Understanding the sharing of injecting equipment

To understand how to intervene to reduce the risks from injecting it is important to develop a comprehensive understanding of the complex issues covered by the term 'sharing'.

This means understanding:

• what is known about infection risks;

• the beliefs and knowledge of injecting drug users;

• the actual injecting practices that people use;

• what people share and why; and

• the contexts in which injecting occurs.

All of these issues have an impact on what is shared, when, and why, and will inform efforts to reduce sharing.

The 'causes' of injecting risk
There has been a tendency, now changing, for drug workers (and other health professionals) to understand risk only in terms of individual decision making. This 'individual health' way of looking at risk sees avoidance of sharing as people understanding the risks that they might be exposed to, and engaging in behaviours that avoid those risks. Conversely it sees sharing risk as part of a decision taken through lack of information, or regard for personal safety.

However, this is only one part of the equation. There are other important factors that are key drivers of risk such as:

• the availability of injecting equipment;

• the environment that the injector is preparing and injecting thier drugs in;

• the law enforcement context; and

• social norms amongst injecting groups.

These are discussed in more detail below.

Availability of injecting equipment
Injecting drug users in the UK are well aware of the risks of sharing, and take significant steps to avoid risk wherever possible. When faced with the choice between a new syringe and a used syringe injectors will choose the new one, and the main reason both cited by injectors and observed in practice, for syringe reuse is lack of availabilty. Calculations of syringe coverage (the % of injections for which a new sterile syringe has been supplied) in the UK usually approximate to around just 30% - which means that the average syringe is used 3 times. Removing obstacles to syringe collection, and improving coverage is the single most important step that can be taken by needle and syringe programmes to reduce sharing and blood borne virus transmission.

The frequent re-use of syringes leads to accidental or indirect sharing of syringes in situations where people store injecting equipment together and/or inject in close proximity to others and cannot easily distinguish their injecting equipment from that of others, if for example all the syringes being used are the same. Suggestions for better ways of distinguishing equipment, for example by producing syringes in different colours came from video ethnographic research in Scotland (Taylor 2004).

Exchange Supplies subsequently acted on this research by producing the ‘Nevershare’ syringe, which is a 1ml syringe available in 5 different colours and is a useful tool in helping to prevent accidental sharing, especially between couples and groups of close friends who had previously accepted that it was practically impossible to prevent some accidental sharing of syringes that were being reused.

Social drivers of risk
Social drivers of risk include social norms amongst some groups of injectors including reciprocation and the display of trust may 'demand' that sharing extends also to drugs and injecting equipment (Rhodes 2001). More directly, economically poor injectors commonly pool resources to buy drugs and sometimes too jointly commit crimes to fund those purchases. Group-based purchase encourages group-based use, which also promotes sharing of injecting equipment.

Adversity can also precipitate risk. In open drug markets subject to intense police pressure, injecting drug users are reluctant to carry needles on them, and are anxious to consume drugs rapidly. The result is that many resort to using whatever equipment is to hand, even if it may have been previously used by someone else, as well as other practices (such as mouth to mouth transfer of drugs) which could spread infection (Kumar 1998, Dixon 1999).

Close sexual and friendship relationships may also be seen as mandating closeness in the form of using from the same syringe (Stimson 1995). In the UK (Hunter 2000, Dolan 1992) and other countries with developed harm reduction services (Smyth 2001, Franken 1997) most injectors now limit their sharing of needles and syringes to one or two partners and friends and may not see this as an infection risk (Ball 1997). Where young injectors have grown up together and know each other well or have initiated drug use as a group, the perception of risk may be low (‘I know where you’ve been’), compounding the ties of friendship and leading to a high level of sharing (Klee 1995).

As a result networks and groupings of drug users tend to develop risky practices together and also to reduce risk together through example, influence and changes in social norms (Jose 1996). As well as the capacity to avoid known risks, what is seen as a risk in the first place is itself socially defined, not just in terms of the people with whom sharing is considered too risky, but also in terms of the practices which the network as a whole and its opinion leaders dismiss or emphasise (Rhodes 1997).

Such factors are not the only ones to lie behind the risk behaviour seen even in societies with relatively well-developed services. Indicators of social exclusion and deprivation such as homelessness, poor education, parental unemployment, and poverty are consistently linked to unsafe injecting practices (Bluthenthal 1998, Guydish 1998, Strathdee 1997, Smyth 2001). Lack of a secure home base may be partly why in the north west of England, heroin/polydrug injectors who injected in the street or in public spaces were more likely both to re-use other people’s syringes and needles and to pass them on (Klee 2003). Material deprivation and high levels of dependence, psychiatric problems and depression also obstruct risk reduction efforts (Des Jarlais 1998). It is, for example, very difficult to follow injecting hygiene guidelines when injecting takes place in public spaces or abandoned buildings with no water supply.

Risk of infection must also be placed in the context of a lifestyle imbued with risks such as fatal overdose, which to the drug user may seem more immediate, more probable and more serious. To the rest of the population, the argument that ‘You could get HIV or hepatitis C’ might be enough to stimulate precautions, to an injector it might not.

The law enforcement context
Ethnograpic and allied researchers have shown that some of the ties which make sharing injecting equipment seem natural are generated by the business of obtaining and using drugs, and this is one reason why it will not be easy to eliminate sharing completely in the UK while the regulatory system remains as it is.

In the illicit drug economy, personal networks take the place of the more impersonal mechanisms (‘shopkeepers’, ‘customers’) available to legal retail markets (Wiebel 1996). Under attack from mainstream society, vulnerable to the fluctuations of the illicit market and to the whims of treatment and enforcement authorities, injecting drug users develop solidarity and mutual support mechanisms (Maher 1998). The entire ethos is one of shared risk, shared resources, reciprocal favours and reliance on one’s contacts.

Actual injecting practice
We have produced a DVD which shows ethnographic footage of injecting, and describes the risks in the injecting process – you can watch a clip by clicking here

High risk situations
Another notion that it's important for workers to understand is that of 'high risk situations' - because there are times when injecting drug users who otherwise always use thier own equipment may share.

High risk situations commonly reported to precipitate sharing include:

• release from custody; and

• being in withdrawals, having drugs, but not having own injecting equipment.

It can be very helpful for injectors to develop contingency plans to deal with such situations such as:

• having a store of injecting equipment with friends and family;

• always having an 'emergency supply' kept somewhere; and

• making sure that you always collect enough equipment from the NSP to be able to give friends needles and syringes so that you're not left short

can all help ensure that high risk situations are kept to a minimum or never occur.

Services can reduce the incidence of high risk situations by implementing measures such as:

• custody suite needle and syringe supply;

• extended opening hours equipment availablity:

• vending machines;

• encouraging secondary exchange;

• outreach;

• mobile NSP; and

• supervised injecting facilities.

The role of equipment in blood borne virus infection
Syringes are by far the most significant vectors of blood borne virus infection amongst injecting drug users. This is because they contain more blood than any other item involved in the injecting process, and it is contained in a protected environment so will be subjected to less change in temperature, and drying by exposure to air. It is also the case that other items in the injecting process become contaminated with infected blood through contact with syringes - so if syringe reuse and sharing can be stopped, the risks from items of paraphernalia will be greatly reduced or prevented.

However, while syringe reuse is common, because it is highly infectious, hepatitis C may be spread through ‘paraphernalia’ sharing. Prevention of sharing of paraphernalia is a complex issue to address, and will involve changing social norms and reciprocation practices such as the donation of used filters (from which drug residues can be extracted) to occupants who allow their premises to be used for injecting. While few injectors will be ignorant of the risks of sharing needles and syringes, many are unaware that sharing spoons, filter and water may also risk infection (Speed 1997,1998).

There is also a practical incentive to share which does not apply in the same way to needles and syringes (Koester 1996, Power 1996). Re-used syringes are liable to clog and re-used needles lose their edge, making injecting more painful and difficult. Purely in terms of getting a problem-free and rapid hit, there is some incentive to use new equipment each time.

There is no such incentive to encourage avoidance of re-using spoons, filters and water. Instead, purely in drug taking terms, the incentive is to share.

When a group injects their jointly purchased drugs, practicality and equity tend to promote the collective use of equipment for preparing and measuring out the purchase. In some cases, too, more businesslike cooperation in drug dealing networks (eg, acting as ‘runners’, helping dealers and customers make contact) is remunerated in the form of drugs, which the partners divide between them and inject together.

The most reliable, the quickest, and what may also be seen as the fairest ways to parcel out the drug, risk contamination of each injector’s syringe and needle (Valenciano 2001). Among these are drawing up quantities from a common pool of dissolved drug or using one syringe to squirt measured quantities into each of the others. Filters too will be shared during this process and may be recycled later to extract trapped drug particles.

The value of ethnographic research
Undestanding sharing is difficult to do through questionnaires or discussions that take place outside the injecting environment, not least because the act of injecting is an integral part of many people's lives, and many aspects of it are, like driving a car for a regular driver, done with little conscious thought. In recent years, our understanding of injecting risk has been moved forward significantly by using video recording ethnographic research methods.

Ethnography produces rich descriptions of what people do in natural settings and, coupled with detailed discussions with drug users, it has proved invaluable in examining what actually happens in the injecting process. Ethnographic research is particularly useful when examining areas of behaviour - such as injecting - about which little is known, and the findings are often used to develop questions to be addressed by quantitative research (Lambert 1990).

Many fundamental understandings of injecting behaviour, such as the identification of frontloading and backloading, have been identified through ethnographic research, and their discussion and prevention incorporated into clinical, and injecting practice. There are similarities between ethnographic research methods and aspects of outreach work, and his has led to its incorporation within some outreach work and the development of models of practice that integrate ethnography and outreach (Broadhead 1990, Power 1995).


Key points

• Sharing injecting equipment is not just about decision making - it is a consequence of a number of factors, many of which can be directly affected by the delivery of effective services;

• Understanding injecting risk involves an open and non-judgemental dialogue with injecting drug users;

• ethnographic, qualitative, and quantitative research methods all have an important role to play;

• An effective response to injecting risk must include easy access to injecting equipment, including secondary syringe distribution;

• Needle and Syringe Programmes can't operate in isolation - it works best alongside other harm reduction services including effective opiate substitution therapy.

We have also made a documentary as part of the Harm Reduction Works Campaign on this subject, you can watch 'understanding the sharing of injecting equipment' on Youtube, by clicking here.

References
Bennett G.A. et al. “Low autonomy in injecting is a risk factor for sharing injecting equipment.” Addiction Research: 2000.

Lambert E Y and Wiebel W W (1990) In: Lambert E Y (ed.) The Collection and Interpretation of Data from Hidden Populations: NIDA Research Monograph.

Broadhead R S and Fox K J (1990) Takin' it to the streets: AIDS outreach as ethnography. Journal of Contemporary Ethnography.

Power R (1995) A model for qualitative action research amongst illicit drug users. Addiction Research.

Wiebel W. “Ethnographic contributions to AIDS intervention strategies.” In: Rhodes T. et al, eds. AIDS, drugs and prevention. Perspectives on individual and community action, 1996.

Maher L. et al. Running the risks. [Australian] National Drug and Alcohol Research Centre, 1998

“Understanding injecting risk behaviour.” In: Rhodes T. et al, eds. Injecting drug use, risk behaviour and qualitative research in the time of AIDS. EMCDDA, 2001.

Kumar M.S. et al. “Community-based outreach HIV intervention for street-recruited drug users in Madras, India.” Public Health Reports: 1998.

Dixon D. et al. “Law enforcement, harm minimization, and risk management in a street level drug market.” Presented to the Australasian Conference on Drugs Strategy, April 1999.

Speed S and Bennett A (1997) Sharing Injecting Paraphernalia. An Audit of Risk Behaviours Among Attenders at Syringe Exchange Schemes in North West England. University of Central Lancashire, HIT, Liverpool.

Speed S. “The sharing of injecting paraphernalia among 96 regular attenders at needle exchange schemes in the north west of England: implications for public health policy.” International Journal of Drug Policy: 1998.

Koester S.“The process of drug injection. Applying ethnography to the study of HIV risk among IDUs.” In: Rhodes T. et al, eds. AIDS, drugs and prevention. Perspectives on individual and community action. Routledge, 1996.

Power R. “Promoting risk management among drug injectors.” In: Rhodes T. et al, eds. AIDS, drugs and prevention. Perspectives on individual and community action. Routledge, 1996.

Valenciano M. et al. “Unsafe injecting practices among attendees of syringe exchange programmes in France.” Addiction: 2001.

Stimson G.V. “AIDS and injecting drug use in the United Kingdom, 19871993: the policy response and the prevention of the epidemic.” Soc. Sci. Med.: 1995.

Hunter G.M., et al. “Measuring injecting risk behaviour in the second decade of harm reduction: a survey of injecting drug users in England.” Addiction: 2000.

Dolan K.A. et al. A cohort study of syringeexchange attenders and other drug injectors, 1989–1990. Centre for Research on Drugs and Health Behaviour, 1992.

Smyth B.P. et al. "Syringe borrowing persists in Dublin despite harm reduction interventions." Addiction: 2001.

Franken I.H.A. et al. “Risk contexts and risk behaviors in the Euregion MaasRhein: the Boule de Neige intervention for AIDS prevention among drug users.” AIDS Education and Prevention: 1997.

Ball M. Evaluation of needle and syringe exchange schemes funded by the Avon Health Authority. Final report. 1997.

Klee H., et al. “The role of needle exchanges in modifying sharing behaviour: crossstudy comparisons 1989–1993.” Addiction: 1995.

Jose B. et al. “Collective organisation of injecting drug users and the struggle against AIDS.” In: Jose B. et al, eds. AIDS, drugs and prevention 1996.

Rhodes T. “Risk theory in epidemic times: sex, drugs and the social organisation of ‘risk behaviour’.” Sociology of Health and Illness: 1997.

Bluthenthal R.N. et al. "Use of an illegal syringe exchange and injection related risk behaviors among streetrecruited injection drug users in Oakland, California, 1992 to 1995." Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology: 1998.

Guydish J. et al. “Evaluating needle exchange: a description of client characteristics, health status, program utilization, and HIV risk behavior.” Substance Use & Misuse: 1998.

Strathdee S.A., et al. "Needle exchange is not enough: lessons from the Vancouver injecting drug use study." AIDS 1997.

Smyth B.P. et al. "Syringe borrowing persists in Dublin despite harm reduction interventions." Addiction: 2001.

Taylor A. et al. Effective Interventions Unit. Examining the injecting practices of injecting drug users in Scotland. 2004.