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.
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 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 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.
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?
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.
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?
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?
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.
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.
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.
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.