Introduction
Heroin overdose
Stimulant overdose
Blood-borne viruses
Hepatitis
Human immunodeficiency virus (HIV)
Pulmonary embolism (PE)
Septicaemia
Endocarditis
Other infections
'Dirty hits/bad hits'
Key points

As well as causing damage and infection at or near the injection site, the injection of illicit drugs can cause complications far from the actual site of injection or that involve the whole body. This section discusses these, largely avoidable, hazards of injection.

All the conditions discussed have increased incidence in people who:

Have been injecting for a long time

Inject frequently

Practise risky injecting

Have poor nutrition

Are deprived.

Most of the infections and other serious illnesses described in this section have causes other than injecting drug use. Injecting drug users may, like anyone else, suffer from illness ­ this can be unrelated to their drug use.

Drug users tend to disregard many health problems, thinking that they are a direct result of their drug use, whether they are or not. This can lead to people not reporting problems until they have become much more serious.

Traditionally, treatment services have tended to compound this problem by similarly viewing drug users' health problems as being always directly related to their drug use.

These factors mean that drug workers often have an important advocacy role to play with medical services in order for their clients' health needs to be met.

Needle exchange workers need to be familiar with the causes, symptoms and first aid treatment of overdose. Many of their clients will regularly be experiencing overdose themselves and seeing it happen to their peers.

By dispelling the myths surrounding overdose and giving appropriate first aid advice, needle exchange workers can, indirectly, save lives.

An overdose is the taking of more of a drug than is required or safe.

With regard to sedatives it usually refers to a dose that causes death, with phrases such as 'going over' being used to describe a non-fatal overdose.

It might be thought that a fatal overdose would be more likely to affect younger, less experienced drug users. However, in a comprehensive review of the literature, Darke and Zador¹⁰¹ found that those overdosing on heroin were most likely to be male and in their late twenties or early thirties.

Non-fatal heroin overdose

In an Australian study, Darke et al.¹⁰² found that two-thirds of their study sample of heroin users had at sometime experienced non-fatal overdose and one quarter had done so in the last 12 months.

Darke found no differences in overdose rates between males and females, although subsequent actions by others present were different between sexes, with males much less likely to take actions, such as calling an ambulance, because of fear of prosecution.

The second part of this study also found that users were consistently good at identifying signs of overdose in others and differentiating this from heavy intoxication.

Fatal heroin overdose

The dividing line between a fatal and a non-fatal overdose will often be slim and may be affected by the actions or inaction of others present at the time.

An unknown proportion of fatal overdoses will be deliberate. Some authors have suggested that opiate users are more likely to employ violent methods of suicide over deliberate overdose, as they view their heroin use as 'survival orientated'¹⁰³ ­ in other words, part of their coping mechanism. This may or may not be so.

Violent methods of suicide among drug users are much easier to quantify when examining coroners' records than a deliberate drug overdose in an already drug-tolerant individual, where it can be difficult to determine exactly what it was that ultimately proved fatal.

Causes of heroin overdose

The reasons why accidental overdose occurs are often uncertain.

It has been suggested that it is sensible for injectors to smoke a small amount of heroin in order to gauge its strength before injecting¹⁰⁴.

Many overdoses are not due to contaminated or 'especially pure heroin' as is commonly believed, but rather a combination of one or more of the following factors:

Lowered tolerance of the individual ­ especially on release from prison or on relapse from detoxification

Poly-drug use ­ especially alcohol and benzodiazepines; any combination of many drugs with a respiratory depressant effect will increase the likelihood of overdose

Allergic reaction

Unfamiliar surroundings which may lead to individuals experiencing higher than normal stress levels, or not engaging in their normal drug-taking routine.

Other associated factors

Associated factors which may have negative effects on the outcome of an overdose are:

Injecting alone ­ if an overdose occurs there will be no one to take appropriate action

People who take inappropriate action or no action

Leaving cigarettes or naked flames burning ­ increases the risk of fire

Leaving a tourniquet in place ­ increases the risk of circulatory damage

Injecting whilst in a bath.

Signs and symptoms of heroin overdose

Heroin overdose may be difficult to distinguish from any other cause of unconsciousness. Signs which indicate that unconsciousness may be due to heroin are:

Recent opiate use ­ especially combined with other depressants or opiates (particularly methadone because of its long duration of action)

Pinpoint pupils

Cyanosis (bluish tinge to skin) ­ especially around the lips

Shallow or absent breathing

Person is cold to the touch (hypothermia)

Person is unrousable.

Treatment of heroin overdose

Treatment of overdose requires that the respiratory depressive effects of the drug(s) are countered as quickly as possible.

Treatment and immediate actions could include:

Ensuring that the airway is not blocked with vomit or the tongue

Placing the person in the recovery position

Attempting to rouse the person

Calling an ambulance

Giving naloxone

Giving cardiac massage and mouth-to-mouth resuscitation if necessary.

Teaching injectors basic resuscitation techniques which could be employed until emergency treatment services arrive could help to prevent many overdose deaths.

Naloxone (Narcan)

Naloxone is an opiate antagonist which, when given, reverses the effects of opiates and opiate overdose very quickly.

Naloxone can be life-saving, but the effects wear off quickly (the serum half-life is one hour and the duration of action is two to three hours). The person can then slip back into overdose. This danger is greatest with longer-acting opioids such as methadone and LAAM (a form of methadone with a half-life of 48­72 hours).

This means that those who have overdosed on methadone will require much longer monitoring than those who have overdosed on heroin.

Initially 0.8 mg naloxone (two ampoules) should be given intramuscularly and then 0.8­1.2 mg intravenously, which will need to be adjusted or repeated depending upon the amount and type of opiates taken¹⁰⁵

Naloxone, as well as counteracting the effects of overdose, can also precipitate immediate and unpleasant opiate withdrawal. Those administering it should be prepared for abuse or even violence. It should be noted that many overdoses are not of a single substance and a coma may be due to the action of drugs not counteracted by naloxone.
There have been suggestions that consideration should be given to teaching opiate users resuscitation techniques and perhaps, more controversially, supplying naloxone and instructions for its use as an over-the-counter medication from UK pharmacies¹⁰⁶, as it is in Italy.

Cocaine and amphetamine can cause death by overdose, although the exact mechanism by which death occurs may be difficult to establish.

Death by cocaine overdose often involves:

Hyperthermia (high body temperature)

Convulsions

Circulatory problems

Respiratory collapse.

Signs of stimulant overdose

Someone who is overdosing on stimulants may initially:

Feel hot to the touch

Look flushed

Have the above signs but not be sweating.

An ambulance should be called and the person kept as cool as possible with damp cloths.

Section 3: Viral transmission, drugs and their preparation, discusses the transmission of blood-borne viruses.

Viral survival in the environment

There is often confusion about the relative survival times of different blood-borne viruses; HIV is sometimes mistakenly referred to as a 'fragile virus'. Injectors may have unrealistic beliefs about the ability of the HIV virus to survive outside the body.

In a study of syringe exchange attenders in South Kent, Hunt et al.¹⁰⁷ found that the majority had unrealistic beliefs about survivability of HIV virus outside the body, with times ranging from one minute to up to a day, given by over half the study.

In fact it has been shown that, given the right conditions, viable HIV DNA can be retrieved from syringes for several weeks. The Advisory Committee on Dangerous Pathogens said of HIV and Hepatitis B:

"Experimental work with HIV and HBV has established the stability of these viruses under various conditions. In dried blood, depending on relative humidity and other factors, HIV in high starting concentration may remain infectious for three weeks or more while HBV in dried plasma may retain its infectivity for at least four months."¹⁰⁸

For practical purposes, hepatitis C virus should be regarded as being at least as, if not more, resilient than the hepatitis B virus.

Hepatitis means 'inflammation of the liver'. It can be caused by:

Viruses

Drugs ­ notably alcohol

Toxic chemicals.

Inflammation of, and damage to the liver, caused by a hepatitis virus, may develop without symptoms over many years.

Where liver disease causes significant liver damage, symptoms may include:

Jaundice (yellow skin ­ usually most evident in the whites of the eyes)

Nausea and lack of appetite

Weight loss

Pale stools

Dark urine

Joint pains

Depression

Chronic fatigue

Raised level of liver enzymes, which can be measured by a simple liver function blood test (LFT).

The type of viral hepatitis causing a particular episode of illness can only be established by blood tests.

Six main types of viral hepatitis have been identified. Hepatitis B and C, which cause most problems for injecting drug users, are now discussed.

Hepatitis B

Hepatitis B is primarily a blood-borne virus, but it is present in all the body fluids of an infected person and so is also spread sexually. The main methods of spread of hepatitis B are parenteral (blood to blood) and sexual.

It is a much more easily transmissible infection than HIV, requiring a minuscule 0.00004 ml to be infective¹⁰⁹. It can survive for at least four months in the environment.

Blood tests for viral infections usually identify antibodies that have been produced by the body in response to exposure to the virus. The time between contracting hepatitis B and producing antibodies (sometimes referred to as the window period) can vary between four weeks and six months.

Vaccination

As a safe vaccination for hepatitis B exists, it is an almost entirely preventable infection.

The current UK strategy is one of only vaccinating 'high-risk groups' against hepatitis B infection. Current rates of infection amongst injecting drug users in the UK are high. A policy of vaccinating the general population has been recommended by the Viral Hepatitis Prevention Board who have stated that they believe:

"that the most effective way to protect this group is through universal vaccination, before they start to use drugs." ¹¹⁰

Vaccination uptake by attenders at drug services is usually quite low. Those not attending exchanges will very seldom have access to vaccination. Hepatitis B vaccination should be available easily through syringe and needle exchanges and drug services but often in the UK it is not. However, even if availability of vaccination is increased, it will remain very difficult to reach meaningful numbers of injecting drug users for vaccination.

Hepatitis C

Hepatitis C is extremely prevalent amongst injecting drug users, with studies showing 60­90% prevalence in some areas of the UK¹¹¹. The general response to hepatitis C in the UK to date has been patchy and inconsistent.

There is no vaccination available to prevent hepatitis C infection.

Most people who have hepatitis C have no obvious symptoms and may be unaware that they are infected.

If people do have symptoms, they are often non-specific, including:

Chronic or extreme tiredness

Anxiety and depression

Poor concentration.

Although jaundice and other obvious symptoms are rare in the first ten years of infection among people with hepatitis C, liver damage may well be occurring.

Transmission

Hepatitis C is almost universally transmitted by blood or blood products. The highest risk group for new infections of hepatitis C is now injecting drug users.

Before 1991 when donor screening was introduced, transmission of hepatitis C through blood transfusion was widespread, accounting for around 90% of post-transfusion hepatitis infections.

Haemophiliacs treated with factor concentrates to assist blood clotting, before 1991, were at high risk of contracting hepatitis C and there is now a large population of hepatitis C positive haemophiliacs.

The risk of sexual transmission of hepatitis C through vaginal sex appears to be very low, although any sexual activities in which there is a greater chance of blood exchange, such as anal sex or during menstruation, will increase the risk.

Vertical (mother to baby) transmission of hepatitis has been recorded, but appears to be unusual. Babies are often born with hepatitis C antibodies from the mother. As these usually disappear within the first 12 months, it has been suggested that babies should not be tested for their hepatitis C status until they are one year old¹¹². The risk of mother to baby transmission is increased if the mother is HIV positive.

The risk of infection following needlestick injury is thought to be between 2.7% and 10%.

It is thought that injecting drug users who do not share needles and syringes still often place themselves at high risk of contracting hepatitis C by repeated exposure to 'low-risk' events such as the sharing of injecting paraphernalia (e.g. spoons, water, filters).

Progress of the disease

The majority of those who have been infected will give a positive antibody test after eight weeks, although it may take up to six months for some people to develop antibodies.

The most reliable test is a PCR (polymerase chain reaction) test, which checks for the circulating virus.

Chronic infection (lasting longer than six months) is thought likely to occur in at least 80% of cases¹¹³.

Much of what is known about the progress of the disease comes from studies of people who were infected through blood transfusion. Some evidence suggests that those infected with hepatitis C through injecting may have more benign outcomes than those infected through blood transfusion.

Alcohol use (especially if excessive) is associated with a greater likelihood of progression to serious liver complications.

Over a time period of 15 to 40 years about 50% of the people infected with the virus will develop symptoms of liver disease. About 50% of those people (i.e. 25% of the infected population) will develop serious, long-term liver disease.

About 10% of those who become ill (i.e. 5% of the infected population) will develop cirrhosis of the liver. Cirrhosis is the process by which damaged liver tissue dies and the liver becomes incapable of fulfilling its many functions. It is usually a terminal disease.

About 5% of those who become ill (i.e. 2.5% of the infected population) will develop life-threatening cancer of the liver.

Treatment

Conventional medical treatment of hepatitis C is limited at the moment to alfa interferon which has a success rate (clearing the virus to undetectable levels) of about 20%.

The vast majority of doctors insist that a drug user is no longer injecting before they are started on a course of interferon. It is usually administered by subcutaneous self injection three times a week. Interferon often produces significant side effects which cause some people to discontinue treatment.

Clinical trials appear to suggest that using interferon in conjunction with ribavirin significantly improves the success rate of treatment.

There are many alternative treatments available for hepatitis C, although none has been conclusively shown to be of benefit.

'Task Force' recommendations on hepatitis

A UK government sponsored independent review of drug services in England in 1996²⁷ made the following recommendations:

Injectors should have easy access to hepatitis B vaccinations through drug services, GUM clinics and GPs

Purchasers should review their local arrangements for providing hepatitis B vaccinations and monitor their progress towards universal vaccinations for drug service clients

Consideration should be given to how best encourage those who could benefit from treatment for hepatitis B and C to come forward.

Information

An excellent source of free, up-to-date and accurate information about hepatitis is:

The British Liver Trust
Central House
Central Avenue
Ransomes Europark
Ipswich
IP3 9QG
Information line tel. 01473 276328.

HIV infection is not common amongst injecting drug users in the UK, although there have been localised outbreaks of widespread infection amongst injecting drug users in the past.

There are two main types of HIV infection, HIV-1 and HIV-2. HIV-1 is the type that is predominant in Western Europe, North America and Central Africa.

HIV disease affects the ability of the immune system to fight infection. It specifically affects the CD4 helper T lymphocytes, which are responsible for initiating nearly all of the body's responses to infection. As the CD4 count in the body falls, the person becomes increasingly susceptible to infection. The CD4 count is one of the measures used to assess the severity of the disease.

Transmission

The main transmission routes for HIV are:

Unprotected anal sex

Unprotected vaginal sex

Shared injecting equipment

From an infected mother to her child.

Symptoms of HIV infection

The symptomatology of HIV infection and AIDS is too wide a subject to be included in detail here. However, needle exchange workers should be aware of the general signs and symptoms of symptomatic HIV infection, which may include one or more of the following:

Fatigue

Fever

Severe night sweats

Weight loss

Malaise

Diarrhoea

Enlarged lymph glands

Oral thrush

Anal herpes.

HIV testing

A blood sample for an HIV antibody test should only be taken after thorough pre-test counselling from an appropriately trained worker. The giving of the result should be accompanied by appropriate post-test counselling.The initial test will usually be an ELISA (enzyme linked immuno assay) which has a low rate of false negative results.

This is the type of test usually provided by same-day testing services. If this test proves positive it is likely to be confirmed by the more sensitive Western Blot test.

A pulmonary embolism is the name given to a blood clot that gets stuck in the blood circulation of the lungs. 70­80% of pulmonary emboli occur as a result of the detachment of a clot from a deep vein thrombosis in the leg¹¹⁴ (see page 76 ­ deep vein thrombosis (DVT)).

The clot travels from the leg, via the veins, to the lungs. The severity of the resulting symptoms largely depends upon the size of the embolus. A large embolus can be immediately fatal.

Signs and symptoms of pulmonary embolism may include one or more of the following:

Chest pain

Breathlessness

Cold clammy skin

Tachycardia (fast pulse rate)

Hypotension (low blood pressure)

Haemoptysis (coughing up blood)

Unconsciousness.

If you suspect somebody has had a pulmonary embolism, sit them upright to help their breathing and call an ambulance.

Figure 6.1: Pulmonary embolus

Septicaemia is a generalised bacterial infection of the blood which may be caused by a variety of organisms. Bacteria commonly responsible are Staphylococcus aureus and E. coli.

A person with septicaemia may have the following symptoms:

Feeling generally unwell or very ill

High temperature.

They may also:

Become confused

Have convulsions

Go into a state of circulatory shock.

If a person is suspected of having septicaemia, they should be seen by a doctor urgently ­ the best advice is to call an ambulance. They will need to be given intravenous antibiotics to control the infection.

Endocarditis is an inflammation of the valves and/or smooth tissue (endocardium) lining in the heart.

Many of the wide range of organisms which cause endocarditis in injecting drug users can be present on the skin or in the mouths of injectors, which is a good reason for making the injecting process as hygienic as possible. If untreated, endocarditis prevents the heart valves operating properly and leads to heart failure.

Several factors have been identified as possible predisposing factors for the development of endocarditis in injecting drug users:

A pre-existing heart condition

Poor hygiene when injecting

Failure to wash hands prior to injecting

Failure to clean the injecting site before injecting

Licking or blowing on the needle tip

Licking the injection site

Injecting crushed tablets or other particulate matter

Injecting cocaine.

The infections detailed in this section are not the only ones transmissible by the sharing of injecting equipment. Other potential infections include anything which is spread by blood to blood contact and some infections that are normally sexually transmitted, such as syphilis. Other infections known to have been transmitted by injecting equipment include malaria, tetanus and botulism.

A 'bad hit' is an occasional experience for most injectors. It is difficult to be precise about exactly what constitutes a bad hit, or what the causes of it may be.

Injectors describe a powerful feeling of physical illness shortly after injecting, usually characterised by shivering, sweating and/or headache. The experience is short-lived, in that it is usually over within a few hours, and it is not severe enough to be life-threatening.

It is possibly a reaction to:

The drug

The cutting agent

Something contained in another constituent of the injecting process (i.e. water, filter or spoon) which may have been contaminated with bacteria.

In the USA bad hits are referred to as 'cotton fever'.

Practices which may make bad hits more likely are:

Using potentially contaminated water for mixing

Saving filters for later use

Using other people's filters

A lack of basic hygiene in preparation.

It is common for people to believe that the best way of dealing with a 'bad hit' is to re-inject. This should be strongly discouraged as the risk of overdose is high.

Although injecting drug users tend to have greater health care needs than the general population, they are inclined to use primary health care services less. Workers may need to strongly advocate for clients in order to get their health care needs met.

Overdose deaths are usually caused by poly-drug use ­ especially combinations of depressants. Alcohol increases the effect of many depressant drugs.

Drug users are often well acquainted with overdose. Consideration should be given to teaching first aid responses to overdose to drug injectors.

Injectors may have unrealistic beliefs about the survivability of the HIV virus outside the body ­ it has been shown that, given the right conditions, viable HIV DNA can be retrieved from syringes after several weeks.

Hepatitis B virus can survive in dried blood for up to four months.

All drug injectors should be vaccinated against hepatitis B.

Hepatitis C is easily transmitted by injecting drug use ­ at least 60% of injectors are likely have the disease.

Basic hygiene measures such as hand washing before and after injecting can help prevent a wide range of infections ­ including hepatitis C.

If in doubt always refer people for medical advice.