to pool finances with the others to obtain enough heroin, he was unable to remove his share of powder for smoking, prior to it being made into solution. His first injection was prepared and administered by another hostel resident with whom he subsequently said he was not familiar.

4.43 Many participants reported refining their preparation and injecting technique through a subsequent process of 'trial and error' in the time after initial injecting. Some described selectively following the advice or actions of others and choosing to disregard practices they considered to be unsafe or ineffective. Commonly interviewees who had been injecting for some time considered that their current injection preparation and administration methods were either 'better' or less risky than their early techniques. This is reflected in the data on ever sharing and sharing in the past month, reported in tables 20 and 21, where sharing in the past month was undertaken by less people compared to the proportion who had 'ever' shared the items. Some interviewees spoke of past practices and risks taken with regret:

'Yes I've done that quite often [used someone else's needles and syringes]… when I haven't had a needle….so I've had to or I've been rattling….It was a while ago' M37D(9)

4.44 Supplementary sources of information which were said to have informed injecting practices at a time after first injection, were other IDUs, needle exchange staff and safer injecting leaflets. Some interviewees reported that it was some time, typically several months after beginning injecting, before they accessed a needle exchange for the first time. Lack of awareness of services was given as a reason for this by some. Others expressed initial concerns and fears about accessing services, including confidentiality worries. They reported relying on others for information, advice and equipment early in their injecting careers.

Control over the injection preparation process

4.45 It was previously thought that if a person prepared their own injections they would be in control over their paraphernalia use and risk taking. However the qualitative interviews showed this to be more complicated. When asked about injection preparation, several interviewees who prepared their own injections described situations where the circumstances forced them to take risks that they did not perceive able to control, as illustrate in this quote:

'You want to boil your water but there is not always the means….if you are injecting in the house where you are getting your drugs, you can't always use their kettle to boil the water…' M32A(12)

4.46 Many people described the use of communal water provided by the host in the facility where they were injecting. Reasons given for sharing water despite perceiving it to be a risk, included fear of offending or being disrespectful to the host, cultural 'norms' and the urgency with which the person needed to inject. Many people described worrying about risks after they had taken them. However, others described high levels of control over their preparation environment and consequent practices. For example, always having their own water which they did not allow others to use, e.g. by carrying it in a medicine bottle or bottled drinking water. Some interviewees appeared to be much more assertive than others in dictating injecting circumstances to their peer groups.

4.47 Just as preparation of ones own injections can not assume perceived control over the process, similarly, there were interviewees who did not prepare their own injections who described high levels of control over the process. These were female participants who, despite not preparing their own injections, described observing preparation and dictating the standards of hygiene and choice of equipment used by their preparer, who was their partner. However, there were other participants who did not prepare their own injections who described little control over the preparation of their injections.

Administering injections

4.48 Interviewees in both locations gave many reports of difficulties accessing peripheral veins. Similar difficulties were well illustrated in Glasgow by Taylor et al (2004). The use of tourniquets to raise peripheral veins was common, with most interviewees describing the use of a belt or shoe lace for this purpose. In Dundee the lack of supply of tourniquets from needle exchanges was specifically mentioned. These had been supplied in the past. Some indicated it would make the injecting process more convenient if tourniquets were supplied, describing their ease of use compared to makeshift tourniquets. Others wanted them to be supplied in order to facilitate the use of 'clean' equipment. Some interviewees in both locations reported no need for tourniquets.

4.49 Careful administration techniques tended to be described in both Aberdeen and Dundee. For example participants often described taking some time to raise a vein and injecting slowly in the direction of blood flow. Some reported that a considerable number of attempts were needed to access veins, sometimes taking several hours. This was also noted by Taylor et al (2004). Many reported that peripheral vascular access had become increasingly difficult over time, now requiring several attempts with several new (sharp) needles for each injection.

'Sometimes I can go through 10 sets trying to get in' M25D(9)

4.50 The need for several sets of needles to deliver one injection was given by some as a reason for running out of clean sets of needles and syringes. Safer injecting information encourages injectors to replace the needle after one unsuccessful attempt to access a vein. However it is sometimes assumed that the number of sets of injecting equipment supplied equates to the number of injections delivered. These interviewees reported that this was not the case. In such circumstances the number of needles and syringes needed to facilitate delivery of every injection with sterile equipment would far exceed the number of daily injections. Many described reusing their own equipment several times. This was also evident from the NESQ data where 65% (n=123) of Aberdeen participants and 70.0% (n=119) of Dundee participants had kept a needle and syringe for reuse in the past month.

4.51 Those who reported using the groin acknowledged that it was particularly risky and many expressed reluctance in having to do so.

'I do find it is actually slightly easier [comparing groin injecting with previously described difficulties with peripheral access] but I think there is a lot mair to worry about …it's quite dangerous and I have always been warned about how dangerous it is to inject there….but I don't have much choice..' M32A(12)

4.52 A minority of injectors who used peripheral veins above the waist said they would not inject into their groin indicating that they would prefer to stop injecting than do so. Whether this would be the case if they had no peripheral access is of course not known.

'…Once these veins are done it is game over…' M46D(25)

Injection preparation and administration summary:

Participants in both locations used very similar heroin preparation steps. They emphasised the need for acid in the process. Participants had learned how to prepare and inject from other IDUs, often having had their first injection prepared and administered by another. Risk taking and vulnerability surrounding the injection preparation process was particularly high when people were early in their injecting careers and when in other people's homes. Knowledge on safer injecting was accumulated and applied over time. Many had not accessed a needle exchange service until they had been injecting for several months, so had previously relied on other injectors for information and equipment. Strategies to draw newer injectors into needle exchanges and more rapidly expose them to safer injecting advice should be explored and evaluated. The level of control felt over preparation circumstances varied, for example some felt unable to refuse to use communal water. Others were more assertive. Many experienced difficulties accessing peripheral veins and reported using several sets of injecting equipment to deliver one injection. Therefore it cannot be assumed that the number of sets of needles and syringes supplied equates to the number of injections administered. The high level of reported saving of needles and syringes for reuse illustrates the need to increase the availability of clean needles and syringes.

Access to injecting preparation equipment in Dundee

4.53 Tables 13 (page 52) shows that in Dundee the majority of participants reported currently using the paraphernalia that was supplied from the exchanges. In Aberdeen, almost all used makeshift paraphernalia. However, table 13 shows that makeshift paraphernalia was also used in Dundee. Table 21 (page 59) shows that many participants in both locations had undertaken risky injecting equipment practices in the past month. This raises questions which the qualitative interviews helped answer.

Views of Dundee participants on the supplied paraphernalia

4.54 Dundee interviewees all emphasised that the paraphernalia supplied by the exchanges was their preferred choice, with the exception of mixed views on filters. There were three reasons identified as to why the supplied paraphernalia was preferred:

(i) Cleanliness and safety

Supplied paraphernalia was seen as 'clean' and described by many as 'safer'. This was equated with reducing the risks to one's own self such as vein damage and loss of peripheral access to veins, or HIV prevention. Less explicit emphasis was given to HCV prevention. All interviewees in Dundee had experience of using some form of makeshift equipment. Comparison with the perceived risks from makeshift items was commonly made, for example citric in sachets was often described as being 'gentler' than citric bought from a food shop. The risks of ophthalmic infection from the use of lemon juice were cited by many as a reason why supplied citric acid was 'safer'. Some favoured vitamin C over citric acid, considering it to be less irritant. Many participants also attributed reusing makeshift paraphernalia, especially filters, to experiencing a 'dirty hit'. The use of the supplied paraphernalia was reported to prevent this as it enabled 'fresh' items to be used each time. Some interviewees considered that use of clean paraphernalia prevented skin and soft tissue infections. Cellulitis infections were mentioned by a couple of interviewees who attributed past infections to makeshift paraphernalia reuse. Many interviewees believed that the supply of paraphernalia reduced sharing of paraphernalia. This was equated by many with preventing HIV. As said, only a minority of interviewees specifically mentioned HCV prevention unprompted.

'I've been in the company of people with HIV [referring to injecting groups] so I know the importance of not sharing it [paraphernalia] ' M33D(new injector)

Some interviewees described the nature of single use items as 'forcing' them not to share, for example, by encouraging each person to have their own 'kit'. However others also described sharing supplied items, especially cookers, during batch preparation of drugs.

(ii) Quality

Paraphernalia quality was a common theme, with the supplied items considered to be more reliable and of better quality than makeshift items. This was equated by some with increased safety. Others equated quality with better reliability and less risk of losing the 'hit', for example through product failure and spillage.

'Yes, it [paraphernalia supplied] is definitely [better for me]… when I used to work in [name of place].. I stayed down there and it was a wee village, so I used to have to travel to score and plus to get works. They weren't giving out citrics at that [needle exchange] office, so it was like vinegar and lemon juice that you're using and it doesn't break down the heroin as well plus somebody said if you use lemon juice repeatedly it …damages your eyesight'. M29D(5)

(iii) Convenience

Readily available supplied paraphernalia was also a recognised as being convenient and this was linked explicitly with prevention of risky behaviours. For example, some who lived close to needle exchanges or received outreach reported that the supply of paraphernalia with needles and syringes made it unnecessary to use makeshift items, and easier to follow safer injecting advice about not sharing.

Mixed views on the filters supplied in Dundee

4.55 Some interviewees in Dundee spoke favourably about the Stericup filter and Sterifilt. Others had unfavourable opinions. When this study began, the supplied filter in Dundee was the one contained within the Stericup. Later in this study the Sterifilt was also supplied. Many interviewees had experience of using both.

4.56 Some interviewees spoke strongly in favour of the Stericup filter, reporting that it was easy to use and they thought it made the injection safer. Some reported retaining it to 'bash down' with others in times of drug drought. However a common theme identified in those who disliked the Stericup filter was that it was 'too big'. Further exploration identified that what participants meant was it was visibly seen to retain an unacceptable quantity of drug. This was attributed not so much to the physical size of the filter but to the density of the material that is was made from. The visible colour of the used filter and reduced volume of the resulting injection were seen as signs that significant heroin was retained. Some reported ripping it into smaller pieces before use. Hence, although retention of drug was seen as important for reuse, retention of too much drug due to too absorbent a filter was undesirable and deterred use.

4.57 The Sterifilt was shown in the laboratory to retain minimum amounts of drug. Some in Dundee recognised this and expressed a liking for it. The fact it was seen not to visibly retain drug was welcomed. Lack of drug retention was considered by these interviewees as a reason to discard the Sterifilt after first use, which was linked to cleanliness and less risk of 'dirty hits'. Some did retain it for future filtration purposes if they thought they were running short of filters. Others did not like the Sterifilt for this same reason, as it did not give them anything to save 'for a rainy day'. Some also reported that the Sterifilt was difficult to use. However some who spoke in favour of the Sterifilt said that it had taken some practice to get used to it and suggested training on use to be important for injectors.

'The Sterifilts are good but people will need shown how to use them' M35D(3)

4.58 The dislike of the Stericup and Sterifilt helps explains why 34.5% of participants in Dundee reported using cigarette filters, coupled with the issues on access and convenience that have been discussed. Those interviewed in Dundee who disliked the supplied filters reported using pieces of cigarette or hand rolling filters. Many reported past problems with the Strericup bending on heating, but this had now been resolved with a new style handle.

Why did the Dundee participants still sometimes use makeshift paraphernalia?

4.59 It is important to understand why, if most supplied paraphernalia was favoured over makeshift items, use of makeshift items and risky paraphernalia practices were still identified in Dundee.

4.60 For some in Dundee the supplied paraphernalia was used for every injection and they described having no access problems. However, for most it was not exclusively used. Interviewees reported that makeshift paraphernalia was used when they had run out of needle exchange supplies. Reasons for running out of supplied paraphernalia were thinking they'd need less than they did when they went to the exchange, or thinking they'd be back to the exchange in a shorter time span, reluctance to carry large quantities, not being close geographically to a supplying needle exchange prior to injecting and donating paraphernalia to others who did not access the exchange or had run out. Many said the amount of paraphernalia needed cannot be easily predicted. 'Convenience' was a factor, which was related to makeshift paraphernalia use. Some interviewees described difficulties with the distance between where they lived and needle exchanges where they could access injecting paraphernalia. Many said paraphernalia was easy to access in the city but more problematic for those based out of town. Some interviewees used pharmacies that did not provide paraphernalia and some rural areas did not have a needle exchange. Occasionally pharmacies ran out of supplies. This caused access difficulties. In addition, many comments were made expressing difficulty accessing paraphernalia at weekends and at night. Those who described not having access to paraphernalia at the time it was needed, often described the time between obtaining and using drugs as very short. Essentially, obtaining more paraphernalia from the exchange was often less of a priority than injecting, when faced with the possibility of withdrawal effects.

Access to makeshift paraphernalia in Aberdeen

4.61 All Aberdeen interviewees described using makeshift items. A few had obtained supplied paraphernalia from needle exchanges in other cities and all spoke very favourably of this, emphasising a strong preference compared to makeshift items. A range of household items were used as paraphernalia in Aberdeen. Interviewees expressed preferences for particular items, for example citric acid in preference to lemon juice. Reasons given included less perceived health risks and more satisfactory performance.

General comments on paraphernalia access in Aberdeen

4.62 It may be assumed that since makeshift paraphernalia items usually come from household items such as cooking grade citric acid and cigarette filters that they could easily be obtained. The qualitative interviews showed this not to be the case. Significant problems in obtaining some makeshift paraphernalia were identified, particularly citric acid in Aberdeen. Less difficulty was identified in Dundee, where distance from shops that sold citric acid was the main issue mentioned.

4.63 Some Aberdeen interviewees reported little difficulty in accessing makeshift paraphernalia. For a minority this was because their drug preparation appeared to be forward planned for and organised. For example some reported having their own assembled preparation kits that they carried around for use when needed or they only injected in their homes. In some cases these items were shared with others, for example a partner, but care was expressed not to share this with others. It is not known if these interviewees were also on a methadone prescription, hence may have less pressing urgency around their injecting. These interviewees tended to be able to purchase paraphernalia easily. In the case of citric acid they commonly lived or worked close to an outlet selling it, found the vendor willing to sell it to them and did not consider the cost to present a difficulty for them. For many, being a cigarette smoker meant ready access to cigarette or hand rolling filters. However, others who did not perceive they had any problems accessing paraphernalia said this was because there was always someone around them from whom they could borrow or share. Some did not explicitly recognise this as an aspect for concern, although others did.

'When I am out of citric…you have tae' share it, there is nae' choice you just share it' M32A(12)

'When I am strung out I am not going to travel to buy citric when I could use lemon juice…' M28A(7). This interviewee later acknowledged he thought lemon juice could make you blind adding 'but this hasn't happened to me'.

4.64 However, the majority of interviewees in Aberdeen reported they had difficulty accessing makeshift paraphernalia. Commonly this related to accessing citric acid.

'I am surprised there is not more sharing in Aberdeen…citric is a nightmare to get hold of…' M31A(6).

This person went on to describe times when he had traded some of his prepared 'hit' for citric in order to prepare it. The liquid was removed from his spoon by the citric donor, using the donor's needle and syringe.

Difficulties reported in obtaining citric acid in Aberdeen

4.65 The interviewees issues relating to the difficultly in obtaining citric acid in Aberdeen.

(i) Availability of citric acid

Few shops sold citric acid and some who did, refused to sell it to IDUs. This included both pharmacies and food shops. Many interviewees reported that food shop keepers had informed them that the police had instructed them not to sell citric acid to injectors.

'I have never been refused…but I have to go in for a number of my friends to get theirs [citric acid] for some reason they will sell it to me but won't give it to them' M40A(27)

Two food shops in the city and one on the outskirts were repeatedly mentioned by interviewees as sources of citric acid. Few knew of more than two or three outlets. Access to these shops was difficult for some due to their location, the need to spend money on transport and reported erratic opening hours.

(ii) Cost of citric acid

Cost of citric acid from those shops willing to sell was also reported to be a problem by many. Escalation of the reported price over the course of this study was identified from several sources. Early interviewees reported the cost of £2 per bag. This cost was reported as consistently increasing throughout the study for the same product. Later many interviewees reported a cost of £4 for 100 grams. Some also said this was packed down into unmarked half bag quantities (50g) aimed at injectors, still at a cost of £4.

'When I first started [injecting] it was £1 a bag, now it's £4…' M33A(12)

'The boss told them [the shop staff] that they had to put the prices up because I actually spoke to him one day and he goes 'well you boys need it so I can charge whatever I like' that was his exact words' M33A(17)

Some said they were unable to afford citric acid or other paraphernalia. Lack of money was a barrier to obtaining it reported by many.

'I haven't got any money to get it [paraphernalia]' Interviewer: 'what happens if you don't have the money?' 'Basically I have to go borrowing to people or sharing it you know' M24A(5)

'It costs me £7.60 to get citric including the bus fares' F29A(8)

'Every penny I don't need for my habit goes on my daughter' F19A (new injector).

This woman did not include paraphernalia items in the expense of her habit.

'Junkies are poor people, you need a way to fund it [drug use]… prostitution, theft, dealing….those that don't do that use their social money, their housekeeping'. F44A(3)

This woman, her sister, her son and her cousin were all injectors. They prepared communal batches divided between them. She described how her cousin had obtained injecting kits in London and brought them to Aberdeen. She considered their injecting practices were safer and 'cleaner' during the short time when they had access to the kits and described preparing single injections for their own use. However, others said they were willing to buy paraphernalia, including a small number who said they would buy it from exchanges. One cited employment as facilitating his ability to pay. However those willing to pay identified that many others wouldn't be so able or willing and considered that charging for paraphernalia would limit uptake or increase crime to fund it.

(iii) Quality issues regarding citric acid

Quality concerns were raised by some. The use of citric acid intended as a food ingredient was expressed as a concern. Trust in the supplier was mentioned by some who considered citric acid products supplied from needle exchanges would be safer to use and of guaranteed content. Variation in perceived strength of shop bought citric acid was reported by several. Many mentioned they had no way of knowing if what they bought was citric acid as it was sometimes packed down and sold unmarked. One person had been sold a packet of powder from an Aberdeen food shop believing it was citric acid. On using it he found the heroin did not dissolve and he was unable to inject it. Subsequently he said he had identified this powder to be Monosodium Glutamate.

(iv) Distress

Distress caused by difficulties in obtaining citric acid was reported by many. For some they described this largely in terms of inconvenience. They reported time and cost of travel as a deterrent from attempting to purchase citric acid, but expressed worries about using other acids. Others described lack of citric acid as pushing them to take risks in order to avoid withdrawal. Some said it created a 'borrowing frenzy', when people were desperate to inject, often in withdrawal, but did not have paraphernalia. They described situations where they had been pestered by injectors to lend items such as citric acid. Others described observing people desperate for an injection putting themselves at risk. This was also noted in Dundee when lack of paraphernalia when needed was discussed.

'I have even had people coming to my door at 2 and 3 O'clock in the morning…[looking for citric] ' M31A(new injector)

Some said shop owners had threatened to stop selling them citric acid and this was causing distress.

(v) Reluctance and anger towards spending money on paraphernalia

These were expressed by some, sometimes questioning why needles and syringes were distributed for free, but nothing else.

'Some people just won't spend any money at all on anything other than drugs, they will never have any money for food or cigarettes. They will use cigarette filters from cigarettes that have been smoked…or other people's filters' M40A(27)

Some expressed bitterness that paraphernalia was not supplied in Aberdeen, often aware that it is supplied in other cities.

'People from other areas must be laughing at us we are so far back in time….it is the addict again thrown on the heap, people don't want to bother with us….I'd like to come in here and get all the stuff and cut out all the side roads so I wouldn't have to share….it is bad enough I have to inject' M33A(12)

'I have lived in Edinburgh….and they were giving out citric..they have like such a good centre…..you come up to Aberdeen and it is like the bloody dark ages…nothing has changed from 5 years ago…because of your postcode, that matters whether you get drug equipment or not, whether you get hep C or not, whether you get HIV or not, whether you are going to die or not….they should try and make it as equal as possible for everybody' F26A(8).

Lack of availability of citric acid was emphasised by most interviewees as a significant problem in Aberdeen. Other items such as spoons and filters could more easily be improvised. However, this was not without risk, although these were not always recognised when described by the interviewees.

Access to clean makeshift filters in Aberdeen

4.66 The main barrier to accessing clean filters in Aberdeen was having no money to buy cigarettes. The majority reported that this was overcome by obtaining cigarettes or hand rolling filters from others. Clearly these would be non-sterile and run the risk of being handled by contaminated hands. Some reported borrowing used filters.

What do injectors do if they do not have access to the paraphernalia they need?

4.67 Interviewees were asked what they did when they could not obtain the paraphernalia they wanted or did not have enough of it. There were several different themes in response:

Unlikely to run out

4.68 In both Dundee and Aberdeen a small number always planned ahead, so said it was unlikely that they would not have access to their own preferred equipment. They described a high level of organisation in their drug use, making plans to ensure they always had the equipment they needed. It is unknown if they were on any substitution therapy. In Aberdeen this high level of organisation related to undertaking the sometimes costly and time consuming task of purchasing citric acid before they ran out of their current supply. Access to cigarette filters and spoons was less problematic and some carried their own bottled water with them or only injected at home. In Dundee this related to visiting the exchanges or requesting outreach service home visits ahead of the time when they expected to run out of equipment. Several outreach clients in Dundee who said they lived remotely from a static exchange, attributed the 'home delivery' nature of the service as being key to ensuring they had access to equipment ahead of need.

4.69 For both the Aberdeen and Dundee interviewees who can be categorised into this group, a sense of pride in their level of cleanliness and organisation was clearly expressed. They often considering themselves different in this respect from most other injectors they knew. Most could however recall a time in the past where they had not been as organised and had improvised or shared equipment. The sense of improved injecting practices over time described earlier was reflected strongly in many of this group.

Improvise

4.70 Another group reported improvising on the equipment used when they did not have access to their preferred equipment. The 'improvisers' used items that they perceived to be less effective or less safe, but perceived improvisation to be safer than borrowing or sharing. For example risks were perceived to be less from reusing their own filters as opposed to using filters previous used by others. Using lemon juice instead of borrowing someone else's citric acid was also mentioned. The 'improvisers' included people who reported batch preparation and sharing with a sexual partner. Injection preparation practices were described that were thought to keep the couple as a unit safe as opposed to each person safe as an individual.

4.71 The range of household items used to improvise was much wider amongst the Aberdeen interviewees than the Dundee interviewees. Items used as filters when improvising included cotton buds (reported in both Aberdeen and Dundee); pieces of clothing or tissue, nappies and sanitary materials (Aberdeen only). The use of acidic household items in the absence of access to citric acid was commonly reported, although often described as unsatisfactory. Dissatisfaction included the perceived extent to which the heroin had dissolved and the perceived risks that use of the household items presented, including damage to veins and risks to eyes. However most chose to take these risks describing the need to inject as unavoidable. Bottled lemon juice and fresh lemon was reported in both Aberdeen and Dundee. Vinegar, Lemsip® preparations, vitamin C tablets, alcohol squeezed from swabs and sterilising preparations were mentioned in Aberdeen.

Borrow from and share with others

4.72 In Aberdeen many considered running out of paraphernalia to be unlikely, but when probed this was because there was always someone to borrow from, indicating that they considered 'running out' to mean no one in the injecting group had the necessary item available. Borrowing was seen as an entrenched part of drug use culture by these people. Some of whom did not describe blood borne virus transmission risks.

'…but you cannae' get AIDS from sharing it [citric] ...can ye?' F42A(10)

4.73 Some mentioned an expectation amongst injectors that someone else will have paraphernalia they can borrow and that these people do not bother to get their own.

4.74 However others did acknowledge risks from borrowing, but saw it as inevitable. They described borrowing as a preference to improvising, only doing the latter if no one else could lend them paraphernalia. For example they would rather use someone else's citric acid than use lemon juice as they perceived citric acid to perform better and to be safer than lemon juice, often mentioning ophthalmic risks from using lemon. Some said if they had difficulties finding someone to borrow from they would then make do with other things. Some did not consider sharing citric acid to present any risks.

4.75 There seemed to be more explicit recognition in Dundee that running out of paraphernalia meant running out of your own equipment - in all cases this was referred to as equipment supplied by the exchanges. Borrowing exchange supplies from others was usually undertaken in such circumstances, but this also depended on how accessible a supplying exchange service was at the time.

'If I've not got I'll go down town to see if I can get off them [exchange service], but 9 times out of 10 cause I am living with 3 or 4 users I can borrow off one of them….but it's always clean' M33D(0).

4.76 New sterile exchange supplies could easily be identified because it was still in the packaging. Such loans were sometimes repaid by supplying others with sterile equipment when obtained from the exchange at a later date. Interviewees did not consider there to be any risks from lending and borrowing sterile new equipment that was sealed in the packaging, which will be the case if hands that pass the items are not contaminated.

4.77 Others in Dundee reported saving their last set of supplied paraphernalia until they could get more. For example, saving Stericups® and cleaning them for reuse. It was noted that this practice tended to be reported by interviewees who injected alone or in couples.

'If it is the last cooker I'll clean it with boiling hot water and lemon or lime' M46D(25)

Use alternative administration routes

4.78 A couple of interviewees said they would not inject if they could not get all their own new equipment. It is unknown whether they were in drug treatment such as a methadone programme, which may have influenced their need to inject. These interviewees described being unwilling to take the risks from sharing or improvising and expressed a greater level of control in choosing when to inject compared to the majority of interviewees.

'If I dinnae hae the stuff I winnae be havin' a hit ….I'll find a bit o' tin foil and smoke it' M43D(24)

Access to injecting preparation equipment summary:

All the Dundee interviewees had experience of using makeshift paraphernalia. They expressed a strong preference for the paraphernalia supplied by the exchanges, perceiving it to be safer and of better quality. The exception was the Sterifilt and Stericup filters, where mixed opinions were expressed. Those who did not rely on retaining used filters to prepare injections at times of drug drought tended to favour the Sterifilt. However, those who relied on keeping used filters for later use did not like the Sterifilt because they do not retain drug. Some disliked the Stericup filters because they retained too much drug and reported reducing their size before use or using alternative makeshift filters. The need for IDU training when introducing new items of paraphernalia was highlighted.

Despite a preference for the supplied equipment, makeshift paraphernalia was still also used in Dundee. It was used when supplied paraphernalia was not available at the time when needed. Dundee interviewees did not convey any major difficulties obtaining makeshift paraphernalia per se, in that they knew where and how to obtain paraphernalia. However various reasons were identified for lack of supplied paraphernalia when needed, which are discussed in the next section. These included lack of forward planning and prioritisation -it was clear that priority was given to obtaining drugs and preventing withdrawal. Also many reported donating supplied paraphernalia to others in need, if injecting in their company. This meant the amount of paraphernalia needed by individual IDUs between exchange visits could not easily be predicted. Convenience in accessing paraphernalia was also a factor, with exchange opening times and distance from location when needed being a factor.

A spectrum of responses to lack of access to preferred paraphernalia was identified in both Dundee and Aberdeen. These ranged from risk avoidance strategies such as smoking heroin instead of injecting if they had no equipment, but for many identified risks were taken in order to facilitate an injection, including sharing used paraphernalia. Because of the sterile sealed packaging, paraphernalia supplied from needle exchanges can easily be identified as unused. This was noted by Dundee participants, although not always a factor that influenced the decision to borrow or share. In Aberdeen, lent equipment had inevitably been handled by others even if it was unused. Borrowing and sharing appeared to be more common in Aberdeen and some described a 'culture of sharing'. In Aberdeen, major difficulties in accessing citric acid were reported. A lot of distress due to this was expressed, particularly around fear of withdrawal effects if drugs could not be quickly administered. This was identified as promoting risk taking. A 'borrowing frenzy' was described by some.

Promoting factors such as forward planning when collecting exchange equipment and increasing risk avoidance strategies are challenges for needle exchange staff. The data here suggests a need to further develop and deliver education interventions. Many in Dundee recognised the difference between borrowing and passing on sterile unused paraphernalia and borrowing or passing on used paraphernalia in terms of risk. Therefore, in areas where paraphernalia is supplied, this could form part of education strategies, coupled with encouraging IDUs to collect increased amounts of equipment.

Sharing and risk taking behaviours

Why do injectors share needles and syringes despite accessing needle exchange services?

4.79 Sharing needles and syringes was something that most who took part in the interviews had engaged in at some point. At the time of this 'direct sharing', they did not possess a new set of injecting equipment and the need to inject overrode immediate concerns. For some, needle sharing had been some time ago and they reported no longer doing it. However for others it was something that had done in recent times. As said, the majority of interviewees who had been injecting for some time considered that their current injection preparation and administration methods were either 'better' or less risky than their early techniques and spoke with regret about past sharing. This is reflected in the data on ever and past month sharing. Many said, on reflection, direct sharing was something that they had not planned to do or necessarily wanted to do. Most talked about being 'forced' to borrow used needles and syringes in order to have a 'hit' because of the pressing immediate need to inject.

'Some people aren't willing to wait…when they get to a dealers house they are so overwhelmed and glad to get their bit and they would be prepared to use whatever was there to have it' F26D(4)

'I know about the concept of it [sharing] but whether it is always practical [to use clean needles] is another matter.. ….there is no choice you have to take it, it is nae' practical in the world we live in'. M33A(12)

'Not many places in Aberdeen do needle exchange, so if you can't come into town or it's after 5pm you do get [needles] from someone else' F44A(3)

'…..they always say sort of have your own spoon and that, but it doesn't work like that…..it doesn't, it just doesn't go like that, I mean fair enough I try really hard to keep my own clean needles like but… umm… that doesn't happen all the time either.' F26A(8)

4.80 Many expressed worry and fear from a past incident, particularly with reference to HIV. Less overt concern was expressed about HCV. In cases where the interviewee expressed worry, the researcher encouraged them to talk with the blood borne virus specialist within the service and ensured they were aware of local testing services. A few people said that using someone else's needles and syringes was a normal part of their injecting practices which they routinely did and demonstrated a fatalistic approach towards blood borne virus risks. Risks were discussed with these participants and safer injecting information offered.

4.81 Some described having seen others empty cin bins in order to obtain injecting equipment. They emphasised a lack of self-respect or care held by these people, who were viewed as desperate. The fear of withdrawal in driving this desperation was acknowledged and empathised with by some. Others were scornful and saw it as something the person could avoid doing.

Why do injectors reuse their own needles and syringes despite accessing needle exchange services?

4.82 In Aberdeen 65.1% of participants in the NESQ had kept their own needles and syringes for reuse in the past month. In Dundee this figure was even higher at 70.0%. This practice is of concern for two main reasons. Firstly, if stored needles and syringes get mixed up with those of others there is a risk of blood borne virus transmission. Such risks are evident in the video work of Taylor et al (2004). Secondly, it means injecting with non-sterile and potentially blunt equipment. This can promote infections and exacerbate vein damage. In the interviews, the reason given for reuse of one's own needles and syringes was lack of sufficient quantities of clean equipment. On exploration three factors seemed to be important:

Many interviewees reported using more than one set of needles and syringes per injection

4.83 The reason for this was that each attempt to find a vein made the needle blunt and several attempts may be needed. It was said to be less painful if sharp equipment was used. It was also advocated in safer injecting literature. Hence the assumption that one set of injecting equipment equates to administration of one injection cannot be made. Interviewees said it was not always possible to predict when visiting a needle exchange how many sets of equipment would be needed before the next visit. Some were reluctant to take more than the minimum amount they perceived necessary for fear of carrying large quantities on their person.

Some supplied others in need with equipment

4.84 Many conveyed a feeling of comradeship and duty to help out other drug users when they were in need, albeit of equipment or drugs. Some felt morally responsible to intervene if they saw someone about to share, so donated sterile equipment. Some reported doing this for people they did not know. Therefore own supplies may suffer unplanned depletion, through donations made to others.

Convenience of accessing needle exchanges

4.85 This was an important factor in influencing whether the person had enough sterile sets of equipment or not. Those who lived close to a needle exchange or were frequently in the city centre did not express the same difficulties with quantities of equipment as those who lived more remotely or relied on outreach. Similar findings were also shown by Hutchinson et al (2000) in Glasgow. The notion that injectors will make daily trips over longer distances to collect clean equipment prior to using drugs was not evident. This was often due to other challenges that arose daily regarding acquisition of money and drug, which gained priority in the face of addiction and the risks of withdrawal. Some cited 'laziness' as a factor.

4.86 Some interviewees expressed concern around vein damage from reusing needles. Others acknowledged the risk of blood borne virus transmission if their used equipment was accidentally taken by another or vice versa. Some reported marking their own equipment in some way to make it recognisable.

Why do injectors share and reuse paraphernalia?

4.87 For the majority, sharing paraphernalia appeared to be perceived as less of a risk than sharing needles and syringes. Sharing needles and syringes was clearly a big concern for many. For some, sharing paraphernalia was seen as inevitable, especially in Aberdeen.

'I'd say 8 out of 10 people would share -never a needle, but a spoon, filter…yes' M33A(15)

'Well I share spoons and filters and works…it is not easy [to obtain paraphernalia] as I haven't got any money for it….basically I have to go borrowing to people…' M24A(5)

4.88 The communal nature of injecting was seen to necessitate sharing. Those who avoided sharing in such situations described actively devising strategies to avoid this such as carrying self-prepared kits. In some cases strategies perceived to reduce risks were reported. For example, borrowing only from trusted people or attempting to clean equipment prior to use. Others described judging risk based on how they had seen the item handled.

'I wouldn't use someone else's needle but if there was only one cigarette filter, I would share it. One of us take one half and the other take the other. Or like the citric….as long as it has not been on somebody else's spoon or somebody else has touched it' F22A(2)

Keeping and sharing used filters

4.89 Keeping one's own filters for reuse was common; 65.6% of the Aberdeen cohort and 55.9% of the Dundee cohort reported doing this in the past month. However giving someone else a used filter was less common in the past month in both locations (Aberdeen = 42.3%; Dundee = 33.5%). Interviewees in both Aberdeen and Dundee said filters were kept for reuse because they retained some drug. This was verified and quantified in the laboratory investigations in stage one (figure 13). Retained filters were seen by some as an important 'back up'. Stored filters could be 'bashed down' to prepare an injection at times when no heroin was available, either due to lack of finance or lack of dealer supplies. This was seen as an important way to control withdrawal symptoms. Passing on used filters to others to help them prevent withdrawal was seen as part of the culture of 'looking out for' other drug users. This explains the saving of filters for own use reported by over half the group in Dundee despite availability of clean ones from the exchange.

4.90 However, some interviewees said 'bashing down' filters in this way presented the risk of a 'dirty hit'. This is an acute febrile reaction attributed to a response to contamination within the filter, possibly microbial grown on the filter material. For some this deterred them from this practice. They regarded the use of a new filter each time as 'clean' and 'safer', but most did not explicitly mention blood borne virus risks from sharing. For others, although they considered 'dirty hits' to be a risk from reuse, they still undertook this practice:

'I'll save my ones [filters] from the day…say I have five hits in a day…that's a decent hit, so I do that… but I do think in the back of my head that I could get a bad hit off it..' F26A(1)

'I know we shouldn't do it [save filters to bash down] , I know they are breeding germs…but they tide you over' F26D(4)

Sharing water

4.91 80.2% of Aberdeen participants and 67.3% of Dundee participants reported having shared water at some point ever. In the past month, 56.1% of Aberdeen participants and 54.7% of Dundee participants had shared water.

4.92 The use of a communal container of water for preparation was commonly described both in Aberdeen and Dundee interviews. Many described risky situations such as using communal water in the house of another. Some perceived they were in control of the risks around communal water, for example because the cup was in their home. They described only allowing 'clean tools' to be put into their cups and some explicitly stated that they required to see the needles and syringes being removed from their packaging. The cultural norm of supplying water for those who inject in your house was acknowledged as the reason for having only one water container. The single-use nature of small volume water ampoules may potentially break this cultural norm. However, batch preparing would also have to be discouraged, otherwise multiple numbers of single-use ampoules could be emptied into a communal cooker from which several injections may be drawn. If used needles and syringes were used to draw out individual injections this could present both blood borne virus and bacterial risks and negate the benefits of single use ampoules.

4.93 Some interviewees stated they only shared water with certain people such as sexual partners. They used explicit strategies and applied definite rules to avoid sharing with anyone else. Those who shared with sexual partners did not explicitly acknowledge any risks from this practice.

4.94 However, others did describe avoiding communal water containers. Some had their own water which they did not allow others to use, for example by carrying it in a medicine bottle or having bottled drinking water. They expressed concerns about the risks of communal water and stated they always took water from the tap or kettle directly for their own use.

4.95 Many interviewees in Dundee said they would like to see water supplied. Some said this would complete the 'kit' to facilitate safer injecting, stating that they felt water was the 'missing link' at present. Some said they thought supply would prevent sharing of water. Some said they would like water supplied to prevent infections such as abscesses and cellulitis. Blood borne viruses were mentioned by fewer. This suggests that supply of water would have to be accompanied by education to prevent sharing and batch preparation, as discussed below. One person thought cost would prevent water being supplied. Some interviewees in both locations perceived bottled water to be better than tap water because it did not contain chlorine which was perceived to be harmful if injected. Chlorine content was judged by the smell of the water. Use of bottled water was also described as a way to protect ones self as it could be passed to others after use to remove water for their own use. This assumes others do not put used needles and syringes into the bottle which is subsequently kept for further use.

Sharing cookers

4.96 Cookers can be shared in one of two ways: They can be shared by means of batch preparation, as described by Taylor et al (2004). This is where drugs are prepared on one spoon then divided up amongst injectors. Risks present where one or more persons drawing up from the cooker is using a used and potentially contaminated needle and syringes, which contaminates the batch. Cookers can also be shared by being used by an individual and then passed to another for subsequent use. Both practices were reported by interviewees in both locations, although batch preparation appeared to be more common and a cultural norm. Interviewees in both locations described batch preparation as often related to times when money was pooled together to purchase drugs. Batch preparation was seen as a way of ensuring that the prepared quantity was shared fairly. Taylor et al (2004) noted this previously in Glasgow. Batch division described as each person drawing their entitled share of liquid into their syringe. This practice was also described by a few interviewees in Aberdeen as a way of 'paying' another for lending paraphernalia items. Some risk management strategies were described as being applied to batch preparation by some such as a hierarchy of removal of the solution:

'If there is 3 of us I make sure we have 3 clean needles, one clean pot. The hit gets drawn from the same pot. If somebody has not got a clean set of works it is up to them to go and get….either reuse their own set or come here [to needle exchange]… they get whatever is left in the pot for them…Usually the one who is paying for it goes first and if someone's getting it for free he'll go last' M33D(new injector).

4.97 For some, they only undertook batch preparation with one injecting partner who was usually their sexual partner. They did not appear to consider this a risky practice. Batch preparation probably explains the sharing of cookers reported in Dundee (69.2% ever), despite their supply.

4.98 Passing on of Stericups in Dundee was seen as a risk in drug preparation, as the flimsy hot handle could bend and spill the contents on second use. This was also noted in the laboratory work. Some Dundee interviewees described this as a factor that stopped second use, so hence deterred sharing. Passing on of spoons was reported by interviewees in Aberdeen. Access to cookers was not identified as a problem in either location, although obviously makeshift items would be non-sterile. Tea spoons and drinks can bases were seen as suitable makeshift items, including by those in Dundee when they ran out of cookers. Some described cleaning cookers with swabs prior to sharing them and considered this to be adequate to reduce risks.

Perceptions on blood borne virus risks from sharing paraphernalia

4.99 Early in the study, the Aberdeen researcher noted that the term 'paraphernalia' appeared not to be one commonly used by or understood by interviewees. Therefore it was defined by both researchers as 'spoons, water, citric, filters and any other equipment you use to prepare'. Many interviewees did recognise sharing to include paraphernalia items, although some needed prompting before they did so. Some did not consider borrowing or lending of paraphernalia to be 'sharing', equating this practice with needles and syringes only.

'I've nae shared nothing…..I have shared a touni' an cookers, but I winnae share needles or nothing' M43D(24)

'Is it just with needles?….umm…I don't know…I wouldn't use someone else's needle but if there was only one cigarette filter, I would share it…' F22A(2)

4.100 The majority of interviewees in both locations described having engaged in risky injecting practices at some point since they began injecting. In Dundee many interviewees described borrowing sterile packaged injecting paraphernalia or lending sterile packaged items to others when in need. This is unlikely to present risks as long as blood spillages do not contaminate packaging. However others in Dundee described borrowing used items. In Aberdeen some described borrowing only unused paraphernalia from others, such as cigarette filters from unsmoked