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Safer injection guide: Difference between revisions

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{{Danger/Injection}}
'''Injecting''' is the process of dissolving a compound in a liquid and drawing the resulting solution into a needle-tipped syringe for the purposes of self-administration.  
{{#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}}


Substances are typically either injected directly into the bloodstream via their veins (a practice known as intravenous or ''I.V. injection'') or into the muscle tissue (known as intramuscular or ''I.M. injection''). More rarely, substances are injected in the flesh right under one's outer layer of skin (known as subcutaneous or ''S.C. injection''), which is referred to as "skin popping" in street drug circles.<ref>http://www.thefreedictionary.com/skin-popping|Skin-popping - definition of skin-popping by the Free Dictionary</ref>
'''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]]).


==Risks and Hazards==
Injecting substances removes any bodily filtering mechanism and IV injection results in 100% bioavailability of a substance.<ref>{{Citation | vauthors=Editor | year=2011 | title=Bioavailability of Drugs | url=http://howmed.net/pharmacology/bioavailability-of-drugs/}}</ref> Any impurities present in the product will pose a significantly greater health threat. Even medical grade substances specifically manufactured for injection carry a risk of infection and death. As a result, this guide has been deliberately named the "safe(r) injection guide" to emphasize the fact that there is no such thing as truly safe injection.


* ''' Risks of infection ''' - The simple act of penetrating one's skin with anything is a way to introduce bacterium, viruses, etc. directly into your body. Be as sterile as humanly possible! Use alcohol swabs to wipe the injection area before and after injection. There is also infection risk if one is injecting impure, adulterated, or unfiltered substances into their body. These drugs are not passing any membrane for filtration and '''any''' impurity in the drug will be directly introduced into the body.<ref>http://jpet.aspetjournals.org/content/279/3/1345.short</ref>
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]].


* ''' Blood-borne diseases''' - Sharing needles with other users is the most obvious way to transmit a blood-borne disease or infection, but there are other less commonly thought of ways too. Using multiple needles in the same water supply can easily spread illness and disease. Sharing the same spoons and other equipment used to prepare the injection solution is also a way to contract a blood-borne disease.
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.


* ''' Re-using needles ''' - Reusing needles is not advised for some medically relevant reasons. If upon injection you do not hit a vein, only retry with that same needle one more time IF NEEDED. It is always best to use fresh needles every time you inject.
==Risks and hazards==
[[File:Used-needles.webp|245px|thumb|right|Used needles have more crevices for blood and viruses to adhere to, and can transmit disease. Image courtesy of NCHRC. Credit: courtesy NC Harm Reduction Coalition]]
[[File:Blausen 0007 Abscess.png|245px|thumb|right|A diagram showing what an abscess looks like. If anything resembling an abscess occurs at an injection site it is imperative to seek medical attention immediately.]]


* ''' Abscessed infections ''' - An abscessed infection is a collection of pus that has built up within the tissue of the body at or underneath an administration site that is usually caused by a bacterial infection. If one recognizes an abscess following an injection it is imperative that they <span style="color:red">GO SEEK PROFESSIONAL MEDICAL HELP IMMEDIATELY</span> as abscessed infections can lead to severe health complications and not uncommonly, death.
See also [[#Dangers specific to IV drug use|Dangers specific to IV drug use]].


*'''Injecting into the wrong tissue''' - Some substances need to be injected into certain types of tissue in order to be effective. This can inform which injection method should be used. For example, [[heroin]] has been shown to work "best" when IV'd and can be extremely harmful when injected into the subcutaneous tissue. This is why it is so important that one makes sure they are 'in a vein' before proceeding to inject themselves.
Health problems arise from poor hygiene and injection technique (be it IV, IM, or SC), such as [[cotton fever]], phlebitis, abscesses, vein collapse, ulcers, malaria, gas gangrene, tetanus, septicaemia, thrombosis, embolism and all results thereof. Drug injection is also commonly a component in HIV-related syndemics.


*'''Increased withdrawal effects''' - This can be experienced with substances like [[opiates]], such as [[heroin]]. The higher bioavailability and time to peak blood plasma levels (i.e. "rushiness") of the drug when it is injected -- along with increased [[Cognitive euphoria]] and [[Physical euphoria]] that accompanies it -- is thought to contribute substantially to compulsive use, addiction, [[withdrawal]], and persisting drug cravings long after cessation of use.
*''' 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.


==Materials==
*'''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>
*'''[[Dosage#Milligram scales|Milligram scale]]''' - It is vitally important to weigh out the substance one is going to inject to help mitigate the risk of overdose.
**'''Blood-borne diseases''' - Sharing spoons (or other containers), syringes, and/or hypodermic needles with other users is the most obvious way to transmit a blood-borne disease or infection, but there are other ways too. Using multiple needles in the same water supply can easily spread illness and disease. Sharing the same spoons and other equipment used to prepare the injection solution is also a way to contract a blood-borne illness such as HIV/AIDS or Hepatitis B & C.<ref name="NHS-What-Should-I-Do"/> Refer to the [[sharing injection materials]] page for more information about the sharing of injection materials and the inherent risks of contracting infection and disease.
**''' Abscessed infections ''' - An abscessed infection is a collection of pus (usually caused by a bacterial infection) that has built up within the tissue of the body at or underneath an administration site.<ref>{{Citation | title=Skin infections in intravenous drug users | publisher=DermNet NZ | url=https://dermnetnz.org/topics/skin-infections-in-iv-drug-users}}</ref> If one notices an abscess forming following an injection, they should <span style="color:red"><b>seek professional medical help immediately</b></span> because abscessed infections can lead to severe health complications and, not uncommonly, death. Abscessed infections are especially common when IV injecting into the feet, as the blood circulation in the extremities is poor and decreases the foot's ability to heal.
**'''Endocarditis''' - an inflammation of the inner layer of the heart, the endocardium.
**'''Gangrene''' - If one injects into an artery or muscle tissue, a gangrenous infection may develop.<ref>{{cite journal | vauthors=((Gaspar, M. R.)), ((Hare, R. R.)) | journal=Surgery | title=Gangrene due to intra-arterial injection of drugs by drug addicts | volume=72 | issue=4 | pages=573–577 | date= October 1972 | issn=0039-6060}}</ref>


*'''Insulin syringe with I.V. needle''' - Used for I.V. injection, this type of syringe has a short needle meant to penetrate surface veins.
*'''Increased [[withdrawal effects]]''' - This is observed with many substances such as [[opiates]], [[methamphetamine]], and [[cocaine]]. The higher bioavailability and shorter time to reaches peak blood plasma levels (i.e. "rushiness") of the substance when it is injected along with increased [[cognitive euphoria]] and [[physical euphoria]] that accompanies it is thought to contribute substantially to [[compulsive redosing|compulsive use]], [[addiction]], [[withdrawal]], and persisting substance cravings long after cessation of use.


*'''Syringe with I.M. Needle''' - This type of syringe is used for the less common intramuscular (IM) injection. These needles are longer than the traditional insulin needles seen for IV use because it is designed to penetrate deep into the muscular tissue and deposit the solution there, instead of in a vein.
*'''Intensified [[comedowns]]''' - Substances that have comedowns, such as [[stimulants]] and [[U-47700]], have a greatly exacerbated comedown when injected. This means that the symptoms of a comedown, such as [[depression]], [[anxiety]], [[cognitive fatigue]], and [[motivation suppression]] are intensified and harder to deal with, which could lead to [[compulsive redosing]].


[[File:IM needle diagram.jpg|300px|thumb|right|An IM needle differs from an IV needle in length.]]
*'''Stroke risk''' - Injecting into an artery and not a vein can be a potential cause of strokes and blood embolisms. This risk is especially present with IV drug use, when one misses a vein and injects into the artery instead. This is why it is important to make sure '''one is in a vein before IV injection'''. This risk increases with the use of uncommon injection sites such as the neck: the chemicals being injected might enter an artery and go straight to the brain, causing neurological problems and strokes.<ref name="3-Potentially-Deadly-Spots">{{Citation | year=2015 | title=IV Injection Sites - Potentially Deadly Spots to Shoot Up | url=https://drugabuse.com/blog/iv-drug-abuse-3-potentially-deadly-spots-to-shoot-up/}}</ref>


*''' Alcohol swabs''' - For sterilization before and after injection.
*'''Nerve damage''' - Injecting into the muscle tissue during an IM injection, missing a vein during IV injection, and SC injecting can all present the risk of nerve damage. The hypodermic needle may puncture a nerve and cause serious, painful, and possibly fatal bodily harm. This risk is especially present if injecting into the groin, as the femoral nerve located there controls leg and muscle movement - '''damaging this nerve can result in serious problems with mobility or even paralysis.'''<ref name="3-Potentially-Deadly-Spots"/>


* '''Sterile water''' - It is important to use deionized water or distilled water when injecting substances as tap water may contain harmful impurities. It is also important to change the water at a regular interval to prevent bacteria growth within the water. Placing a small amount (10ml max) in a shot glass and using this for IV/IM purposes is a good way to ensure a fresh water supply.
*'''Deep Vein Thrombosis (DVT)''' - Deep vein thrombosis is a blood clot occurring in the deep arms of the legs and extremities, especially the legs.<ref>{{Citation | title=Deep Vein Thrombosis (DVT) Symptoms, Treatment, Causes, Diagnosis | url=https://www.medicinenet.com/deep_vein_thrombosis/article.htm}}</ref> This is a risk that is especially present with IV drug use into the groin are and the deep veins in the arm. Signs of deep vein thrombosis include; pain, swelling, redness, or tenderness of the leg or arm around the injection site. IV drug use leads to a higher rate of DVT in younger patients, with most DVT issues occurring in the groin area and the thigh.<ref>{{cite journal | vauthors=((Cornford, C. S.)), ((Mason, J. M.)), ((Inns, F.)) | journal=The British Journal of General Practice | title=Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors | volume=61 | issue=593 | pages=e781–e786 | date= December 2011 | url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3223775/ | issn=0960-1643 | doi=10.3399/bjgp11X613115}}</ref>


* '''A buddy!''' - If possible, do your best not to I.V./I.M. alone. Things can go wrong. The risk of overdose is significantly increased when injecting and having someone there to call the emergency services or give you medical aid can literally be the difference between life and death.
*'''Hitting an artery''' - One should always inject into a vein and '''never inject into an artery'''. One can differ between a vein and an artery by the following signs: Upon injection, when the plunger is pulled down the pressure of the blood in the artery will push it back up. The blood in the syringe is bright red, frothing and gushing versus the dark red and slow moving blood found within veins. You can avoid hitting an artery by never injecting where you feel a pulse and never trying to IV inject into deeper veins than those at the surface.


* '''Micron filters''' - These are used to filter out solid impurities in the drug solution. A cotton filter is better than nothing, but a micron filter is considered to be the best.
*'''Development of scar tissue''' - This is especially present with IV injection, but can occur with IM and SC injections as well. If the site of injection is not varied, scar tissue can develop and can impede further injections.
 
*'''[https://en.wikipedia.org/wiki/Extravasation_(intravenous) Extravasation]''' - Extravasation is the leakage of intravenously (IV) infused, and potentially damaging, medications into the extravascular tissue around the site of infusion. Extravasation of medication during intravenous therapy is an adverse event related to therapy that can potentially cause serious injury and permanent harm, such as tissue necrosis.
 
*'''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===
Survival time for dried viruses:
* [[Sharing_injection_materials#Hepatitis_B|Hepatitis B]] virus (HBV): 7 days<ref>https://www.cdc.gov/hepatitis/hbv/bfaq.htm</ref>
* [[Sharing_injection_materials#Hepatitis_C|Hepatitis C]] virus (HCV): <span style="color:red">'''6 weeks'''</span>.<ref name="pmid24273176">{{cite journal |last1=Paintsil |first1=E |last2=Binka |first2=M |last3=Patel |first3=A |last4=Lindenbach |first4=BD |last5=Heimer |first5=R |title=Hepatitis C virus maintains infectivity for weeks after drying on inanimate surfaces at room temperature: implications for risks of transmission. |journal=The Journal of infectious diseases |date=15 April 2014 |volume=209 |issue=8 |pages=1205-11 |doi=10.1093/infdis/jit648 |pmid=24273176 |pmc=3969546}}</ref><!-- Added to: Safer_injection_guide, Sharing_injection_materials -->
* [[Sharing_injection_materials#HIV|HIV]]: 7 days<ref name="pmid24273176" />
 
==Materials and equipment==
*'''A friend, and antidote''' - If possible, do your best not to IV/IM alone due to its high risk. The risk of overdose is significantly increased when injecting and having someone there to call the emergency services or give you medical aid (such as [[naloxone]] if an opioid is injected), can literally be the difference between life and death.
 
*'''[[Dosage#Milligram scales|Milligram scale]]''' - It is vital to weigh out the substance one is going to inject to help mitigate the risk of [[overdose]].
 
*''' Alcohol swabs''' - This is for sterilization before and after injection. Hydrogen peroxide or other disinfectants can also be used.
 
*'''Soap''' - One should always wash their hands with soap and water before injecting. If soap and water are not available, alcohol-based hand sanitizer may be used, however, washing one's hands with soap and water is always preferable.
 
*'''Micron filters''' or '''cotton filters''' - These are used for [[cold water extraction]], to filter out solid impurities in the substance solution. A cotton filter is better than nothing, but a micron filter is considered to be the best. If one is using a cotton filter it is important to '''never''' re-use this cotton filter as it can harbor bacteria and cause severe health consequences known as "[[cotton fever]],"<ref>{{cite web |url=http://heroinhelper.com/pdf/heroin-helper.pdf}}</ref> that are releasing an endotoxin. This is due to the bacteria that grow in the moist conditions of the cotton filter - one should always dispose of their filters after a single use.
 
* '''pH regulation'''
**'''Vitamin C (ascorbic acid)''' - Useful for substances with high pH like [[crack]] (free base form may be too basic to be suitable for injection)<ref>{{cite web |title=Ask Erowid : ID 2854 : What form does 5-MeO-DMT have to be in to be smoked? |url=http://www.erowid.org/ask/ask.php?ID=2854 |website=www.erowid.org}}</ref>. Also, a weak acid can be added to [[heroin]], and [[cocaine]] solutions to dissolve them from impurities more easily. It is important that one does not use fruit juice or vinegar as these lead to greater risks of infection. Vitamin C powder can be found in packets online. Too much vitamin C will make the solution too acidic and can cause vein problems.<ref>Safer injection (catie.ca) | http://www.catie.ca/en/practical-guides/hepc-in-depth/prevention-harm-reduction/safer-injection</ref>
**'''Baking soda''' - Useful for substances with low pH.
**'''pH indicator''' - Especially useful if acid or bases are used.
 
*'''Elastic tourniquets or stockings''' - These can be used to "tie off", or make the veins more visible and accessible, during IV injection. These materials are better for skin than leather belts or other similar objects used to "tie off". Neckties, lubricated condoms, and socks can also be used. One should always use a slip knot when tying off so the tourniquet can be removed quickly if needed. The tourniquet should be removed <b>immediately</b> if there is a loss of sensation in the limbs or the limb discolors or turns blue.
 
===Sterile water for injection===
[[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&nbsp;°C||<1.3 μS/cm at 25&nbsp;°C
|-
| Total organic carbon (TOC) || <0.5&nbsp;mg/L || <0.5&nbsp;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]
** 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>
* 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===
"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 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===
[[File:Rig.png|300px|thumb|right|The full injection set up is shown above. The hypodermic needle is the part that penetrates the skin, the barrel is the part that contains the drug solution, the plunger is pulled to check if one is in a vein and pushed down upon injection.]]
 
About 0.1 mL of the solution is lost in conventional syringes through the [https://en.wikipedia.org/wiki/Luer_taper Luer taper] tip and the Luer taper adapter of the hypodermic needle. That can be compensated by either adding extra 10% or 5% substance in 1 mL or 2 mL syringes respectively, or by using [https://en.wikipedia.org/wiki/Low_dead_space_syringe low dead space syringes].<!-- Added to: Routes of administration, Safer injection guide -->
 
Color coded syringes, hypodermic needles, and single-use spoons (also shared by [https://en.wikipedia.org/wiki/Needle_and_syringe_programmes needle and syringe programmes]), are can help people under the influence to avoid sharing tools by mistake. Some people are marking the syringe with a marker pen, or colored tape.
 
Thinner hypodermic needles cause smaller wounds and scars.
 
====Sterile syringe with sterile intravenous hypodermic needle====
Used for IV injection. Insulin syringes (with cemented hypodermic needles) are common, but 1-2 mL syringes with short hypodermic needles (0.5 inch (13 mm), and 14-30 G) are also used (e.g. "tuberculin syringes"), meant to penetrate surface veins.
 
Drug users typically use a 25 g rapid (5-16 seconds) intravenous injection by arm via the median cubital vein to get a [https://en.wikipedia.org/wiki/Rush_(psychology) rush]. However, smaller gauges such as 30 g can be used to prevent a vein collapse for repeated administration. Hypodermic needles smaller than 30 G are normally used for subcutaneous injection, but not for intravenous (coagulated blood immediately after blood response) or intramuscular use (the finest hypodermic needles are very short).
 
====Sterile syringe with sterile intramuscular hypodermic needle====
[[File:Needle length diagram.png|300px|thumb|left|IM hypodermic needles are longer than IV hypodermic needles.]]
 
This type of syringe is used for the less common intramuscular (IM) injection. The syringes are typically 1 mL to prevent slow injection, and the hypodermic needles typically has a hole size of 22-25G, and are typically 1- to 1.5-inch (25–38 mm, and up to 3 inch (76 mm) for large adults) depending on body weight, which is longer than the traditional insulin needles seen for IV use because it is designed to penetrate deep into the muscular tissue instead of a vein.
 
"It is common to have muscle pain when injecting larger doses of liquid Ketamine into muscle tissue. The pain can continue for several days if it is not administered properly. The muscle soreness can be somewhat controlled by using a very fine (small gauge) needle and by injecting very slowly. It should take 15-30 or more seconds to inject a dose into a muscle. If you feel it begin to sting, slow down the injection rate."<ref>{{cite web |title=Erowid Ketamine Vault : Dosage |url=http://www.erowid.org/chemicals/ketamine/ketamine_dose.shtml#im |website=www.erowid.org}}</ref>
 
===Naloxone===
If injecting an opioid, it is highly recommended to carry [[naloxone]] if it is available. Naloxone is a substance used to reverse the effects of opioids in an overdose. Many jurisdictions have programs to distribute naloxone for free or at discount prices to people who are in need of it. Naloxone may be available as a nasal spray under the brand name "Narcan" or as an autoinjector with voice instructions.


==Procedure==
==Procedure==
In the interest of harm reduction, the use of any substance via I.V./I.M. administration is not an advisable from a health and safety point of view. It should be noted that I.M. administration is more commonly found when using drugs like [[ketamine]].
[[File:Angles for injections.png|400px|thumb|right|A diagram showing the different angles needed for different types of injections]]


==== I.V. Injection====
From the standpoint of [[harm reduction]], all injection drug use is strongly discouraged because it maximizes harm potential while reducing the user's ability to use substances in a sustainable manner. It should be noted that intravenous injection is the most common form and is observed with opiates (e.g. [[heroin]]) and stimulants (e.g. [[cocaine]] and [[methamphetamine]]). Intramuscular administration is mostly observed with [[ketamine]].
#Dissolve the chosen substance in water, be careful not to exceed the amount of water that your syringe can hold.
 
#Heat the solution up, suck the solution into the syringe through the filter. Checking to make sure that no air bubbles are present in the reservoir before the plunger is released is also of dire importance as air bubbles in the bloodstream can easily result in fatal injury.<ref>Embey, D. J., & Ho, K. (2006). Air embolus revisited-a diagnostic and interventional radiological perspective (bubble trouble and the dynamic Mercedes Benz sign). SA Journal of radiology, 10(1), 3-7.</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>
#Using a fresh needle, prep your injection site with an alcohol swab.
 
#If using the traditional crook of the elbow injection site, you may need to apply pressure above the vein to make the vein stick out more. This is typically achieved through "tying off", which refers to the practice of wrapping a solid band or tourniquet around the upper forearm so that blood constricts and the veins become more visible.
====Solution for injection====
#The needle will most likely have a slant. It is important to angle the slanted edge toward your skin, so the point of the needle penetrates the vein and injects downwards.
[[#Sterile water for injection|Sterile water for injection]] (SWFI) should be placed in a [[#Sterile single-use spoon|single-use spoon]] when substances for injection are dissolved, in order to avoid spreading blood-borne diseases.
#Once you have penetrated yourself with the needle, pull back on the plunger of the syringe. If you see blood, you've hit a vein and are good to inject. If you see nothing or feel a suck back, '''you are not in a vein; you are in subcutaneous tissue, do NOT inject! Repeat steps 1-5 until you hit a vein.'''
 
#Once you are in a vein, push the plunger down *SLOWLY*. Especially if one is IVing a strong [[opiate]], such as [[heroin]], it is highly advised to not not rush the injection no matter what.
====IV injection====
#Once all of the solutions has been injected, slowly remove the needle and use a new alcohol swab to clean the injection site. There may be a little blood.
[[File:Correct needle insertion2.png|400px|thumb|right|A diagram showing the angles that are optimal for IV injection. This image is from the "Getting Off Right Guide"<ref name="Getting-Off-Right">{{Citation | title=Getting Off Right (Safety Manual) | url=https://harmreduction.org/issues/safer-drug-use/injection-safety-manual/}}</ref>]]
 
[[File:Incorrectinjection.png|300px|thumb|left|A diagram showing the angles and positions of the body that may cause harm to the body when used for IV injection. This image is modified from the "Getting Off Right Guide"<ref name="Getting-Off-Right"/>]]
 
*'''Administration sites''' - The most common administration site for an IV injection is in the body-facing side of the elbow, into the veins in the arm. The practice of injecting into extremities such as the hands, the feet, the legs, or even the pelvic area can lead to serious complications and bodily harm. <span style="color:red"><b> The most dangerous places to inject are into the groin, the hands & feet, and the jugular veins in the neck. </b></span> Injecting into the groin area is especially risky due to the femoral vein's location next to the femoral nerve and artery. The neck is the riskiest area to inject into because the jugular veins lie very close to the carotid artery, which can be fatal if injected into. Damaging the jugular veins can interfere with blood circulation to the brain. Also, veins in the legs are more likely than those in the arm to develop clots that can obstruct circulation and eventually break off and lodge in the lungs or heart, causing fatal bodily harm.
 
[[File:Veins0001.jpg|300px|thumb|right|The safest injection sites for IV use are on the inside of the arm.]]
====='''Dangers specific to IV drug use'''=====
*'''[[Cotton fever]]''' - A medical condition that indicates as a fever that follows intravenous drug use where cotton is used to filter the drugs.<ref name=Harrison>{{cite journal | last1=Harrison | first1=D. W. | last2=Walls | first2=R. M. | title="Cotton fever": a benign febrile syndrome in intravenous drug abusers | journal=The Journal of Emergency Medicine | date=April 1990 | pmid=2362114 | doi=10.1016/0736-4679(90)90222-H | issn=0736-4679 | volume=8 | issue=2 | pages=135–139}}</ref> The condition derives from an endotoxin released by the bacteria ''Pantoea agglomerans'' which lives in cotton plants.<ref>{{Cite journal|last=Ferguson|first=R.|date=1993-10-25|title=Enterobacter agglomerans--associated cotton fever|journal=Archives of Internal Medicine|volume=153|issue=20|pages=2381–2382|doi=10.1001/archinte.153.20.2381|pmid=8215743|issn=0003-9926}}</ref>
*'''[https://en.wikipedia.org/wiki/Collapsed_vein Collapsed vein]''' - Collapsed veins may never recover.
*'''[https://en.wikipedia.org/wiki/Pulmonary_embolism Pulmonary embolism]''' (PE) - Embolization of air, fat, and talc in the drugs is responsible for a small proportion of PE of people who inject substances.
* '''[https://en.wikipedia.org/wiki/Thrombosis Thrombosis]''' - After prolonged injection, thrombosis in the veins can occur. Thrombosis occurs when a vein’s blood flow is increasingly disrupted, creating blood clots in the lining of the vein. Eventually, the vein can become completely blocked by these clots, transforming the peripheral veins into scar tissue. This is commonly referred to as a collapsed vein.<ref name="3-Potentially-Deadly-Spots"/> To avoid this issue, the injection site should be rotated.
*'''[https://en.wikipedia.org/wiki/Phlebitis Phlebitis] (inflammation of a vein)'''
*'''Development of peripheral veins scar tissue''' - One should always inject the substance towards the heart, not away from it. By injecting with the flow of blood you may avoid problems caused by creating scar tissue or clots which occur when injecting against the flow of blood in the veins <ref>{{Citation | vauthors=((Brunsdon, N.)) | year=2018 | title=Better Vein Care Guide | url=https://anypositivechange.org/better-vein-care/}}</ref>. If the substance flows towards against the heart, instead of away from it, it may lead to increased scar tissue and risk of infection.
 
=====Procedure=====
{{Safer injection guide-basic procedure}}
#If using the traditional crook of the elbow injection site, one may need to apply pressure above the vein to make the vein stick out more. This is typically achieved through "tying off," which refers to the practice of wrapping a solid band or tourniquet around the upper forearm so that blood constricts and the veins become more visible.
#Take three deep breaths.
#The hypodermic needle will most likely have a bevel. It is important to angle the beveled edge away from the skin, so the point of the needle penetrates the vein and injects.
#[https://en.wikipedia.org/wiki/Venipuncture Venipuncture]: However, for typical injection in the arm, penetrate the skin at a 15 to 35-degree angle and always inject toward the heart. Avoid to push the hypodermic needle deeply into the vein to avoid [https://en.wikipedia.org/wiki/Extravasation_(intravenous) extravasation] which can serious injury and permanent harm, such as tissue necrosis.
#Once you have penetrated the skin, and it feels that you have punctured the vein with the hypodermic needle: Pull back on the plunger of the syringe, or hold the syringe vertically, so the blood can flow into it. If there is blood present in the syringe, the needle has hit a vein, and it is good to inject. If there is no blood in the syringe barrel or one feels a suck back, '''the needle is not in a vein; it is in subcutaneous tissue, so do NOT inject! Repeat the former ''venipuncture'' steps until the needle hits a vein.'''
#Once the hypodermic needle is in the vein, push the plunger down ''GRADUALLY'' for at least 30 seconds. It is highly advised not to rush the injection, especially if one is IVing a strong [[opiate]], such as [[heroin]]. However, leaving the needle in the vein for a long time can cause it to be irritated.
#Once all the solutions have been injected, slowly remove the hypodermic needle.
#Block the bleeding from the vein by gently pushing a piece of toilet paper on it for approximately 20 seconds.
#Use a new alcohol swab to clean the injection site. There may be a little blood.
 
======Foot injection======
For self-administration it is often easier, especially for people with a high percentage of body fat, to inject a [https://en.wikipedia.org/wiki/Great_saphenous_vein great saphenous vein] in a foot rather than the [https://en.wikipedia.org/wiki/Median_cubital_vein median cubital vein] by arm. Also, wounds in the feet might look less suspicious and are easy to cover with socks. A foot bath will enlarge the veins.
 
====IM injection====
 
*'''Administration sites''' - Common injection sites for intramuscular injections include the buttocks, the arm, and the thigh.<ref>{{Citation | year=2022 | title=Intramuscular Injection | url=https://www.healthline.com/health/intramuscular-injection}}</ref>
 
<center>
<gallery caption="" widths="200px" location="centre" perrow="4">
File:IM injection site.jpg|IM injections are generally safe in the arm areas and in the muscular tissue of the legs and buttocks.
File:HIP LATERAL MUSCLES.jpg|The muscles flanking the hip and the gluteus medius and maximus muscles can be used as IM injection sites.
File:GLUTEAL MUSCLES.jpg|The gluteal muscles are a common spot for IM injections due to the abundance of muscle tissue.
</gallery>
</center>
 
*'''Hypodermic needle length''' - It is important that one uses a hypodermic needle that is longer than the IV needle in order to reach the muscle tissue.
 
{{Safer injection guide-basic procedure}}
#To prepare the hypodermic needle, hold the syringe with the dominant hand and pull the cover off with the other hand. Place the syringe between the thumb and first finger.
#Hold the skin around where the injection will be administered. With the free hand, gently press on and pull the skin so that it is slightly tight.
#Hold the syringe barrel tightly and use the wrist to inject the hypodermic needle through the skin and into the muscle at a 90-degree angle.
#Let go of the skin with the other hand. Hold the syringe, so it stays pointed straight in. Pull back on the plunger a little to make sure the hypodermic needle did not hit a blood vessel. The point of intramuscular injection is to inject within the muscle itself. '''If blood comes back into the syringe barrel, remove the needle immediately and do not inject.''' If possible, dispose of the needle and syringe and get a new one. When giving the second injection, use a different injection site than the first.
#Push down on the plunger to inject the solution. Do not push the plunger down hard and fast; some substance solutions may burn. Injecting at a slower rate reduces the pain.
#Once the solution is injected, remove the hypodermic needle at the same angle as it went in. Re-swab the area of injection with an alcohol swab.
 
====SC injection====
[[File:SC injection skin pinch.jpg|300px|thumb|left|Hold and pinch the skin to inject into the subcutaneous tissue.]]
'''<span style="color:red">Warning: This method of injection is uncommon and is not advised. The hypodermic needle may break off in the skin, hit a nerve, or cause scarring, lumps, and other skin problems. Additionally, the risks of infection are greatly increased when using this method of administration.</span>'''
 
*'''Hypodermic needle type''' - An IV or insulin hypodermic needle length is suitable for this type of injection. Do not use a longer needle length as it can penetrate other types of tissue and cause medical problems.
*'''Administration sites''' - The areas where SC injections can be administered in are the abdomen, the thigh, the lower back, and the upper arm.<ref>How To Give A Subcutaneous Injection (drugs.com) | https://www.drugs.com/cg/how-to-give-a-subcutaneous-injection.html/</ref> It is important to vary the injection site to avoid infections or injuries. Seek immediate medical care if a rash develops at the injection site or swelling is present after injecting.
 
{{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.
#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 tissue.
#Remove the hypodermic needle at the same angle that it entered and re-wipe the injection site with an alcohol wipe.
 
==Cleaning up after injection==
In order to prevent the spread of blood-borne diseases and bacterial infections, <span style="color:red"><b>clean up and dispose of used hypodermic needles and syringe barrels properly</b></span>. The needle and barrel of the syringe can hold old blood, that can harbor viruses.
 
===Single-use spoons===
Single-use spoons are made of thin metal sheets, which make them easy to press together to indicate that they have been used.
 
===Hypodermic needles===
One should always re-cap their '''own''' old hypodermic needle after injection to ensure that other people are not exposed to the old blood that still resides in the needle. The needle can and will cause accidental skin pricks that transmit disease. '''Do not let others re-cap someone's own used needle!'''
 
After the needle has been re-capped, it should be disposed of properly. Take the used needle and syringe to a medical waste/sharps disposal facility near you. Do not simply leave the needles lying around as this makes them available for re-use by others and is a possible vector for disease. Leaving needles lying around, especially if they are uncapped, also leads to an increased risk of accidental skin pricking which can cause injury, infection, or disease.
 
===Syringes===
After you have attached the cap to the hypodermic needle, make sure that the needle is still fully attached to the syringe adapter, and discard them in a [[#Sharps disposal containers|sharps disposal container]]. If you don't own a sharps disposal container, you can carefully bend thin 1 mL plastic syringes (with the plunger fully attached) 90 degrees, to prevent anyone from re-using them.
 
===Medicine bags===
If there are residues of injection fluid left in the syringe, it is considered medical waste. Then put the needle-free syringe in a pharmacy's plastic medicine bag. The same applies to ampules with residual injection fluid.
 
===Sharps disposal containers===
[[File:Improperly_Discarded_‘Sharps’_Can_Be_Dangerous_(6322401388).jpg|thumb|200px|FDA-approved sharps disposal containers are made with puncture and leak-resistant plastic.]]
 
You'll find sharps disposal containers in your local drug store, often offered gratis. They are also offered in needle exchange programs.
 
However, if you don't have access to a sharps disposal container, please collect the syringes and hypodermic needles in a puncture and leak-resistant plastic container, and leave it to your drug store as soon as possible.
 
===Biological residues===
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==
 
The injection site should be monitored for swelling, redness, or any other signs of infection. Seek medical attention from a doctor if you think the injection site may be infected or an abscess forms. An abscess may appear red, filled with puss, and hard and it may be a sign of a potentially serious infection. <span style="color:red"><b>Seek medical care immediately if persisting discomfort is experienced.</b></span>
 
*'''Getting tested''' - Regular STD tests and hepatitis B & C tests should be performed, especially if one suspects that they have injected with contaminated materials or has shared injection materials with others. Anonymous STD tests can be performed at local clinics or national organizations like Planned Parenthood.<ref>{{Citation | title=STD Testing Procedure - Facts About STD Screening & Tests | url=https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/get-tested}}</ref>
 
*'''Proper vein care''' -  One should avoid using veins that are tender, hardened, or inflamed until these veins have healed. It is important to take care of past injection sites, monitor them for signs of infection, and vary current injection sites.
 
*'''Shooting into the wrong tissue''' - If one misses an IV injection, it is important that the area is treated with a warm water soak or compress to reduce the likelihood of irritation and abscess formation. Warmth will open the capillaries and bring disease-fighting white blood cells to the affected area.
 
==Sterilization of re-used equipment==
 
===Equipment that never should be re-used===
Cotton is often used for filtration. However, [[cotton fever]] is a condition derives from an endotoxin released by the bacteria ''Pantoea agglomerans''.
 
===An autoclave is required to sterilize equipment===
Glass syringes, and single-use spoons, can be sterilized with an autoclave. It's not advised to sterilize solid metal hypodermic needles that have been used, because their needle points are blunt.
 
Sterilizing capacity of an autoclave:
* [[Sharing_injection_materials#Hepatitis_C|Hepatisis C virus]] (HCV): Sterilizing hypodermic needles using bleach, boiling water or alcohol may not kill HCV.<ref>{{cite journal |last1=Mukherjee |first1=TI |last2=Pillai |first2=V |last3=Ali |first3=SH |last4=Altice |first4=FL |last5=Kamarulzaman |first5=A |last6=Wickersham |first6=JA |doi=10.1016/j.drugpo.2017.05.041 |pmid=28652072 |pmc=5592150}}</ref> So it is not advised to share cooking pans to sterilizing equipment.
 
Sterilizing capacity of an autoclave or pressure cooker:
* [https://en.wikipedia.org/wiki/Prion Prion]: "For prion elimination, various recommendations state 121–132 °C (250–270 °F) for '''60 minutes''' or 134 °C (273 °F) for at least 18 minutes."<ref>{{cite journal |last1=Rutala |first1=WA |last2=Weber |first2=DJ |last3=Society for Healthcare Epidemiology of |first3=America |title=Guideline for disinfection and sterilization of prion-contaminated medical instruments. |journal=Infection control and hospital epidemiology |date=February 2010 |volume=31 |issue=2 |pages=107-17 |doi=10.1086/650197 |pmid=20055640}}</ref> A pressure cooker reach 120 °C at full pressure.
 
==Legality==
 
The injection of illegal drugs may lead to a higher risk of legal consequences. These consequences differ by country, state, and county. One should research the laws in their region before choosing to inject.
 
*'''[https://en.wikipedia.org/wiki/Hypodermic_needle Hypodermic needles] and syringes''' - Hypodermic needles and syringes are illegal to possess without a prescription in some states,<ref>{{Citation | title=Syringe Distribution Laws | url=https://lawatlas.org/datasets/syringe-policies-laws-regulating-non-retail-distribution-of-drug-parapherna}}</ref> and countries.
 
*'''Overdoses''' - If someone overdoses, the person who stays with them and calls emergency medical services will not be prosecuted. Do not simply leave a person who has overdosed to die out of fear of legal repercussions. The legal repercussions of staying with someone that has experienced [[drug overdose]] and calling emergency medical services vary by location.
**In the United States, the states that have "good samaritan" laws (in varying degrees) protecting those that call EMS as of January 2016 are: Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oregon, Pennsylvania, Rhode Island, Tennessee, Vermont, Washington State, West Virginia, and Wisconsin.<ref> State Good Samaritan Laws in the USA | http://www.drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29.pdf</ref>
 
*'''[[Naloxone]]''' - This life-saving drug is illegal to possess in some states, counties, or countries. Throughout the world, naloxone is not considered a controlled substance. In most countries, it is a prescription drug.
**'''Australia''': In Australia, naloxone is considered an over the counter drug and is available at most pharmacies.<ref>{{Citation | year=2016 | title=How painkiller use becomes a heroin addiction | url=https://www.abc.net.au/triplej/programs/hack/how-painkiller-use-becomes-a-heroin-addiction/7129964}}</ref>
**'''Canada''': In Canada, naloxone kits are distributed in many emergency rooms and clinics.
**'''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.
 
==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==
*[[Responsible use]]
*[[Responsible use]]
*[[Routes of administration]]
*[[Routes of administration]]
*[[Preparation]]
*[[Sharing injection materials]]
*[[Tutorial index]]


==External links==
==External links==
*[http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/ Getting Off Right Safety Manual (harmreduction.org)]
*[https://en.wikipedia.org/wiki/Drug_injection Drug injection (Wikipedia)]
*[http://www.drugs.ie/resourcesfiles/guides/mqi_safer_injecting_guide.pdf Safer Injecting Guide.pdf (drugs.ie)]
*[http://www.erowid.org/psychoactives/hardware/hardware_syringes.shtml Hardware Vault Syringe & Needle Basics (Erowid)]
*[https://injectingadvice.com/ Injecting Advice – A website for harm reduction workers and people who inject drugs]
*[http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/ Getting Off Right Safety Manual (Harmreduction.org)]
*[http://www.drugs.ie/resourcesfiles/guides/mqi_safer_injecting_guide.pdf Safer Injecting Guide.pdf (Drugs.ie)]
*[http://lawatlas.org/datasets/syringe-policies-laws-regulating-non-retail-distribution-of-drug-parapherna lawatlas.org - provides needle access information on a state by state basis]
*[http://www.drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29.pdf Fact Sheet States With Naloxone Access and Good Samaritan Laws for 2016]


==References==
==References==
<references/>
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{{references}}
 
[[Category:Responsible drug use]]{{Responsible use2}}
{{Responsible use2}}
 
[[Category:Responsible drug use]]
 
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