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Author: Nigel Brunsdon

Competing Priorities

Working in a needle programme can be psychologically a difficult job for some people, but attending an exchange is also a difficult situation for our clients, we have to try and understand the competing priorities both groups face.

In a perfect world the advice that workers give would be instantly taken to heart by injectors and passed onto their peers. In fact this is what’s normally expected by some of the staff I’ve trained in the past. After all, if you are telling someone that their actions are likely to cause a DVT why wouldn’t they change?

I’ve often heard staff complaining that some of their (if not all) needle exchange visitors are being ‘resistant’ to change, or that they are ‘not bothered’ about the risks. Of course that’s not really what’s happening, the fear of DVT gets included with every other issue the person is dealing with.

Competing priorities

We have to remember that health is only one of a number of priorities on the minds of injectors. In much the same way that it is for the rest of us (if you doubt this then stop eating any high fat or processed food… it’s bad for you). There are of course hundreds of these priorities but here are a few:

  • Cost of drugs: It’s all well and good for us to say “never share any equipment”, but if the only way that client can get a deal is to split it with a mate then they will
  • Speed: Imagine you are a homeless street injector and you have managed to find somewhere sheltered enough to cook up; you can’t afford the time to struggle to get a vein. But going in the groin can be a fast solution – yeah it’s risky, and the chances are your hands aren’t as clean as they should be, but there’s an urgency caused by the fear of discovery
  • Peer influence: This to me is one of the hardest to work with. Whilst running one workshop on ‘Safer Crack Piping’ I had one young guy turn and say:

    it’s easy for you to say that we should put clean stems on our pipe. But if a Yardie hands me a crack pipe I’m not going to turn it down, I’d get battered

    It can be difficult, especially for someone who may be young or lacking in self confidence to go against this kind of pressure.

  • Relationships: Most of us have at some time relented to a partner and done something we normally wouldn’t do, maybe even something dangerous. If a partner was withdrawing and the only way you could help was with a used set of equipment then the chances are that you are going to give them a shot, even though it may be against your best judgement.

Staff priorities

Of course clients are not the only people with competing priorities. Staff in drug services have them as well, and their priorities can have serious impact on both the kind of advice they give and its quality:

  • Large workloads: Not every service has the capacity to have full time needle workers and a lot of programmes are staffed by whoever is available at the time. This can of course result in longer waits to be seen and rushed sessions where the worker is eager to get back to filling in their casenotes/tops forms/database/cristo scores etc.
  • Service targets: This one is more obvious towards the end of the year (January to April). This is the point that a service realises that it’s going to come up short on something – maybe referrals into treatment or it could be vaccinations. Staff are then put under pressure to focus on these issues at the expense of others.
    Finances: The needle programme in most cases is the poor relative of drug services. Some of this is because in the past all a Drug Action Team had to do was evidence it had enough exchanges, not make sure they are fully equipped. Because of this there’s a postcode lottery when it comes to equipment available.
  • Attitudes: It’s got to be said that some staff have a problem with the concept of NSPs. This can mean that they may resent being in the exchange or that they may do things like limit equipment. This can also mean some staff have unrealistic goals for clients that they try to impose, e.g. thinking that every client in needle exchange should be eager to stop their drug use. While a great concept, trying to impose this view on unwilling clients will only antagonise them and make them avoid the service. This of course also happens with some services trying to impose the goals onto staff.

There are of course far more priorities for both clients and staff teams than this but I think you may be getting the idea.

Conclusion

We have to realise is that these priorities exist both for injectors and staff and that they will affect the way we work and the way advice is used. Be realistic when you give advice and ask questions, and don’t be judgemental of the replies you get (that last point is for both workers AND injectors). Remember, injectors have as full a life as anyone else, and that your own competing priorities might be affecting the way you work.

Really Bad Injecting

I’m quite a liberal NSP worker at heart; I’m happy to work with people to support them to get to where they want to be, how they want and at their own pace. That of course doesn’t mean I don’t do my best to get people thinking about reducing or stopping, but if they are going to inject I’ll work with them to do it as safely as possible. But today was one of those very rare times that I say to someone, “Look mate, just stop injecting”.

It’s only the second time I’ve been in a situation where I’m so at a loss with someone that the only way out is to say “stop” (and I’ve been doing this work for a fair few years now). The following article explains why I needed to say it and how we planned to make it happen.

One of my colleagues rang me to ask if I’d have a word with someone about their injecting sites, so I picked up an injecting guide and joined them in the one to one session.

After the initial introductions the guy pulled up his sleeves to show what can only be described as a battle ground of scabs, abscesses, open wounds, swelling and scars. I promise that I’m not exaggerating when I say that not a part of his arm from elbow to wrist wasn’t affected. He had at least two abscesses badly infected and in need of antibiotic treatment.

What was he doing wrong?

He said he was injecting about a bag of heroin a day on top of a small methadone script, plus the occasional shot of amphetamine when he was feeling low. I asked him how much of his injections were ‘skin popping’ (injecting just under the skin and not into a vein) and how many were just missed hits. He said he skin pops the amphetamine and often missed with the heroin. But during the conversation we found out that:

  • He chews his filters before using them (the mouth is full of nasty bacteria)
  • He licks his needle before injecting (like I said, really nasty bacteria)
  • He compulsively picks the scabs and wounds on his arm with hands that are in no way clean
  • Uses tubs of acidifier that are large course grain rather than smaller sterile packets
  • Rarely washes his hands or sites (he is sleeping rough so has limited access to facilities)
  • Uses a tourniquet but ties it far too tightly
  • Plus may other smaller issues of concern

Basically he was doing everything you shouldn’t do. Add to this the fact that his arms had no simple access points left and his legs had cellulitis. The only real thing he had going for him was his total reluctance to groin inject, which considering his poor technique would have been a disaster anyway.

I’d normally have no issues working with someone who had a few of these issues, but this guy had almost every bad practice. So I said it: “Stop injecting mate, you’re crap at it”.

Putting in a plan

Now, of course it’s rarely that simple, but luckily this guy had an appointment that day with the nurse prescriber so his keyworker agreed to liaise with her to get his medication increased and to get his wound looked at by one of the doctors with a view to some antibiotic treatment. I gave him advice on a move to smoking for any remaining need before his appointment and agreed to see him along with his keyworker at his next appointment to check how it’s going.

Conclusion

Sometimes the right advice to give is to just stop. Get a good relationship with local prescribers, there are times when the only harm reduction option left is script based. If you get on well with the prescriber then you’re in a better position to work as an advocate.

Painless Injections

Ways of making injections as painless as possible may seem to be a strange thing for a needle exchange worker to be trying to find. After all if an injection is painful then the person is less likely to inject, right…. no, just think of the number of injectors that come into needle exchanges who are afraid to get their vaccinations because it means being injected.

Why make it painless

As I’ve already mentioned, I come across large numbers of people who inject inject that are afraid to get vaccinations or blood tests because they are afraid of injections, yes they inject themselves 4 times a day, but that’s when heroin (insert other drug of choice if required) is involved. Never dismiss the call of the poppy. So being able to reduce injecting pain is an important skill for nurses delivering vaccination and testing services.

Another one though is people who are injected by others. In some cases this may just be the fear of it hurting more when they self inject. So helping then reduce this fear is an important part of teaching them to do it themselves (this reduces risk of injury, abscess, and long prison stays for the person who normally injects them).

Finally I’ve met some very big, burly, steroid injectors who won’t inject in the thigh because it hurts too much (thigh injecting is slightly more painful than glute injecting).

How to make it painless

Method 1: Pinching the skin before injecting. This can reduce any pain to just a very slight sting. The same effect can be gained by pressing for a short time on the are to be injected. This is caused by ‘pressure anaesthesia’, and is commonly used by dentists before they give you a local.

Method 2: Coughing. German researchers have discovered that coughing during an injection can lessen the pain of the needle. According to Taras Usichenko, author of a study on the phenomenon, the trick causes a sudden, temporary rise in pressure in the chest and spinal canal, inhibiting the pain conducting structures of the spinal cord.

Article References

Method 1, Jim Rose: Snake Oil . A great book on how to perform cons and sideshow magic.
Method 2, Mechanisms of “Cough-Trick” for Pain Relief during Venipuncture: An Experimental Crossover Investigation in Healthy Volunteers

An Unusual Exchange

Occasionally someone will come though an exchange with injecting issues that don’t fit into any ‘standard’ drug training. The person I saw last week had issues that challenged my background in drug services, mental health services and expectations.

Some people may have issues with both the advice given and the fact that the person left the exchange with equipment in their hand, if so please feel free to leave a comment on how you would have handled the situation.

The guy was in his early 50s and not known to the service previously, we have a short needle exchange assessment which I went though with him. This covers confidentiality issues, if the person has a GP or not (but not the details of the GP), some stuff on pin storage and returns. All the way though this the guy was in a good mood but also wrote everything he or I said on a bit of paper he had with him, and when I say everything, I mean everything.

When we got to the stage where I was asking him about what he would be injecting he told me “that’s my business and I’d rather not tell you”, I explained to him that this was fine but would of course limit the advice I could offer him. We continued and he asked for one 2ml barrel, 2 long blue needles and 2 orange needles, he already had a 2ml barrel which I asked if he wanted to dispose of as used equipment is an obvious risk. He said it had only ever been used for filling a printer with and he wanted to keep it for this.

Now of course we don’t give pins out for filling printers and I let him know this. At that he decided he would tell me what he did want the equipment for. He started talking about the Hemlock Society and Exit and asking if I was aware of them, which I am. Both are information and advocacy services for people wanting to end their lives. He said that he wanted the equipment ‘in case’ he wanted to kill himself at some time in the future.

We talked about this at length including him telling me how he would do it and what he would use. It is important at this stage to note, he was NOT talking about killing himself in the near future, but was saying that if he became ill in the future and it seriously effected his life he would want to be prepared.

We talked about his mental health and I asked had he ever been diagnosed with Bipolar Disorder (manic depression) or with Obsessive Compulsive Disorder as his note talking and need to prepare so far in advance seemed to indicate this, he stated that he had only ever been diagnosed with mild depression and wasn’t currently seeing mental health services.

The whole session was relaxed and he was talkative and open (after he had talked about what he intended).

After the session I had a long phone conversation with my manager to go over the issues raised, She agreed that although the guy was talking about ending his life the fact that he was talking about some possible time in the future and only in a limited range of situations there was no duty to break confidentiality, and that given the situation at the time it was better to give him the small amount of equipment he requested rather than refuse him on the grounds that we are only commissioned to give equipment to substance users.

I think in these situations the important thing is to always check in with your manager if you get something really out of the ordinary, yes it’s after the fact, but as long as you have a robust confidentiality agreement that the person is aware of this shouldn’t be a problem.

Like I said at the start of the article, I’m sure that some people may not agree with what I did, but consider having a conversation with your colleagues about what you would all do in similar situations.

The image above is The Death of Socrates a painting by Jacques-Louis David from 1787. Socrates had been sentenced to die by drinking the poison hemlock, he uses his death as a final lesson for his pupils rather than fleeing when the opportunity arises, and faces it calmly.

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 force through the clot – not a great idea, clots tend to make their way to places you don’t want them.

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.

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.