Heroin Addiction - Help for Addicts

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Preventing Unnecessary Vein Damage

Preventing unnecessary vein damage: a briefing paper for those working with injecting drug users
by Paul Hardacre, Andrew Preston and Jon Derricott

Published by Exchange Campaigns for Queensland Health,
the South Australian Drug and Alcohol Services Council (DASC),
and the Victorian Department of Human Services (DHS).
© Exchange Campaigns 2003
info@saferinjecting.org

Introduction
Intravenous injecting is a highly efficient way of introducing drugs into the body. However, when drugs are injected, the filtering and delaying mechanisms that protect us when things are absorbed via the gastro-intestinal tract, lungs or skin are bypassed. This makes injecting by far the most hazardous way of introducing drugs into the body. In particular the potential for infection and overdose are much increased.

A large body of research shows that injecting is associated with increased levels of drug dependence, and increased risk to health from:

• blood-borne viruses;

• bacterial infections;

• fungal infections;

• damage to the circulatory system; and

• increased likelihood of overdose.

Although the best way of reducing the harm associated with injecting is to stop injecting, it is clear that many injectors do not want to stop, nor will they accept interventions and treatment that only seek to stop them injecting.

Services working with injectors must therefore be able to provide appropriate information and support on how to reduce a range of injection-related harms.

The focus of much information and advice is on preventing the sharing of injecting equipment, and the transmission of blood borne viruses such as hepatitis B and C and HIV. However, many injectors experience injection site problems such as infections and physical damage, and most do not seek appropriate treatment for them unless they become serious. This results in greater levels of permanent damage, and the injector requiring more intensive and expensive treatment.

It is important that staff at NSPs are able to give advice to reduce the incidence of problems at injecting sites, and to encourage appropriate help seeking when they do occur. The needle and syringe program (NSP) is an obvious first port of call for injectors concerned about problems caused by injecting. Although it would be desirable to have staff with nursing and/or medical expertise available within all NSPs, this is not practical for many services. However, providing they have the knowledge and confidence, NSP staff are able to give clear and useful advice on preventing and responding to local injuries and infections, and on ways of reducing injecting damage.

The Vein Care materials are designed to:

• enable medical and non-medical staff to give correct and consistent advice about vein care;

• raise awareness and knowledge amongst injectors about the issues; and

• change injecting practice to reduce damage to veins and other health problems associated with injecting.

Prolonging the life of injection sites in the arm can prevent or delay the progression to more dangerous injecting sites, and therefore prevent or delay many serious health consequences of injecting. Furthermore, changing injecting practice to preserve veins (which, because the benefits are instantly realised, may seem like a more desirable goal to some injectors than avoiding illness in the long term from viral infections) can - by incorporating handwashing and the use of a new syringe every time - also reduce risk of viral transmission.

Correct intravenous injection technique
Irreversible damage to the veins can occur where there is:

• repeated use of the same injecting site;

• poor technique;

• injection with blunt needles;

• injection with needles that are too large; and

• injection of irritant substances.

In the course of conversations about injecting technique drug workers should ensure that their clients understand the importance of:

• washing hands, and cleaning the injection site with soap and water, or an alcohol swab;

• preparing drugs for personal use in your own space, and using equipment that has not been used by anyone else;

• choosing the smallest possible bore and length needle for the site;

• selecting a suitable vein, and introducing the needle by carefully sliding it under the skin, at a shallow angle and with the bevel up, and then into the vein;

• injecting with the blood flow, i.e. towards the heart;

• pulling 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 once you have drawn blood back into the syringe;

• injecting slowly to reduce the likelihood of drugs leaking around the needle into the tissues surrounding the vein and damaging the vein;

• injecting the hit in two halves with a short break (a few seconds) between will reduce the overdose risk;

• not jacking back blood and ‘flushing’ after a shot - as this can significantly increase damage to the vein;

• removing the needle slowly and carefully;

• applying pressure to the site with a blood proof pad, cotton wool or tissue (bruising is caused by bleeding into the surrounding tissue. Immediate firm pressure will limit the amount of bruising caused); and

• safely disposing of used injecting equipment, and whatever has been used to stop bleeding.

Sites for intravenous injection

Arms
The loss of usable arm veins (Figure 1) will leave the injector with stark choices: either to stop injecting and switch to another route of administration, or to move to another site on the body with greater inherent risks.

It is for this reason that injectors should be encouraged to do everything they can to preserve the veins in their arm for as long as possible.

It is important that workers seeing clients who are having difficulty accessing veins in their arms discuss with them the plans they have for the time when it becomes impossible.

Reinforcing any taboos the client has about moving to more dangerous sites may help prevent or delay transitions to more dangerous routes of injection.

Hands
The veins on the backs of the hands (Figure 2) can be highly visible, although they tend to be small and fragile.

As it can be difficult to hide the evidence of injecting here, many injectors avoid these sites. Furthermore, if complications such as infection of cellulitis occur, they are likely to be much more disabling in the hand than in the arm and lead to severe problems, especially if rings are left in place on the fingers.

Fingers should be avoided as the veins are very small. If clients insist on injecting in their fingers, they should understand the vital importance of removing rings prior to injecting. If a finger starts to swell with a ring in place, it can quickly obstruct the blood flow leading to loss of the finger. The artery that supplies the finger lies just below the vein - if the artery is damaged the finger can ‘die.’

Legs
The superficial leg veins are unlikely to be viable long-term prospects for injecting. The blood flow in the veins is slow, and so if people inject too quickly there is often leakage into surrounding tissue: this can cause infection and further vein damage. They also contain more valves, which increases the likelihood of problems, as injecting at or around a valve causes more turbulence, and therefore clotting of the blood, and can damage the valve which further slows blood flow. The superficial veins of the leg tend to ‘wobble’ when people try to get a needle in them, and this can result in more frequent ‘missed hits’ and vein damage.

As the flow of blood in the leg veins is upwards (i.e. towards the heart) it can be difficult to self inject in the correct direction in the legs, i.e. with the needle pointing up towards the top of the leg. Because they are furthest from the heart, and due to gravity, blood flow through the leg veins is slow. If drugs are injected too fast, the veins will be unable to cope with the extra fluid. When this happens, fluid can escape from the vein, around the needle, causing a ‘miss.’ This can be reduced by injecting slowly.

Healing of injection site damage and resistance to infection are less reliable because the blood flow is slow. Abscesses and other infections are therefore a greater risk for those injecting into their legs.

Varicose veins form, usually in the leg veins, because of damaged valves. The varicose vein has tight, thin walls and is often raised, stretching the skin. They should not be injected into, as they can bleed profusely because the damaged valves mean that blood can run back down the vein and out of the wound.

Feet
Although the veins in the feet are used by some injectors, there are several factors which make them an unsuitable choice for anything other than occasional use:

• venous blood flow in the feet is slow - if local infection occurs, this can lead to loss of mobility;

• injury to the feet may be slower to heal than in other areas, especially in individuals with already damaged circulation;

• fungal infections of the feet are common - there may be an increased risk of introducing these into the body; and

• for most people there is a need to wear shoes and socks - this may encourage or compound problems of infection.

As with the legs, injections in the feet should be done as slowly as possible to prevent overloading the vein.

Highly dangerous sites
The highly dangerous sites included in this section - such as the neck and penis - are not discussed to enable workers to recommend their use to clients. It is not possible to ensure that the use of these sites is safe enough to make their promotion an ethical option.

Workers may well be faced with users who are already using, or talking about using these sites. As it is often impossible to make these dangerous behaviours safe enough, workers should advocate the use of other, safer sites or routes of administration. Where the use of other, safer sites is not a possibility, workers should be encouraging these injectors to:

• move to another safer route of drug taking;

• take a break from injecting; and

• contemplate community or inpatient drug treatments.

Breasts
Although there are usually small veins visible in the breasts, especially in pregnancy, it is dangerous to try to inject into them because they are very small and liable to break. They are also next to milk ducts which can be accidentally filled with fluid. Because there is no direct blood supply to the inside of the ducts, the fluid stays there and the risk of developing mastitis or abscesses is high.

Deep veins
When searching desperately for a usable vein, some injectors will ‘look’ for deep veins, by simply ‘digging around.’ Where this is because of a lack of awareness of available sites, supplying relevant information may be useful. For those who have limited knowledge of their body structures, education about the risks of hitting arteries, nerves and bones should be offered.

Armpit (axilla)
The armpit is a dangerous site for injecting because of the close proximity of arteries and nerves to the subclavian vein.

Neck
Self injecting in the neck is extremely dangerous, difficult to do and should be strongly discouraged. Arteries, veins, tendons and nerves are all very close together. Engaging in discussion about ways to ‘make it safer’ should not distract from the central message that it is too dangerous.

Part of the risk arises from the fact that for self injectors, self injection in the neck requires the use of a mirror. This difficulty may lead injectors to ask others to attempt neck injection for them, thereby increasing the chances of both viral transmission and local injury, and removing all personal control over the process. It may also lay the injector open to at least a manslaughter charge if the person dies - even if they requested the injection.

The common complications of neck injecting may be similar to those in other areas, such as cellulitis and abscess formation, but have even more devastating effects. An abscess or cellulitis in the neck can cause dangerous pressure on nerves or obstruct the airway.

Other problems include:

• accidental injection into an artery - if this occurs, then the drug and any other matter contained in the solution will go directly to the brain, potentially causing a range of neurological problems, including strokes;

• weakening of the blood vessel wall (aneurysm); and

• nerve damage, including vocal chord paralysis.

Penis
Injecting in the penis is sometimes attempted when other possible sites are no longer available. The penis is dangerous for injection, and complications such as local infections are almost inevitable.

A condition known as priapism - a permanent, painful erection - is a possible consequence of penis injecting. This is because an erection is caused by the veins becoming smaller and restricting the flow of blood out of the penis. For the penis to return to its normal size the veins must be able to re-open. If this is not possible because of damage, the erection will not subside.

Some injectors mistakenly think that ‘groin’ injecting refers to injecting in the penis. When talking about groin injecting it is vital to clarify that you are referring to femoral injecting.

Femoral injecting

The femoral artery, vein and nerve lie very close together and their relative position varies from person to person (Figure 3). Gray’s Anatomy (1977:616) describes the femoral vein as follows:

‘The femoral vein accompanies the femoral artery through the upper two thirds of the thigh.’

Femoral (or ‘groin’) injecting is usually begun when access to the veins in the arms becomes difficult or impossible, and is always dangerous. The main dangers are:

• injecting into the femoral artery causing damage;

• hitting the femoral nerve and causing intense pain and possible paralysis;

• abscess/ulcer formation at the injecting site;

• formation of sinuses at the injecting site (sinuses are permanent tracks from the vein to the skin surface caused by infection or persistent use);

• fistulae (communicating tunnels) between the femoral artery and vein are also a possible complication of injecting into the femoral vein;

• circulatory damage to the leg, including deep vein thrombosis; and

• varicose ulcer in the lower part of the leg - caused by damage to the leg veins.

Rozler et al. (1988) noted seeing an increase in the number of complications associated with femoral injecting. As well as many of the above, these also included mycotic aneurysm (fungal infection of the artery wall) and pseudoaneurysm (weakening of the artery wall).

Just how dangerous and damaging femoral injecting will be on any one occasion is affected by:

• the understanding the injector has of their underlying structures;

• the dexterity of the injector;

• the state of mind of the injector (eg. intoxicated or not);

• the substance being injected; and

• luck.

Of the dangerous sites, femoral injecting is the most frequently practised. It has to be acknowledged that some individuals with good technique use this site for many years before they experience problems.

Working with femoral injectors
It is impossible to remove the risk from injecting into the femoral vein. It is however, possible to increase the knowledge level of many injectors about their own anatomy, without encouraging or helping with femoral injecting. By increasing the knowledge of the risk simply by using the diagrams included in this briefing paper (with the clear understanding that these diagrams are only representative and that each individual’s anatomy will in reality be somewhat different) some injectors may choose not to use this site.

Many will not change their behaviour and will choose to continue femoral injecting, sometimes requiring treatment for the results of poor injecting technique.

For those agencies prescribing injectable drugs, it would be unethical to do so to known femoral injectors without confirming that their understanding of femoral injecting is sound and their technique good.

An agency policy accompanied by adequate staff training on the level of advice it is acceptable to give femoral injectors will help to remove a lot of the existing uncertainty and stress for workers. Unfortunately, it cannot do the same for injectors.

The following advice is sometimes given to femoral injectors. It should be clearly understood that whilst this advice is likely to help injectors avoid accidental injection into the femoral artery, it in no way guarantees a successful injection into the femoral vein, or avoidance of the femoral nerve.

It is advice that should only be given by workers who are trained and confident in their understanding of the issues, and have the support of their agency to do so. The femoral injector should be advised to:

• use the correct needle (depending on the amount of fat and tissue between the skin surface and the femoral vein);

• find the femoral pulse;

• keeping the fingers on the pulse, move two fingers’ breadth away towards the centre line of the body (it is important to be very clear about which direction to move in, as movement in the wrong direction will increase the chance of hitting the femoral nerve);

• push the needle in straight (i.e. at a 90 degree angle with the skin surface);

• pull back the plunger to establish that the needle is in the femoral vein;

• inject slowly; and

• apply pressure to the site for at least one minute following removal of the needle.

This instruction should be given on the clear understanding that the worker is offering no guarantees for the safety of the procedure, which is carried out at the client’s own risk.

If the injector accidentally hits the femoral artery they should:

• discontinue the injection;

• remove the needle;

• apply firm pressure to the site for at least 15 minutes; and

• seek medical advice.

As stated earlier, when discussing ‘groin’ injecting, clarification should be given that the conversation is about femoral injecting - as some people may think that the term refers to injecting in the penis.

The circulatory system
Needle & Syringe Program (NSP) workers should have a good understanding of the circulatory system in order to be able to explain it to clients, so that they in turn have a basic understanding to help them avoid or delay some of the potential harms associated with injecting.

The circulatory system exists to facilitate the flow of blood to all tissues in the body.

The transfer of oxygen and nutrients between the cells and the blood takes place through microscopic vessels called capillaries.

The heart is the pump that drives this flow of blood to the capillaries in the body tissues, to facilitate oxygen transfer and then back to the lungs to be re-oxygenated.

Arteries and veins
Arteries take oxygenated blood from the lungs to the rest of the body. They progressively branch out, diminishing in size, until they reach the capillaries.

The blood then passes through the capillaries in the tissues, releases its oxygen, and is collected in small veins, which by joining together progressively increase in size. The veins return de-oxygenated blood to the lungs via the heart.

Accordingly, all drugs injected onto veins must follow a route back - through veins of increasing size - to the heart.

From the heart the drugs are pumped the short distance to the lungs where the blood passes through the capillaries of the lungs to be re-oxygenated, and then they return to the heart to be pumped to the brain.

When a drug is injected into a vein, it reaches the brain via the lungs in a few seconds (i.e. 3 or 4). The drug is not significantly diluted: hence the experience of the ‘rush’ or ‘hit’ as the brain becomes rapidly intoxicated.

The exception to this description is the pulmonary artery, which is unique because it carries ‘de-oxygenated’ blood from the heart to the lungs. All other arteries carry oxygenated blood. Similarly the pulmonary vein is unique because it carries oxygenated blood from the lungs to the heart.

Valves are only present in veins, and assist the flow of blood back to the heart by preventing back flow (Figure 7).

The fact that all venous blood must pass through capillaries in the lungs before going to the arteries means that solid matter and air bubbles that are injected into veins cannot reach the brain (except in exceedingly rare circumstances - it is only possible if someone has a hole between the chambers of the heart); they will instead get trapped in the capillaries of the lungs. The idea that they can cause strokes (damage to the blood vessels in the brain) is untrue for the vast majority of people.

Differences between arteries and veins
General differences between arteries and veins have been summarised below (adapted from Aldridge & Cranfield 1993).

Arteries

• carry blood away from the heart;

• carry oxygen-rich blood (except between the right side of the heart and the lungs);

• hold bright red blood;

• blood at high pressure;

• bleed profusely - spurt blood;

• served by many nerves;

• thick walls;

• very elastic/muscular;

• no valves;

• less numerous;

• recognisable pulse; and

• mostly deep.

Veins

• carry blood towards the heart;

• carry oxygen-depleted blood (except between the lungs and the left side of the heart);

• hold dark red blood;

• blood at low pressure;

• do not bleed profusely - ooze blood;

• served by few nerves;

• thin walls;

• not elastic/muscular;

• valves;

• more numerous;

• no pulse; and

• deep and superficial.

Consequences of blocking arteries and veins
There is only one arterial route to each area of tissue in our bodies. If an artery is blocked for any length of time, all the tissue it supplies die.

Venous blood return tends to be more adaptable: veins form a complex network with many junctions. If a vein becomes blocked, blood can find its way through a smaller vessel further back down the system. It is when these smaller vessels become overloaded with blood that swelling occurs in the hands or feet.

Collateral circulation
When a vein becomes thrombosed or obstructed, blood can no longer flow through it to return to the heart. The blood will therefore take an alternative route, using other smaller blood vessels to get around the blockage.

This diversionary circulatory route is called ‘collateral circulation.’

When most of the veins have become obstructed, this process may result in the appearance of ‘new’ superficial veins on or near the skin surface. Injectors should be discouraged from attempting to use these veins, as they are likely to be small veins that have become engorged by the necessity for them to carry more blood.

They will therefore be under greater pressure than normal, so that injecting into them carries a greater risk of damage to the vein. The usual consequence of injecting into such veins is that within a few injections the vein becomes damaged and is no longer viable.

If the remaining veins are also damaged, then the return of venous blood from the affected limb is likely to be even more severely restricted. This will lead to slower blood flow out of the arm and lead to the limb becoming swollen and blue. The consequences of this are discussed below under ‘Long term consequences of substantial vein damage.’

Arterial injection
All drug injectors should be warned that they should never inject into a blood vessel in which they can feel a pulse.

Although most arterial injections are accidental, occasionally people attempt arterial injection deliberately. The practice of deliberate arterial injection should be strongly discouraged.

For those who hit an artery by mistake or otherwise, advice should be to:

• immediately withdraw the needle - do not complete the injection;

• put strong pressure on the site for at least 15 minutes;

• raise the affected limb if possible; and

• seek medical advice.

Arterial injection can sometimes cause weakening of the artery wall (pseudoaneurysm) or fungal infection of the artery wall (mycotic aneurysm). Both conditions can lead to life-threatening arterial bleeding.

Thrombosis
Blood clots form when there is turbulence in the flow. Damage to, or inflammation of, the lining of the vein (figure 8.1) can trigger clotting of the blood at the site of the damage (figure 8.2).

These clots stick to the lining of the vein, and are known as thromboses. The clots themselves cause turbulence and this, in turn, can cause further clotting (figure 8.3).

A blood clot inside a vein does the same things as a blood clot on the surface - it hardens and turns to scar tissue that shrinks and pulls the edges together (figure 8.4).

It is this pulling together of the edges that makes veins ‘collapse.’

Veins that have collapsed in this way do not ‘unblock’ - the blood has to find another way back to the heart.

Vein blockage and collapse
Veins may become temporarily blocked if the internal lining of the vein swells in response to repeated injury or irritation. This may be caused by the needle, by the substance injected, or both. Once the swelling subsides the circulation will often become re-established.

Smaller veins may block as a consequence of too much suction being used when pulling back against the plunger of the syringe to check that the needle is in the vein. This will pull the sides of the vein together and (especially if they are inflamed) the sides of the vein may stick together, causing the vein to block. Removing the needle too quickly after injecting can have a similar effect.

Permanent vein collapse (Figure 8) occurs as a consequence of:

• long-term injecting;

• repeated injections, especially with blunt needles;

• poor injecting technique; and

• injecting of substances which irritate the veins.

Long-term consequences of substantial vein damage
When the flow of blood through the limbs has been severely affected, there are a number of problems that can arise. These include:

• ulcers;

• local infection; and

• gangrene.

Ulcers
One possible result of serious deterioration of circulation can be painful areas of broken skin known as ulcers.

Ulcers form when the skin is knocked or scratched (or injected into) and the surface is broken. The slow flow of blood means that the cells cannot reproduce quickly enough to heal the wound. The resulting moist and painful wound can take years to heal, and can be compounded by infection.

Factors affecting healing

• diet and nutrition;

• stress;

• poor accommodation; and

• drug and alcohol use.

Treatment of ulcers
Unless a NSP is specifically set up to provide primary health care to clients, the client should be referred to either their general practitioner or an A&E department for assessment and treatment.

Ulcers take many months to heal and may require frequent attendance for treatment. There are strong arguments for advocating that these and other health care needs will best be met within drug treatment and NSP services, because:

• users of drug treatment agencies may not attend if referred to other agencies;

• drug users may tend to believe health problems are to be expected and therefore do little about them; and

• they are less likely to receive discriminatory treatment.

Local infections
As well as risks of systemic infections such as hepatitis and HIV, injecting carries the risk of introducing bacterial and fungal infections to the tissue surrounding the injection site.

Often local infections are caused by bacteria which live harmlessly on the skin being picked up by the needle and forced below the skin where they multiply.

The risks of local infection will be increased by:

• sharing of needles and syringes, and injecting paraphernalia;

• reuse of unsterile injecting equipment (including filters);

• the use of non-pharmaceutical medication;

• unhygienic preparation of drugs; and

• poor personal hygiene.

Providing injectors with an understanding of the ways in which infection may be introduced is crucial. Ideally, they should be aware of the risks they may be exposed to and how to reduce them.

Local infections include abscesses, phlebitis, and cellulitis.

Abscesses
An infected abscess is a localised collection of pus that is encapsulated within inflamed tissue (Figure 9). It can be caused by a wide range of bacterial and fungal infections. An abscess is different from cellulitis in that it has a defined edge and shape.

An abscess is characterised by:

• raised skin surface;

• localised heat;

• tenderness and pain;

• redness of the skin (in white people);

• pus formation; and

• a foul smell if it has begun to discharge.

People with abscesses should be referred for medical advice and treatment. The abscess will require antibiotic treatment and/or lancing to release the pus.

Injectors should be told never to try to lance or puncture abscesses themselves. This can spread infection and without appropriate antibiotic cover they can quickly develop septicaemia (blood poisoning). They should be encouraged to alternate injecting sites as this will lessen the risk of localised inflammation, infection and abscess formation.

Phlebitis
Phlebitis is irritation of the smooth inner lining of a vein (tunica intima). The roughening of the vein lining can encourage the formation of clots.

The vein is reddened or inflamed and can sometimes be felt as a thick cord beneath the skin.

Phlebitis can occur as a result of:

• injecting irritant substances (such as benzos, pills, etc.);

• poor injecting technique;

• infection; and

• accidental injury (i.e. knocks or blows).

An important complication of phlebitis is deep vein thrombosis (DVT) leading to pulmonary embolism.

If phlebitis is suspected the person should be referred for immediate medical advice. Treatment includes resting and raising the limb, antibiotics and anti-inflammatory drugs.

Cellulitis
Cellulitis refers to a painful spreading inflammation of the skin, which appears red and swollen with fluid (this is known as oedema).

Cellulitis can occur as a result of:

• irritant substances lodged in body tissues; and

• serious infection.

Where cellulitis is suspected the client should be referred for immediate medical advice. Treatment includes resting and raising the affected limb, and treatment with antibiotics and anti-inflammatory drugs.

Advice for people who have had cellulitis would include the following measures to prevent reinfection:

• using sterile injecting equipment;

• using sterile water where available and discussing alternatives where it is not;

• avoiding the injection of irritant or heavily adulterated drugs; and

• removing rings prior to injecting if injecting in the hands.

Gangrene
Gangrene is the death of body tissue caused by impaired or absent blood supply. Gangrene can occur as a result of arterial or serious venous damage.

The effect of gangrene can be disastrous, leading to loss of limbs. It can also cause the products of tissue breakdown to enter the bloodstream causing blood poisoning and threatening life.

Arterial damage
Gangrene as a result of arterial damage occurs when an artery is injected into instead of a vein. Often this is as a result of injecting irritant drugs (such as benzos, pills, etc.) into the femoral artery rather than the femoral vein. However, it can occur when people inject into the smaller arteries in the arm.

Gangrene as a result of injecting into an artery can occur in the following ways:

• the artery can go into spasm and interrupt the supply of oxygenated blood to the tissues;

• the injected substance can block the artery,

• interrupting the blood supply to the tissues; and

• small particles of the injected substance

• (micro-emboli) can be transported into and block the capillaries in the tissue - causing their breakdown.

Venous damage
Gangrene following venous damage may be slower to develop, and results when damage to the veins is such that the return of venous blood from the affected limb is no longer adequate; blood gets into the tissues at a faster rate than it can get out. In the end the reduced flow of blood through the tissues is inadequate to sustain them and they die.

Signs and symptoms

• pain;

• loss of feeling and control in an area of skin;

• swelling and dicolouration of affected limb;

• affected extremities, i.e. fingers or toes;

• affected tissue initially becoming white;

• affected tissue eventually blackening; and

• if untreated, affected tissues dropping off.

Prevention and treatment
Injecting drug users need to be given advice on the following subjects to enable them to prevent gangrene occurring:

• the dangers of arterial injection;

• the signs and symptoms of injecting into arteries;

• first aid treatment following accidental arterial injection; and

• discourage injection of crushed tablets and gel-tabs, especially Temazepam tablets,
  Temazepam Gelthix capsules, and Diconal.

In the event of symptoms of gangrene occurring, injectors must be aware that:

• this is a serious complication that will not go away unless they get medical help; and

• they must get urgent medical treatment - if the onset is sudden they should call an ambulance.

Other injection site problems
‘Missed hits’
‘Missed hit’ is a phrase used to describe swelling which appears around an injection site during or immediately after injection. It may be caused by fluid entering the tissue surrounding the vein because the needle has:

• not entered the vein properly;

• entered the vein and slipped out again;

• entered the vein and gone through the opposite wall; and

• entered the vein correctly but excess pressure caused the vein to split.

These problems can be prevented by encouraging injectors to:

• check that the needle is in a vein by gently pulling back on the plunger to see that venous blood enters the syringe;

• always releasing the tourniquet before injecting;

• maintain a steady hand whilst injecting;

• smoke a small amount of heroin before injecting, when in opiate withdrawal (if possible);

• use the smallest possible needle and syringe barrel;

• inject at the correct angle (i.e. in line with the vein); and

• inject the fluid slowly.

A ‘missed hit’ will mean that the drug is absorbed much more slowly by the body, so that the effect will be less pronounced. It can also lead to other problems such as abscesses, cellulitis, and cutaneous foreign body granulomas.

‘Lumps and bumps’
Many injectors have various ‘lumps and bumps’ under their skin, and these often cause anxiety.

The vast majority are not serious, and are caused by the mechanisms outlined below. Checking the history of that site for causes such as:

• previous abcesses;

• frequently used veins that have now collapsed;

• previous misses; and

• history of tablet injecting

will give strong indicators of the cause.

However, clients should be advised that if they are worried, or if the lump/bump ever changes (size, colour, mobility) they should seek medical advice.

Scar tissue
The scar tissue filling collapsed veins can remain visible, and feel like there is a ‘bit of string’ under the skin, for many years. Sometimes, there can be hard ‘knots’ under the surface of the skin, at the points where there were valves.

As with scar tissue from injuries we suffered as children that persists into adulthood, so scar tissue below the skin surface caused by injecting injuries can remain as a lifelong reminder.

Old abscesses can also leave lumps of scar tissue that remain for many years. When clients mention a lump under their skin the first question to ask is ‘have you ever had an abcess at that site?’

Very often the answer will be yes, and you can reassure them that the probable cause is scar tissue that filled the infected capsule when the abscess healed.

Sterile abscess
A sterile abscess occurs as a result of injecting irritant substances such as crushed tablets and possibly as a consequence of a ‘missed hit.’

It will often disperse without treatment but, over time, a granuloma may form around it.

Cutaneous foreign body granuloma
Granulomas are benign growths of scar tissue that are associated primarily with subcutaneous injecting or ‘missed hits,’ where the solution has by accident or design ended up in the surrounding tissue. In such cases a residue may stay for many years, eventually leading to granuloma formation.

Many of the common cutting agents for injectable drugs, such as quinine, mannitol, dextrose and lactose, are not thought to cause foreign body granulomas. However the injection of crushed tablets will increase the risk. The principle filler of the tablet is often hydrogenous magnesium silicate, frequently referred to as ‘chalk’ by users.

It should be noted that ‘successful’ intravenous injection of crushed tablets does not remove the risk of granuloma formation. It simply changes the place that they may be found, to the lungs.

Injecting myths
Strokes from air bubbles
There is a generalised belief amongst injectors and the general population that injecting air is ‘not a good thing.’ Whilst this is true, it tends to be somewhat overstressed in terms of importance when priorities for injecting drug users are being considered. It is possible to observe some injectors taking little or no care about hygiene or cross-infection risks whilst injecting, but exhibiting infinite patience when expelling the minutest of air bubbles from a syringe.

Compared to the size of an air bubble, it takes a gigantic volume of air to cause circulatory problems (the blood would froth in the chambers of the heart). Although it is desirable not to introduce air into the veins, even a few 1 ml syringes completely full of air would be unlikely to cause any problems.

Carefully removing tiny air bubbles from a syringe can be seen as evidence that injectors are concerned about their health and are prepared to act to preserve it. Some injectors simply need more information about more important priorities such as hygiene.

Having a second hit to ‘sort out’ a bad one
Some injectors have expressed a belief that the best way to deal with a ‘dirty hit’ (an acute reaction to injection, characterised by shivering and sweating that is usually self-limiting) is to inject again.

Whatever the cause of the reaction, repeating the procedure could at best make the experience worse, and at worst cause overdose.

Common practices that damage veins
Licking the needle tip
It is not uncommon for injectors to lick the tip of the needle before injecting. While it is understandable that people would want to avoid loss of any of their drug, and on seeing a small drop run down the needle want to lick it this practice will add large numbers of bacteria to the needle, and greatly increase the risk of infections (especially fungal infections such as thrush). The dose of drug in the droplet that is ‘saved’ will be tiny, and as heroin is not effective orally it will make no discernable difference to the ‘hit.’

Explaining these facts to injectors should help reduce this practice, which adds unnecessarily to the risk.

Licking the injection site
Again, this behaviour is not that uncommon and may be part of an attempt to ‘clean’ the injecting site prior to injection. This should be discouraged as it will increase the risk of infections, as discussed above.

Injectors should be encouraged to include stopping the bleeding with a disposable pad or tissue, and both hand and injection site washing with soap and water to their post-injection routine.

‘Flushing’
‘Flushing,’ ‘booting,’ and ‘kicking’ are terms which refer to drawing blood back into the syringe after the drug solution has been injected, in an attempt to ensure that no drugs are wasted by being left in the hub of the syringe.

As a small amount of the drug solution will be retained in the hub of the syringe (how much depends on the type of needle and syringe being used), it makes sense in terms of maximising the amount of drug getting into the body to do this.

However, the small benefit of this must be weighed against the extra damage that will be done to the vein and the fact that this practice will ensure that the injecting equipment used is heavily contaminated with blood. This makes the transmission of blood-borne viruses much more likely if the equipment is re-used by another person.

Some users claim that the process of booting or flushing intensifies the rush, so that they get more pleasure from injecting by doing it (and accordingly do it several times). There is no pharmacological basis for this belief, and they are likely to greatly increase the amount of local irritation caused by injecting if they flush repeatedly - thus shortening the ‘injecting life’ of the vein.

Alternatives to injecting
Smoking or ‘chasing’
The smoking of commonly injected drugs clearly offers lower risks than injecting, both in terms of viral transmission and risk of overdose.

When compared with injecting, smoking commonly injected drugs will offer:

• no risk of viral transmission;

• a lower risk of overdose;

• lower health risks;

• an alternative for those who are finding venous access difficult; and

• an alternative route of administration whilst injection sites are allowed to rest.

There is a potential value in using carefully thought-through campaigns promoting the smoking of commonly injected drugs.

Snorting
Snorting drugs is usually safer than injecting them in terms of the relative danger of transmission of blood-borne viruses. Viral transmission can occur if straws, etc. are used by two or more people.

As with injecting, it is best for each user to have separate equipment for the snorting of drugs. Prolonged frequent snorting of drugs (especially cocaine) can lead to damage to the mucous membranes in the nose and cause, or exacerbate, sinus problems.

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Swallowing
Of the commonly injected drugs, swallowing is most effective for amphetamines, which are often taken in this way, either by mixing the drug in a drink or by ‘bombing’ (wrapping it in a cigarette paper to reduce the unpleasant taste).

If an injector is contemplating using a ‘risky’ substance (eg. what is left on a spoon after filtering), swallowing usually represents the safest way of getting it into the body.

For those using benzodiazepines by injection - often as crushed tablets - taking them by mouth is by far the safer alternative and the effect, although slower to ‘come on,’ will ultimately be much the same.

If heroin is swallowed it gets converted to morphine in the stomach and as a result it becomes roughly half the strength. This fact, coupled with the slow absorption into the blood stream, means that it is unlikely to be thought a viable alternative to sniffing or ‘shafting’ by drug users.

Rectal administration: ‘shafting’
The functions of the rectum are to store faeces and reabsorb fluid in order to prevent dehydration. It has an excellent supply of blood in order to carry out this function, and this means that any fluid introduced to the rectum is quickly absorbed.

There may be some cultural resistance to this route of administration from injectors as this is an unusual route of drug administration, although some medications are given as suppositories which use the same absorption process.

It can provide for very rapid uptake of the drug (almost as fast as injecting), although not everyone finds this to be the case. In some opiate users the cause of this may be constipation and absorption of the drug by faeces.

The method is simple: the needle is removed from the syringe (essential!), then the tip of the syringe is inserted into the rectum, and the plunger depressed.

It can be suggested as a route of last resort in the event of not being able to find anywhere to inject which is much better than just sticking the needle in anywhere and injecting into the muscle.

It can also give injectors the ritual of drug preparation without the delay of fruitless attempts to find a vein, and slow absorption when they miss.

Source:  info@saferinjecting.org