Hygiene and cleanliness: Safer methods of preparation.
Environmental cleanliness
Like hand-washing and clean/sterile injecting equipment, the general environment in which injecting occurs is as important to the health and wellbeing. Most injecting in New Zealand is reported to occur in the home or that of a friend. Other places where injecting occurs include the car, the pub or club or in public toilets. For the later, at best these are unsanitary environments in which to inject.
Injecting equipment
Injecting drugs is a hazardous activity. There are a range of risks, including the spread of communicable disease (HCV, HIV, S.aureus), overdose, and death.
Injecting equipment should be sourced from an NEP, sterile. Injecting equipment should never be shared.
The sharing of injecting equipment, like needles and syringes, increases the risk of communicable disease transmission. Compared to the sharing of needles and syringes, the sharing of ‘other’ injecting equipment has not received a great deal of attention in the past. Other injecting equipment that could have come in contact with blood of other bodily fluids include: spoons, tourniquets, swabs, and filters, for example.
The importance of not licking the site of injection nor the needle tip before injection should also be emphasized. This is primarily due to the increased risk of a Staphylococcus aureus infection at the site of injection. Staphylococcus aureus is concentrated in the mouth and nose and thus readily transferred.
Filtering
Filters are useful and generally effective in removing organic material, small to large particles, residual bacteria and fungi and impurities from solutions prepared for injection. Not only do sterile wheel filters make for a cleaner injection, they also take away ‘the roughness of the hit’.
Injection solutions prepared by people who inject drugs are not of the same quality as those available and administered in a medical setting. Such injection solutions may include tablets that have been crushed and dissolved and also clandestine manufactured solutions, crystals and powders and those solutions (particularly steroids) that have been sourced from the counterfeit black market. These injection solutions may contain solid particles, organic substances and organisms, as a result of their procurement, storage and final preparation.
This presents health risks. Among the myriad of health problems associated with the injection of insoluble particles, the formation hard lumps and vascular irritation and inflammation remain the most significant. The first signs of vascular damage are referred to as ‘‘track marks’’ and may lead to collapsed veins and venous embolism, a result of partial or complete blockage of the vein or capillary with solid material or the formation of a thrombus (blood clotting as a result of vascular damage).
In an attempt to remove insoluble particles people who inject drugs may filter the solution. Filters commonly used include makeshift filters like a cotton bud, a cigarette or hand rolling filter, or sterile wheel filter available from NEP. The size of the pores of the filter is important because it has the potential to limit hard solids and organic material from passing through into the injection solution. The presence of poorly soluble and in-soluble particles smaller than lung capillaries (approx. 5 microns) may potentially block lung capillaries.
The New Zealand NEP makes available the sterile filters Minisart® (a product manufactured by Sartorius Stedim biotech™). Minisart® are the the NEP’s choice of filter for New Zealand. Minisart® filters are non-pyrogentic, single use filter units, available in the following pore size: 0.2 um, 0.45 um, 0.8 um, 1.20 um and 5.00 um.
The pore size difference accounts for the type of solution being filtered, for example a opium solution made from cultivation of papaversomniferumwill contain organic material (5 um and a 0.2 um), a morphine sulphate pill solution will contain in-soluble and poorly soluble particles – mainly consisting of pill excipients and diluents (0.45 um and 0.2 um); amphetamine crystal/powdered will contain both organic and solutes that require filtering from the solution (0.2 um).
All are capable of removing some level of bacterial and fungal organisms that most often reside with a non-sterile injection solution.
Filters save limbs, save lives factsheet
An easy to read, visually descriptive wheel filter factsheet can be downloaded for printing: Sterile Filters Factsheet. The Quadrant Approach. C2017
References:
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Bassetti and Battegay. 2004. Staphylococcus aureus infections in injection drug users: risk factors and prevention strategies. Infection. 32:163-169.
Caflisch C, Wang J, Zbinden R. 1999. The role of syringe filters in harm reduction among injection drug users. American Journalof Public Health. 89(8): 1252
Health Protection Agency. 2010. Shooting Up: infections among injecting drug users in the UK 2009. An update: November 2010. HPA: London.
Hernandes, et al. 2004.The Effectiveness of alcohol gel and other hand cleansing agents against important nosocomial pathogens. Brazilian Journal of Microbiology. 35: 33-39.
Kluytmans J, van Belkum A, Verbrugh H (July 1997). Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms and associated risk. Clinical Microbiology Review,10 (3): 505–20.
Scott, J., Bond, C., Kennedy, E & Winfield, A. (1997).Investigation into the Effectiveness of Filters for use by Intravenous Drug Users.The Robert Gordon University, School of Pharmacy, Aberdeen &University of Aberdeen, Department of General Practice.
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Scott, J. 2008. Safety, Risks and Outcomes from the Use of Injecting Paraphernalia.Scottish Government Social Research.
Taylor A., Fleming A., Rutherford J., and Goldberg, D. 2004.Examining the Injecting Practices of Injecting Drug Users in Scotland. Scottish Executive: Edinburgh.
Taylor A., Fleming A., Rutherford J., and Goldberg, D. 2004. Examining the Injecting Practices of Injecting Drug Users in Scotland. Edinburgh: Scottish Executive.
WHO. 2004. Training guide for HIV prevention outreach to injecting drug users. Programme Management workshop. World Health Organisation, Department of HIV/AIDS.
Vlahov, D., Sullivan, M., Astemborski, J &Nelson, K. (1992).Bacterial infections and skin cleaning prior to injection among intravenous drug users.Public Health Rep. 107(5):595-8.