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Safer injection guide: Difference between revisions
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{{Danger/Injection}} | {{Danger/Injection}} | ||
{{#ev:youtube|https://www.youtube.com/watch?v=MppHWdZ-S_I|340x240|right|[[#Sterile single-use | {{#ev:youtube|https://www.youtube.com/watch?v=MppHWdZ-S_I|340x240|right|[[#Sterile single-use spoon|Sterile single-use spoons]] for preparation of drugs for injection complement [[#Sterile syringe and sterile hypodermic needle|sterile syringes and sterile hypodermic needles]] in preventing transmission of blood-borne diseases, which often goes unnoticed through communal pools: ''Boiling, burning, or using common cleaning fluids, alcohol, or peroxide can reduce the amount of the hepatitis C virus (HCV), but this may not prevent you from getting infected.''<ref>https://www.cdc.gov/hepatitis/hcv/pdfs/factsheet-pwid.pdf</ref> The [[Sharing_injection_materials#Hepatitis_C|hepatitis C]] virus can survive outside the body for <span style="color:red">'''6 weeks'''</span>.<ref name="pmid24273176" /> The international prevalence of {{nowrap|hepatitis C}} is between <span style="color:red">'''60% and 80%'''</span> among people who use injection drugs.<ref name=Lancet2011>{{cite journal | vauthors = Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, Degenhardt L | title = Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews | journal = Lancet | volume = 378 | issue = 9791 | pages = 571–83 | date = August 2011 | pmid = 21802134 | pmc = 3285467 | doi = 10.1016/S0140-6736(11)61097-0 }}</ref><ref name=China2008>{{cite journal | vauthors = Xia X, Luo J, Bai J, Yu R | title = Epidemiology of hepatitis C virus infection among injection drug users in China: systematic review and meta-analysis | journal = Public Health | volume = 122 | issue = 10 | pages = 990–1003 | date = October 2008 | pmid = 18486955 | doi = 10.1016/j.puhe.2008.01.014 }}</ref> Hepatitis C cannot be prevented once the virus has already been introduced into the body, and currently, there is no vaccine.|frame}} | ||
'''Injection''' is the act of delivering a [[psychoactive substance]] into the body using a hypodermic needle. Injected substances are mixed with a liquid (such as [[#Sterilie water for injection|sterilie water for injection]]) to form a solution, which is usually either injected directly into the bloodstream via the veins (i.e. intravenous or [[#IV_injection|IV injection]]) or into the muscle tissue (i.e. intramuscular or [[#IM_injection|IM injection]]). | '''Injection''' is the act of delivering a [[psychoactive substance]] into the body using a hypodermic needle. Injected substances are mixed with a liquid (such as [[#Sterilie water for injection|sterilie water for injection]]) to form a solution, which is usually either injected directly into the bloodstream via the veins (i.e. intravenous or [[#IV_injection|IV injection]]) or into the muscle tissue (i.e. intramuscular or [[#IM_injection|IM injection]]). | ||
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While most psychoactive substances are capable of being injected, the practice is most commonly associated with [[opiates]] like [[heroin]], [[stimulants]] like [[methamphetamine]] and [[cocaine]], and [[dissociatives]]. | While most psychoactive substances are capable of being injected, the practice is most commonly associated with [[opiates]] like [[heroin]], [[stimulants]] like [[methamphetamine]] and [[cocaine]], and [[dissociatives]]. | ||
When using opiates it is highly recommended to have [[naloxone]] nasal spray, available for free at some pharmacies, in order to reverse the effects of the opiate, and then call or get someone to call emergency services, as multiple doses of the naloxone are needed in order to continue effects, which first responders and the hospital will have. This can save a life. | |||
==Risks and hazards== | ==Risks and hazards== | ||
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*''' Reusing hypodermic needles ''' - Reusing needles (including '''stainless steel hypodermic needles''' that can be autoclaved) is not advised for a number of medical reasons. If upon injection the needle does not hit a vein or muscle tissue, only retry with that same needle one more time if needed. It is always best to use fresh needles for each injection because needles are designed to penetrate the surface of the skin only once. After the first use, the needle becomes dulled and each additional time increases the dullness. Reusing the same needle can lead to greater risk of bodily injury and abscessed infections. Fresh needles can be found at [[needle exchange programs]] in certain areas. Needles that have been re-used many times will get macro trauma to the needle tip, resulting in a hook shape. If the needle gets hooked when injected it will cause tissue damage (e.g. a collapsed vein when taken intravenously) when it is pulled out. | *''' Reusing hypodermic needles ''' - Reusing needles (including '''stainless steel hypodermic needles''' that can be autoclaved) is not advised for a number of medical reasons. If upon injection the needle does not hit a vein or muscle tissue, only retry with that same needle one more time if needed. It is always best to use fresh needles for each injection because needles are designed to penetrate the surface of the skin only once. After the first use, the needle becomes dulled and each additional time increases the dullness. Reusing the same needle can lead to greater risk of bodily injury and abscessed infections. Fresh needles can be found at [[needle exchange programs]] in certain areas. Needles that have been re-used many times will get macro trauma to the needle tip, resulting in a hook shape. If the needle gets hooked when injected it will cause tissue damage (e.g. a collapsed vein when taken intravenously) when it is pulled out. | ||
*'''Increased risk of infection ''' - The simple act of penetrating the skin with anything is a way to introduce bacteria and viruses directly into the body. One should be as sterile as humanly possible when injecting, making sure to use alcohol swabs to wipe the injection area before and after injection. There is also the risk of infection if the injected substance is impure, adulterated, or unfiltered, which is extremely common. These substances do not pass any membrane for filtration, and ''any'' impurity in the substance will therefore be directly introduced into the body.<ref>{{cite journal | vauthors=((Evans, S. M.)), ((Cone, E. J.)), ((Henningfield, J. E.)) | journal=Journal of Pharmacology and Experimental Therapeutics | title=Arterial and venous cocaine plasma concentrations in humans: relationship to route of administration, cardiovascular effects and subjective effects. | volume=279 | issue=3 | pages=1345–1356 | date=1 December 1996 | url=https://jpet.aspetjournals.org/content/279/3/1345 | issn=0022-3565}}</ref> People who inject are at an increased risk of bacterial infections such as MRSA.<ref name="NHS-What-Should-I-Do">{{Citation | year=2018 | title=What should I do if I injure myself with a used needle? | url=https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/what-should-i-do-if-i-injure-myself-with-a-used-needle/}}</ref> | *'''Increased risk of infection ''' - The simple act of penetrating the skin with anything is a way to introduce bacteria and viruses directly into the body. One should be as sterile as humanly possible when injecting, making sure to use alcohol swabs to wipe the injection area before and after injection. There is also the risk of infection if the injected substance is impure, adulterated, or unfiltered, which is extremely common. These substances do not pass any membrane for filtration, and ''any'' impurity in the substance will therefore be directly introduced into the body.<ref>{{cite journal | vauthors=((Evans, S. M.)), ((Cone, E. J.)), ((Henningfield, J. E.)) | journal=Journal of Pharmacology and Experimental Therapeutics | title=Arterial and venous cocaine plasma concentrations in humans: relationship to route of administration, cardiovascular effects and subjective effects. | volume=279 | issue=3 | pages=1345–1356 | date=1 December 1996 | url=https://jpet.aspetjournals.org/content/279/3/1345 | issn=0022-3565}}</ref> People who inject are at an increased risk of bacterial infections such as MRSA.<ref name="NHS-What-Should-I-Do">{{Citation | year=2018 | title=What should I do if I injure myself with a used needle? | url=https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/what-should-i-do-if-i-injure-myself-with-a-used-needle/}}</ref> | ||
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*'''Injecting into the wrong tissue''' - Some substances need to be injected into certain types of tissue in order to be effective. For example, [[heroin]] is most potent when IV'd and can be extremely harmful when injected into the subcutaneous tissue. [[Ketamine]], however, is typically IM'd. It is vital to ensure that one's hypodermic needle is correctly inserted into the vein before proceeding with an I.V injection. | *'''Injecting into the wrong tissue''' - Some substances need to be injected into certain types of tissue in order to be effective. For example, [[heroin]] is most potent when IV'd and can be extremely harmful when injected into the subcutaneous tissue. [[Ketamine]], however, is typically IM'd. It is vital to ensure that one's hypodermic needle is correctly inserted into the vein before proceeding with an I.V injection. | ||
===Substances that are dangerous to inject=== | |||
* '''Substances''': See [[List of psychoactive substances to avoid#Contraindicated substances for injection]] | |||
*'''Increased risk of [[Drug overdose|overdose]]''' - This risk is especially present with [[opiates]] such as [[heroin]]. If one is injecting opiates, it is important to have [[naloxone]] available, if possible, as this can reverse the effects of an opiate [[drug overdose]] if administered quickly.<ref>Overdose Prevention For Injection Drug Users (drugpolicy.org) | http://www.drugpolicy.org/resource/overdose-prevention-injection-drug-users</ref> The risk of fatal overdoses rise sharply after a period of cessation and relapse, largely because of reduced tolerance.<ref>Why Heroin Relapse Often Ends In Death - Lauren F Friedman (Business Insider) | http://www.businessinsider.com.au/philip-seymour-hoffman-overdose-2014-2</ref> To account for this lack of tolerance, it is safer to only dose a small fraction of one's usual [[dosage]] if relapsing after an extended break. It has also been found that the environment one is in can play a role fatal overdosing. In one scientific study, rats were significantly more likely to die after receiving their dose in an environment not associated with the drug in contrast to a familiar environment.<ref>{{cite journal | vauthors=((Siegel, S.)), ((Hinson, R. E.)), ((Krank, M. D.)), ((McCully, J.)) | journal=Science | title=Heroin “Overdose” Death: Contribution of Drug-Associated Environmental Cues | volume=216 | issue=4544 | pages=436–437 | date=23 April 1982 | url=https://www.science.org/doi/10.1126/science.7200260 | issn=0036-8075 | doi=10.1126/science.7200260}}</ref> Other drugs are conditionally intramuscularly self-injected to prevent intravenous complications that can be prevented in a hospital setting. For example, [[ketamine]] taken intravenously quicker than 1.5 minute can cause breathing depression for short time (up to a minute).<ref>Ketamine: Dreams and Realities, p276</ref> | |||
====Dosage forms not intended for injection==== | |||
See [[List of psychoactive substances to avoid#Dosage forms]] | |||
===Virus survival time outside the body=== | ===Virus survival time outside the body=== | ||
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===Sterile water for injection=== | ===Sterile water for injection=== | ||
[[File:Sterilewater.jpg|245px|thumb|right| | [[File:Sterilewater.jpg|245px|thumb|right|USP sterile water for injection. Also sold as glass or plastic [https://en.wikipedia.org/wiki/Ampoule ampoules] by harm reduction supplies sometimes offered by needle and syringe programmes.]] | ||
'''Sterile [https://en.wikipedia.org/wiki/Water_for_injection water for injection]''' (sometimes abbreviated SWFI) is standardized [https://en.wikipedia.org/wiki/Ultrapure_water ultrapure water] used to create solutions that will be administered by injection. Water for injection is generally made by distillation or reverse osmosis.<ref>https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/018632s051lbl.pdf</ref><ref name=Gh2004>{{cite book|last1=Ghosh|first1=Tapash K.|last2=Jasti|first2=Bhaskara R.|title=Theory and Practice of Contemporary Pharmaceutics|date=2004|publisher=CRC Press|isbn=9780203644478|page=396|url=https://books.google.com/books?id=whiC7aSFLY8C&pg=PA396|language=en|url-status=live|archiveurl=https://web.archive.org/web/20170116162803/https://books.google.ca/books?id=whiC7aSFLY8C&pg=PA396|archivedate=2017-01-16}}</ref> Water for injection can also be used for [[Nasal spray guide|nasal sprays]], and eye drops. | |||
''' | '''Pharmacopoeia specifications for water for injection'''<br /> | ||
{| class="wikitable sortable" | |||
|- | |||
! Properties !! European Pharmacopoeia (Ph.Eur.)<ref>{{cite book|title=European Pharmacopoeia|date=2013|publisher=Council of Europe|location=Strasbourg, France|isbn=978-92-871-7531-1|pages=3555–3558|edition=8|language=English|chapter=Water for injections}}</ref> !! United States Pharmacopeia (USP)<ref>{{cite book|title=United States Pharmacopeia and the National Formulary (USP-NF)|date=October 2014|publisher=U.S. Pharmacopeial Convention|location=Rockville, MD, USA|page=5805|edition=USP38–NF33|chapter=USP Monographs: Water for Injection}}</ref> | |||
|- | |||
| Conductivity || <1.3 μS/cm at 25 °C||<1.3 μS/cm at 25 °C | |||
|- | |||
| Total organic carbon (TOC) || <0.5 mg/L || <0.5 mg/L | |||
|- | |||
| Bacteria (guideline) || <10 {{abbr|CFU|colony forming units}}/100 mL || <10 {{abbr|CFU|colony forming units}}/100 mL | |||
|- | |||
| Endotoxin || <0.25 IU/mL || <0.25 EU/mL | |||
|- | |||
| Nitrates || <0.2 ppm || N/A | |||
|- | |||
| Aluminium || <10 ppb || N/A | |||
|} | |||
# If in-line conductivity exceeds values additional testing is required before a conclusion can be made. Refer to the respective pharmacopoeia for details. | |||
# One USP Endotoxin Unit (EU) is equal to one International Unit (IU) of endotoxin | |||
====Other water sources==== | |||
* Boiled tap water: It is also important to change the water at a regular interval to prevent bacteria growth within the water. Be mindful that using multiple hypodermic needles in the same water supply can easily spread illness and disease. No other liquid substance should be added to the injection, even if it is supposed to increase the solubility of the drug in the water solution. Heat can be used to aid dissolution, but fruit juice or vinegar can lead to infections. Hot tap water should always be avoided because it contains heavy metals. | |||
* [https://en.wikipedia.org/wiki/Eye_drop Eye drops] | * [https://en.wikipedia.org/wiki/Eye_drop Eye drops] | ||
** Eye drops '''with medications (e.g. the deliriant tropicamide only used for ocular administration) can be deadly when injected'''. | ** Eye drops '''with medications (e.g. the deliriant tropicamide only used for ocular administration) can be deadly when injected'''. | ||
** Syringe designed saline drops (e.g. Wallace Cameron Ultra Saline Minipod) are distributed in modern needle-exchange programmes as they can be used efficiently either by injection or ophthalmic (if the drug is potent in small doses) route of administer which is compared to intravenous use; by demonstration, the elimination of latanoprost acid from plasma is rapid (half-life 17 minutes) after either ophthalmic or intravenous administration.<ref>{{cite web|url=https://www.drugs.com/mmx/latanoprost.html|title=Latanoprost Drug Information, Professional|publisher=Drugs.com|access-date=18 September 2014}}</ref> | ** Syringe designed saline drops (e.g. Wallace Cameron Ultra Saline Minipod) are distributed in modern needle-exchange programmes as they can be used efficiently either by injection or ophthalmic (if the drug is potent in small doses) route of administer which is compared to intravenous use; by demonstration, the elimination of latanoprost acid from plasma is rapid (half-life 17 minutes) after either ophthalmic or intravenous administration.<ref>{{cite web|url=https://www.drugs.com/mmx/latanoprost.html|title=Latanoprost Drug Information, Professional|publisher=Drugs.com|access-date=18 September 2014}}</ref> | ||
* Distilled water should be avoided in large amounts directly into a vein, as it can cause your blood cells to become hypotonic, possibly leading to death. | * Distilled water should be avoided in large amounts directly into a vein, as it can cause your blood cells to become hypotonic, possibly leading to death. Distilled water is often sold as battery water, but since it's not designed for medical use, it may lack specifications and may be unsafe to inject. | ||
===Sterile single-use spoon=== | ===Sterile single-use spoon=== | ||
"Do not put your needle into a common pool with others. This practice may be responsible for the spread of hepatitis C in people who say that they don't share needles."<ref>[Ketamine: Dreams and Realities, p269]</ref> | "Do not put your needle into a common pool with others. This practice may be responsible for the spread of hepatitis C in people who say that they don't share needles."<ref>[Ketamine: Dreams and Realities, p269]</ref> | ||
Typically, a small aluminum single-use spoon specifically designed for the purpose of dissolving and sterilizing the substance for injection. | Typically, a small disposable aluminum single-use spoon, ideally color-coded, specifically designed for the purpose of dissolving and sterilizing the substance for injection. | ||
====Risk of shared, non-sterile reservoirs==== | |||
In situations where people inject drugs, there's a chance of unknowingly sharing equipment like spoons, shot glasses, or even the concave bottom of a soda can. | |||
This can happen for several reasons: | |||
* '''Incomplete sterilization:''' Washing with dish soap doesn't guarantee sterility. Used equipment might be put back for reuse by others, creating a risk of bloodborne disease transmission. | |||
* '''Memory lapses:''' People may forget that the equipment was previously used and unintentionally share it, putting themselves and others at risk. | |||
===Sterile syringe and sterile hypodermic needle=== | ===Sterile syringe and sterile hypodermic needle=== | ||
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<span style="color:red"><b>It is extremely important to vary the administration sites of injections.</b></span> The overuse of one particular injection site can lead to degradation of the tissue of the site. With IV use, this can lead to collapsed veins.<ref>http://new.sfaf.org/tspsf/speedometer/shooters/vein_care.html</ref> Once a vein has collapsed, it cannot be used again. In regard to IM injection use, there have been animal studies that show there is risk of permanent scarring and damage the peripheral veins and muscle tissue if the site is overused.<ref>{{cite journal | vauthors=((Diness, V.)) | journal=Acta Pharmacologica Et Toxicologica | title=Local tissue damage after intramuscular injections in rabbits and pigs: quantitation by determination of creatine kinase activity at injection sites | volume=56 | issue=5 | pages=410–415 | date= May 1985 | issn=0001-6683 | doi=10.1111/j.1600-0773.1985.tb01311.x}}</ref> | <span style="color:red"><b>It is extremely important to vary the administration sites of injections.</b></span> The overuse of one particular injection site can lead to degradation of the tissue of the site. With IV use, this can lead to collapsed veins.<ref>http://new.sfaf.org/tspsf/speedometer/shooters/vein_care.html</ref> Once a vein has collapsed, it cannot be used again. In regard to IM injection use, there have been animal studies that show there is risk of permanent scarring and damage the peripheral veins and muscle tissue if the site is overused.<ref>{{cite journal | vauthors=((Diness, V.)) | journal=Acta Pharmacologica Et Toxicologica | title=Local tissue damage after intramuscular injections in rabbits and pigs: quantitation by determination of creatine kinase activity at injection sites | volume=56 | issue=5 | pages=410–415 | date= May 1985 | issn=0001-6683 | doi=10.1111/j.1600-0773.1985.tb01311.x}}</ref> | ||
====Solution for injection==== | ====Solution for injection==== | ||
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{{Safer injection guide-basic procedure}} | {{Safer injection guide-basic procedure}} | ||
#Hold the syringe in the dominant hand and grasp and pinch the skin where one will administer the SC injection. | #Hold the syringe in the dominant hand and grasp and pinch the skin where one will administer the SC injection. | ||
# | #Insert the hypodermic needle into the skin and slightly pull the plunger back. No blood should enter the syringe barrel to ensure that you are in subcutaneous tissue. | ||
#Slowly inject the substance into the subcutaneous | #Slowly inject the substance into the subcutaneous tissue. | ||
#Remove the hypodermic needle at the same angle that it entered and re-wipe the injection site with an alcohol wipe. | #Remove the hypodermic needle at the same angle that it entered and re-wipe the injection site with an alcohol wipe. | ||
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===Biological residues=== | ===Biological residues=== | ||
Don't flush residues from | Don't flush residues from the hypodermic needle and syringe in a glass of water and leave publicity available. Blood residues can fool someone to think it's actually squash and drink from it (yes, for real). Also, glass or other containers, contaminated with blood, can cause blood-borne diseases when used by others. It's safer to flush the syringe and needle under an interior water tap in the sink, as long as they don't get in touch with it. | ||
==Aftercare== | ==Aftercare== | ||
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**'''United States''': At a federal level in the USA, naloxone is a prescription drug. Many states have programs that make naloxone over the counter and available at request at most pharmacies. In the United States, most jurisdictions have programs to deploy naloxone to law enforcement and fire and rescue services. The states that have a [[naloxone]] access laws (in varying degrees) as of January 2016 are: Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington State, West Virginia, and Wisconsin.<ref>State Naloxone Laws in the USA http://www.drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29.pdf</ref> | **'''United States''': At a federal level in the USA, naloxone is a prescription drug. Many states have programs that make naloxone over the counter and available at request at most pharmacies. In the United States, most jurisdictions have programs to deploy naloxone to law enforcement and fire and rescue services. The states that have a [[naloxone]] access laws (in varying degrees) as of January 2016 are: Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington State, West Virginia, and Wisconsin.<ref>State Naloxone Laws in the USA http://www.drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29.pdf</ref> | ||
**'''United Kingdom''': In the United Kingdom, naloxone is considered a Prescription Only Medicine. It is also given out at drug intervention programs and needle distribution centers, provided one has undertaken a quick 10 minute training protocol. | **'''United Kingdom''': In the United Kingdom, naloxone is considered a Prescription Only Medicine. It is also given out at drug intervention programs and needle distribution centers, provided one has undertaken a quick 10 minute training protocol. | ||
==Substance notes== | |||
===Drugs that are useless to inject=== | |||
* [[Lisdexamfetamine dimesylate]] (Vyvanse) - is formulated with a low potential for abuse as it is a prodrug necessitating conversion to dextroamphetamine in the gastrointestinal tract or liver. | |||
===Drugs that require special consideration to inject=== | |||
* Some psychoactive substances such as [[benzodiazepines]] (valium, oxazepam, clonazepam) are water soluble to a small degree (about 3.5ml/mg). | |||
==See also== | ==See also== | ||
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[[Category:Responsible drug use]] | [[Category:Responsible drug use]] | ||
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