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Shootin’ with Care Safer Injection Presented by: The Speed Project SFAF Terry Morris tmorris@sfaf. Shootin’ with Care Safer Injection Presented by: The Speed Project SFAF Terry Morris [email protected] org

This slideshow contains images, text, and information that was gathered from websites, books, pamphlets, This slideshow contains images, text, and information that was gathered from websites, books, pamphlets, and other resources developed by The Harm Reduction Coalition www. harmreduction. org, Chicago Recovery Alliance www. anypositivechange. org, RTI International www. rti. org/, Seattle King County Department of Public Health www. kingcounty. gov , and the Harm Reduction Therapy Center www. harmreductiontherapy. org. In most cases the origin/creator of the image or information isn’t sited, so I owe apologies to folks whose hard work isn’t credited. Please mention these folks if you use the material. I have used the slides to invite people into conversations about injecting at workshops, small groups, and one on one. I also email it to people who would like the information but aren’t into groups. Please make any edits/changes to the slideshow that suits your needs. If you have any suggestions, corrections, or additions that might help me out, please send them my way. Take what’s useful and ignore the rest. Thanks! Terry Morris [email protected] org Speed Project Coordinator San Francisco AIDS Foundation (415) 487 -8043

WELCOME! This slide show contains explicit harm reduction information and images about injecting drugs. WELCOME! This slide show contains explicit harm reduction information and images about injecting drugs. This workshop is not intended to be a source of medical advice. Always seek medical advice from a licensed provider. If you need medical advice please consider taking advantage of the wonderful nurses and physician assistants who staff the 6 th street needle exchange site every week. All info in this presentation was gathered from websites, organizations, books, and most importantly; people who have life experience injecting. Thanks to the Harm Reduction Coalition, Chicago Recovery Alliance, SFNE/HYA, Harm Reduction Therapy Center, Seattle king county health department, tweaker. org, exchange tools in the United Kingdom, Edith Springer, Alex Kral of RTI, Urban Health Study, Mona Bennett, Fred Johnson, and people at the needle exchanges in Atlanta and San Francisco who have taught me. Please take what you find useful in this presentation and ignore anything that is not helpful to you. Thanks so much for coming tonight! The only “expert” in the room is YOU!

What you are looking at is North America’s only safer injection site… What you are looking at is North America’s only safer injection site…

There are 65 supervised injection facilities worldwide. Supervised injection facilities reduce the risk of There are 65 supervised injection facilities worldwide. Supervised injection facilities reduce the risk of drug overdose. (People injecting in public places are 3 x more likely to overdose) Supervised injection facilities reduce the risk of sharing equipment. Supervised injection facilities reduce the risk of injection related injury. Supervised injection facilities improve public health. Supervised injection facilities reduce high visibility injecting and other drug related activity. If there was a safer injection site in SF, would you use it? why or why not?

The Risks The way you see it…. what are some risks that a person The Risks The way you see it…. what are some risks that a person can be exposed to when injecting?

Some Risks The main risks you can expose yourself to when injecting are: • Some Risks The main risks you can expose yourself to when injecting are: • Getting exposed to HIV (the virus that can lead to AIDS) • Getting exposed to viral hepatitis (Hepatitis B and C which damage the liver) • Soft tissue infections (abscesses, cellulitis) • Vein damage • For some people injecting can impact how they manage drug use or increase use…. • Overdose/overamping • Accidental death • Damage to circulatory system, loss of limbs, tissue damage, Deep Vein Thrombosis • other possible bummers… • Stigma • Jail (getting busted for paraphernalia and/or possession/dealing) • Inability/difficulty to enjoy getting high in other ways… Injecting is definitely dangerous. Alternatives to injecting are taking the drug by a different route, mixing it up: injecting some times, using by other methods sometimes, getting hooked up with substitution therapy, or taking a break. Most people who inject want to take care of themselves and their friends. This workshop invites you to share things you do to inject more safely and to learn from all the other experts in the room. Harm reduction is about doing what you do as safely as possible. And it is realistic DO WHAT YOU CAN, when you can

How many people here have been vaccinated for hepatitis A and B? Getting vaccinated How many people here have been vaccinated for hepatitis A and B? Getting vaccinated for hepatitis A and B is one of the best things you can do to protect your liver. How many people here have had a tetanus shot within in last 10 years? Tetanus is a bacterial infection that occurs when tetanus spores enter a wound. The bacteria then enter the bloodstream and cause an infection, which is characterized by muscle spasms or rigidity, especially in the neck and jaw (tetanus is commonly called "lockjaw"). Tetanus is fatal if not treated. Tetanus spores live in the soil and on rust, which is why a tetanus shot is recommended if you step on an old nail or other rusty object. If your needle, syringe, or other injection equipment is contaminated with tetanus spores due to dirt or rust, you could infect yourself. Skin-poppers and muscle-poppers are particularly susceptible to tetanus infection and should always use new, sterile equipment. All injectors are at risk for infections related to using needles. Muscling and skin-popping allow germs to "sit" inside muscle and fat tissue or under the skin. These are great places for abscesses and other infections to brew. Infections in these areas can be very serious. They can also spread to the blood, bones, heart and other places in the body. Some of the worst infections include wound botulism, tetanus (also called "lockjaw") and necrotizing fasciitis ("flesh eating disease"). If not treated quickly, these and other infections can become life-threatening and result in death.

How many people here have an easy time hitting? How many people here have How many people here have an easy time hitting? How many people here have a safe, private place to get high most of the time? How many people here drink at least 8 glasses of water a day? Hydration…will make hitting easier…. plump your veins up! Beware of alcohol, coffee, cigarettes, speed/coke. They all dehydrate you.

How many people here get their needles from a syringe exchange? How many people How many people here get their needles from a syringe exchange? How many people buy their syringes at a pharmacy? What’s that like? Any tips for making a purchase?

http: //sfhiv. org/syringe_locations. php Access & Disposal Locations http: //sfhiv. org/syringe_locations. php Access & Disposal Locations

♥ Pharmacy Request Card ♥ Exchange name Pharmacy description SHORTS 28 G x 1/2 ♥ Pharmacy Request Card ♥ Exchange name Pharmacy description SHORTS 28 G x 1/2 in. U-100 BD Micro-Fine IV (Orange) 1 ml LONGS 27 G x 5/8 in. U-100 BD Micro-Fine 1 ml MICROS 28 G x 1/2 in. U-100 BD Micro-Fine IV (Orange) 1/2 m. L BD Lo-Dose Insulin Syringe 29’s 29 G x 5/8 in. U-100 BD Micro-Fine IV (Orange) Bee Stings 31 G x 5/16 in. U-100 BD Ultra-Fine Short BD insulin

How many people here save and re-use their own syringes? How many tries (sticks) How many people here save and re-use their own syringes? How many tries (sticks) does it usually take for you to get a hit?

New Needle Point, used TWICE Needle Point, used ONCE Needle Point, used over six New Needle Point, used TWICE Needle Point, used ONCE Needle Point, used over six times

New Needle Point, used TWICE Skin is tough! Every time you hit, each time New Needle Point, used TWICE Skin is tough! Every time you hit, each time the needle goes through your skin it bends and barbs. Sadly, syringes are really cheaply manufactured and designed to be used once and destroyed. Damaged points can lead to: ■ Abscesses ■ Infections ■ Blown veins Needle Point, used over six times Needle Point, used ONCE If you can…use a brand new syringe EVERY TIME you poke your skin or vein. Save your veins! ■ If you miss your vein and don’t get a register, re -load a new syringe and try again. ■ Don’t use the same spot and hit it over and over again. Rotate your sites to allow them time to heal. ■ Don’t try to sharpen a used point- this makes more barbs. ■ Don’t use the tip of your needle to mix your hit.

 • How many people here shoot alone some of the time? • How • How many people here shoot alone some of the time? • How many people here shoot alone all the time? • How many people use the same amount of dope after taking a break? (after jail/prison, detox/drug treatment/ “clean” time, hospital time) • How many people here use more than one drug in a day (i. e. Crack and heroin, cocaine and heroin, benzos and heroin, alcohol and heroin, speed and alcohol) • How many people here have overdosed in the last 6 months? • How many people here have seen someone else overdose in the last 6 months?

How many people here knew someone who died from an overdose? How many people How many people here knew someone who died from an overdose? How many people here have an overdose plan they share with friends?

Drug Overdose In the United States, each year, more injection drug users (IDUs) die Drug Overdose In the United States, each year, more injection drug users (IDUs) die from heroin overdose than from any other cause, including AIDS, hepatitis, or homicide. In fact, heroin overdose was the single largest cause of accidental death in San Francisco, California from 1997 to 2000. Overdoses happen when toxic amounts of drug or combinations of drugs cause the body to shut down • • Heroin & Other Downers (e. g. , alcohol, benzos) Breathing slows and stops, then heart stops Stimulants (e. g. , cocaine, speed) Heart speeds up, body temp rises, resulting in seizure, heart attack, stroke Many of these deaths are preventable. Heroin overdose can be reversed through the timely injection of naloxone, a legal, unscheduled opiate antagonist routinely used by emergency medical personnel to quickly and safely reverse opiate overdose. Peers witness most overdoses (people are not fixing alone) but deaths occur because people are hesitant to call emergency medical services for fear of police involvement, and often their attempts at resuscitation are unsuccessful.

Overdose Deaths Unintentional drug overdose is the second leading cause of accidental death in Overdose Deaths Unintentional drug overdose is the second leading cause of accidental death in the United States, just behind automobile crashes. According to the Centers for Disease Control and Prevention (CDC), between 1999 and 2004, the number of overdose deaths in the United States rose 77 percent, to almost 20, 000. The CDC attributes the 62. 5 percent rise in drug overdose deaths to a higher use of prescription painkillers and increasing numbers of overdoses of cocaine and prescription sedatives. What are some of the main causes of overdose?

What are some of the main causes of an overdose? 1) Doing too much What are some of the main causes of an overdose? 1) Doing too much at once 2) 3) 4) 5) 6) Doing too much over a short period of time Lowered tolerance (time away from use lowers a person’s tolerance…people often O. D. after time spent in rehab, detox, jail, or the hospital) Quality (purity) of the drug How you take the drug (snort/shoot/smoke) Believe it or not, WHERE you get high can affect whether you overdose or not.

naloxone (Narcan®) • An opiate antagonist that temporarily reverses the effects of an opiate naloxone (Narcan®) • An opiate antagonist that temporarily reverses the effects of an opiate (heroin) overdose • Traditionally administered by paramedics • Legal, nonscheduled, prescription medication • Since November 2003, over 700 people have received training and take-home naloxone. • To date, over 180 of these participants have reversed an overdose using naloxone.

 • How many people here can hit themselves? • How many people here • How many people here can hit themselves? • How many people here sometimes have another person inject them? • How many people here sometimes inject other people?

Hepatitis C • An estimated 91% of all 18, 000 injection drug users in Hepatitis C • An estimated 91% of all 18, 000 injection drug users in San Francisco have been infected with hepatitis C. • Hepatitis C (HCV) is a virus found in blood. It is usually spread by sharing syringes, cookers, cotton, water, ties, or other equipment among people who inject drugs. • Using other people’s filters is dangerous because they often come into direct contact with used needles and they are moist and warm - which is an ideal environment for both viruses and bacteria.

How many people here bring up hepatitis and HIV prevention when shooting in groups? How many people here bring up hepatitis and HIV prevention when shooting in groups? Median 3. 4 years from initiating injecting to HCV sero conversion

How small is the hepatitis C virus? How small is the hepatitis C virus?

 • If you are splitting drugs with another person, be careful to use • If you are splitting drugs with another person, be careful to use a clean cooker and cotton, and split the drugs with a clean syringe. Splitting drugs with a used syringe can transfer small amounts of blood from the used syringe to everyone else, even people using a new syringe to inject. If you don’t have a clean syringe to split the drugs with, split them dry instead of mixing them together. • Hepatitis C found in blood outside the body can remain infectious for up to 2 days – longer if the blood is inside a syringe. Clean up after shooting up, and before injecting don’t put your syringe, plunger, or needle down on a surface- such as a tabletop that might have blood on it-Wash your hands thoroughly with soap and water before and after injecting, and be careful not to get blood on your equipment other people might use (such as cotton/filters and ties/tourniquets). • Use sterile water if possible. Otherwise, always use the cleanest water you can find for mixing and injecting drugs and rinsing injection equipment. If you only have one source of clean water, like a water bottle from a kit, don’t contaminate the water – avoid drawing up from it with a used syringe that could still have blood in it.

 • Prepare and inject your own drugs yourself, if at all possible. ü • Prepare and inject your own drugs yourself, if at all possible. ü One study has suggested that you have higher risk of sharing needles if other people inject you: your partner might not be as careful about using someone else’s syringe, cooker, cotton, water or tourniquet as you would be! ü Another study has observed groups of users where only one person knew how to shoot up. The person doing the injecting would get blood on his or her finger and then touch (and contaminate) the injection sites of everyone else in the group. • If you can’t inject yourself, make sure that the person who’s injecting you does not get his or her blood, or anyone else’s, on or around your injection site. And make sure that he or she uses a new or at least properly cleaned syringe. • Talk to the people that you inject with about hepatitis C. Make sure everybody knows the risks, and how to prevent spreading it to each other. If you know that you have hepatitis C, do your part to protect the people that you use drugs with.

How many people here have a friend who has been injecting less than a How many people here have a friend who has been injecting less than a month? How many people here have a friend who has been injecting less than 6 months? How many people here have a friend who has been injecting for 5 years? 10 years? 20 years? How many people here have a friend who has had an abscess right now?

Abscess and Wound Care in SF Where to go to get help with and Abscess and Wound Care in SF Where to go to get help with and Abscess in SF Compiled by the speed project of SFAF, a harm reduction project for gay/bi/heteroflexible guys who party with speed. www. thoughtsonspeed. com events line (415) 788 -5433 If we need to correct stuff or got it wrong please let us know! thanks! San Francisco The ISIS Clinic/ Wound and Abscess Drainage Treatment 4 C Where: San Francisco General Hospital, 1001 Potrero Avenue. When: Monday thru Friday 8: 00 -4: 00 PM. (show up by 2 PM to get seen) and Saturday and Sunday 8 AM-12 PM (show up by 11 AM to get seen) To make an appointment or to get more information, call them at (415) 2068287. HPP Syringe Exchange Indoor sites with nurses or physician assistants who can care for abscesses. Where: 117 Sixth Street (near Mission) When: Tuesdays 10 AM-12 noon Fridays 12 noon– 2 PM Saturdays 3 PM– 5 PM Tom Waddell Health Center (showing up EARLY is best) Where: 50 Lech Walesa (Ivy) Street, San Francisco, CA When: Monday through Friday 8: 30 AM-6: 30 PM & Saturdays 8: 30 AM-5: 00 PM (Tuesdays they are closed from 12: 30 -2 PM so show up either before or after that) 415 -355 -7400 Maxine Hall Health Center Drop-In Clinic Where: 1301 Pierce Street, San Francisco CA When: First come, First Served Mon-Fri. 8 AM

How did you first start injecting? When you think back to your first injection… How did you first start injecting? When you think back to your first injection… • What made you want to start? • What attracted you to injecting? • What were your expectations? • How did seeing other people doing it (or talking about it) affect you? • Do you remember what you thought injecting before you tried it? • How did seeing other people do it or hearing them talk about it impact your decision to try it? • The decision to try injecting…what are your feelings and thoughts about it now? The Panic in Needle Park is a 1971 American film directed by Jerry Schatzberg and starring Al Pacino in his second film appearance.

There is an idea called social Learning theory that says that people can learn There is an idea called social Learning theory that says that people can learn how to do something by seeing people modeling (doing) the behavior, or hearing them talk about it - even if this is not intended by the person doing the modeling. The decision to adopt a particular behavior depends in part, on whether the person thinks… Most people don’t plan on injecting. We learn about injecting by talking about it and listening to people who have experience injecting. It makes sense that you’d get accustomed to seeing injecting if you are hanging out with people who inject. Fear of it goes down. It gets normalized. the benefits of the behavior outweigh the risks; and whether or not they think they will be able to it.

The first time • Are there things about injecting that you didn’t expect when The first time • Are there things about injecting that you didn’t expect when you first started? • How were your early experiences? • What do you think about your decision to inject today? • What was your first injection like? • Did someone else inject you? • What was that like? What were the dynamics between you? • Did the person who injected you injure you/expose you to any bugs? • How do you feel about that person today?

Have you ever been asked to give someone else his or her first hit? Have you ever been asked to give someone else his or her first hit? Have you ever given someone else his or her first hit? What do you think of people who help someone inject for the first time?

For you…when would it feel okay to give someone their first hit? When would For you…when would it feel okay to give someone their first hit? When would it not feel okay? It is a big responsibility. On some level if you are injecting someone else you are responsible for their safety. • Their future injecting (what if they go off the chain, what if it radically alters their relationship to drugs, it could) • Often someone who is asked doesn’t want to do it, but has difficulty dealing with those requests…it can be hard to say no. saying no can feel hypocritical. • What are some things people have said to you, or have you said to people, to get them to inject someone else?

If you don’t want to be put in the position of turning someone else If you don’t want to be put in the position of turning someone else on to injecting, there are things you can do To avoid it. This part of the slide show is NOT meant to vilify or put down people who DO introduce people to injecting. This Is just an invitation to think about this issue and make plans that work for you. Things you can do to avoid introducing someone to injecting. : Being aware is helpful…. without meaning to you can influence someone by talking about injecting with people who don’t inject. Talking about what its like, how to do it, problems, and payoffs to injecting can serve to raise people’s comfort level and curiosity. injecting in front of people who don’t inject and help a person who doesn’t inject get habituated to it, they Get used to it. It becomes less mysterious and scary. And again, people are naturally curious. When in mixed company… some people go to the bathroom or another space to get high so they won’t be observed. Some people switch from injecting to a different route of administration. It helps to cultivate flexibility (an open attitude/not being married to doing things one way) and to be open to having a different kind of experience with a drug. This flexibility and willingness to use another way if you want to can help you cut down on the number of injections you do and/or make it easier not to inject in ‘mixed’ company. If everyone else in the room is going to be smoking, booty bumping, snorting- that’s how you do it too. Getting good at something so you get the most out of it- having the ability and information so you feel competent at it and get what you are looking for out of the experience makes it more likely you will do it. Substitution therapy…methadone, bupe, pills.

What are the risks to the person getting injected? • The risk of overdose What are the risks to the person getting injected? • The risk of overdose can increase more than tenfold when opiates are injected. • Even with our widespread needle exchange services, new injectors have a 7 in 10 chance of getting hepatitis C in their first year. • Research shows that people who inject have a higher ‘severity of dependence’ than those who do not. • undiagnosed medical condition such as asthma or problems with blood pressure, heart, thyroid, liver or kidneys. These health problems could make injecting more dangerous than using drugs in other ways. • If a woman is pregnant (and in the early stages it may not be possible to tell if she is), injecting drugs will increase the risks to the baby. • Do you think the person asking for an injection can accurately predict how much they might enjoy injecting and whether they will be able to ‘just try it’ whatever they might say at the time.

What are possible risks to the person doing the injection? • criminal prosecution - What are possible risks to the person doing the injection? • criminal prosecution - especially if something goes wrong. In law injecting someone else is an assault and manslaughter charges have been brought against people in cases where the person they injected overdosed; • guilt - if the person they initiate goes on to have problems associated with injecting; • criticism from injectors and other people you know for giving someone their first hit; and • The risk of verbal or physical assault by a relative or friend of the person they initiated.

How do you decide to inject another person? How do you decide to inject another person?

How do people learn to inject? How do people learn to inject?

Think about the last time you injected. Where were you? Who were you with? Think about the last time you injected. Where were you? Who were you with? What supplies did you have with you? What was going on with your body? What was going on with your feelings and emotions?

Where you use… Where you use…

Where you use Some places are safer for injecting than others, and you should Where you use Some places are safer for injecting than others, and you should always choose from among your options the safest one possible. What's your least favorite place to use? How come? What's your best case scenario? How come? The ideal location for injecting is one that is relatively clean, dry, warm, and well-lit, and where: * your chances of getting caught by the police are minimal * you feel comfortable that there will be no surprise interruptions or unwanted observers * you can take as much time as you need * you have adequate space for yourself and your equipment * you have access to a sink or other source of clean water * you are sheltered from the wind and weather.

Who are you using with? • What is your best case scenario? • What Who are you using with? • What is your best case scenario? • What is your worst case scenario? • What are the good things about using alone? • What are some of the good things about using with other people?

 • What was going on with your body? • What was going on • What was going on with your body? • What was going on with your feelings and emotions?

The circulatory system 101 Arteries in red Veins in blue The circulatory system 101 Arteries in red Veins in blue

♥♥♥♥ The heart ♥♥♥♥ A strong, muscular pump (a little larger than a fist) ♥♥♥♥ The heart ♥♥♥♥ A strong, muscular pump (a little larger than a fist) Your heart works as a pump that pushes blood to the organs, tissues, and cells of your body.

Blood just doesn't slosh around your body, once it leaves the heart. It moves Blood just doesn't slosh around your body, once it leaves the heart. It moves through many tubes called arteries and veins that are attached to the heart. The movement of the blood through the heart and around the body is called circulation and your heart is really good at it. It's so good at it that it takes less than 60 seconds to pump blood to every cell in your body. The blood vessels that carry blood away from the heart are called arteries. The ones that carry blood back to the heart are called veins.

Blood vessels (veins, arteries) are part of a closed network of narrow elastic passageways Blood vessels (veins, arteries) are part of a closed network of narrow elastic passageways whose main function is to circulate blood to all the far out places of the body. This wiring system has finger thick to microscopically slender cables and connectors. Without this wiring system, the blood would not be able to acquire and accumulate essentials for the nourishment and health of the entire body. There are two kinds of blood vessels: arterial arteries carry blood away from the heart and venous veins (carry blood toward the heart to be repumped). If all the vessels of this network in your body were laid end-to-end, they would extend for about 60, 000 miles which is far enough to circle the earth more than twice! One drop of blood takes less than one minute to make the entire trip through the circulatory system.

Arteries carry oxygen rich blood away from the heart. Veins carry blood from various Arteries carry oxygen rich blood away from the heart. Veins carry blood from various parts of the body back to the heart

Blood is carried from your heart to the rest of your body through a Blood is carried from your heart to the rest of your body through a complex network of arteries, arterioles, and capillaries. Blood delivers oxygen and nutrients to every cell. Blood is returned to your heart through venules and veins. and removes the carbon dioxide and waste products made by those cells.

Capillaries • Arteries branch into capillaries, which are very thin and spidery. • Capillaries Capillaries • Arteries branch into capillaries, which are very thin and spidery. • Capillaries are really more like a web than a branched tube. It is in the capillaries that the exchange between the blood and the cells of the body takes place. Here the blood gives up its carbon dioxide and takes on oxygen • Capillaries are so small that when you look at blood flowing through them under a microscope, the cells have to pass through in single file.

Arteries • Arteries have to expand to accept the blood being forced into them Arteries • Arteries have to expand to accept the blood being forced into them from the heart, and then squeeze this blood on to the veins when the heart relaxes. • Arteries have the property of elasticity, meaning that they can expand to accept a volume of blood, then contract and squeeze back to their original size after the pressure is released. • A good way to think of them is like a balloon. When you blow into the balloon, it inflates to hold the air. When you release the opening, the balloon squeezes the air back out. It is the elasticity of the arteries that maintains the pressure on the blood when the heart relaxes, and keeps it flowing forward. • Arteries are tough, elastic tubes that carry blood away from the heart. As the arteries move away from the heart, they divide into smaller vessels. The largest arteries are about as thick as a thumb. The smallest arteries are thinner than hair. Arteries carry bright red blood-the color comes from the oxygen that it carries

Only inject into veins. It is dangerous to inject into arteries because the blood Only inject into veins. It is dangerous to inject into arteries because the blood is under such high pressure that it can: • split the artery wall; and • bleed so fast that it can’t form a clot to stop the bleeding.

Hitting an artery on accident Larger arteries have a pulse - never inject into Hitting an artery on accident Larger arteries have a pulse - never inject into a spot that has a pulse. If you hit a big artery the blood will probably: • force back the plunger; and/or • be frothy and bright red when you draw back.

This is dangerous because: • You might bleed heavily when you take out the This is dangerous because: • You might bleed heavily when you take out the needle and/or cause a rapidly growing bruise under the skin; and hurt if you try to inject. • if you are pushing a needle deep into your arm or leg and hit a small artery, it may be too small to push the plunger back so you might not know you are in an artery… but injecting into it could still cut off the blood supply to the area it supplies - this is one of the risks of digging around for a deep vein. • Remember that capillaries become so small that nothing bigger than a single blood cell can get through; and any particles in the injection will block the capillaries; and irritants in the drug can cause swelling and blockage of capillaries and the small vessels that supply them. • If you block an artery all the tissue it supplies will die: there is no alternative route the blood can take. Dead tissue will quickly turn black and become gangrenous. Gangrene spreads into healthy tissue unless it is removed by surgery. • Injecting into arteries has resulted in many people having to have fingers, toes and even legs amputated in hospital.

If you hit an artery: • • apply firm pressure for at least half If you hit an artery: • • apply firm pressure for at least half an hour; lie down; if possible, raise the affected area; If the bleeding doesn’t stop, dial 911 for an ambulance; and • even if you stop the bleeding, contact a doctor.

Veins The veins carry dark red blood that doesn't have much oxygen. Veins have Veins The veins carry dark red blood that doesn't have much oxygen. Veins have thin walls. They don't need to be as strong as the arteries because as blood is returned to the heart, it is under less pressure. Veins do not have as many elastic fibers as arteries.

Valves Veins do have valves, which keep the blood from pooling and flowing back Valves Veins do have valves, which keep the blood from pooling and flowing back to the legs under the influence of gravity. When these valves break down or are damaged (as often happens in older or inactive people) the blood does flow back and pool in the legs. The result is varicose veins, which often appear as large purplish tubes in the lower legs.

Valves are flaps of tissue in veins that help bring the blood back up Valves are flaps of tissue in veins that help bring the blood back up to the heart, by acting as a oneway door. Valves are found along the length of the vein. Injecting into a valve is the most common reason for missing a hit or collapsing a vein or not getting a “register” You have valves all along each vein and where 2 veins meet. Valves look like small bumps. When you press on it, the bump goes away then pops back. In deeper veins, valves are hard to feel. But watch as you register. If the plunger gets stuck pulling back or won’t move, or the blood stops- you hit a valve. Don’t use this spot again.

Valves: they direct the flow of traffic! Valves: they direct the flow of traffic!

Safer injection Why do veins collapse? Safer injection Why do veins collapse?

Sticking a needle into a vein (that tears and scratches the vein lining) and Sticking a needle into a vein (that tears and scratches the vein lining) and then pushing in drugs (that can irritate and cause swelling of the vein lining) creates turbulence (bumps like on an airplane) in the blood flow. Injection can scratch the inside of the vein and leaves a hole which, during healing, roughens the lining of the vein. If blood is unable to flow smoothly it clots. The lining of arteries, veins and capillaries are perfectly smooth so that the blood can flow Without clotting. The reason blood clots when you cut yourself is because as it leaves the blood vessels it stops flowing smoothly.

This can cause tiny clots to form on the lining of the vein. These This can cause tiny clots to form on the lining of the vein. These clots roughen the lining causing more turbulence and more small clots. Gradually the vein can fill up with the clots and block. Clots form in the turbulent blood around the site.

These clots roughen the lining causing more turbulence - and more small clots. Gradually These clots roughen the lining causing more turbulence - and more small clots. Gradually the vein can fill up with the clots and block. As the vein becomes narrower the turbulence increases and the clots form more quickly.

Gradually the vein can fill up with the clots and block. The clots then Gradually the vein can fill up with the clots and block. The clots then turn into scar tissue which shrinks, pulling the sides of the vein together, leaving it ‘collapsed. ’ The edges of the vein heal together and the vein collapses as the scar tissue draws the sides together. Veins that are damaged or swollen may partially recover, but collapsed veins never recover. The blood finds another way back to the heart and lungs through smaller or deeper veins further back down the system.

Injection can scratch the inside of the vein and leaves a hole which, during Injection can scratch the inside of the vein and leaves a hole which, during healing, roughens the lining of the vein. Clots form in the turbulent blood around the site. As the vein becomes narrower the turbulence increases and the clots form more quickly. Finally, the edges of the vein heal together and the vein collapses as the scar tissue draws the sides together. Veins that are damaged or swollen may partially recover, but collapsed veins never recover. The blood finds another way back to the heart and lungs through smaller or deeper veins further back down the system.

The appearance of 'new' veins When veins have been blocked, the blood still needs The appearance of 'new' veins When veins have been blocked, the blood still needs to get back to the heart. The blood has to find another way. Veins are connected at lots of junctions – so this means taking a different route and going up veins that are further back in the system. But as the bigger veins collapse, the ones that get used to re-route the blood become smaller and smaller. When a very small vein has to carry a lot of blood it sometimes swells up like a balloon and becomes much bigger. When a ‘new’ vein appears it is usually one of these small, weaker veins that has ‘blown up. ’ If used for injecting ‘new’ veins usually burst as soon as they are punctured, or block within a few days, when the bruise clots.

Long-term consequences of collapsed veins By the time ‘new’ veins start appearing, vein damage Long-term consequences of collapsed veins By the time ‘new’ veins start appearing, vein damage is quite bad - the lack of veins means that blood is being pumped into the arm or leg faster than the veins can carry it away. This makes the hands, feet or whole limb swollen, puffy, cold and blue. This is irreversible. It is a sign that injecting has caused serious, long-term damage. Collapsing veins mean that the return blood flow is reduced. Blood flow is essential to healing - without enough blood flow, injection sites and cuts become more prone to infections and boils. If the collapsed veins are in the leg or groin, small scratches and knocks to the feet and legs can’t heal and can form ulcers. These are incredibly painful sores that take months or years to heal. • • • Sometimes blood flow is so poor that areas of skin start to die, gangrene sets in and the infected bits have to be removed by surgery. infections that don’t get better; areas of skin dying; ulcers; gangrene; or rings you can’t get off swollen fingers can get really serious. If you experience any of these things, it is good to seek medical help early on.

Drugs that damage veins There a number of substances that are known to cause Drugs that damage veins There a number of substances that are known to cause more damage to veins if injected. Cocaine is a very powerful local painkiller. This can cause big problems because once even a small amount has been injected, bad injecting technique causes no pain. Also, it is a very short-acting drug which people often use in non-stop binges. This can result in lots of injections and a huge amount of damage being done in a short period of time. CRYSTAL METH causes veins to tighten and shrink. (so Do coffee, cigarettes, cocaine, soda, chocolate) each of These substances contain stimulants that cause the body to go into ACTION MODE. Because your heart has to work harder your veins actively shrink to force more blood towards the heart. When veins shrink they are harder to hit! Also, meth has some toxic chemicals In it that can burn and irritate the lining of the veinswith frequent injection the tissue becomes inflamed and then breaks down

Vitamin C powder and pills • Pills and capsules contain lots of added substances Vitamin C powder and pills • Pills and capsules contain lots of added substances to make the pill hard, solid and the right size and color. In this mixture will be a relatively small amount of the drug. This is why there is always powder left in the spoon. • Injecting anything solid into your veins is likely to speed up the process of them collapsing. If you are going to inject a tablet, try to draw up as little of the powder as possible into the syringe. Filter the shot more than once. • If you can’t get powder and are shooting crack you should know that injecting acids can cause vein damage. To keep vein damage to a minimum it is important to use as little acid as possible. • HPP supplies vitamin C powder because other acids such as lemon juice and vinegar can cause serious health problems, including eye infections that can cause blindness. • If you get pain or redness at an injecting site it could be caused by the acid you are injecting - stop injecting there. Ask your needle exchange, drug service or doctor for advice.

Picking a Spot No two people have the same network of veins; size and Picking a Spot No two people have the same network of veins; size and position vary from person to person. Men tend to have slightly bigger veins than women.

Picking a Spot Picking a Spot

Inside elbow If you are going to inject this is the least dangerous place Inside elbow If you are going to inject this is the least dangerous place to inject. Alternate and rotate your injection sites. Always try to inject at least one inch from your previous injection site. Give your veins a chance to rest in between injections. Stay away from veins that are red or tender until they heal.

Hands are somewhat less safe than arms because the veins are significantly smaller and Hands are somewhat less safe than arms because the veins are significantly smaller and more delicate and therefore more likely to bruise or become damaged. Circulation is also slower in the hands, causing healing to take longer. If you’re getting off in your hands, be sure to use thinnest needle possible (highest gauge) or, if you can find one, a butterfly needle. Be vigilant about rotating the sites, and keep in mind that it is difficult to conceal injection marks and bruises on the hands.

Circulation in the legs may be poor, especially in people who don’t use theirs Circulation in the legs may be poor, especially in people who don’t use theirs a lot. Veins in the legs are more likely than those in the arms to develop clots that can obstruct circulation and eventually break off and lodge in the lungs or heart. Also, damaging the valves in the leg veins is more serious that damaging those in the arms since they play a greater role in getting blood back to the heart.

Feet As with the hands, the veins in the feet are generally smaller than Feet As with the hands, the veins in the feet are generally smaller than in other parts of the body, and close to nerves, cartilage, and tendons which you want to avoid hitting when you inject. Because they are farther from the heart than the veins in the hands, arms, and legs, blood circulates more slowly in the foot veins and they therefore require more time for healing and repair. In addition, foot sweat and dirty socks act prevent wounds from healing And increase the chance of infection from bacteria.