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Author: Nigel Brunsdon

Dr Gabor Maté Interview

Nearly ten years ago, North America’s first safe-injection site opened in Vancouver, B.C., providing sterile needles and other harm-reducing amenities for struggling addicts. A driving force behind this facility for two years was Hungarian-born author and physician, Dr. Gabor Maté. In his bestselling book, In the Realm of Hungry Ghosts, Dr. Maté shares his experiences working with the down-and-out of Vancouver’s East Side. The All Treatment blog spoke with this renowned physician about addiction stigmas, America’s war on drugs, and what it means to be a “hungry ghost.” (‘All Treatment’ have kindly allowed the interview to be reposted here).

All Treatment: Dr. Maté, thank you for making the time to do this interview. Tell us a bit about yourself and your book, In the Realm of Hungry Ghosts.

Dr. Gabor Maté: I’m a medical doctor and author. After twenty years in family practice and palliative care, for twelve years I worked in the Downtown East Side of Vancouver, notorious as Canada’s poorest postal code and North America’s most concentrated area of drug use. Within a few square blocks’ radius, there are thousands of human beings dependent on injecting, ingesting or inhaling a multiplicity of substances such as heroin and other opiates, crystal meth, cocaine, and alcohol, not to mention cannabis and nicotine. For two of those years I was the physician at a detox facility associated with Insite, North America’s only legalized supervised injection site. In The Realm of Hungry Ghosts is my depiction of the people who inhabit that world, an inquiry into what drove them to their life-threatening habits, an examination of the biology and psychology of addictions in general—including my own addictive behaviors—and, finally, a look at the irrationality of the War on Drugs, so-called, and an exploration of saner ways of responding to the human tragedy of addiction, including substance dependence.

AT: What surprising or significant information about addiction did you learn through working in North America’s largest drug hub?

GM: I don’t know that I learned anything absolutely new, but what was driven home to me daily was the humanity of the people I served—humanity in the sense that their needs for peace, harmony, validation, relief from suffering, agency and dignity in their lives were shared characteristics with all human beings. Their dysfunctional attempts to meet those needs through substances were also representative of the common human urge to fill from the outside the yawning emptiness within.

AT: What is this phenomenon of the “hungry ghost”? Do you think that these individuals are misrepresented in society?

GM: The “hungry ghost,” a Buddhist phrase, is the precise part of ourselves that experiences unbearable emptiness and spends its whole life attempting to satiate that emptiness by seeking something, anything, from the outside. Of course, the task is impossible so the ghost remains hungry forever. That’s addiction, whether to drugs, power, wealth, food, looks, status, relationships, sports, video games—in short, to anything. Since our society breeds such ghosts in all of us and since it’s a part of ourselves we loathe and fear, we ostracize the person who most nakedly represents our own ghost selves: the drug addict. We look in his eyes and see our own emptiness; we don’t like it, so we reject him.

AT: What are some of the major mistakes you see addicts making in recovery that keep them from coming (and staying) clean?

GM: Addictions are always about attempts, mostly futile, to soothe pain. In the case of hardcore drug addicts, that pain almost invariably originates in childhood trauma, emotional loss, neglect or abuse. Hence, the addiction is not the primary problem—it is an attempt to solve the problem of pain. Of course, it creates more pain. But trying to give up the “solution” without addressing the underlying problem of the emotional suffering that potentiated the addiction is often doomed, because we are not dealing with the source.

AT: What are your views on the social and biological causes of drug addiction?

Gabor's BookGM: Addiction is, of course, biological in that it involves brain circuits, hormones and neurochemicals. The question is, what causes the biology? It is not genetics. Genetics can predispose but not predetermine; so genes might be implicated, but they cannot cause addiction by themselves, as they are turned on and off by the environment. It’s the child rearing environment we need to look at, especially during the key first years of brain development. We now know that it’s experience, not genetics, that shapes the fine circuitry of the brain. More broadly speaking, we need to look at the entire culture and economic context in which we live, because they exert such a great influence on the family environment in which the child’s brain develops. The more stressed the social environment, the more addiction we are likely to see. A prototypical example is provided by the aboriginal populations of North America in the wake of brutal colonization.

AT: In your book, you express your support for the decriminalization of all drugs. Do you see this as a possibility in the near future? How do you envision drug addicts operating under this new freedom?

GM: I don’t see any possibility of decriminalization in the near future, despite the overwhelming evidence in favor of it and many respectable international voices calling for its adoption, including current and former world leaders. However, the system represented by the so-called War on Drugs (in reality, a war on drug addicts) is far too entrenched economically and politically to yield to sanity. As to what it would mean, this has been demonstrated in, say, Portugal, where people are no longer jailed for the possession of drugs for personal use. That’s not exactly decriminalization, but it’s certainly a step in the right direction. In a decriminalized system, confirmed addicts would receive their drugs under controlled conditions, as in the heroin clinics that have been successfully established in a number of countries. The results are uniformly positive.

AT: Why is harm reduction important?

GM: Harm reduction is important because it reduces the harm. For example, injecting with a clean needle eliminates the risk of HIV transmission. It is difficult to see what is controversial about that. But, equally important, harm reduction also gives the message to a highly traumatized population that they are accepted for who they are, without having to meet someone else’s unrealistic expectations for how they should be. That begins to remove the burden of trauma from their shoulders. For many, that’s a necessary first step.

AT: Some of your work, including your studies on the addiction treating benefits of the Amazonian hallucinogenic, ayahuasca, has been deemed too progressive by government agencies. Tell us a bit about these studies. How have you dealt with the backlash, and what are your hopes for the future of addiction research?

GM: Ayahuasca, a traditional healing plant from the Amazon, is no panacea for addiction or anything else. But the powerful visions it can induce, if experienced in a safe context in the right ceremonial guidance, can open people up emotionally and spiritually to deeper realities than their ordinary minds can usually experience. And that, in turn, can be a powerful impetus to healing. I’ve seen it work—but, again, in the right context. The latter is as important as, or more important than, the plant itself. In regards to backlash, Health Canada—our regulatory agency—has informed me that the plant is illegal for healing purposes, although they have conceded that it’s neither addictive nor harmful and have approved it for religious use.

AT: As a physician who works with severely addicted patients—people who, as you state in your book, “value their health and well-being less than the immediate, drug-driven needs of the moment” (p. 13)—you show incredible empathy for all who come to you. If society were to recognize addiction in the same way you do, how would addiction treatment change?

GM: How would society change if we acknowledged that mistreated children may (and often do) become dysfunctional adults? If we recognized that people do not choose to be mentally ill or to be addicted? If we offered compassion instead of contempt to those amongst us who have been most traumatized? If we put the resources now wasted in an oppressive legal system and a narrowly-conceived medical system into real rehabilitation? I will leave your readers to ponder those questions for themselves, as, I believe, we all should.

Legal Highs, Injecting is No Surprise

Years ago when I started doing harm reduction work it was a very different drug landscape, heroin was the main drug used by people coming into services (after alcohol of course) Most injectors I saw used heroin, and possibly the occasional ‘treat’ of a rock of crack. Of course there where also people injecting steroids and the occasional amphetamine injector but these where far less common. Now though we have the rise of the legal high.

These drugs have been around for quite a while already (as any reader of Pihkal will tell you), they’ve been there on the verges used by experimental users that are unlikely ever to engage with a drug service for support/treatment. But over the last few years they’ve gone mainstream, we have mass production of drugs like mephedrone, wide media coverage (great advertising for the dealers) and of course the resulting knee jerk law making from government.

Injecting

The rise in popularity also coincided with our latest heroin drought which may help to explain how fast some groups have taken to injecting these drugs. I was surprised to see the injecting of mephedrone in some areas come as a shock to some of my colleagues in drug services. For me it was obvious that when you have a number of people who have been using their choice of drugs by a particular route that they would then try a new drug in the same manner.

It’s also no real surprise that injecting a new type of drug can be a very risky affair leading to increased abscesses and other related injuries, people get used to injecting a drug using their own ritual, often when a new drug comes up they’ll use exactly the same method of preparation (look at how many people still use heat when preparing crack for injection even though ‘cold cooking’ it is more effective). But every new drug will have its own unique ‘personality’ some might need heat, some might need an acid, some will even get thick and viscous if heated.

Treat the effect

But the main-streaming of these drugs has a knock on effect on drug services and workers, many are struggling to keep up to date with the new drugs and come up with specific targeted messages for each one, personally I think this is an impossible task. Since 1997 there have been over 150 new ‘legal highs’ identified, 50 of these in the last year. This gets further complicated when you consider that people give random names to the drugs, and that these names are often interchangeable across drug types. For instance the name ‘Bubble’ is used for almost any legal high.

In the recent HIT Hot Topics seminar on legal highs Dr. Harry Sumnall suggested that a better way would be for people to work with the ‘range of symptoms’ a drug delivers. To me this makes prefect sense. At the stage someone is looking for help and support all the worker really needs to know is how the drug is effecting someone, is it a stimulant causing sleep deprivation, a hallucinogen causing them to question reality, or a depressant that’s worrying their family because of overdose risks (or a combination of any of these). The worker needs to know is someone’s use binging or daily and the route they use to administer. The knowledge that a drug effects a particular neuroreceptor or that it’s related to an obscure family of plant stimulants is ‘interesting’ but not essential for working with someone who needs support. This further research can be left up to the scientists to write dense wordy papers about, or the forum members on places like Drugs-Forum to discuss (their advanced knowledge of chemistry is something I’m often in awe of).

Conclusion

We need to remember that the key to harm reduction is to work with the presenting issue of the person in front of you. Whether this is problems with injecting resulting from using a novel compound, or helping someone deal with the fallout from the effects a drug has had to their social life. These drugs are not going to conveniently disappear, and more will be appearing every month, what we have to do is adapt to respond to their effects without getting bogged down in the tiny details of chemistry.

Human Enhancement Drugs: The Emerging Challenges to Public Health

Drug use is usually portrayed as a hedonistic pursuit of pleasure, whether being the use of thought-expanding hallucinogens, the excitement of stimulants or the euphoria of opiates. However, there are many drugs that are being primarily used for their functional purposes rather than for any instant gratification. These substances, termed ‘Human Enhancement Drugs”, represent a new challenge to public health and reflect a society that in recent years has shifted from an attitude of “a pill for every ill” to a drive for “better than well”. While this evolution of medicine is a topic which has readily been discussed by ethicists and philosophers (and has been the fertile ground for novelists and film makers) it has been largely ignored by drug professionals and public health in general. The drugs that are (at least in part) an exception to this are the drugs used to enhance the structure and function of skeletal muscle. By far the best known of these are the anabolic steroids (and to lesser extent, growth hormone). These are well known to many drug professionals as they are now the main drugs of use amongst clients of many needle and syringe programmes across the United Kingdom. They are also well known to the legislators, having been brought under the Misuse of Drugs Act in 1996 and subject to several amendments, most recently on the 23rd April 2012.

Anabolic steroid users will usually take a variety of other drugs, some for their anabolic properties and others to prevent or minimise side effects. In recent years, an array of new drugs which are taken to stimulate the secretion of growth hormone (including CJC-1295, GHRP-6 and GHRP-2) have been added to the menu. It is difficult to predict the impact of further drug developments such as the selective androgen receptor modulators (SARMs).

The anabolic steroids (and associated drugs) are just one group amongst a diverse range of substances that will sculpt the body, focus the mind or hold back the ravages of time. For the purposes of evidence review we have separated the human enhancement drugs into six categories of function.

  • Structure and function of muscle, such as anabolic steroids to get a ‘six pack’ or ‘bulk up’, or growth hormone to ‘get toned and trim’
  • Weight loss, such as rimonabant or sibutramine to suppress the appetite, or DNP to ‘burn fat’
  • Cosmetic appearance of the skin and hair, such as mercury–containing creams for ‘healthy, lighter, more radiant skin’, or Melanotan II for that ‘holiday tan’
  • Sexual behaviour and function, such as sildenafil to ‘get a better, stronger erection’ and bremelanotide to ‘get in the mood’
  • Cognitive function, such as methylphenidate and modafinil to ‘help study’
  • Mood and social behaviours, such as paroxetine to be ‘better than well’.

While these drugs have diverse pharmacological effects, they have several things in common with each other and with the wider grouping of illicit drugs:

  1. They are easily obtained
  2. There is no guarantee as to the quality or safety of the product when purchased on the illicit market

Thanks to technological advances and improved communications these products can be delivered overnight at the mere click of a mouse. This ease of access, without recourse to the traditional illicit drugs market, makes the purchase and use of these much more attractive and accessible to sections of the population. Obviously there are overlaps between groups of drugs, with many being used for different or multiple reasons. Public health has a considerable challenge in responding to an advertising strategy that promotes a drug that can cause weight loss, provide a sun tan and enhance sexual performance. Clearly, a ‘just say no’ approach will have limited impact in deterring many from being attracted to this particular drug.

It is important that drug workers remain aware of new and emerging substances, including the use of enhancement drugs. It is difficult to assess which of the substances will result in individuals presenting to drugs services or health services in general, whether that be at primary care services, accident and emergency, or any other health setting. In 2007/8, needle and syringe programmes first started reporting melanotan use amongst its clients. There was little information about the drug, its risks or relevant advice that could be provided to users of this drug. Despite the relatively recent identification of human enhancement drugs as a public health issue, the toll of health harms is growing and the potential for the future detrimental impact on health becoming clearer. ‘Human enhancement drugs: the emerging challenges to public health’ provides the first systematic and comprehensive exploration of this issue.

Discourage the Use of 2ml barrels

I’m sure its a common experience of needle programme workers around the UK (even around the world), people asking for 2ml barrels when they are planning to groin inject. But a 2ml isn’t the best equipment for this and it’s a behaviour that we as workers or peer educators need to challenge.

Why do people ask for 2ml

In the geographical area I worked in the main reason was one of historical availability, and I think this is the case in many areas. Often it’s because pharmacy exchanges, and even some main site needle & syringe programmes (NSPs) didn’t stock 1ml barrels as standard. The county I worked in used to use a ready made series of ‘exchange packs’ in both the NSPs and the pharmacies, the only pack available with needles long enough for groin injectors was the “2ml steroid” pack.

So with this historic availability it’s not really a surprise that a culture develops where a 2ml barrel is seen as the kit of choice for the groin. As a result I now often find people who say it just doesn’t ‘feel right’ injecting the groin with any other size of barrel.

There is of course another reason people ask for a 2ml, and that’s because no one talks to them about the alternatives.

Why a 1ml is better

It’s a simple matter of volume. A 1ml barrel can contain a volume of just over 1ml of fluid (the clue is in the name) but a 2ml barrel contains over 2.5ml of fluid. This isn’t in itself an issue for injecting into the groin, after all the femoral vein is relatively large and can cope well. But many injectors continue to ‘flush’ after the injecting process is over. Flushing is the repeated drawing back of blood into the barrel and back into the vein, in the perception that this will help deliver more of the drug. (I’ve written about flushing before).

When using a 2ml though this flushing involves far greater volumes of blood, and as a result increases the risk of damage this this major vein.

So the next time someone comes into the NSP you work in, or your friend who goes in the groin asks you get get them kit, encourage them to go for a 1ml barrel not the 2ml.

Low dead space

Any separate needle/barrel combination introduces the risks of ‘high dead space’ from a blood borne virus (BBV) aspect this is a risk (previous article on this). It’s this ‘dead space’ that gives people injecting the perception that they are losing some drug if they don’t flush (although in reality this is a minimal amount, especially in a 1ml barrel). Now though Exchange Supplies have started stocking low dead space 1ml barrels, the main reason is of course to minimise BBV risks, but the added benefit of delivering a greater amount of the drug is a major point for us to target injectors with. These new barrels also come in the now iconic multiple colours to help discourage accidental sharing.

PIED Outcomes Tool

Back in June I released the NSP Outcomes Tool This was an attempt to make a simple to use but flexible assessment/review tool that could be used in the relatively short time that most needle transactions happen in. Because of the need to make it so simple it unfortunately didn’t include anything around the use of steroids and other performance/image enhancing drugs (PIEDs). So now I’ve designed a NSP tool specifically for use with PIED users.

PIED tool

PIED/Steroid use has been on the rise in the UK for a few years now. Each year at the annual meetings of the National Needle Exchange Forum we get reports from around the UK and in some cases PIED use accounts for more than 50% of NSP visits. This is why back in 2010 I released the first ‘Steroid assessment’ which provides a very detailed look at someones use, but can take quite a while to use fully.

This new tool is has been written with the same formatting as the NSP tool to be easy and intuitive to use, but still be robust enough to enable workers to have in-depth conversations and keep track of outcomes and work done with people who use performance and image enhancing drugs.

The tool itself is a single page based on a mind-map. This includes areas of discussion around the main topics for working with people who use (steroids, injecting injury, BBV etc) as well as other topics that are often discussed in NSP but that workers rarely ever document (education, housing, employment). Recording of these discussions and related outcomes are increasingly important when it comes to talking to commissioners and maintaining funding.

Like the NSP tool this records both the risk factors and the protective factors, resulting in a ‘score’ that can be tracked.

Supporting notes

As with all downloads on the site this has extensive worker notes that explain the whole process. I’ve also included a detailed example of how to ‘score’ the sheet and a tracking tool to monitor each individuals scores. Within the notes are some tips on the kinds of advice to give, although I would encourage any service seeing a significant number of PIED users to make sure that their staff have sufficient training to work with this group.

If you decide to use this tool, or the other companion outcomes form then I’d really love to know what you think of it.

I’d like to thank Bournmouth DAAT who kindly sponsored the creation of this tool

Back Yard

The time is right to look at new ways of reducing mortality among people who use illicit drugs. Across the UK, we are seeing record levels of drug-related deaths. These deaths often occur among people who use heroin, as well as alcohol and tobacco. The appearance of synthetic opioids like fentanyl and carfentanil in the UK drug markets threatens to cause even more harm. Many of the most vulnerable people are not well served by existing models of treatment. So we need new ways of engaging these people in services that can save their lives. The need for drug consumption rooms is urgent.

DCRs are now a viable policy option and serious consideration should be given to their introduction.

The Bad, The Sad, & The Redeemed

All too often the media representation of drug users is two dimensional at best. The stereotypical representation of drug users in the media can be enormously damaging not only to drug users themselves but also to their family members and has implications for both drug treatment and harm reduction efforts. This article examines three classical stereotypes of drug users utilised by the media and discusses the issues incumbent in them.

The Bad

It’s not difficult to find representations of drug users as ‘bad’. The offending media is very easy to spot, just look for the word ‘junkie’ and yell ‘Bingo’. The incitement of moral panic by perpetuating the myth that drug users are bad people leading morally reprehensible lives is ingrained in our social consciousness. Sure some people who use heroin do bad things. So do some people who drive cars or who use computers. So why then do we make the connection between drug use and ‘bad’ behaviour?

The reality is that many of the perceptions regarding the morality of drug use have been shaped by a range of historical and social factors that had little if nothing to do with drugs and drug use.

The excellent resource ‘Why wouldn’t I discriminate against all of them?’ , examines the historical determinants that have supported the stigmatisation of drug users and found that the historical, political, social and economic changes that occurred over the last 200 years have informed the current discourse on drug use and drug users that has resulted in drug users being stigmatised.

The media plays a twofold part in this drama: firstly as a reflection of the common attitudes to drug use that have been shaped by the last 200 hundred years of history, and secondly as perpetrators of the myths and stereotypers that portray dug users as bad people, continuing the cycle of stigmatisation.

The link between the portrayal of drug users as bad people and the resulting damage incurred is not difficult to draw. Drug users, regardless of the context of their individual drug use, have all too often faced discrimination in the realms of the law, employment, health treatment and socially, premised upon the idea that drug users are people who are not to be trusted.

The Sad

Often the province of media reporting about dependent drug use and overdose amongst young people, the media portrayal of drug use as a cautionary tale comes with its own potential harms. The archetypal story of this kind paints the picture of once happy young people, who started experimenting with drugs and through some happenstance, experienced dependency or indeed overdose.

The most apparent difficulty with this type of reporting is that it does not ring true with many young people’s experience of drug use, therefore posing little in the way of deterrent effect. Additionally, this kind of reporting often only contributes to a moral panic about drugs and rarely provides anything in the way of evidence based information about the risks associated with drug use and how people can reduce these harms. Drug dependency and overdose are important issues and should not be ignored by our society or indeed by the media, however inciting fear rather than an evidence based discussion of how we can reduce the occurrence of drug related harm only encourages young people to hide their substance use rather than discuss it openly.

The Redeemed

This story archetype follows the pattern of I once was lost, but now I’m found. It is a tale of struggles and deprivation that ultimately end in the individuals redemption through some form of recovery. Stories of hope are important to people seeking to change their drug using behaviour, but they can also contribute to the sense of otherness that people who have not entered recovery are subjected to. Not everybody who uses drugs wants, or needs recovery. If the only socially acceptable way for me to disclose my drug use is to state that I am in, or seeking recovery, where does that leave the millions of people who use drugs that are not?

In short these types of stories can reinforce the concepts of moral behaviour that have been shaped by history rather than evidence and contribute to the stigma that non recovering drug users experience.

What can we do?

We need to continue to tell the stories of hope and recovery, as well as acknowledging the sadness that ensues when we lose a person to an overdose, but we also need to ensure that this is balanced with messages that cater to the needs of all drug users within our community.

We need to foster an acknowledgement that we are all drug consumers, whether it be licit or illicit drugs, thereby reducing the sense of ‘otherness’ experienced by some in our communities. We can do this by ensuring that we regularly question and test our own beliefs and prejudices regarding drug use and drug users. We can do this by ensuring that we vocally support media stories that provide factual, non judgemental reporting of drug issues. Where there is a lack of factual, non judgemental media coverage of drug issues we can become the media creators ourselves. Thanks to online social networks, simple to use applications and accessible media production software, now more than ever the means of media production is in the hands of you and me.

What we chose to do with this power is completely up to us.

Forget The Great Divide

At heart I’m a harm reduction kind of person. I’ve spent the last decade working in needle programmes, running a website that provides injecting advice and presenting sessions at conferences promoting harm reduction. For me this work has always had as one of its goals the idea of helping people who want to stop using drugs achieve this. And for the people who don’t want to stop, it’s been about helping them stay safer and, if I can, ‘nudging’ them to the idea of stopping at some time in the future.

So the idea that harm reduction and recovery are somehow opposite ends of drugs work has been something I’ve always found confusing. To me recovery is harm reduction and harm reduction is something that sits perfectly in recovery – even the original ACMD document statement that kicked off needle programmes in the UK had as one of its stated goals ‘increase abstinence’.

For some people though, this false dichotomy is an advantage. The press rarely has an interest in stories where people agree that working together is a good way to help people stay alive and healthy. What they want is an element of conflict. This is something that some members of our community – and I include both harm reduction and recovery here – have taken full advantage of to make sure they stay in the public eye. But the other week I attended and spoke at the UKRF Recovery Summit (UKRF11) and was pleased to see that there are so many people who understand that not only would it be a good idea for the two camps to work together, but that it’s necessary.

Recovery has many paths to it and I know from experience that a number of those paths are made possible by harm reduction based services, which are, as Stephen Bamber has stated, ‘the vanguard of recovery‘. Currently drug services are being asked to give more robust evidence that they are helping people make changes and move towards recovery and this is to be welcomed in my opinion – after all it’s what I’ve been doing for years.

Back when I started working in drug services, our area had a ten-month waiting list for treatment. The people coming into the needle programme where I worked got sterile equipment but also received advice and support on reduction strategies and self-detox. I can remember many times when people would stop using drugs without ever needing to engage in ‘structured treatment’. But up till now needle programmes have rarely been asked for this kind of data. Instead, all DAATs have been interested in is the number of needles given out – it’s almost as if all they think we do is just throw needles at people and never actually talk to them. So yes, I’m all for evidencing the work we do better.

But that’s not enough. We need more people from the recovery community to be actively involved in harm reduction. When I spoke at UKRF11 I asked the people attending my session about their experience of overdose interventions in rehabs. I’ve since asked the same question to other people both online and off. I always get the same kind of answer – ‘there was no mention of overdose’ or ‘there was no overdose advice’.

Previously I’ve been told that this is because talking about overdose with people in the early stages of recovery is ‘difficult’, and that it would mean implying that they may return to using substances, which could act as a trigger for using. I do understand this point, but as anyone who understands the Cycle of Change could tell you, there is always going to be a portion of the rehab community that returns to substances.

This is especially true in the early stages of recovery when rehab can be an intimidating place full of strange new situations and difficult questions people have to ask themselves. And it’s exactly this situation – people dropping out of rehabs and support services – that poses the greatest risk of overdose. Tolerance is reduced, stresses are high and people often return to the old coping strategy of drug use. Personally I would love to see overdose interventions becoming one of the first things discussed for people entering recovery.

We are losing over 1,000 people a year to overdoses in the UK. This is a number that needs to be reduced and in my mind the only real way we can do that is to all work together. It’s not harm reduction or recovery, it’s harm reduction AND recovery.

Note this article was first published in DDN magazine.

Harm Reduction And Recovery

This presentation was delivered to the UK Recovery Federation who invited me to speak at their conference on how Harm Reduction and Recovery could work more closely together.

Foot Injecting

One of the exercises I do when I’m delivering safer injecting training looks at the most common injecting sites and the associated risks. People are usually quite good at putting the different sites in some kind of order of risk, but when it comes to the feet they often underestimate the dangers.

Why would someone inject in the foot?!

OK, first lets understand what some of the drivers are for people to use this site for injecting. There is of course the most obvious one, not being able to find a suitable vein elsewhere. This can for many people be a way of avoiding a move to sites that are perceived as higher risk like the groin, which of course does show that someone is taking steps to keep themselves safer.

But there are other reasons people choose the feet, one that I keep coming across is that this is a hidden area so the track marks won’t show on arms where family members/friends/treatment workers may see them. One thing is pretty sure though, people don’t inject in the foot because it feels good.

Problems with the foot

The first one that really comes to mind is that the blood pressure in the feet is incredibly low. You can’t get any further away from the heart (ie the ‘pump’) and you are fighting against gravity. This will effect the way the drug feels for a person (no real ‘rush’ with this one) but it will also mean you have an increased chance of things like abscess and problems with veins, healing is slower in the foot so missed hits turn into abscesses with a predicable regularity.

And those missed hits are common. Although there are some very tempting veins on the feet that at first glance seem big and juicy (Am I the only one who thinks of veins as juicy?) they are in reality quite thin veins with a tendency to burst if put under pressure. Not only that but they have a habit of rolling around when you try to put a needle in them, leading to more misses.

Another reason for the increased chances of infection in feet is the way that (for most people) they are kept enclosed in sweaty shoes and socks all day, this keeps wound hot and wet which makes it a great breeding ground for bacteria.

Advice for people who injecting in their feet

An obvious piece of advice would, of course, be to stop injecting in the feet, although for many people struggling with vein access this may not at first seem possible. Take time to help people find veins elsewhere, show them how to use a tourniquet correctly (see my article on tourniquet use for tips).

This is also the ideal opportunity for people to exit injecting behaviours, support people to transition back to smoking, or encourage them to access treatment services (if people want treatment then do the assessment now, not give them an appointment for two weeks time).

Of course some people will want to continue injecting in this high risk area, if that’s the case:

  • Encourage them to take good thin needles (in the UK I’d always suggest a 30 gauge nevershare syringe)
  • Give advice on ways to minimise ‘rolling’ of the vein (this can be done by gently applying pressure beside the vein to reduce the area it can roll to)
  • Give advice on injecting VERY slowly so they don’t put the vein under stress
  • If possible have a stock of clean dry socks that can be given to homeless injectors

The most important thing as always with people injecting in higher risk areas is to give them good advice and other options.