Author: Nigel Brunsdon

Crack Pipe Workshop

This is a workshop on crack cocaine and safer pipe use, and of course includes all the information needed to run a successful harm reduction focused workshop with clients and/or staff. The workshop may also be of interest to people currently smoking crack cocaine as it contains important information on keeping yourself safe.

This pack will help run a Safer Piping workshop for crack users and has been written in a way that even inexperienced workers will be able to pick it up and know enough to get a great discussion going with clients.
The pack includes:

  • Outline of the scope of the workshop
  • List of required equipment
  • Details of how to make 5 items of smoking kit
  • Explanatory photos
  • Associated harm reduction advice
  • Further group discussion topics
  • Advice on running the workshop
  • Information on recycling cocaine residue
  • Legal issues for the workshop (UK)
  • Ready made feedback form

Consensus Statement on Best Practice

A consensus best practice statement has been published by the UK National Needle Exchange Forum, UK Harm Reduction Alliance and Exchange Supplies in response to the increasing numbers of requests for a document to set out the principles by which needle and syringe supply should be organised.

The NNEF submitted it to the NTA in October 2006 as part of their review of harm reduction with a recommendation that they publish it, or something like it in order to ensure that there is no doubt in the minds of commissioners or providers as to what constitutes good (and bad) practice.

Crack Preparation

Well I’m just back from the National Conference on Injecting Drug Use and I can honestly say it was one of the best yet. The high point for me was the last session in which Jon Derricott presented a film on crack cocaine production and its preparation for injection, this film contained plenty of learning points for drugs workers and people who inject alike …

Production Stage

The film covered small scale (on the spoon) production of cocaine into crack using both the ammonia method and the bicarb method. Both of these appeared to require plenty of patience from the user, but the bicarb method seemed far more quick and simple. With ammonia the process seemed to take ages and the residue that would become crack had to be constantly teased from the edges of the spoon. Of course if you’ve ever done this yourself or even researched about it in books or online then this is nothing really new to you, the interesting bit was still to come….

Preparation Stage

There has been a lot of talk on the UKHRA discussion list of the last few months about the right way to cook crack for injection, and whether or not some of the problems from crack blocking pins is due to wax being used by dealers to bulk out rocks.

The crack used for the cooking up was the crack that had been made in the previous part of the film. The first attempt involved the crack being heated in water with no citric, the crack melted and floated on the water but as soon as the heat was stopped this quickly became a solid again (in just 14 seconds) Jon suggested that this could be the source of the idea that wax is used. The interesting part was that no matter how much citric was added after this stage the crack would not become a solution again.

The second attempt was using warm solution that heroin had just been cooked in this of course already contained citric, the crack smeared onto the bottom of the spoon and again wouldn’t easily go into a solution

The last attempt involved cooking the crack using no heat at all and just a small amount of citric, although this did take some time (which Jon admitted could have been shortened by pre-crushing the rock) it did become a clear solution. Once in solution they then added heroin and heated to check if there would be any issues with heating at this stage. No issues, and the solution stayed stable for days.

What this all means

It’s pretty clear from this (and from a previous talk by Ross Coomber) that it’s unlikely that anyone does add wax into the rocks they are selling and that the times people talk about getting crack with wax in then needle exchange workers should be talking with them over their cooking process in detail.

Crack should be cold cooked for injection, although this does take time it is the only real way to ensure a good solution.

If mixing heroin and crack then the crack should be prepared first, this is of course slightly different to previous advice some of us have given about adding the crack in last.

I did talk to Jon after the presentation and the intention is to release this film as a DVD training aid, I for one look forward to seeing the finished product.

Update

About a year after writing this I asked Jon when the film was going to be released, he said due to technical problems there’s now unlikely that this film will be released.

Being Injected By A Partner

A young woman came into the exchange saying she was having a lot of problems with finding a vein, but during the conversation she mentioned that normally her partner injects her. So what are the health issues around letting someone else inject you, and more importantly what are the legal implications both for the injector and for the needle exchange worker.

The first thing of course was to talk her though the injecting process to help increase her confidence in injecting for herself, this included talking about the importance of good tourniquet technique, slow injecting and using the right amount of acidifier.

I talked to her about the increased health risks she faced from allowing her partner to inject her:

  • Increased risk of missing (and abscess) from him not being able to feel when the injection is hurting
  • Risks from when she is injected, e.g. is she injected after him or before him, and what state is he in when he’s injecting her
  • Risks from BBVs if his hands are not washed between shots

I also talked with her at length about the legal issues. If you inject someone and that person dies as a result of the drug then you can be prosecuted for manslaughter, even if all you do is site the needle for them and they take their own shot. It’s of course important when you have this conversation with people to make it clear to them that while it may be the partners choice to take this legal risk, it is also their responsibility for asking them in the first place.

Although I didn’t discuss it at the time it’s also good to consider the social aspects of being injected by another, and the possible control issues from her relying on the partner for her shots (a large number of female injectors are initiated by a partner), and the problems that can happen if for any reason the partner isn’t around.

For further reading on being injected by others I’d recommend the following thesis by Kirsten Mary Gibson “Women who inject drugs: barriers to their access of Needle Exchange services, and gendered experiences” and the presentation given to the 2005 NCIDU “The experiences of women receiving injections from others” by Charlotte Tomkins and Nat Wright.

When’s it best to UYB?

I’m sure that most people who read this site know what UYB means, but for anyone stumbling across it randomly (and yet still reading it, well done you) and are unsure its Up Your Bum.

Although by most needle exchange workers UYB is a recognised tool for harm reduction there is still some confusion and disagreement on when and why to give this advice. Or even if we should give it in the first place. Hopefully this should answer some of the more common questions and give some tips for workers who want to give the advice but haven’t yet felt comfortable doing it.

So whens it best to UYB?

Well personally I’m not that convinced that anybody is ever likely to do this route on a regular basis. Even ignoring the fact that some men feel uncomfortable with putting a syringe up their arse (women are more used to the idea of ‘inserted’ meds in my experience), I don’t see it being as effective with a constipated heroin injector, as meds inserted this route are with anyone else.

But to me there is one situation that really suits this advice, the struggling arm injector. You see, once you have blood in the solution you have about 10 minutes at most before it starts clotting. Once you have a clot you have a couple of options:
Just inject the clot – not a great idea, clots tend to make their way to places you don’t want them. Mainly to the heart, brain or lungs; none of which are good for continued health.

Filter out the clot – to most people its not a great option, if a fresh filter is used then more of the gear is lost plus there is always the chance of the filtering process not being that effective. This option also means that blood has been introduced to the cooker/spoon increasing the risks of hepatitis transfer.

If I get someone struggling with a site that’s when I go the UYB route, I’ll discuss it with the injector as an option and give them a couple of 1ml barrels and lube.

Make the discussion quite light hearted, personally I start by saying “ok I’m going to suggest something that might sound strange if no one has mentioned it before, but bear with me.” You’d expect most people to struggle with the idea, but from experience I can honestly say most people seem fine with this advice.

Just one last note, there has recently been a discussion on UKHRA’s discussion list about possible complications caused by over acidified heroin being used rectally. The consensus seems to be that it may be a problem with long term use or if you have a pre-existing problem in the area, but on the most part it should be OK.

If you don’t already have a copy in your exchange HIT produce a great leaflet that can be purchased from their website.

Swabbing

Whenever I move jobs to a new exchange, or if I’m seeing someone I’ve never worked with before then swabbing is normally the first bit of advice I give. Mainly I do it as a trust builder, if someone’s never met me before then they have no frame of reference on my abilities or knowledge. Plus it seems that anywhere I go, even though this is the most basic of the harm reduction messages I use, that no one seems to have been giving it.

Everyone takes swabs. Heroin, crack, pills, steroids it doesn’t matter what’s being injected. In reality for most people soap and water is a better idea, but there is something wonderfully …. medical… about a swab.

So… when people ask for them I usually ask “When are you swabbing, before or after?”. And you can put money on it that the answer is either “after” or “both”.

Unfortunately the time you should use a swab is BEFORE injecting, ideally about 10 seconds before (to allow the alcohol to evaporate) and with just a single, firm rub on the skin. So why not use it after? Well its because alcohol thins blood, if you put it on an open wound then you will promote rather than stem the bleeding. The more you bleed, the more you bruise. Also the more you bleed the more blood you have to cross contaminate with.

Of course the first thing most people ask then is “well how the hell do I stop the bleeding then?”. If you are lucky enough to have an exchange that gives out any form of stericup there is a small square of absorbent paper, that is for post injection swabbing and not … I repeat …. not, a coaster for putting the used cooker/spoon on to stop soot marks getting on your table.

Why this is important

Obviously it’s important for the health implications. But more than that it’s about building relationships. I could spend ages talking about hepC, or detailing the details of vein structure, but that is all so horribly abstract. Someone you give swabbing advice to is know to know the very next time they inject that you know what you are talking about.

We should be focusing on these basics first, they build trust.

Acidifiers Advice (Part 2)

In the previous article I spoke about the differences between ‘bad’ acids like lemon juice and good commercially available acids. In this short article I’m going to explain the differences between the two main acids available in needle exchanges to people who inject, along with what advice we should be giving people who are using them.

Citric acid

Citric is by far the most commonly used commercial acid, some of this is because some exchanges only stock Citric and some is because to most injectors it’s just what they are used to using. As I’ve already discussed in the previous article , citric is sold in packets containing MORE than is needed for a £10 bag of heroin.

VitC

Citric vs VitCVitC is ascorbic acid, again like Citric it’s sold in packets that have plenty of acid in (both have about enough for 3 bags of heroin) but in the case of VitC the packs have more powder in because it’s weaker.

Weaker is better? Citric vs VitC

It may seem strange but for once weaker IS better. I’ve included a small image that I’d use with injectors, this shows that if you don’t included enough acid then you don’t cook down your gear, then you get a sweet spot where the solution is cooked down but the PH level is quite neutral, and finally you get to the stage where you have too much and the solution becomes an acid itself.

A solution that’s an acid will increase the chances of both vein damage and abscess. Because VitC is weaker the point where you hit the ‘sweet spot’ is far easier to reach without the solution going over into an acid.

For more information on VitC and Citric visit Exchange Supplies.
Read Acidifiers Advice (Part 1)

Acidifiers Advice (Part 1)

Not all acids are created equal, but they do all have risks.

‘Brown’ heroin (ie Afghan heroin sold in Europe) and crack cocaine both require the user to ‘cook down’ their drug with an acidifier if they are going to be injected. But which are the best options and what’s the advice that we should be giving along with them?

Bad Acids

Firstly there are some acids that should always be avoided outright like vinegar and lemon juice. Not only are these non-sterile to start with, but they are also able of growing a fungus that can lead to both blindness and endocarditis. OK, so lemon juice is out. What, historically have people used? I’ve put some of the usual suspects here along with their risk factors:

  • Brewers/Cooking Citric: This is non-sterile, food grade citric.So while the amount of bacteria is fine for ingesting it isn’t anything you’d want to put in your veins. This kind of citric is also made up of large, course grains which increases the chances of adding in too much to your solution.
  • Kettle De-scaler: Another common form of citric, however this isn’t even at a food grade so may contain even more impurities than cooking citric. The grains are also usually very large.
  • Citric/VitC sold in tubs: OK things are getting better, at least we’ve reduced the grain size and have a product that’s sterile. Well…. it’s sterile until its opened. Once opened this is only slightly better than the food grade, and may even cause extra problems by making people think it’s safer than it is. Bacterial from the air, peoples breath, or dirty fingers taking pinches can increase the bacterial load.

Other things

Some people have used a wide range of different acids for cooking up, personally the strangest I’ve heard of was the coating of ‘fizzy cola bottle’ sweets. As Jim Morrison said ‘people are strange’.

Right that covers the bad acids, so what do we want people to use?

Good Acids

Both citric acid and VitC (ascorbic acid) are now legally distributed (in the UK) available in single use sachets from a number of different companies. So great risk free, just give it to them and off they run right?

Nope.

In reality any acid added to an injecting solution is likely to cause vein damage.

Most of the sachets available contain more powder than is needed for a standard £10 bag. While this may seem a strange thing to do there is a good reason for it. the general idea is that you’re giving people enough acid to cook down the gear for a single shot, even if the person injecting is having more than one bag at a time. So, we have to make sure that people who inject know to only use as little as they can to ‘cook down’ their shot, and then THROW THE REST AWAY, after all its no longer sterile.

Using too much acid will increase the risk of vein damage as well as possibly damaging some of the drug being taken. Now I don’t know about you, but I have long conversations with people insisting that they even need a couple of sachets for just a single £10 bag. One company (Exchange Supplies) have done something to help, if you order your citric or VitC via them they will supply you with free DVD’s or videos that explain the science behind acidifiers, including the effect the acid had on the quantity of the drug. The best bit is they will give you enough of these DVDs for each needle exchange visitor to have one each for free. In our exchange these have not only proved very popular, but they have also helped change the injecting habits of a number of our visitors.

Acidifiers Advice (Part 2): differences between citric and VitC and go into more detail on the risks of using too much acid.

Someone using steroids for the first time

When I get someone new in the exchange, I wonder how much the person in front of me has actually found out about their drug of choice before they put it in their body. Especially when they are getting equipment to inject a drug for the first time like today’s newest visitor who was planning to use steroids.

This guy was a 19 year old who has recently started using cocaine (both snorted and injected) and is intending to start his first course of steroids. While the guys knowledge of cocaine appeared to be quite basic, his knowledge of steroids was, as you’ll see, very poor.

First we covered some issues about his cocaine use, he at first has said he both injected and snorted coke, personally I go the impression he wasn’t being very truthful about the injecting from our conversation. We did discuss risks around the snorting and sharing of equipment, he showed that he was already aware of the risks of contracting a blood borne virus from shared notes.

I discussed overdose with him, while he was aware that there was an overdose risk from cocaine, his knowledge of the possible symptoms appeared to be confused with those of heroin overdose. So I explained to him what he should look out for in himself or others around him using cocaine or amphetamine.

Onto the steroids. He seemed unsure on which steroids he was going to be using, in the end we worked out it was Decca and Sustanon which in our area (and most others I’ve worked in) is a common mix. I asked him where he was intending to inject and he nervously answered his arm. Now for anyone who doesn’t already know this, steroids are not injected IV but into the muscle, this is important because this was the steroid is released slowly into the system. I advised him that if he is determined to use steroids he should be injecting himself ideally into the upper outer quadrant of his glute, this way he would be putting the steroid into deep muscle and avoiding the sciatic nerve. I went though the muscle injecting process with him in detail. Putting the steroid into deep muscle makes the delivery nice and slow, while the shallow muscle of the arm would have resulted in his steroid being taken up too fast.

When I asked him how long his course was going to be, 5 weeks, with a break between courses of 1 week (again looking nervous and unsure as he answered). I advised him that ideally he should be doubling his on cycle to get the length of his off cycle (at a minimum I want him to have a 5 week break).

By this point I wasn’t really happy that this guy knew what he was getting into by starting to use steroids, it was clear he had done no research past the point of asking someone to get him his supply. So I asked him if he knew the possible side effects, he as expected didn’t. So I informed him of all the usual stuff to do with his heart and the stuff around having extra testosterone in his system (he was aware of the risks of aggression). I then pointed out to him that as he was only 19 years old he wouldn’t yet have stopped growing, but if he uses steroid there is a good chance that the height he is now will be as tall as he gets. But even after all the risk factors had been covered he was still saying he was sure he wanted to use the steroids.

He wasn’t sure what equipment he wanted when he was asked (at this stage I really didn’t expect him to be) so I went though the standard injecting equipment with him.

  • Green needles: for drawing up the steroid only, not for injecting.
  • Short blue needles: this guy only had light muscle mass so short blues would do the trick.
  • 2ml barrels: its not rocket science this stuff, a needle is no good without a barrel.
  • Swabs: to clean the injection site.
  • Sharps bin: to return his used works in.

When I gave him the swabs I told him that they should only be used pre-injection, and not after. I also told him that whoever is advising him on how to inject may try to contradict this information. The need to not post swab is because the swabs are alcohol based, using them after injecting will only encourage bleeding and therefore cause bruising.

As he left I encouraged him to do some research before he actually uses his steroids, recommending some websites he could try.

Conclusion

It’s clear this guy had no idea what he was doing when he attended, but though the conversation it was also clear that he was going to use steroids no matter what advice he was given. In situations like this it’s important for workers to concentrate on the basics to reduce any levels of harm that the injector is facing. If you cover the basics well people will follow future advice you give them with more confidence. In this case at a couple of points I did mention that his friends (or at least fellow injectors) may contradict some of the advice, but the reasons for the advice was given in detail so he could peer educate them himself.

WHO: Guide to Starting and Managing a Needle Exchange Programme

This guide is designed to assist in expanding the response to HIV among injecting drug users globally. The transmission of HIV among injecting drug users and related populations of sex workers, youth and other vulnerable people is greatly adding to the burden of disease in countries worldwide. Evidence from 20 years of research shows that needle and syringe programmes (NSPs) prevent, control and ultimately reduce prevalence of HIV and other blood-borne infections among injecting drug users.

To do this, many more NSPs will need to be established. Many existing NSPs also need to expand the services that they offer and greatly increase their coverage. How to do this is the topic of sections III and IV. The scaling up of programmes must also include the establishment of many more NSPs in prisons and detention centres. The particular needs of NSPs in such “closed settings” are also covered.


Images and content © Nigel Brunsdon unless stated otherwise, all rights reserved.

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