Opioids and Injection Drug Use

Injection drug users have unique challenges because of additional social stigma, substantially increased risk for infectious diseases, the health consequences of injection drug use, and the addiction to the injection process itself. Needle fixation is when people become addicted not only to the drug, but also to the ritual of drawing their drug up into a needle, and the act of injecting it.

Heroin, cocaine, methamphetamines, prescription stimulants, and prescription opioids can be injected into the bloodstream through a vein. Users prefer discrete injection sites. Most users start by injecting in their forearms. When there is scarring, inflammation at the injection site, damaged or collapsed veins, lesions, or bruising, access to those veins becomes extremely painful or impossible. Users will move to other areas of the body such as neck, groin, hands, feet, or face. The more visible the injection site, the more likely a user is going to try to cover it up with clothing, make-up, or tattoos. The ability to identify track marks is one way to detect use.

The patterns of when and how and where someone injects can change over time. Typically, a person who injects will fall into a pattern that works to balance the need to get high, the symptoms of withdrawal, and what is financially feasible. Some people who inject drugs (PWID) inject multiple times a day in smaller doses to have a somewhat stable high. Other PWID inject only a few times a day; they may wait until withdrawal symptoms have just begun, so that the surge from the drug is more dramatic, and contrast between withdrawal and high are more distinct.

When people are using injection drugs chaotically, life is chaotic and the health risks are even greater:

Life is lived out in the elements. No privacy. Nowhere to shower. Dirty clothes. You might not get eye contact all day. You inject in a park, library, stairwell, or parking ramp. You have a hard time keeping up with your basic needs. You have track marks and wounds that won’t heal. You’re robbed. You’re assaulted. You deal with malnutrition, cellulitis, MRSA, HIV, HCV, Syphilis, lack of sleep, fractures, dumpsters, turning tricks, pan handling, no clean water, scabies, lice, diarrhea, constipation, ulcers, amputations, isolation, stigma, and death. -Terry Morris

It is most common, at this time, for support groups to either be a sober group, or an active-use group. One example of an inclusive support group based in California is the Stonewall Project Come as You Are: Come High, Come Low, Come Sober, Come Crashing. Some people who come are simply taking a look at their use—how it serves them, and how it is hard. Other people are looking to use more safely—with safe company, clean needles, or in a safe place.  Others want a space to talk about what is underlying their use—their depression, anxiety, or trauma. And some are looking to eliminate one drug, reduce their use, or eliminate use all together. One of the benefits of having an inclusive group is that people who relapsed can continue to attend the same group where they have established relationships. There is a lot of information-sharing across the various groups. People who are shelfing one drug (abstaining from one type of drug for a period of time) are able to ask questions about withdrawal symptoms. People who are in full abstinence were reminded about the consequences of daily or chaotic use.

Each drug use is a distinct experience with unique circumstances. If someone is using after a period of sobriety, they are at greater risk of overdose death. If a person has been using for many days continuously, they are at risk of not being able to inject safely, missing a vein, or measuring incorrectly. When the only need that’s met is getting high, a person is extremely sleep deprived, dehydrated, and may display erratic behavior.

To address the harms of each drug use circumstance, inquire about:

• DRUG: What type of drug is being used? In what manner? If meth is being taken by smoking or injecting, then the person has developed some flexibility. If IV supplies aren’t available, this person is less likely to put themselves at risk, because they can smoke as well. If this person has an obligation in a few hours, smoking might be a better option so they can feel the onset and it doesn’t all come at once.
• SETTING: What is it cut with? What is the environment like? How do others feel about their use? What do they anticipate will happen? If this person was going to use in a party atmosphere, the conversation might be about sexual safety or finding someone to observe the injection. If this person was going to use alone, the conversation might be about ensuring the person has access to clean water, a cooker, cotton, and multiple needles.
• BODY: What is their tolerance? How is their emotional well being? Reducing harm during use has a lot to do with addressing the headspace that someone is in when they use. Have they been awake for 4-5 days and are disorganized in their thoughts? Then the conversation would probably be about safe injection practices. If this person is feeling guilty about their use or has had a recent loss due to their use, the conversation might be about family dynamics, sexual safety during use, or suicidal ideation assessment.

There are some simple tips or harm reduction strategies for injecting more safely:

• One needle, one use. Do not share needles with others, and do not re-use your own needle. Needles are cheaply made and become dull after one attempt. If you miss the vein, stick again with a fresh needle.
• Rotate injection sites. Scar tissue develops under injection sites and it is important to change the location and side of the injection.
• Use soap and water at the injection site.
• No sharing. No sharing needles, cookers, wipes, or tourniquet. All supplies needed to inject have the potential to pass infectious diseases.
• When possible, use with someone. Take turns. Observe for signs and symptoms of overdose.
• Plan ahead. Stock up on needles, cotton, sterile water, and a variety of needle sizes. Have a safety plan.
• Have naloxone available. Tell family and friends that you carry naloxone in case of an emergency. Carry multiple doses if possible.

Terry Morris presented at the 6th annual Harm Reduction Summit at White Earth.

Please visit the Opioid Dashboard for more information on opioid overdose death, nonfatal overdose, use, misuse, substance use disorder, prescribing practices, supply, diversion, harm reduction, co-occurring conditions, and social determinants of health.