Safer Injection Practices
    • Using new gear
    • Handwashing
    • Finding veins
    • Vein Care
    • Preventing cotton fever
    • Preventing abscesses
    • Using a tie

Potential Learning Outcomes
Familiarizing with risks and routes of infection related to injecting drugs. 
Strategies to reduce risks, including single-use, single-user gear.


Discussion Topics
Gear tour and identify/ familiarize best practice uses of
  • Hand washing
  • Ties
  • Sterile water
  • Cookers
  • Cotton filters
  • Range of tip/barrel options
  • Swabs 
  • Sharps Boxes and alternatives
 
If necessary can syringes be cleaned for reuse? What is the process? What are the risks?
  • Yes always best to use new gear, but if you can’t, water-bleach-water washing procedure (video in suggested resources) can clean most pathogens. The needle will become more blunt with every re-use, increasing potential vein damage.  

What helps veins “show themselves”? What strategies can you use to help “shy” veins present?
When having trouble finding a vein, what strategies do you use?
  • Being warm and relaxed. Use a warm compress prior to tourniquet. Dehydration can cause veins to hide, drink a glass of water or warm tea, have a hot bath or shower. Rub the injection site to stimulate blood flow. 

What is the function of “bevel up”? What other tips can be used to minimize impact to veins?
What are the steps for safer injection into the vein (intravenous injection)?
  • Many problems can be caused by incorrect injecting techniques. Below are some guidelines for a safer and more effective technique for intravenous injecting.
  • Prepare drugs for solely personal use, using preferably clean and new equipment that is only used by the injector.
  • Identify the vein to be used, using techniques mentioned in “how to find a vein” section. Also, look for possible valves. You can inject either above or below a valve, but do not inject into the valve or right near it, as this can cause great vein damage. Also, never inject into an artery (arteries have pulses). 
  • Always inject with the blood flow – towards the heart.
  • Choose the smallest possible bore and length needle for the site for superficial veins.
  • Clean the site with soap and water or an alcohol swab.
  • Introduce the needle into the vein at a shallow angle with the bevel facing up. A change in resistance is felt as the needle enters the vein.
  • Pull back the plunger to identify that the needle is in a vein. A small amount of dark red venous blood should trickle into the syringe. If a tourniquet is used it should be loosened immediately after accessing the vein.
  • Inject slowly to reduce the likelihood of damage to the vein and to lower the overdose risk. Do not flush out the syringe, this will significantly increase trauma to the vein.
  • Remove the needle slowly, if the needle is removed too quickly, the vein may collapse.
  • Immediately apply firm pressure to the site to reduce bruising.
  • Risks: Bloodborne viruses HIV, Hep B & C, vein damage, circulatory problems, abscesses, systemic (blood/body) and local (at the injection site) infections, blood clots & Deep Venous Thrombosis (DVT), and many other serious health problems.
​
What impact does hand washing have in injection safety? What does proper hand-washing look like? 
youtu.be/MazSUqYAUJI?si=J25QHRoOozF_xqtb
https://youtu.be/xgbfv4CIBe8?si=NYuWwW-JixA-T483​

What does it mean to “save one for the ladies”?
  • This slang refers to saving a vein for phlebotomists or nurses so that if/when you need to get tested, or get an IV in the hospital, that there is a vein with minimal damage. 

What is cotton fever? What are the best/worst options for filtering drugs? What risks come with each?
  • A flu-like sickness that usually lasts 24-48 hours, and is believed to be a result of bacteria that can live in cotton used to filter. 
  • Keeping filters clean, in closed packaging, and using only once. 
  • Wheel filters are preferable, especially for injecting pills, but can be harder to come across. 
  • Filtering with other products like a cigarette filter can come with its own risks, like microscopic fibreglass. Plain cotton, clean as possible, is best.

What is an abscess? What can we do to keep our blood vessels from becoming infected? 
  • An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed.
  • A skin abscess can be the result of a bacterial infection that occurs when Staphylococcus aureus bacteria enters the skin.
  • Clean hands, Clean injection site, Clean Gear, Good Wound care, good hygiene

What can cause vein collapse and vein damage?
  • Repeated use of the same area/site.
  • Using old or blunt needles.
  • Using the wrong tourniquet or using incorrectly
  • Flushing veins which can cause clots and blocked veins – you do not get an extra buzz from flushing.
  • Pulling back on the plunger too quickly to see if the needle is in the vein, or removing needle/syringe from vein too quickly, can cause the vein to collapse on itself.
  • Using lemon or vinegar – this can cause damage and collapsed veins, leading to use of more dangerous veins, or vinegar/lemon juice can be contaminated with bacteria or fungus (because it isn’t sterile) leading to life-threatening infections including abscesses, cellulitis, heart infections, or eye infections causing blindness.
  • Using too much citric acid can also irritate and weaken veins so only use the smallest amount possible to dissolve the drug.
  • Missed hits occur when you miss the vein and inject into the surrounding tissue – this can cause infections and abscesses.

What concerns should be considered if injecting in the legs or feet?
Legs: 
  • Superficial leg veins are unlikely to be practical long-term prospects for injecting. 
  • They contain more valves (see “finding veins” lesson plan for more info on valves) which increases the likelihood of problems since injecting near a valve can damage the valve, causing circulatory problems.
  • Blood flow is slower in legs, so inject as slowly as possible to avoid overwhelming the vein and causing a “miss”. 
  • Because of the slow blood flow, there is also an increased risk of abscess and infection. 
  • Avoid behind the knees as major arteries lie here. 
  • Veins in legs often don’t last long and have an increased risk of forming blood clots, which can travel through your bloodstream and cause a heart attack, respiratory embolisms (clots in lungs), and strokes.
  • Injecting regularly into veins may also cause varicose veins to form because of damaged valves. The varicose vein has tight, thin walls and is often raised, stretching the skin and should not be injected into, as they can bleed profusely.
Feet: 
  • Although the veins in the feet are used by some injectors, factors such as very slow blood flow, and increased germs, make them an unsuitable choice for anything other than occasional use. 
  • Because of these factors, there is an increased risk of infection and abscess which will be slower to heal than other parts of the body (because of slow blood flow and increased germs) and may lead to temporary loss of mobility. 
  • As with legs, inject into the feet as slowly as possible to avoid overloading the vein, and make sure to clean foot and swab site with an alcohol swab before injection.

What is the procedure to inject into a muscle? Why might you use an IM method, and what are the risks?
  • Injecting speed, cocaine, pills or methadone into muscle can cause abscesses, and leave the muscle feeling sore and stiff. Short term use (other than steroids) is recommended.
  • The safest muscle-injecting site is the upper, outer section of your buttocks, the outer thigh, and the upper arm/shoulder area. 
  • If you try to inject into your bum or thigh, be particularly careful to avoid hitting the sciatic nerve. Damage to this nerve can be irreversible and can cause chronic pain, and even paralysis. For intramuscular injection, follow this procedure:
  • Wash & dry the injection site. Wipe the injection site in one direction with a new swab.
  • Prepare drugs for sole personal use, using preferably clean and new equipment that is only used by the injector. 1 to 1½ inch needle will need to be used to reach the muscle.                                                              
  • Only inject in the upper and outer area of the buttocks.
  • Keep the site straight, skin pulled tight, and muscle as relaxed as possible.
  • Holding the barrel of the syringe, push the needle in with one swift jab, not quite up to the hilt.
  • Draw back. If you get blood in the syringe, you have hit a vein or an artery. Pull the needle back a centimetre and try again.
  • As long as the syringe remains free of blood, inject slowly and continue to relax. 2 mL should be the maximum amount put into a muscle at one time.
  • The effects may take 10 to 20 minutes to come on so you need to be patient and wait a while before thinking about using more.
Suggested Resources
Video about Syringe Sharing, how and why it happens, tips to avoid (without ready access to unlimited free supplies): 
https://youtu.be/t0KD2diDvTQ?list=PL40D8E249F1025C7E

Cleaning Works: how to clean a used syringe youtu.be/SnsK_4gOYHU?si=Y7-OtoYN0P3wCBTR 

Science behind cleaning syringes: http://www.harmreductionworks.org.uk/2_films/does_cleaning_syringes_work.html

Citric Acid (TW: researcher uses real heroin in the video): https://www.youtube.com/watch?v=e_hlxbW1v20

How to Prepare and Inject Heroin: 
https://youtu.be/Miv8i-slK2w

Collapsed Vein Module from AVI: https://docs.google.com/document/d/1W1Cgr23OLW133WCfZbDtevRVa0uFC059iVU5O1mdt9s/edit?usp=sharing

Guidance For Injecting Tablet Medication  https://youtu.be/Qh6eTS9q4bA?si=SJUuKQ6q3fiMY9Sv  
https://www.bccsu.ca/wp-content/uploads/2021/01/Resource-Safer-Tablet-Injection_01.27.21.pdf
Pleasure Principle Module from AVI: 
https://docs.google.com/document/d/1UD0dTOETCQtyGvsLPvQZucgfMYhLVLlmzXY_wSGIDeU/edit?usp=sharing 

Reframing how we discuss use. 
Staying Safe Project London: https://www.youtube.com/watch?v=PsWn0_gOT4Q

Harm Reduction Works film collection 
https://www.harmreductionworks.org.uk/1_compilation_dvds/launch_dvd.html​
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