It has been suggested that this page be merged with the Intravenous and Intramuscular Injection article.
Finished putting it together for version 0.1a. Have pictures aligned and thumbnailed and all sections up. I will be rewriting all sections in my original hand. Would like to find photos to use under the creative commons license.
Intravenous drug injection is in most cases, the most efficient method to deliver drugs to the body. The liver, skin and stomach, our natural protection mechanism's against toxins are bypassed as drugs are delivered directly to the bloodstream. As a result, the risk of infection and overdose is greatly increased, but so is the "high".
Personal Statement: This mission of this guide is to help reduce the harm associated with intravenous drug use. Many of the risks (infection, hepatitis, abscesses, HIV, scarring), can be avoided with proper technique and care. The information in this guide can help save your life, so learn it! The problem with the other guides to drug injection are scope of knowledge. Guides written by medical professionals are too idealistic and naive, suggesting hospital-like conditions. The guides written by users lack accuracy and depth. The fact is the conditions for illicit drug injection injection constantly change - IV users are at the mercy of the black market and supplies available. Much of this guide was written by former or current intravenous users, and its our goal to help pass down some of that real-world experience, while maintaining an objective, factually accurate representation of all things related to illicit drug injection.
Even though most who start injecting are already drug addicts, there is something symbolic about starting intravenous use. In heroin culture, it is referred to as "getting your wings" and most junkies look down upon users who help someone shoot up for the first time. Once you inject, it moves your drug use from a vice to a complete lifestyle. While it doesn't seem like this when starting, this is the all too common result. The cliche' of the naive user saying "I'm only going to do this once, I just want to see what its like", is all too real. The road down this path is always different, but the result is the same. Don't assume you're somehow special.
What is typically injected? Street Drugs - Heroin, Cocaine, Methamphetamine
Traditionally, Heroin has had the highest rate of intravenous use, as its cost was enough that it eventually drove many users to inject to save money. However, in recent years the percentage of heroin users injecting has dropped, largely because high quality street heroin has become the standard. This was done to attract users who only snort or smoke the drug, and thus increase sales. Although purity rates vary wildly, it has been generally accepted that 45-75% pure heroin is normal on the East coast of the United States. Because of this, its become more of a conscious choice whether to start injecting, rather than an economic necessity. For this reason, I urge not to become an intravenous drug user.
While this risk if often ignored, it necessitates a disclaimer. IV drug use is extremely addicting psychologically. The act of IV drug preparation detailed in this guide becomes a ritual for many, often more pleasurable than the drug itself. Many addicts, when out of drugs, end up injecting water just to fulfill their cravings. Overpowered by cravings for the ritual and the drug, its easy to disregard the risks of injection use, and the harm reduction steps to minimize them. While a craving will last a few minutes, many mistakes injecting can have life-long (or life ending) consequences. Try to remain objective and realistic.
Injection Drug Users are one of the most persecuted groups on the planet. In almost every culture, they are treated with rejection, mistrust, fear, and hate. Even among drug users and addicts they are marginalized, as many drug users consider those who inject to be the most of extreme of all users. In most countries, vindictive laws are written to punish users rather than for treatment. So many drug cases move through the courts that judges have become unsympathetic and stoic in their sentencing. In many states there are cruel and unusual sentencing mandatory minimums exist that imprison people with possession charges. A Politician's short term political gain can ruin an addicts life. While not fair, the cost of getting high can be a rejection from your friends, family, and society. Keep this in mind.
Drug Injection Basics - n4k
Intravenous injecting is a highly efficient way of introducing drugs into the body. However, when drugs are injected, the filtering and delaying mechanisms that protect us when things are absorbed via the gastro-intestinal tract, lungs or skin are bypassed. This makes injecting by far the most hazardous way of introducing drugs into the body. In particular the potential for infection and overdose are much increased.
How Injection Works - n4k
Injection drug use puts you at risk for:
* Blood-borne viruses: Hepatitis A, Hepatitis B, Hepatitis C, HIV/AIDS, Human T-cell Lymphotropic Viruses (HLTV), * Bacterial infections Streptococcal disease, Tuberculosis
* Fungal infections
* Damage to the circulatory system Superficial thrombophlebitis (Damage to vein walls),blood clots,
* High risk of overdose * Psychological addiction (needle-fetish)
The best way to avoid these risks is not to inject in the first place.
If you decide to ignore this and inject, this guide provides methods to minimize these risks.
Cultivation of Good Veins
#below written by n4k Irreversible damage to the veins can occur when you:
* Frequently inject at the same site * Use poor technique * Use dull needles * Mismatch needle size with veins * Injecting pill binders / some cuts
Genetics play a large role in the veins you have. Some are born with massive veins close to the surface of the skin. Others were born with deep, small veins. Because of this, it is easier to "hit" the veins of some people, while others can be difficult. While this guide will prepare you with the proper technique, proper injection is partly a learned skill, and will take practice. Even if you become frustrated, take care not to injure yourself. If you're already an IV addict and your veins are in bad shape, don't worry - the body can heal. Use these exercises and follow this guide's safety methods and it will certainly help.
Repeated use of veins makes them more difficult to access. Exercise is one of a few vital ways to keep your veins healthy and viable, and reduce the likelihood of "track marks".
Here are a few tips for simple exercises to plump up your veins: #above written by n4k
1. Push ups - doing about two sets of 20 push ups before injections can make a noticeable difference in your veins. This technique is good to use both as a daily routine to build your veins as well as a quick way to plump up your veins before shooting. When you do push ups the muscles in your arms require blood to give them energy and carry away lactic acid, After this blood supplies your arms with nutrients guess where it goes? Right into your veins to start back towards the heart ... so tying off after a set of push ups will collect all of this extra blood making your veins really stand out. Also, the natural position of this exercise (with your hands towards the floor below your body) helps blood flow more easily into your forearms and hands.
2. Stress Reliever / Squeeze Ball - These are soft and squishy balls about the size of a tennis ball that are sold to relieve stress. They are also used to aid in rehabilitation for people who have injured their arms and lost muscle tone. You can find one at any walmart... some are made from a nerf-like foam and others are a rubber skin filled with either a gel or small beads. You can always improvise if necessary... any ball of this size will do. (Try looking in the pet toys department) You can even take a balloon and fill it with dry flour, although this is tedious to do. Keep this toy handy and get in the habit of using it when you have idle time... such as watching tv. Squeeze and release about 1 times every 2 seconds. If you do about 30-40 reps and then pass to the other hand you can give one side a chance to rest and then switch back.
About Veins and Arteries
* carry blood away from the heart; * carry oxygen-rich blood (except between the right side of the heart and the lungs); * hold bright red blood; * blood at high pressure; * bleed profusely - spurt blood; * served by many nerves; * thick walls; * very elastic/muscular; * no valves; * less numerous; * recognizable pulse; and * mostly deep.
* carry blood towards the heart; * carry oxygen-depleted blood (except between the lungs and the left side of the heart); * hold dark red blood; * blood at low pressure; * do not bleed profusely - ooze blood; * served by few nerves; * thin walls; * not elastic/muscular; * valves; * more numerous; * no pulse; and * deep and superficial.
Dilution - n4k
Diluting your the shot with more water will make the solution safer for injection. Additionally, dilution helps stop needles from clogging. This procedure is especially important when shooting tar heroin and pills, as they consist of potentially dangerous substances to inject (plant matter, binders).
This process isn't an exact science - Just remember, the more water, the better. After you draw in your normal solution into the syringe, continue to draw up water until it fills the barrel to approximately 60% of its capacity.
For example - If you are using a 1cc syringe, and the heroin solution fills up 30 units, draw in more water until it hits the 60 unit mark.
Rotation - *To Do*
Strokes from air bubbles: below - n4k
This is a prolific rumor among injectors has been over dramatized to the point that many users are living in fear that they might accidentally inject a bubble and end up dead. However, fact is, while technically possible to die from injecting air, it would take an enormous amount (more than any insulin syringe can hold).
This energy and time should be spent focusing on hygiene and proper injection procedure.
Having a second hit to ‘sort out’ a bad one: Some injectors have expressed a belief that the best way to deal with a ‘dirty hit’ (an acute reaction to injection, characterised by shivering and sweating that is usually self-limiting) is to inject again. Whatever the cause of the reaction, repeating the procedure could at best make the experience worse, and at worst cause overdose.
Injection No-No's - n4k
Licking the needle tip: Sometimes users lick the needle tip so they don't lose even a drop of heroin. This is a bad idea! Infection occurs this way. Frequently an immediate reaction will occur with the skin turning red with white spots for 20 minutes. Most people assume its the heroin causing this, but its almost always from licking the needle. Licking the injection site: Read Above. If you are bleeding, use an alcohol swab or clean cloth, and wash with soap and water when finished.
Injectors should be encouraged to include stopping the bleeding with a disposable pad or tissue, and both hand and injection site washing with soap and water to their post-injection routine.
Booting: ‘Flushing,’ ‘booting,’ and ‘kicking’ are terms which refer to drawing blood back into the syringe after the drug solution has been injected, in an attempt to ensure that no drugs are wasted by being left in the hub of the syringe.
"Booting" and "Flushing" are terms given to the practice of drawing blood in and out of a syringe after the drug has already been injected in order to not waste anything. This is a bad practice. Something could go wrong resulting in vein damage, or accidently bruising. The amount of heroin left in the syringe is just a couple drops and will make little difference.
Collateral circulation: When a vein becomes thrombosed or obstructed, blood can no longer flow through it to return to the heart. The blood will therefore take an alternative route, using other smaller blood vessels to get around the blockage.
This diversionary circulatory route is called ‘collateral circulation.’
When most of the veins have become obstructed, this process may result in the appearance of ‘new’ superficial veins on or near the skin surface. Injectors should be discouraged from attempting to use these veins, as they are likely to be small veins that have become engorged by the necessity for them to carry more blood.
They will therefore be under greater pressure than normal, so that injecting into them carries a greater risk of damage to the vein. The usual consequence of injecting into such veins is that within a few injections the vein becomes damaged and is no longer viable.
If the remaining veins are also damaged, then the return of venous blood from the affected limb is likely to be even more severely restricted. This will lead to slower blood flow out of the arm and lead to the limb becoming swollen and blue. The consequences of this are discussed below under ‘Long term consequences of substantial vein damage.’
Arterial injection: All drug injectors should be warned that they should never inject into a blood vessel in which they can feel a pulse.
Although most arterial injections are accidental, occasionally people attempt arterial injection deliberately. The practice of deliberate arterial injection should be strongly discouraged.
For those who hit an artery by mistake or otherwise, advice should be to:
* immediately withdraw the needle - do not complete the injection; * put strong pressure on the site for at least 15 minutes; * raise the affected limb if possible; and * seek medical advice.
Arterial injection can sometimes cause weakening of the artery wall (pseudoaneurysm) or fungal infection of the artery wall (mycotic aneurysm). Both conditions can lead to life-threatening arterial bleeding.
Thrombosis: Blood clots form when there is turbulence in the flow. Damage to, or inflammation of, the lining of the vein (figure 8.1) can trigger clotting of the blood at the site of the damage (figure 8.2).
These clots stick to the lining of the vein, and are known as thromboses. The clots themselves cause turbulence and this, in turn, can cause further clotting (figure 8.3). A blood clot inside a vein does the same things as a blood clot on the surface - it hardens and turns to scar tissue that shrinks and pulls the edges together (figure 8.4). It is this pulling together of the edges that makes veins ‘collapse.’ Veins that have collapsed in this way do not ‘unblock’ - the blood has to find another way back to the heart.
Vein blockage and collapse: Veins may become temporarily blocked if the internal lining of the vein swells in response to repeated injury or irritation. This may be caused by the needle, by the substance injected, or both. Once the swelling subsides the circulation will often become re-established.
Smaller veins may block as a consequence of too much suction being used when pulling back against the plunger of the syringe to check that the needle is in the vein. This will pull the sides of the vein together and (especially if they are inflamed) the sides of the vein may stick together, causing the vein to block. Removing the needle too quickly after injecting can have a similar effect.
Permanent vein collapse (Figure 8) occurs as a consequence of:
* long-term injecting; * repeated injections, especially with blunt needles; * poor injecting technique; and * injecting of substances which irritate the veins.
Problems with "missed hits" n4k
* Not entering the vein properly; * Slipping out of the vein * Poking through the vein wall * Back pressure causing the vein to rupture
These factors can cause you to miss your hit, depositing the drug in the flesh, possibly resulting in bruising, swelling, infection, and possibly rendering a vein unusable.
* Check to see if the needle is in the vein by "registering" - pull back plunger to see if blood enters * Release tourniquet before injecting to avoid rupturing veins * Place your arm on a surface or knee to keep it stable while injecting * If in withdrawal, snort/smoke a bit before injecting so you're not too shaky. * Use a needle that's a good match with your veins and body; * Inject at the correct angle (in line with veins and blood flow) * Inject the fluid slowly and carefully
Missing a hit means the drug will take longer to hit you. Don't be stupid and inject again out of impatience, wait until it kicks in first. Remember, missed hits can become serious and result in abscesses, cellulitis, and cutaneous foreign body granulomas.
Lumps and bumps: Many injectors have various ‘lumps and bumps’ under their skin, and these often cause anxiety.
The vast majority are not serious, and are caused by the mechanisms outlined below. Checking the history of that site for causes such as:
* previous abscesses; * frequently used veins that have now collapsed; * Scar tissue; * previous misses; and * history of tablet injecting
will give strong indicators of the cause.
However, clients should be advised that if they are worried, or if the lump/bump ever changes (size, color, mobility) they should seek medical advice.
Scar tissue: The scar tissue filling collapsed veins can remain visible, and feel like there is a ‘bit of string’ under the skin, for many years. Sometimes, there can be hard ‘knots’ under the surface of the skin, at the points where there were valves.
As with scar tissue from injuries we suffered as children that persists into adulthood, so scar tissue below the skin surface caused by injecting injuries can remain as a lifelong reminder.
Old abscesses can also leave lumps of scar tissue that remain for many years. When clients mention a lump under their skin the first question to ask is ‘have you ever had an abscess at that site?’
Very often the answer will be yes, and you can reassure them that the probable cause is scar tissue that filled the infected capsule when the abscess healed.
Abscesses / Infection
The risks of local infection will be increased by:
* sharing of needles and syringes, and injecting paraphernalia; * reuse of unsterile injecting equipment (including filters); * the use of non-pharmaceutical medication; * unhygienic preparation of drugs; and * poor personal hygiene.
Septic Abscess: This is a painful localized infection surrounding the site of injection. As white blood cells surround the infection, inflammation will occur and the injection site might look puffy and red, be warm to the touch, and will be filled with pus. Abscesses sometimes heal themselves, but medical attention is needed in many cases. Treatment consists of an antibiotic cycle, and lancing of the abscess to drain the pus. As Staphylococcus aureus bacteria is a common cause, an anti-Staphylococcus antibiotic such as Flucloxacillin or dicloxacillin is used.
A small abscess can sometimes be treated at home by applying pressure with a hot washcloth for 30 minutes, 4 times a day. If ineffective,or worsening, get medical attention right away.
If the Abscess does not go away on its own, and it continues without medical attention, it can lead to Gangrene (tissue death). This is an extremely dangerous condition and requires hospitalization. Antibiotics by themselves are ineffective, and are only used when complementing surgery. Failure to treat Gangrene will lead to death of tissue and a likely amputation.
Sterile Abscess: This is occurs as a possible result of missing an injection, leading to granuloma. Granuloma is the buildup of scar tissue associated with injecting subcutaneously from missing a shot. This condition is caused most frequently from injecting pills.
Granuloma from Injecting Pills: This is a dangerous process. Pills are frequently designed to prevent abuse, and injecting them can lead to injury and death. Many drugs,(such as morphine), are manufactured in many different strengths, with different fillers and combinations. The most common pill filler magnesium silicate,is often the suspect, but recently an even more dangerous "wax matrix" is used. As these fillers accumulate, they cause scar tissue to build up. A granuloma/sterile abscess is cool to the touch.
Different pills have different methods of injection and danger profiles. Check here for more detailed information on specific pills.
The most critical thing to do if someone overdoses on heroin is to keep them breathing! Knowing and using rescue breathing/cardiopulmonary resuscitation (CPR) will save lives as might naloxone, the drug shown here. Although naloxone has no effects on its own it dramatically reverses the effects of opiates. If given intravenously naloxone reverses an overdose almost instantly, injecting it into a muscle take only a little longer to work. While 1mg IV is the suggested initial dose more can be given if there is no response up to 10mg, at which point the overdose is probably not opiate induced. If you only give a naloxone shot under the skin, and not into the muscle it takes longer to have an effect and unless you are breathing for the person they could die. Breathing for them until they do it on their own is always a good idea.In addition to possibly performing miracles in case of overdose, naloxone also stimulates withdrawal in those who are opiate addicted. Also, naloxone's effects only last 60 to 90 minutes and so, depending on the length of action of the opiate used, the overdose can return after the naloxone wears off. Clearly, learning about naloxone's benefits and limitations is very important to using it helpfully. Discussing 911, CPR, naloxone and other overdose management techniques with the people you inject with is critical to being prepared for effective action in case of an overdose.
Supplies and Preperation
Soap and water are very effective at both killing and loosening and washing away all kinds of germs which can cause infections including HIV and Hepatitis B and C. Washing your hands and potential sites of injection prior to preparing your shot will greatly reduce the amount of germs around and thus their potential for getting into your body.It doesn't appear to matter what kind of soap you use as long a s you make a lather (rubbing well) and rinse well. It even appears than soap and water make for cleaner skin than wiping with an alcohol pad prior to injection. As well, warmer water may help make it easier to find a vein.
We realize that you may not always have the most sanitary conditions to use as a workplace for preparing your drugs for injection. However, it is important to take a moment and create an uncluttered and clean area on which to prepare your meth or heroin.
With Hepatitis B and C, which can live on surfaces for many months, you are at risk of diseases from surfaces. Therefore, it is possible to reduce or eliminate risks from surface contagions by use of clean hands and clean surfaces.This image shows the making of a new, clean surface for preparing and injection. By turning to the middle of a paper pad or to an unread section of a newspaper you are likely avoiding possible sources of previous contamination. Preparing and making a shot with clean hands (washed in soap and water) and clean/new surfaces should greatly reduce hepatitis risks.
Another good idea is a picture frame which has the bonus of a lip around the edge. The glass can be wiped with alcohol and a clean paper towel for added protection. If possible you should crush your speed up inside the baggy first and transfer it to your spoon or other clean mixing container. This reduces the chance of contamination with dust or dirt which may be on your working surface.
As I mentioned before, it's not always possible to have the perfect place to get high... but that is what harm reductiion is all about - making the situation LESS HARMFUL for you. The following is a list of definite no-nos when considering a workspace for fixing your shot
If you are forced to fix in a bathroom NEVER allow your works syringe or any other instrument to touch the bathroom floor. Also, avoid toilet seats... even the lid. These are both infested with potentially life threatening bacteria, fungus, and other germs. If these make their way into your bloodstream or injection site they can lead to infections, abcesses, blood poisoning, endocarditis (heart infection), and a hundred other nasty problems. If the bathroom is your only choice be sure to work out of your lap or wipe a countertop off with alcohol or another disinfectant.
Never fix your shot in the same area or in the middle of sexual play. If you have been PnP-ing or otherwise fucking you may have lot's of germs on your hands, arms, and surrounding surfaces.
Try to set aside a place in another room or at least away from your play and BE SURE to throughoughly wash your hands and arms before touching any of your drugs, needles, spoons, filters, or other works.
Filters for Mixing Drug Injection
All filters are not created equal! The ideal filter would be sterile, require no manipulation to get it the right size, and have fibers which would not easily break off nor carry poisons (or flavorings as they are sometimes called).Each of the filters on the bottom of this card require manipulation by hand, ideally just washed hands, but nevertheless hands, From left to right, a tampon, cigarette filter, cotton ball, and Q-tip. All have to be screwed with to obtain the proper size thus giving an opportunity for contamination. As well, the cigarette filter is composed of relatively inflexible fibers which break off as the right size filter is formed. These small particles and the poisons in the cigarette filter are drawn up into the syringe and become part of the shot. Ultimately, these fibers get caught up somewhere in the body, probably the lungs where they can cause infections (cotton fever) and obstructions.
(*Personal note: I STRONGLY suggest NOT USING cigarette filters. Clean cotton balls would be ideal and Q tips pulled off with clean hands run a close second.)
.The four sizes of cotton pellets shown above are pre-sized so they don't need to be fooled with and they are made of flexible natural cotton fibers. Under ideal circumstances they would be sterilized too!
Each of these images shows three vials of water on the top. The one on the left is distilled water which is not sterilized and usually distributed because of cost limitations in many places. It allows one to have a clean source of their own water so they don't have to use someone else's. The other two vials on top are sterile water or sterile normal saline. Having sterile water definitely gives a cleaner injection. You can also boil water for 10-15 minutes (at sea level) and this will kill all germs in it.
The two vials on the bottom of each panel in this image are sterile drugs of known purity. On the left is a 100mg vial of heroin and on the right a vial of methylamphetamine. Both these vials contain sterile drugs on known purity and thus can greatly contribute to a safer injection. While such drugs are not usually in this sterile and known purity form it is important to show the possibilities. In reality, the contaminates and unknown purity of drugs can be known through testing and purification but this is beyond what we're showing here.
Some disagree with the use of saline for mixing. Saline makes the shot thicker and thus more likely to get clogged or push out slowly. Running tap water will usually suffice. Just avoid stagnant water - don't use water out of the same cup you have left sitting from the night before. Bacteria grows too quickly for you to skip this simple step.
Basic Syringe Information
While there are a bunch of different syringes both in manufacturers and in sizes and function there are important features to consider about each. First and most importantly, is your syringe sterile and new? Every injection should be made with a sterile new syringe, just like in the hospital to maximally prevent disease and tissue damage which comes from using a syringe a second time. A lot of first time users only have movies for reference on syringes, yet most syringes portrayed in movies are laughably large. In real life users use small needles, a 1cc needle with a 28 to 31 gauge tip is considered common for heroin use. Depending on where you are injecting, shorter needles should be used for areas like the hands, while longer needles can be used for arms. Long needles can be dangerous for first timers, as they can easily poke through a vein or accidentally reach an artery. In general, the smaller the needle you can use the less vein and other tissue damage you will cause via injection. On the lower right of the photo are two different syringes. One, on the bottom, which has a separate needle and the other, on top, which has the needle and syringe as one piece. While there are advantages and disadvantages to both of these syringes it is important to note how much blood is left in the syringe on the bottom compared to the used syringe above it. On the other hand, insulin syringes are not designed for IV injections nor is it possible to draw from the cooker with the needle removed thus avoiding possible damage to the needle. Which syringe is right for any given person depends on them, what they are injecting, where they are injecting and how they are preparing their shot. Talking about all the options and coming to use what you feel is the best syringe for you is the goal.
In depth information with photos on syringe classification here
The top image shows several types of things that can be used as ties or tourniquets. They are (from left): a piece of rope, a leather belt, a terry cloth belt, a rubber hose, and a piece of bicycle inner tube. The bottom photo shows the steps in turning a popped bicycle inner tube into a nice tie. Some things to think about with a tie
Is it so thin that it will hurt your skin when you pull it tight?
Does it stretch? If so, it will be much easier to pull it tight and easier to release, an important part of a gentler injection
Is it easy to make, cheap, available, and does it come in various lengths and widths so it can be fit to the person?
Can you clean it? This is critical especially if you and someone else use the same one. Blood on a tie can be a source of infection.
If you have thin arms and need an easy to use tie I suggest 1/4-1/2in wide elastic material. You can pick this up in the fabrics and craft section of your local Walmart or Target store. (If you can't find it just tell a salesperson you are looking for elastic band that goes inside waistbands and other clothing) You can get whatever width suits you but if it's too thin it might leave a mark on your arm and if it's too thick it is difficult to work with. It costs about $1.50 for 6ft which can be cut into sections about 1 1/2 feet long. Then just tie a small loop in one end. Slide the other end through the loop and place around your arm. Pull to tighter and wrap around your arm two times or so, then tuck the remainder underneath the band leaving enough loose so that you can easily pull to release. This is a great idea if you are going to have others over because you can quickly and easily make everyone their own. They are also easy to carry with you. Please be aware that they are made of cloth and can hold germs... so if you put it in your mouth alot or get blood on it you should use a new piece frequently.
Safer Injection Sites
Arms: The loss of usable arm veins (Figure 1) will leave the injector with stark choices: either to stop injecting and switch to another route of administration, or to move to another site on the body with greater inherent risks.
It is for this reason that injectors should be encouraged to do everything they can to preserve the veins in their arm for as long as possible. It is important that workers seeing clients who are having difficulty accessing veins in their arms discuss with them the plans they have for the time when it becomes impossible. Reinforcing any taboos the client has about moving to more dangerous sites may help prevent or delay transitions to more dangerous routes of injection.
Hands: The veins on the backs of the hands (Figure 2) can be highly visible, although they tend to be small and fragile.
As it can be difficult to hide the evidence of injecting here, many injectors avoid these sites. Furthermore, if complications such as infection of cellulitis occur, they are likely to be much more disabling in the hand than in the arm and lead to severe problems, especially if rings are left in place on the fingers.
Fingers should be avoided as the veins are very small. If clients insist on injecting in their fingers, they should understand the vital importance of removing rings prior to injecting. If a finger starts to swell with a ring in place, it can quickly obstruct the blood flow leading to loss of the finger. The artery that supplies the finger lies just below the vein - if the artery is damaged the finger can ‘die.’
Legs: The superficial leg veins are unlikely to be viable long-term prospects for injecting. The blood flow in the veins is slow, and so if people inject too quickly there is often leakage into surrounding tissue: this can cause infection and further vein damage. They also contain more valves, which increases the likelihood of problems, as injecting at or around a valve causes more turbulence, and therefore clotting of the blood, and can damage the valve which further slows blood flow. The superficial veins of the leg tend to ‘wobble’ when people try to get a needle in them, and this can result in more frequent ‘missed hits’ and vein damage.
As the flow of blood in the leg veins is upwards (i.e. towards the heart) it can be difficult to self inject in the correct direction in the legs, i.e. with the needle pointing up towards the top of the leg. Because they are furthest from the heart, and due to gravity, blood flow through the leg veins is slow. If drugs are injected too fast, the veins will be unable to cope with the extra fluid. When this happens, fluid can escape from the vein, around the needle, causing a ‘miss.’ This can be reduced by injecting slowly.
Healing of injection site damage and resistance to infection are less reliable because the blood flow is slow. Abscesses and other infections are therefore a greater risk for those injecting into their legs.
Varicose veins form, usually in the leg veins, because of damaged valves. The varicose vein has tight, thin walls and is often raised, stretching the skin. They should not be injected into, as they can bleed profusely because the damaged valves mean that blood can run back down the vein and out of the wound.
Feet: Although the veins in the feet are used by some injectors, there are several factors which make them an unsuitable choice for anything other than occasional use:
* venous blood flow in the feet is slow - if local infection occurs, this can lead to loss of mobility; * injury to the feet may be slower to heal than in other areas, especially in individuals with already damaged circulation; * fungal infections of the feet are common - there may be an increased risk of introducing these into the body; and * for most people there is a need to wear shoes and socks - this may encourage or compound problems of infection.
As with the legs, injections in the feet should be done as slowly as possible to prevent overloading the vein.
Dangerous Injection Sites
Breasts: Although there are usually small veins visible in the breasts, especially in pregnancy, it is dangerous to try to inject into them because they are very small and liable to break. They are also next to milk ducts which can be accidentally filled with fluid. Because there is no direct blood supply to the inside of the ducts, the fluid stays there and the risk of developing mastitis or abscesses is high. Deep veins When searching desperately for a usable vein, some injectors will ‘look’ for deep veins, by simply ‘digging around.’ Where this is because of a lack of awareness of available sites, supplying relevant information may be useful. For those who have limited knowledge of their body structures, education about the risks of hitting arteries, nerves and bones should be offered.
Armpit: The armpit is a dangerous site for injecting because of the close proximity of arteries and nerves to the subclavian vein.
Neck: Self injecting in the neck is extremely dangerous, difficult to do and should be strongly discouraged. Arteries, veins, tendons and nerves are all very close together. Engaging in discussion about ways to ‘make it safer’ should not distract from the central message that it is too dangerous.
Part of the risk arises from the fact that for self injectors, self injection in the neck requires the use of a mirror. This difficulty may lead injectors to ask others to attempt neck injection for them, thereby increasing the chances of both viral transmission and local injury, and removing all personal control over the process. It may also lay the injector open to at least a manslaughter charge if the person dies - even if they requested the injection.
The common complications of neck injecting may be similar to those in other areas, such as cellulitis and abscess formation, but have even more devastating effects. An abscess or cellulitis in the neck can cause dangerous pressure on nerves or obstruct the airway.
Other problems include:
Accidental injection into an artery - if this occurs, then the drug and any other matter contained in the solution will go directly to the brain, potentially causing a range of neurological problems, including strokes;
Weakening of the blood vessel wall (aneurysm); and
Nerve damage, including vocal chord paralysis.
Penis: Injecting in the penis is sometimes attempted when other possible sites are no longer available.
The penis is dangerous for injection, and complications such as local infections are almost inevitable.
A condition known as priapism - a permanent, painful erection - is a possible consequence of penis injecting. This is because an erection is caused by the veins becoming smaller and restricting the flow of blood out of the penis. For the penis to return to its normal size the veins must be able to re-open. If this is not possible because of damage, the erection will not subside.
Some injectors mistakenly think that ‘groin’ injecting refers to injecting in the penis. When talking about groin injecting it is vital to clarify that you are referring to femoral injecting.
Femoral injecting: The femoral artery, vein and nerve lie very close together and their relative position varies from person to person (Figure 3). Due to the close proximity of the femoral vein, artery, and nerve, femoral injecting is discouraged and should be avoided. Gray’s Anatomy (1977:616) describes the femoral vein as follows: ‘The femoral vein accompanies the femoral artery through the upper two thirds of the thigh.’
Femoral (or ‘groin’) injecting is usually begun when access to the veins in the arms becomes difficult or impossible, and is always dangerous. The main dangers are:
* injecting into the femoral artery causing damage; * hitting the femoral nerve and causing intense pain and possible paralysis; * abscess/ulcer formation at the injecting site; * formation of sinuses at the injecting site (sinuses are permanent tracks from the vein to the skin surface caused by infection or persistent use); * fistulae (communicating tunnels) between the femoral artery and vein are also a possible complication of injecting into the femoral vein; * circulatory damage to the leg, including deep vein thrombosis; and * varicose ulcer in the lower part of the leg - caused by damage to the leg veins.
Rozler et al. (1988) noted seeing an increase in the number of complications associated with femoral injecting. As well as many of the above, these also included mycotic aneurysm (fungal infection of the artery wall) and pseudoaneurysm (weakening of the artery wall).
Just how dangerous and damaging femoral injecting will be on any one occasion is affected by:
* the understanding the injector has of their underlying structures; * the dexterity of the injector; * the state of mind of the injector (eg. intoxicated or not); * the substance being injected; and * luck.
Of the dangerous sites, femoral injecting is the most frequently practised. It has to be acknowledged that some individuals with good technique use this site for many years before they experience problems.
Injecting Salt Heroin
Salt heroin refers to a type of heroin which is usually easier to dissolve in water than base heroin. Base heroin needs to be acidified with an acid, such as ascorbic acid (vitamin C), before it can be adequately dissolved in water. Generally, base heroin is more common in Europe and salt heroin in more common in North America. Both types of heroin are usually heated to assist with dissolving them.
From left to right- Using a syringe to measure an amount of water or saltwater to add to the heroin.- Heating the cooker (in this case a bottle cap but could also be a spoon, etc.) to help dissolve the drug and water. This heating does not kill all germs. You would have to boil it for at least ten minutes to kill all germs and at this point all the liquid would be gone...- Taking a single cotton pellet, with minimal contact with your, hopefully washed, fingers and dropping this into the cooker as your filter. A filter is needed because their is usually some stuff that would not dissolve and it will clog the syringe.
- Drawing the liquid up through the filter.
- Tapping the upright syringe to force air to the top then pushing out the air.
- Letting the liquid cool down prior to injection.
Injecting Base Heroin
On the right is adding dry powered ascorbic acid - an additional step need for injecting base heroin. Powdered ascorbic acid is less damaging to use than vinegar (too strong) or lemon juice (can contain a fungus which infects your eyes) or lemon-flavored drinks (which also have other stuff in them). Adding dry ascorbic acid allows you to take some out if you add too much by mistake. Using as little as possible will save your veins damage when injecting it.On the right is drawing up cooked heroin from a spoon used as a cooker through the barrel of a syringe. This is best done using a larger cotton pellet than that used to draw through a needle. One advantage of using the barrel without a needle to draw with is the needle will not be dulled in this process and thus make for a less painful and damaging injection.
NOTE: It is not necessary to mix ascorbic acid when preparing speed. Amphetamines dissolves in water at room temperature.
This image shows a set of pictures about one way to use a tourniquet which allows you to be gentle on your arm (making it flat against your skin) and be able to release the tourniquet very easily with a tug of your mouth after you get a hit. Using a tourniquet or tie well can greatly ease access of your veins and reduce the amount of damage injection causes. In addition to the points about the tourniquet mentioned in image #8, there are some points to tourniquet use which make injection less damaging
If you use a tourniquet (even if you can find a vein well without one) you make your vein fatter and thus easier to hit. The easier to hit your vein is the less damage you will do to your vein and surrounding tissues.
If you tie the tourniquet in a way you can release it with a slight tug of your mouth (so you are less likely to lose your hit) you can inject into a vein under less pressure and thus have less leakage of blood and drug outside of the vein. As well, you will be more able to taste your shot as you are injecting it and be able to stop or proceed based on how it tastes.
Finally, if you are injecting alone and do not release the tourniquet after you get a hit and your shot is really powerful it may prevent you from releasing it after your shot and your tissue might die from lack of blood flow.
To explain the process above: You want to lay the tourniquet flat against your arm and wrap it around the bicep so that it is rather snug but not so tight that your arm turns purple. Once you have at least 1 1/2 loops you can tuck the remainder under the rest against your arm so that you have a small loop above the tie on your bicep and the remainder hanging below the tie. This piece can later be pulled to release the tourniquet pressure and allow normal blood flow to your arm.
While soap and water probably work better, sometimes they are not available so using an alcohol pad or a piece of clean material with alcohol on it can help clean your skin prior to injection. If you tie a tourniquet on and find and wipe several spots you may try to inject into you may be better off than just thinking one spot will do it. Obviously, if the alcohol is dry the shot will sting less.
For minimal tissue damage and more effective drug delivery you should put the syringe, needle hole up, in your skin at a sharp angle like described here. Hole up gives you more control and this angle makes it easier to get the needle point inside the vein.
Hit and Release
This image shows a way to minimize vein damage and limit the ingestion of bad drug. On the left - he gets a register/hit as blood enters the barrel as he pulls back on the plunger. On the right - after the register/hit he pulls slightly with his mouth to release the tourniquet and then injects the drug. With the tourniquet released there is less pressure in the vein and a more immediate feeling of the impact of the drug.If he waited until he injected the drug before releasing the tourniquet he would have no chance to get the drug back if it was too much or nasty and by injecting into a vein with a lot of pressure he would likely loose some drug and bleed more into his tissues which will more likely lead to bruising, slower healing and infections.
Sometimes, though, releasing the tie can cause your vein to shift and your needle to slip out of the vein. Be sure you are still in the vein after releasing your tourniquet otherwise you will get a painful shot. If you find that your veins roll too much and you often lose your vein when releasing it is better to leave the tourniquet on... as long as you aren't injecting a LARGE amount and as long as you push the solution slowly into your vein to avoid rupturing it.
Controlling your Shot
This image shows a process of injection which allows greater control over your shot. A getting a hit he injects a small amount of drug, stops to taste/feel it (first highlighted picture), injects some more, stops to taste/feel it (second highlighted picture), and then injects the rest. This extra measure of safety can prevent overdoses and other harmful experiences while injecting. Use of this procedure is especially useful when you are not sure of your tolerance and/or are using a newer source or different type of drug.
Stopping the Bleeding
On the left is a exaggerated image of what using an alcohol pad after injection does -- it stops the blood from clotting and prolonged bleeding leads to more bruising, more infections, and slower healing. The juice under the alcohol pad in this picture is really catsup but it makes the point doesn't it?On the right is the hard pressure applied to the injection site with a clean material immediately after withdrawing the needle that reduces bruising, excess bleeding and reduces infections and promotes healing. The sooner an injection site heals the quicker you can use it again (after the redness is gone) without making scarring and track marks.
You can take care of your injection sites in several ways. First and foremost remember: an ounce of prevention is worth a pound of cure. This means that you should make sure you have washed your hands and the injection site with warm water and soap. If possible you can wipe the area to be injected with an alcohol pad before injecting to kill more germs - but this is no substitue for washing your hands.
As far as after care for injection sites the verdict is unclear. Some people swear by a variety of tinctures, creams, and ointments and others maintain that it is best to simply wipe the area with a dry cotton ball and keep it clean and dry. It is generally agreed, though, that you should always wait at least 30 minutes after injecting to apply anything. If you choose to use an aftercare treatment some possibly helpful suggestions are antibacterial ointment (neosporin,) vitamin e oil, and witch hazel. It is NOT a good idea to wipe with alcohol afterwards because alcohol stops blood clotting and may cause you to bleed more profusely.
While there isn't much you can do to completely remove signs of injection drug use such as track marks and bruising, you can alleviate the signs somewhat by applying firm pressure with a dry piece of cotton and running warm water over the area. The pressure will help keep the blood from staining the area around the site and the warm water will increase bloodflow to the area which aids healing.
Placing your used syringes, without recapping in some kind of container which will not allow needles to stick through protects everyone. Your needle exchange should take these containers and a mutually agreeable estimate as to the number inside instead of making you count them -- minimal touching of used syringes is in every one's interest. Breaking off the point leaves a needle, the business end of a stick, floating around somewhere very hard to see. It is always easy to find the point on the end of the syringe. If the needle does break off think about putting the point inside the barrel and putting the plunger back in.If you do need to re-cap a syringe, one way to do it, with minimal risk of a stick, is to do it with one hand against a surface such as shown here. Ideally, everyone will recap their own syringe
This guide was adapted from several sources, including:
Chicago Recovery Alliance's Guide to Safe Shooting
Exchange Campaigns for Queensland Health Preventing unnecessary vein damage
n4k33n for original sections and editing