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{{short description|Method of introducing a
{{Redirect|Shoot up|
{{Hatnote|This article describes drug injections primarily in the context of recreational drug use. For a focus on medical practices, see [[Intravenous therapy]], or [[Intramuscular injection]].}}
{{Original research|date=April 2019}}
[[File:Fragment of hypodermic needle stuck inside arm of IV drug user (x-ray).jpg|thumb|250px|Fragment of a [[hypodermic needle]] stuck inside the arm of an IV drug user (x-ray)]]
'''Drug injection''' is a method of introducing a [[drug]] into the bloodstream via a hollow hypodermic needle, which is pierced through the skin into the body (usually [[intravenous]]ly, but also at an [[intramuscular]] or [[Subcutaneous injection|subcutaneous]], location). [[Intravenous therapy]], a form of drug injection, is universally practiced in modernized medical care. {{As of|2004}}, there were 13.2 million people worldwide who self-administered injection drugs outside of medical supervision,{{clarify|reason=Sentence revised by random editor in passing on a hunch|date=December 2020}}
A wide variety of drugs are injected, often [[opioid]]s: these may include legally prescribed medicines and medication such as [[morphine]], as well as stronger compounds often favored in [[recreational drug use]], which are often illegal. Although there are various methods of taking drugs, injection is favoured by some people as the full effects of the drug are experienced very quickly, typically in five to ten seconds. It also bypasses [[first pass effect|first-pass metabolism]] in the liver, resulting in higher [[bioavailability]] and efficiency for many drugs (such as [[morphine]] or [[heroin|diacetylmorphine/heroin]]; roughly two-thirds of which is destroyed in the liver when consumed orally) than oral ingestion would. The effect is that the person gets a stronger (yet shorter-acting) effect from the same amount of the drug. Drug injection is therefore often related to [[substance dependence]].
In recreational-use [[drug culture]], preparation may include mixing the powdered drug with water to create an aqueous solution, and then the solution is injected. This act is often colloquially referred to as "slamming", "'''shooting up'''",
==
In addition to general problems associated with any IV drug administration (see [[Intravenous therapy#Risks of intravenous therapy|risks of IV therapy]]), there are some specific problems associated with the injection of drugs by non-professionals, such as:
* '''Chance of infection''' – This is generally a twofold major concern:
** [[Needle sharing]] or sharing
** [[Abscess]]ed infections of injection sites are caused by lack of proper hygiene and a lack of [[aseptic technique]] during the injection process.
* '''Increased chance of overdose<ref>{{cite journal | author = Des Jarlais D. C., Arasteh K., Feelemyer J., McKnight C., Barnes D. M., Tross S., Hagan H. | year = 2016 | title = From Long-Term Injecting to Long-Term Non-Injecting Heroin and Cocaine Use: The Persistence of Changed Drug Habits | journal = Journal of Substance Abuse Treatment | volume = 71 | pages = 48–53 | doi=10.1016/j.jsat.2016.08.015| pmc = 5117630 | pmid=27776677}}</ref>''' – Because IV injection delivers a dose of drug straight into the bloodstream, it is harder to gauge how much to use (as opposed to smoking or snorting, where the dose can be increased relatively incrementally until the desired effect is achieved; this gives a user who is in danger of overdosing a chance to seek medical treatment before respiratory arrest sets in). In addition, because of the rapid onset of intravenous drugs, overdose can occur very quickly, requiring immediate action. Another reason that overdose is a risk is because the purity of street drugs varies a great deal.
{{Anchor|Track marks}}
* '''Scarring of the peripheral veins''' – This arises from the use of blunt injecting equipment. This is particularly common with users who have been injecting while in jail and re-use disposable syringes sometimes hundreds of times. IV drug use for an extended period may result in collapsed veins. Though rotating sites and allowing time to heal before reuse may decrease the likelihood of this occurring, collapse of peripheral veins may still occur with prolonged IV drug use. IV drug users are among the most difficult patient populations to obtain blood-specimens from because of peripheral venous scarring. The darkening of the veins due to scarring and toxin buildup produce tracks along the length of the veins and are known as '''track marks'''.
* '''Arterial damage''' – Arterial [[pseudoaneurysm]]s may form at injection sites, which can rupture, potentially resulting in [[hemorrhage]], distal [[ischemia]], and [[gangrene]]. Inadvertent intra-arterial injection can also result in [[endarteritis]] and [[thrombosis]], with ultimately similar consequences.<ref>{{cite journal|last=COUGHLIN|first=P|author2=MAVOR, A|title=Arterial Consequences of Recreational Drug Use|journal=European Journal of Vascular and Endovascular Surgery|date=1 October 2006|volume=32|issue=4|pages=389–396|doi=10.1016/j.ejvs.2006.03.003|pmid=16682239|doi-access=free}}</ref>
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==Methods==
[[File:Clandinjectkit.JPG|thumb|A clandestine kit containing materials to inject drugs, a bottle of a type of [[Purple drank|lean]], [[promethazine]], an [[antiemetic]], and unidentified pills
The drug—usually (but not always) in a powder or crystal form—is dissolved in water, normally in a spoon, tin, bottle cap, the bottom of a soda can, or another metal container. Cylindrical metal containers—sometimes called "cookers"—are provided by [[needle exchange program]]s. Users draw the required amount of water into a syringe and squirt this over the drugs. The solution is then mixed and heated from below if necessary. Heating is used mainly with [[heroin]] (though not always, depending on the type of heroin),<ref>{{Cite journal|vauthors=Strang J, Keaney F, Butterworth G, Noble A, Best D |title=Different forms of heroin and their relationship to cook-up techniques: data on, and explanation of, use of lemon juice and other acids |journal=Subst Use Misuse |volume=36 |issue=5 |pages=573–88 |date=April 2001 |pmid=11419488 |doi= 10.1081/JA-100103561|s2cid=8516420 }}</ref> but is also often used with other drugs, especially crushed tablets. Cocaine HCl (powdered cocaine) dissolves quite easily without heat. Heroin prepared for the European market is insoluble in water and usually requires the addition of an acid such as [[citric acid]] or [[ascorbic acid]] (Vitamin C) powder to dissolve the drug. Due to the dangers from using lemon juice or vinegar to acidify the solution, packets of citric acid and Vitamin C powder are available at needle exchanges in Europe. In the U.S., vinegar and lemon juice are used to shoot [[crack cocaine]]. The acids convert the water-insoluble cocaine base in crack to a cocaine salt (cocaine acetate or cocaine citrate), which is water-soluble (like cocaine hydrochloride).
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|access-date=2008-12-22}}</ref>
Regarding [[route of administration]], much injection drug use, but not all, is [[intravenous injection]], whereas some is [[subcutaneous injection]] or [[intramuscular injection]] (including [[skin popping]], which often involves a [[depot injection]]).
==Recreational drugs==
===Risks===
Risks from drug injection are caused by a variety of factors, including unclean or unsafe injection practices and repeated injections at the same site.<ref name=":0">{{Cite web|url=https://www.who.int/hiv/topics/idu/drug_dependence/hiv_primary_care_guidelines_searo.pdf|title=Management of Common Health Problems of Drug Users|date=2009|website=World Health Organization}}</ref> Injection drug users that fail to adequately sanitize the skin or use clean injection products are at increased risk for [[cellulitis]], [[abscess]]es, and [[thrombophlebitis]]; these infections can subsequently result in [[sepsis]] and [[bacteremia]], which can be fatal if untreated.<ref name=":0" /> Repetitive injections, especially those with unsafe practices, can result in additional medical concerns that include [[thrombosis]] formation and infectious [[endocarditis]].<ref name=":0" /> In rare cases Osteomyelitis of the chest can be caused by IV drug use.▼
====Substances====
=====Contraindicated substances=====
* [[Codeine]] - Injectable codeine is available for subcutaneous or intramuscular injection only; intravenous injection is contraindicated as this can result in non-immune mast-cell degranulation and resulting anaphylactoid reaction.
* [[Ethchlorvynol]] is not compatible with intravenous injection and serious injury (including the loss of limbs due to vascular injury) or death can occur when it is used in this manner.<ref>{{cite journal | vauthors = Glauser FL, Smith WR, Caldwell A, Hoshiko M, Dolan GS, Baer H, Olsher N | title = Ethchlorvynol (Placidyl)-induced pulmonary edema | journal = Annals of Internal Medicine | volume = 84 | issue = 1 | pages = 46–8 | date = January 1976 | pmid = 942681 | doi = 10.7326/0003-4819-84-1-46 }}</ref>
* [[Hydroxyzine]] (brand name Atarax, and Vistaril) is contraindicated for [[subcutaneous administration|subcutaneous]], [[intra-articular injection|intra-articular]], or [[Subcutaneous administration|subcutaneous]] administration.<ref>{{cite web |title=Hydroxyzine - an overview {{!}} ScienceDirect Topics |url=https://www.sciencedirect.com/topics/neuroscience/hydroxyzine |website=www.sciencedirect.com}}</ref><ref>{{cite web |url=https://go.drugbank.com/drugs/DB00557 |title=Hydroxyzine }}</ref>
=====Street drugs=====
* [[Black tar heroin]] is notably risky to inject.
====Infections====
▲Risks from drug injection are caused by a variety of factors, including unclean or unsafe injection practices such as [[Flashblood|blood flashing]]<ref name="flashbloodnyt">{{cite news |last1=McNeil Jr. |first1=Donald G. |title=Desperate Heroin Addicts Inject Blood of Other Users |url=https://link.gale.com/apps/doc/A231383957/HWRC?u=rock21695&sid=bookmark-HWRC&xid=bb4ea1e9 |access-date=11 May 2022 |work=New York Times |agency=Gale Health and Wellness |date=13 July 2010}}</ref> and repeated injections at the same site.<ref name=":0">{{Cite web|url=https://www.who.int/hiv/topics/idu/drug_dependence/hiv_primary_care_guidelines_searo.pdf|title=Management of Common Health Problems of Drug Users|date=2009|website=World Health Organization}}</ref> Injection drug users that fail to adequately sanitize the skin or use clean injection products are at increased risk for [[cellulitis]], [[abscess]]es, and [[thrombophlebitis]]; these infections can subsequently result in [[sepsis]] and [[bacteremia]], which can be fatal if untreated.<ref name=":0" /> Repetitive injections, especially those with unsafe practices, can result in additional medical concerns that include [[thrombosis]] formation and infectious [[endocarditis]].<ref name=":0" /> In rare cases
Additional risks from unsafe injection practices result primarily from sharing materials (needles, cookers, syringes) used in injection.<ref name=":0" /> [[Blood-borne disease|Blood-borne pathogens]], such as [[HIV]], [[Hepatitis B]], and [[Hepatitis C]] are of particular concern among injection drug users who share supplies, and increase the likelihood of infection.<ref name=":0" /> An added challenge, is that not only infected individuals know their positive status and continue to share supplies, placing other users at risk for infection as well.<ref name=":0" /> 30-50% of adults will not experience acute [[Hepatitis B]] symptoms, and those that do experience [[lethargy]], nausea, upper abdominal pain, muscle aches, or a darkening of urine will need to connect these symptoms to a possible infection to seek care and limit spreading of the virus.<ref name=":0" />
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[[Harm reduction]] is a public health approach that serves as an alternative to abstinence-only guidance. While it does not condone the use of illicit or illegal drugs, it does seek to reduce the harms, risks and dangers associated with illicit drug use, both for the person using illicit drugs and the wider community. Injection drug users that re-use drug delivery components put themselves and others at risk for diseases such as HIV, hepatitis B, and hepatitis C, as well as increase their chances of getting a serious infection.<ref>{{Cite web|url=https://www.cdc.gov/nchhstp/dear_colleague/2016/dcl-112916-hiv-and-injection-drug-use.html|title=HIV and Injection Drug Use: Syringe Services Programs for HIV Prevention {{!}} 2016 {{!}} Dear Colleague Letters {{!}} NCHHSTP {{!}} CDC|website=www.cdc.gov|language=en-us|access-date=2017-10-31}}</ref><ref name=":1">{{Cite web|url=https://www.cdc.gov/hiv/risk/ssps.html|title=Syringe Services Programs {{!}} Injection Drug Use {{!}} HIV Risk and Prevention {{!}} HIV/AIDS {{!}} CDC|date=2017-09-28|website=www.cdc.gov|language=en-us|access-date=2017-10-31}}</ref> In 2015, the CDC performed an HIV Surveillance Report and attributed 2,392 (6%) of new HIV diagnoses to IV drug use in the US.<ref>{{Cite web|url=https://www.cdc.gov/hiv/risk/idu.html|title=Injection Drug Use {{!}} HIV Risk and Prevention {{!}} HIV/AIDS {{!}} CDC|website=www.cdc.gov|language=en-us|access-date=2017-10-31}}</ref>
A prominent method for addressing the issue of disease transmission among intravenous drug users are [[needle exchange program]]s (also known as syringe exchange programs, syringe service programs or needle-syringe programs), where people who inject drugs (PWID) can access sterile needles, syringes, and other paraphernalia.<ref name=":1" /><ref>{{Cite journal|last1=Mackesy-Amiti|first1=Mary E.|last2=Boodram|first2=Basmattee|last3=Spiller|first3=Michael W.|last4=Paz-Bailey|first4=Gabriela|last5=Prachand|first5=Nikhil|last6=Broz|first6=Dita|last7=NHBS Study Group|date=2017-07-01|title=Injection-Related Risk Behavior and Engagement in Outreach, Intervention and Prevention Services Across 20 US Cities|journal=Journal of Acquired Immune Deficiency Syndromes|volume=75 Suppl 3|issue=3 |pages=S316–S324|doi=10.1097/QAI.0000000000001406|issn=1944-7884|pmid=28604433|s2cid=3505532|url=https://figshare.com/articles/journal_contribution/10755530 }}</ref> In addition to providing sterile devices used in drug injection, these programs often offer access to infectious disease testing, referrals for substance use or mental health treatment programs, and more.<ref name=":1" /> The idea behind harm reduction approaches is to slow disease transmission, such as HIV/AIDS and hepatitis B and C, and promote public health by reducing the practice of sharing used needles.
In countries where harm reduction programs are limited or non-existent, it is quite common for an IV users to use a single needle repeatedly or share with other users. It is also quite uncommon for a sterilizing agent to be used on needles and syringes. This creates a high risk population for the spread of bloodborne pathogens.▼
▲In countries where harm reduction programs are limited or non-existent, it is quite common for
A new approach to reduce harm to IV drug users was recently started in Southern Nevada in 2017. Trac-B Exchange - Southern Nevada Harm Reduction Program was approved in early 2017 to help reduce the spread of HIV in "People Who Inject Drugs".<ref>{{Cite web|url=http://www.health.ri.gov/disease/prevention/about/notsharingneedles/|title=Do Not Share Syringes: Department of Health|website=www.health.ri.gov|access-date=2017-10-30}}</ref> In Nevada, the sharing of needles for drug injections has led to an increase in the spread of HIV and hepatitis B and C. In an effort to reduce the spread of blood borne pathogens, Southern Nevada installed vending machines to give access to sterile needles to those using them for drug injections. Individuals who use these vending machines are required to register with Trac-B and are allowed 2 boxes a week. The boxes contain sterile needles as well as other supplies necessary to reduce the risk of spreading blood borne pathogens.<ref>{{Cite web|url=https://southernnevadahealthdistrict.org/news17/20170412-health-district-trac-b-exchange-launch-southern-nevadas-first-needle-exchange.php|title=Health District, Trac-B Exchange, launch Southern Nevada's first needle exchange|website=southernnevadahealthdistrict.org|access-date=2017-10-30|archive-url=https://web.archive.org/web/20180709193726/http://www.southernnevadahealthdistrict.org/news17/20170412-health-district-trac-b-exchange-launch-southern-nevadas-first-needle-exchange.php|archive-date=2018-07-09|url-status=dead}}</ref> If this pilot program is successful in reducing the spread of bloodborne pathogens, we may see programs like this spread to other parts of the country.▼
▲A new approach to reduce harm to IV drug users was recently started in Southern Nevada in 2017. Trac-B Exchange - Southern Nevada Harm Reduction Program was approved in early 2017 to help reduce the spread of HIV in "People Who Inject Drugs".<ref>{{Cite web|url=http://www.health.ri.gov/disease/prevention/about/notsharingneedles/|title=Do Not Share Syringes: Department of Health|website=www.health.ri.gov|access-date=2017-10-30}}</ref> In Nevada, the sharing of needles for drug injections has led to an increase in the spread of HIV and hepatitis B and C. In an effort to reduce the spread of blood borne pathogens, Southern Nevada installed vending machines to give access to sterile needles to those using them for drug injections. Individuals who use these vending machines are required to register with Trac-B and are allowed 2 boxes a week. The boxes contain sterile needles as well as other supplies necessary to reduce the risk of spreading blood borne pathogens.<ref>{{Cite web|url=https://southernnevadahealthdistrict.org/news17/20170412-health-district-trac-b-exchange-launch-southern-nevadas-first-needle-exchange.php|title=Health District, Trac-B Exchange, launch Southern Nevada's first needle exchange|website=southernnevadahealthdistrict.org|access-date=2017-10-30|archive-url=https://web.archive.org/web/20180709193726/http://www.southernnevadahealthdistrict.org/news17/20170412-health-district-trac-b-exchange-launch-southern-nevadas-first-needle-exchange.php|archive-date=2018-07-09|url-status=dead}}</ref>
Although this is a new idea in the United States, it was tested in Europe over 20 years ago. In order to combat the AIDS epidemic that was spreading across Europe, France allowed pharmacies to dispense needles without a prescription and implemented needle exchange programs. In 1996, they began a pilot program of syringe vending machines, similar to a coin-operated vending machine. The first vending machines were placed in Marseille due to its high occurrence of AIDS caused by sharing of needles. The results of their study was published in 1999. They found that when the availability of syringes increased, more and more people began to purchase sterile needles. It also provided a
Beyond just needle exchange programs, the other major harm reduction strategy for drug users are safe injecting facilities (SIFs). These provide a sterile environment for people who inject drugs to do so cleanly, and with sterile syringes which are forced to be thrown away after use so that no re-use occurs. The first of these facilities opened in Switzerland, but there are now over 100 globally including one in Vancouver - Canada, Sydney - Australia, and most recently, Melbourne - Australia.
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==Alternatives==
The closest method to IV/overall injection use, in terms of rapid onset, optimal bioavailability, and reduced health risks for most drugs, tends to be rectal administration via concentrated liquid solution (also known as a suppository), usually consisting of only ~1-3ml of liquid (typically not exceeding 5-10ml) assuming the drug in question possesses sufficient water solubility. While oral morphine has a general bioavailability range is only 20-40%, properly administered rectal use of liquid morphine has an effective bioavailability of roughly 70%, or more than double the overall potency of oral morphine and more than two thirds that of IV use. Swallowing tends to be the safest and slowest method of ingesting drugs. It is safer as the body has a much greater chance to filter out impurities. As
==History==
{{Unreferenced section|date=December 2021}}
IV drug use is a relatively recent phenomenon arising from the invention of re-usable syringes and the synthesis of chemically pure [[morphine]] and cocaine.
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===Origin and early use===
{{Unreferenced section|date=December 2021}}
The [[hypodermic needle]] and syringe in its current form was invented by the French scientist [[Charles Pravaz]] in 1851, and became especially known during the wars of that and the subsequent decade. However, the first well-known attempt to inject drugs into the body was a 1667 attempt to inject a solution of [[opium]] into a dog, and some had suspected that parenteral administration of drugs may work better based on the practise of rubbing opium and other drugs into sores or cuts on the skin for the purpose of causing systemic absorption and the beginnings of scientific understanding of the functioning of the lungs.
During most of the 1850s, the previously
In or shortly after 1851, the drugs which had been discovered and extracted from their plants of origin and refined into pure crystalline salts soluble in water included [[morphine]] (1804 or late 1803), [[codeine]] (1832), [[narcotine]]/[[noscapine]] (
A wide variety of drugs are injected. Among the most popular in many countries are morphine, heroin, cocaine, [[amphetamine]], and methamphetamine. Prescription drugs—including tablets, capsules, and even liquids and [[suppositories]]—are also occasionally injected. This applies particularly to prescription opioids, since some opioid addicts already inject heroin. Injecting preparations which were not intended for this purpose is particularly dangerous because of the presence of [[excipient]]s (fillers), which can cause blood clots. Injecting codeine into the bloodstream directly is dangerous because it causes a rapid [[histamine]] release, which can lead to potentially fatal [[anaphylaxis]] and [[pulmonary edema]]. [[Dihydrocodeine]], [[hydrocodone]], [[nicocodeine]], and other codeine-based products carry similar risks. Codeine may instead be injected by the intramuscular or subcutaneous route. The effect will not be instant, but the dangerous and unpleasant massive histamine release from the intravenous injection of codeine is avoided. To minimize the amount of undissolved material in fluids prepared for injection, a filter of cotton or synthetic fiber is typically used, such as a cotton-swab tip or a small piece of cigarette filter.
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==See also==
{{Portal
*[[Air embolism]]
▲*[[Intravenous marijuana syndrome]]
*[[Extravasation (intravenous)]]
*[[Lethal injection]]
*[[Needle and syringe programmes]]
*[[Needle remover]]
*[[Needlestick injury]]
*[[Safety syringe]]
*[[Supervised injection site]]
==References==
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