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Vein love/ vein flow:

Injecting in the same vein repeatedly causes damage to the vein. Thus, planning to use a variety of injection sites improves vein health. This is known as “rotating” injection sites. Classic sources of information include Chicago Recovery Alliance's Better Vein Care/Safer Injection Guide and Harm Reduction Coalition’s Getting off right: A safety manual for injection drug users. Focus on resources that center the voices of people who use drugs.

Vein: best, OK, please avoid

  • Best: Engage in better vein care or take a break from injection with “booty bumping,” inhalation, sniffing, or other drug administration styles

  • OK: Follow the hierarchy of safety of intravenous injection sites[1] from safer to less safe: arms, hands, legs, then feet. Avoid veins that cross over joints, local infection/injury

  • Please Avoid: injecting into your groin or neck

 

Start with injection sites further from the heart and move closer to it to reduce the risk of dislodging a clot from an earlier injection site.

 

Vein care includes:

  • regularly exercising muscles, which makes accessing veins easier,

  • tense and then relax local muscles repeatedly to increase blood flow to the area or tap sharply over the vein to induce reflexive vasodilation

  • learning to identify and then injecting above or below valves

  • drinking a glass of water instantaneously plumps veins

  • warming your body up with a warm compress, shower, or exercise to bring veins to the surface

  • injecting bevel up with the flow of blood

  • choosing the veins that are safer to inject into, as in not near a vulnerable part of the body

 

Give veins a rest and try other ways to ingest drugs. Other drug administration styles may not achieve the same “rush” as intravenous injection but drugs will still absorb most quickly from the rectum and more quickly from nose and lungs than ingesting by mouth. 

 

Vein love: tying off

Applying a tourniquet above the injection site increases the size of vein to improve injection accuracy, and the hole from the injection becomes smaller after removal of the tourniquet, thereby reducing wound and healing time.

  • The material used as a tourniquet should be easy on the skin and have elasticity

  • A tourniquet should be easy to remove one handed, via a slip knot.

  • Tourniquets pose infection risk if splashed with blood and should be sterilized if reused.

 

The purpose of the tourniquet is to restrict blood flow and cause the veins to bulge. A tourniquet should restrict venous return without impairing arterial circulation; to assure arterial patency check for a distal pulse. Tying the tourniquet with a slipknot above the site of injection allows a user to release the tourniquet one handed with ease. Tourniquets should be sterilized with an alcohol pad in between uses.

Vein love: best, OK, please avoid

  • Best: Hospital grade/harm reduction tourniquets

  • OK: Bike inner tube, stockings, something stretchy

  • Please Avoid: Hair ties, belts, neck ties, or using no tourniquet

 

Elastic tourniquets or stockings cause less harm to the skin than leather belts without stretch.

Hair ties are difficult to get off. Anything used as a tourniquet should be tied with a slip knot that can be easily removed.

 

Some found objects that work well as tourniquets include, lubricated condoms, bike inner tubes cut to size, or stockings. Socks and neckties may work in a pinch, but belts are not recommended.

 

Ideal length is like around a foot or 18 inches. The length should allow for the ease of tying a slipknot.

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Glass:​

Routes of administration that most rapidly get drugs into the blood include inhalation- the drugs are suspended in air and pass to the blood through the lungs - and IV injection. Since the lungs are closer to the heart than any venous injection site, the effects will be most rapid from inhalation. However, there is a lot of variability in how smoke is ingested, and once ingested, how well the lung functions to absorb it, so drugs may be lost when smoked too. Furthermore, some substances burn differently than others and require different equipment for different kinds of smoke capture. For example, heroin is smoked through a “hammer” shaped pipe or burned on a piece of foil and the smoke is inhaled through a tube, crystal meth forms a liquid, so it is smoked from a glass bulb, and crack cocaine stays mostly solid and is smoked from a glass stem. The route of administration that most closely resembles IV use is rectal administration. The tissues in the anus change from being part of the gut - where the blood passes to the liver and drugs are broken down - to being more like the skin. There are highly vascularized anal columns at this point in the transition between tissue types. When drugs are slowly dribbled on the anal columns, it delivers a large effect for a smaller, less expensive amount of drugs. Administering drugs there also provides a rush, like IV injection. Any drug that can be made into an aqueous (watery) solution can be administered rectally.

 

Sniffing or snorting, like rectal administration, target highly vascularized tissues in the nostrils, which have rapid effect. Some drug will be lost to postnasal drip, down the back of the throat and into the gut. However, the tissues are fragile and prone to inflammation (we’ve all had stuffy noses!), so even though this is a common and convenient route of administration, it does not work as a long term habit. Heavy use by sniffing or snorting is associated with a breakdown of the vascular plexus in the nose, so less drug can be absorbed there.

Glassware

Rubber or plastic mouthpiece attached at the mouth end of the pipe prevents burns. Mouthpieces can differ in length and width to be the best fit for a stem.

  • Best: Rubber or plastic mouthpiece

  • OK: rubber bands, tape, or an empty cardboard matchbook

 

Pipes made of plastic, pop cans or copper add to the dangers of smoking crack by releasing toxic fumes when heated or burned. Thin glass pipes, such as light bulbs or syringes, break easily and can lead to cuts.

 

If you are aware of people who need glassware but are unable to access it at your program, wish.com has inexpensive glassware options.

 

Mouthpiece

Rubber or plastic mouthpiece attached at the mouth end of the pipe prevents burns. Mouthpieces can differ in length and width to be the best fit for a stem.

  • Best: Rubber or plastic mouthpiece

  • OK: rubber bands, tape, or an empty cardboard matchbook

 

Rubber or plastic mouthpiece attached at the mouth end of the pipe prevents burns. Mouthpieces can differ in length and width to be the best fit for a stem.

 

Push sticks

  • Best: Wooden (such as chopsticks or kebob sticks)

  • Please avoid: Metal pushers (such as a coat hanger or screwdriver) can chip or cause cracks in the glass stem, which can cause oral sores. Plastic pushers (such as a pen or syringe) can melt inside the pipe.

 

Metal pushers (such as a coat hanger or screwdriver) can chip or cause cracks in the glass stem, which can cause oral sores. Plastic pushers (such as a pen or syringe) can melt inside the pipe.

 

Other materials for safer smoking

  • Alcohol swabs and hand- Alcohol swabs and hand wipes for cleaning one’s hands and equipment before using the equipment. This prevents bacteria and germs in the environment from getting into the body.

  • Lighters- Lighters, so every individual can apply consistent heat to their own pipe. The lack of one’s own heat source increases the chance that a person will share a pipe with someone else.

  • Chewing gum- Chewing gum, to prevent lockjaw and keep the mouth hydrated.

  • Condoms, lube

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Membranes: booty bumping

  • “Booty Bumping” 

  • Use syringe barrel with a removable needle that is removed

  • Prepare 1mL of aqueous drug solution

  • Remove needle, put a little lube on the tip of syringe barrel, insert into anus (about 4cm), and slowly push the plunger (no less than 3 seconds from start to finish)

  • Drugs “dribble” and absorb in the highly vascular “anal columns,” which provides a very rapid effect.

  • Notes: If someone is used to 100% drug absorption with IV injection, then drug administration in the rectum is closest. There may not be the same rush, but this is close. More of the drugs are available in the bloodstream than if the same amount were snorted. If transitioning from snorting to rectal, decrease the usual dose.

 

Membranes: water dripping

  • Prepare drugs in a solution, the same way as injection

  • Put into a cleaned handheld squeeze bottle (like a recycled Afrin squeeze bottle)

  • Add some water

  • Less diluting means fewer pumps to get a high

  • Thoroughly clean or get a new bottle every two days

  • If keep longer, can grow bacteria or brain-eating amoebas – very dangerous!

  • Notes: The nose contains a full vascular plexus that provides a straight path into the bloodstream. Due to postnasal drip, some drug is lost to absorption by mouth, which is less bioavailable. Intranasal administration is most efficient using a spray, which maximizes spread of the drug over the vascular plexus.

 

Membranes: nasal: sniffing

  • Bacteria and viral hepatitis may be present on

    • Scoops – often a straw or key used to remove a small amount of powder from a bag

    • Surfaces used to break up particles in the powder

    • Straws (or rolled up dollars) used for sniffing

  • Safer sniffing kits may include:

    • Sniffing straws

    • Sticky Notes

    • Sniffing sterile water/saline strips

    • Chewing Gum

 

  • Used sniffing straws (or rolled up dollars) can carry bacteria and Hepatitis C. An unhygienic straw or key used to scoop small doses from a larger supply introduces bacteria and viruses to the drug supply itself. 

  • The safest way to snort is to use a sterile straw or piece of paper every time, then throw it out. If reusing, reduce (but not eliminate) risk by avoiding sharing.

  • Straws with scoops on the end are great for taking “bumps” and can also be used to break up particles in powder drugs

 

Straws

  • Best: New straw every time

  • OK: Sterilize your straw with alcohol wipes

  • Please Avoid: Sharing or reusing straws – bacteria grow quickly, HCV sticks around and there are lots of blood vessels in your nose

 

Post it notes

  • Best: Use a sticky note (ex. Post-It) for snorting lines with, or to sniff drugs off of

  • OK: Sterilize the surface used to sniff off of

  • Please Avoid: Using dollar bills to sniff with, which collect bacteria and viruses

 

Water

  • Best: Sniffing sterile water/saline strips (Addipaks) before and after a session of drug use will help protect skin.

    • Good for general health

    • Reduces chance of having openings where germs can enter

  • Good: Tap water, sealed bottled water, boil water for 30 mins

  • OK: Opened bottles of water, water from back of toilet

  • Please Avoid: Water from front of toilet, puddle/gutter water

 

Chewing gum

  • Helps increase saliva

  • Saliva protects the enamel on teeth

  • Chewing reduces the risk of teeth grinding

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Bevel up/ bevel down:

 

Gauges

  • Gauge is the circumference (size around) of a needle point

  • Differs according to:

    • Viscosity or “thickness” of blood and fluid being injected

    • The size circumference (around of) the vein

  • Common IV sizes are 27g, 28g, 29g, 30g, and 31g

  • Hormones, use 18g, 20g, 22g

  • Smaller sizes have bigger numbers, large sizes have smaller numbers. As in the sizing of piercings or tools.

  • Blood will be less viscous when a person is well hydrated. Drug preparations can differ in viscosity based on the amount of water or saline mixed with the drug and the type of drug.

 

  • The needle gauge should match the size around of the vein. Veins in the hands are smaller than in the arms, so gauge would be a higher number, like a 30g in the hand, and a 27g in a vein near the elbow

  • Smaller gauges tend to be less painful and do less damage to veins. Conversely, larger gauges clog less easily and are more durable.

 

Volumes

  • The volume of fluid that can be held in a syringe barrel

  • Marked by graduations on the size of the barrel

  • Range from 1/3 mL to 3 mL

  • 1 cubic centimeter (cc) = 1 milliliter (mL)

  • ⅓ mL is seen typically in insulin injections, SSPs more frequently offer ½ mL or 1 mL. 1 mL is the most common volume. Greater than 1 mL barrels are more common with 2-piece syringes or syringes designed for intramuscular injection.

  • A smaller volume may increase the number of times someone injects, and the higher the number of injections increases potential vein damage and infection. More injections of smaller amounts, conversely, can be helpful in reducing overdose risk.

  • Syringe volume may also depend on what drug is being injected: smaller, finer syringes are preferred for fentanyls/opioids, while a larger barrel size may be needed for pills and other drugs that require more water to mix.

  • Smaller gauges are usually manufactured with smaller needle sizes, because the smaller around of a vein, the closer to the surface of the skin. For example, a 31g syringe will only be manufactured in a 5/16-inch length or smaller. Whereas, a 30g syringe (one size larger around) may be manufactured in ½ inch or 5/16 inch. A ⅝ inch syringe will come in a gauge that is 27g or larger. Syringe volumes are generally 1 ml or ½ mL for the gauges between 27g and 31g and will be larger in larger gauges (a number less than 27) or smaller in smaller gauges. 

 

Volumes: best, OK, please avoid

  • Best: Use as small a needle gauge as possible

    • Smaller hole = smaller wound = reduced healing time

  • OK: Continue the injection practice that is most comfortable and reliable, using the appropriate syringe size

  • Please Avoid: Changing to inappropriate and ineffective syringe sizes that cause an increase in the amount of injections

 

Acidifier

  • Some drugs do not dissolve easily in water or saline solution.

  • Adding vitamin c (ascorbic acid) helps dissolve black tar heroin or crack cocaine.

  • Food grade vitamin c is available

    • in bulk at health food stores and small amounts of the powder can be bagged up

    • In small packets

 

  • Lemon juice and vinegar are widely available, but they are harsher acids, causing more pain, irritation, and damage to the veins, which may cause veins to collapse.

  • Vinegar and lemon juice may also be contaminated with bacteria or fungus, lead to life-threatening infections including abscesses, cellulitis and heart infections, or eye infections causing blindness.

  • Medical-grade vitamin C is the safest acidifier. It causes the least damage to the veins, is non-toxic, and is sterile, reducing or eliminating the harms associated with other acids.

  • Shared acidifiers, like shared needles and other injecting paraphernalia, may transmit infection such as hepatitis C or HIV between users

 

Acidifier: best, OK, please avoid

  • Best: Smallest amount of Vitamin C or ascorbic acid from a packet

  • OK: Bulk Vitamin C (ascorbic acid)

  • Please avoid: Vinegar, lemon juice or drink packets with sugar and dyes in them or lemon juice

 

  • Add very small amounts of vitamin C until the drug is fully dissolved.

  • For crack, the amount of vitamin C required is about ¼ the size of the rock; however, for crack and brown or black tar heroin, the amount of vitamin C needed to fully dissolve the drug varies with the purity of the drug.

  • Once the packet of vitamin C is opened, any leftover should be thrown away, so that it does not become contaminated and cause an infection.

  • While bulk options are OK, it can be made of large, coarse grains, which increases the chances of adding in too much in a solution.

 

More info: 

  • Cotton pellets are used to filter out undissolved particles after the drug preparation has been  heated, when it is being drawn up into a syringe.

  • Sharing or use of old filters risks exposure to microorganisms like Staphylococcus aureus, Candida, HIV, and HCV. 

 

Bevel: splitting bags

 

Cookers

  • Sharing cookers is an easy way to contract HCV! Most people think it’s just sharing needles, but it can live in cookers for up to a week!

  • HCV can survive on dry surfaces and equipment for up to 6 weeks. HIV does not survive long outside the body or when it comes into contact with air, but shared injection equipment may contain trace blood, and blood contact can spread HIV.

 

Water

  • Drug preparation includes the dissolving of drugs in water or saline solution. Rinse waters are also used to extract leftover drugs from filters when people face drug scarcity.

  • Studies have shown risk of exposure to HIV and HCV in waters. 

  • Water ampules have the added benefit of easy to read in milliliter graduations (measurement markings) for precise mixing of drugs.

  • Water ampules repurposed from medical nebulizer treatments are labelled “not for parenteral administration” and “Rx ONLY.” They are commonly found in 3mL volumes, which is more than enough for one injection.

  • This is for liability purposes, yes, they can be used for injection! 

 

Water: best, OK, please avoid

  • Best: Sterile water/saline strips (Addipaks), sealed bottled water, or boiled water 

  • OK: Opened bottles of water, tap water, water from back of toilet

  • Please Avoid: Water from front of toilet, puddle/gutter water

 

Cotton filters

Cotton: Best, OK, Please Avoid

  • Best: New cotton pellet for each new cooker for each new needle (each new shot[HE1] )

  • OK: Unused cotton swab or tampon (cotton) or cigarette filter (cellulose)

  • Please Avoid: Old cottons

 

  • In this unregulated drug market drugs are cut with who knows what. This “who knows what” can, if injected instead of filtered out, become an embolus (a solid thing that clots in the bloodstream). An embolus can cause such complications as deep vein thrombosis, stroke, or heart attack

  • Cotton fever – anecdotally, it’s because you inject little pieces of cotton you feel feverish and ill. It’s actually due to bacteria, Pantoea agglomerans, which commonly colonizes cotton plants, that precipitates the rapid (within 15-30 mins) and rarely serious symptoms of fever, headache, *chills/shivering,* nausea, joint and muscle pain; normally self-resolves within a day, can take a warm bath and some ibuprofen to reduce symptoms. There is always a risk with using cotton to inject, so that’s why you use a new, tightly rolled one every time

  • For q-tips or tampons, it is best to tightly roll (with clean and gloved hands) little wisps of cotton to reduce risk of long strands of cotton entering the veins and causing an embolus.

  • Cigarette filters are made of cellulose, NOT fiberglass. Nevertheless, still not ideal to inject it because cellulose particulate may lead to an embolus. Filters from smoked cigarettes should never be considered.

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Fentanyl:

Fentanyl test strips can be used to test drugs for trace amounts of fentanyl. 1 red line = positive, 2 red lines = negative. These are designed as urine drug screenings but work with drug preparation solutions too. Disclaimer: The U.S. Food and Drug Administration (FDA) cleared the use of FTS as a dipstick for detecting fentanyl in urine by trained medical personnel. However, the FDA has not evaluated or approved the use of FTS for the purpose of checking diluted, illicit drugs for the presence of fentanyl, prior to consumption. There are a lot of great resources for naloxone and overdose reversal. The website naloxoneforall.org includes a lot of great tutorials for people who use drugs and their loved ones, and the site https://prescribetoprevent.org/ includes resources that are helpful for prescribers, pharmacists, and other community members.

 

Fentanyl: best, OK please avoid

  • Best: Use with a friend, check drug potency, and have naloxone on hand.

  • OK: If using alone is unavoidable, text or call someone.

  • Please avoid: Using a product of unknown potency alone without telling anyone. 

Take care of each other. Ask someone to be prepared for all outcomes to care for you when you use. And reciprocate!

 

Checking in: 

  • If someone must be physically alone, then webcam, phone, and text can be used for check ins.

  • Make use of drug-use safety monitoring resources such as Never Use Alone (visit http://neverusealone.com/ or phone/ text 800-484-3731) and BeSafe (https://www.besafe.community/ or on Google play and Apple app store).

 

Drug potency varies. Fentanyl test strips help identify its presence, but not its potency. “Tasting” - A practice of injecting a tiny amount of drug solution initially to learn the strength of the solution has been used to prevent overdose. Some people avoid this practice because they are concerned it may dilute the impact of their shot.

 

Sometimes using alone is unavoidable. Is someone available to check in by call or text instead? New apps are designed to sound an alarm if a message to you goes unanswered.

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