Addiction Treatment Blog

Hypodermic injections should be prepared extemporaneously. In most cases they are plain solutions of alkaloidal or other salts in water. All utensils used should be sterilised by thorough washing and drying in an oven at 220 degrees Fahrenheit. The distilled water must also be sterilised by boiling.

Instructions for preparation of injections in ‘Pharmaceutical Formulas’, 1911.

Most intravenous drug users do not start by injecting.

Most intravenous drug users do not start by injecting. Cocaine, amphetamine and heroin are the main drugs which are administered intravenously, and the majority of current users who inject these drugs began by taking them in a non-parenteral form, or started by taking non-parenteral drugs alone. Many chronic drug abusers eventually prefer to inject rather than administer by other routes and there are a number of reasons for this. Intravenous administration provides the quickest access to the circulation, resulting in rapid passage of the drug to the brain. This produces the fastest possible onset of intoxication, and usually a ‘rush‘ or ‘buzz‘ of initial euphoria occurs when a bolus of drug reaches the brain. This effect is particularly sought after. Other methods of administration generally provide a slower onset and a less intense ‘rush‘. Non-parenteral methods often involve a degree of wastage as well: when given orally a proportion of the dose may not be absorbed or may be metabolised by the liver before reaching the brain; smoking or vaporisation usually destroys some of the drug; inhalation wastes the percentage of the drug which passes down the throat to be absorbed more slowly later.

Apart from these considerations, injecting forms part of the ritual drug abuse many individuals. Ritual is not an important component of the injection drug user’s experience – in a similar way, tobacco smokers or coffee drinkers prefer to partake at specific times of the day or to use particular techniques for preparation or administration.

Injection equipment (needle and syringe) is usually referred to at street level as ‘works’ and the process of injection is termed ‘mainlining’, taking a ‘fix‘ or ‘shooting up‘. The typical sites chosen for injection are the veins of the forearms, but users may switch to the lower leg, back of the hand, groin or neck if forearm veins are difficult to access. If intravenous access is severely restricted (as many occur in chronic users due to venous damage), the subcutaneous route may be employed. Anabolic steroid users administer their drugs intramuscularly.

The dangers arising from the process of injecting street drugs are discussed below.

Infection

Infections of street drugs are usually prepared by dissolving a non-sterile powder or crushed tablet in tap water. This is illustrated in the figure right. Occasionally, other liquids are used as diluents, such as lemon juice or vinegar, but this is unusual. The preparation may be heated on an old metal spoon or bottle cap to encourage the drug to enter solution. some injection drug users may employ citric acid or acetic acid to aid dissolution of substances such as heroin. Oral liquid preparations such as methadone mixture can also be injected, but may need to be diluted first. Once a solution has been prepared, a filter may then be used to remove any solid particles – commonly this is a cigarette filter, a piece of permeable fabric, cotton wool or blotting paper.

Finally the preparation is injected with a needle and syringe through the skin which is a common source of pathogenic bacteria, especially given the poor personal hygiene of some users. Bacteria on the skin may be carried through into the bloodstream. The injection equipment may be shared with another or used by the same individual on numerous occasions and may or may not be washed between injections. Even if washing does take place it is frequently done in a manner which does little to prevent contamination.

All of these steps in the injection process are clearly a potential source of contamination with pathogenic organisms – bacteria, viruses and fungi, By conveying a contaminated solution directly into the bloodstream, the individual bypassed all of the body’s normal safeguards against the entry of micro-organisms. For this reason, the infections seen in intravenous drug abusers are frequently well-known conditions but with atypical pathogens, or they may occur in unusual body locations. The likelihood of infection occurring, and of atypical organisms being responsible for them, is further increased if the individual is also suffering immunodeficiency due to AIDS.

Infections can be difficult to diagnose, because of the wide range of micro-organisms which are potentially responsible. However, not all fevers or infections in injection drug users are due to injecting contaminated drug solutions. Many (but by no means all) users have generally poor health due to inadequate nutrition, unsuitable living conditions and deficient personal hygiene, amongst other considerations. In this environment, certain infections are likely to be more common anyway – e.g. chest infections, ‘coughs and colds’ and urinary tract infections. Tuberculosis and other contagious infections can develop due to association with other sufferers, whether the individual has AIDS or not. Another important point is that withdrawal from some drugs, most notably opioids, can cause fever without any underlying infection.

Attempts at harm reduction have aimed at supplying clean equipment and educating users to try and minimise the risk of infection, Needle and syringe exchange schemes seek to prevent users sharing the same equipment ore than once themselves. The Royal Pharmaceutical Society has prepared guidelines for the establishment of needle exchange schemes and these will be reproduced on later blogs. Users should also be encouraged to clean the injection site immediately before injection to decrease the likelihood of skin commensal contamination. Some organisations suggest that if needles and syringes must be reused, then bleach should be employed as a disinfectant. Users should be constantly encouraged not to share needles and syringes.

Skin and injection site infections

The risk of causing superficial infections is increased when injections are given without cleaning the surface of the skin first. The risk is further increased when injection occurs through parts of the skin that carry a particularly high population of commensal bacteria (e.g. groin) and when injections are deliberately given subcutaneously. Nonetheless skin abscesses are common by most injection routes. Other skin infections that have been reported include cellulitis, necrotising fasciitis, gangrene, septic thrombophlebitis and lymphoedema. The bacteria most commonly involved are Staphylococcus aureus, reflecting their prevalence on the surface of the skin itself. Streptococcus spp. are probably the next most common, followed by various Gram-negative rods and anaerobic cocci. These skin infections can metastasise to other areas (e.g. bone, heart valves).

Endocarditis

More than half of the intravenous drug abusers presenting with this condition are found to have Staphylococcus aureus endocarditis. It is assumed that this organism is derived largely from skin infections. Most infections are thought to be of the tricuspid valve, as after intravenous injection any blood contaminated with micro-organisms will drain into the right side of the heart. However, Streptococcus spp. and fungal micro-organisms (especially Candida spp.) are more likely to be responsible if the endocarditis affects the left-hand side if the heart. It has been suggested that adulterants in infected drugs, such as starch or lactose, may cause initial damage to the endothelium of the heart. This could then act as a focus for the damage to the endothelium of the heart. This could then act as a focus for the adherence of platelets and then micro-organisms.

Additional organisms which have caused endocarditis in intravenous drug users include other Staphylococcus species, Pseudomonas spp., Serretia, respiratory organisms and anaerobes. One review highlighted how one micro-organism can predominate in a specific geographical location. This is most often linked to the fact that non-staphylococcal endocarditis is likely to be caused by contaminants of the drug itself.

Infective endocarditis responds favourably to antibiotics once the causative organism has been identified. However, long courses of antibiotics (four to six weeks) are often needed.

Viral Infection

When injecting street drugs, it is widescale practice to pull on the plunger of the syringe during injection to check that the needle has entered a vein. This results in blood being drawn into the syringe together with any micro-organisms. If the injection equipment is then shared, the second user will inject any pathogenic organisms directly into his or her bloodstream. This has been an important transmission route for the spread of HIV and hepatitis B and C. However, the tip of the needle is contaminated whether or not the individual actually draws blood into the barrel of the syringe, hence users of intramuscular anabolic steroids are also liable to contaminate injection equipment. A full discussion of the implications of HIV status is outside the scope of this book, but those who become immunocompromised as a result of their HIV status are more prone to a whole range of other infections, some of which are diagnosed for AIDS – e.g. Pneumocystis carinii pneumonia.

Fungal Infections

One review has estimated that fungal infections represent 5 to 50 per cent of serious infections in intravenous drug users. Candida spp. are most commonly involved, causing disseminated candidiasis, endocarditis, central nervous system infections and endophthalmitis. In the 1980s an outbreak of severe Candida infections in Europe was found to have arisen because of the use of lemon juice to dissolve heroin prior to injection. This is known growth medium for fungi. Aspergillosis and mucormycosis have also been described in the injecting population.

Bacterial septicaemia

This can occur, usually secondary to a skin infection. Streptococcus spp. are typically responsible. Tetanus has been rarely encountered since the widescale adoption of prophylactic vaccination.

Joint and bone infections

Septic arthritis and osteomyelitis have been described in intravenous drug users. In 1987 a study of 37 heroin abusers with septic arthritis revealed that the joints involved were somewhat atypical. In 16 patients sternoclavicular or sternochonral joints were affected and in 14, sacroiliac joints.

Irritant Effects

Most drugs that are injected are not themselves irritant. Temazepam and dextropropoxyphene are notable exceptions. They both cause irritation of tissues or veins after injection, leading to abscesses, tissue necrosis, venous fibrosis and phlebitis. These areas of damaged tissue can then act as foci for infection or thrombosis. irritant effects of most other injectable preparations are largely attributed to adulterants or additives. For example, heroin is often deliberately mixed with acidic substances such as citric acid to aid dissolution. It has also been reported that ammonia may contaminate ‘crack’ cocaine as a result of the manufacturing procedure. This can be very caustic if injected. Other potentially irritant adulterants in street drugs include quinine and sodium bicarbonate. Clearly irritant effects are more likely to occur if the offending preparation is administered subcutaneously or if there os extravasation during venous injection. Those who inject cocaine may be at particular risk because this drug has local anaesthetic properties which can mask the pain of impending damage.

The repeated intravenous administration of injections at the same location eventually destroys the normal pliable nature of the vein due to accumulated effects of fibrosis around numerous puncture marks, episodes of phlebitis, infection and the actions of impurities. This requires injection drug users to seek alternative intravenous access sites and eventually, sometimes, to use subcutaneous injection.

Emboli, Blood Vessel Occlusion and Thrombosis

Most injections given at street level are prepared by mixing a heavily adulterated powder, or a crushed tablet, with water. Most users attempt primitive filtration to try and remove non-soluble particles such as talc, starch and chalk with varying degrees of success. Those that are not removed, or arise from the filter itself, will become microemboli in the bloodstream. In some cases the drug itself may from microemboli (e.g. temazepam). When injected intravenously, these particles can from granulomas in the lung which may impair gaseous diffusion across alveoli (pulmonary granulomatosus) giving rise to dyspnoea, hypoxia, pulmonary function tests can reveal an obstructive or restrictive pattern.

Embolisation of insoluble particles can also cause retinopathy. This has been particularly reported in those injecting crushed methylphenidate tablets, but other crushed tablets and heroin have also been cited as potential causes. In many cases, visual activity is not affected despite the obvious accumulation of obstructive particles in retinal blood vessels. However, impairment of sight can occur. In one study, five out of 23 patients with retinopathy had reduced visual acuity.

Occlusion of the small vessels of the retina and lungs can be relatively easy to observe. Embolisation to other parts of the body also occurs but is frequently undetected because it is asymptomatic. In many cases particulate emboli probably dissolve over a period of time leaving does not occur as a direct result of particulate contamination but as a consequence of drug-induced phlebitis (see above). This can trigger thrombus formation local to the site of inflammation and subsequently thromboembolism may also occur. Deep vein in thromboses are reported quite commonly in the injecting population. However, the most serious forms of blood vessel occlusion occur after intra-arterial injection.

Intra-arterial injection of the contents of temazepam ‘gel’ capsules has been widely reported as it can result in severe damage to many parts of the body. Often the femoral vein. The gel may solidify in blood vessels after injection causing ischaemia and/or act as a focus for thrombus formation by causing an initial damage to the arterial wall (e.g. vasculitis). Temazepam itself is very insoluble and solid particles of it may cause vascular blockade via microembolism; the common practice of filtration through a cigarette filter may also introduce potential microemboli. Severe rhabdomyolysis has been described, necessitating fasciotomy or limb amputation and causing renal failure. Other effects which have been reported include deep vein thrombosis (DVT), pulmonary embolus (PE) and critical ischaemia of digits leading to amputation.

The injection of temazepam gel from capsules represents an extreme example of the potential consequences of intra-arterial injection of irritant substances containing solid particles. Similar affects have been reported after intra-arterial administration of most other parenteral street drugs. The general symptoms are swelling distal to the injection site, pain, discolouration, and sensory and/or motor deficit. The subsequent pattern of events will depend on the site of injection and the tissues affected. Muscle ischaemia will cause rhabdomyolysis and its sequelae. Vasculitis is common and this can result in thrombosis of digits leading to gangrene; vasculitis can also trigger thromboembolism which may manifest as DVT or PE. Arterial penetration also increases the risk of serious haemorrhage.

Judging from the number of cases reported in the medical literature, injection of crushed tablets seems to pose a higher risk to the individual than injection of drugs supplied in powder form; temazepam gel appears to pose the highest risk of all.

Air embolus is a potential hazard when large volumes are injected intravenously. A substantial amount of air in the heart causes blood to froth in the chambers during pumping leading to inefficiency and heart failure. It has been estimated that 10 ml of air would be required in the heart to cause failure; this would be very difficult to achieve after injection with a hand-held syringe and is unlikely to occur at street level.

Pharmacological Effects

Compared to oral administration, the pharmacological effects of street drugs appear much more rapidly after intravenous injection. The effects may in some cases also be more dramatic. Large doses of intravenous opioids are known to cause sudden respiratory depression and death. Usually this occurs because a sample of heroin is more potent than the user anticipated. However, fentanyl analogues are particularly powerful drugs which are known to have caused death so rapidly that individuals have died with the needle still in place.

One reasonably common reaction that can occur after intravenous administration of most street drugs is fainting. In one study of 13 methylphenidate abusers, 12 reported fainting immediately after injection; in a study of 23 temazepam abusers, 12 reported ‘blackouts’ after injection.

Adulterants

At street level no drugs are pure. A variety of cheap inert or pharmacologically active adulterants are used to dilute the drug. The active adulterants are often those considered appropriate to the illicit drug in question. For example, amphetamine, cocaine and ecstasy may be contaminated with stimulants such as other amphetamine derivatives, pseudoephedrine and caffeine. Ecstasy can be cut with ketamine or other drugs with broadly similar effects. Cocaine may be adulterated with local anaesthetics. The pharmacological effects of contaminants or adulterants may be important. Thrombocytopenia has been reported in intravenous heroin users and is believed to be an immune reaction to an unknown toxin. Thrombocytopenia explicitly caused by quinine in street drugs has been identified. Quinine can also be venous irritant. Two deaths associated with strychnine contamination of street drugs have also been described. Strychnine can be found in heroin or cocaine. Arsenic can be a common adulterant of opium in some areas.

Stigmata

Repeated intravenous injection over a prolonged period frequently results in certain characteristic changes around veins which may mark the individual as an intravenous drug user. These are most frequently seen in the forearm. These may include needle marks, scarring due to abscesses, bruising, and discolouration of the skin along the line of veins due to insoluble particles accumulating within the skin.

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