Injection Drug Use

September 15, 2011

The hypodermic syringe was invented in 1853 by a Scottish physician named Alexander Wood. For the first time, drugs could be injected under the skin, intramuscularly, or directly into the bloodstream to alleviate health problems. By the 1870s, the hypodermic syringe was widely used by American physicians to administer drugs, such as morphine, heroin, cocaine, and even strychnine. By 1885, however, the dangers of addiction as well as potential infection at the site of injection were recognized by medical professionals.

A wide range of psychoactive substances can be injected illegally for their euphoric effects. The most common intravenously injected illegal drugs include heroin, various pharmaceutical opioids (analgesics), cocaine, and methamphetamine. LSD, MDMA (ecstasy), and methylphenidate (Ritalin and others), among other drugs, are sometimes injected intravenously, although the number of people who administer these drugs in this way is comparatively small. Even crack cocaine can be injected when dissolved with an acid (e.g., vinegar or lemon juice), although the practice is not very common. While most illegal drugs are injected intravenously, some (e.g., ketamine and sometimes heroin and morphine) are injected just below the skin, a practice called “skin-popping.”

Injection drug users are at risk for a wide range of health problems. The most common include infection at the site of injection, endocarditis, hepatitis B and C infection, human immunodeficiency virus (HIV) infection, overdose, and dependence. The emergence of HIV in the early 1980s has severely impacted injection drug users, particularly women. By June 1994, 64% of the AIDS cases among women were attributable to injection drug use. Of these, 48% were related to injection practices, and 20% were associated with sexual contact with a man who had injected drugs.

Injection drug users are at risk of infection with HIV and other bloodborne pathogens through a variety of mechanisms. The most well-known direct route of exposure to pathogens is through sharing contaminated syringes. Unless cleaned adequately with household bleach or another effective viricide, syringes used sequentially by more than one individual may contain small amounts of blood that enable the transmission of pathogens. Sharing syringes was initially perceived as a form of “ritual bonding” by public health professionals. However, ethnographic research demonstrated that syringe sharing is more directly related to difficulties in gaining access to sterile syringes. Sharing “cookers” (small containers used to mix drugs and water), “cottens” (material used to strain the solution while drawing it into a syringe), and rinse water is also recognized as potential routes of exposure to bloodborne pathogens. For example, water is used to rinse syringes to prevent clogging, thereby enabling syringes to be used multiple times. In a group setting, a number of individuals may share a common source of rinse water and potentially be exposed to pathogens through this process. Finally, various methods of mixing and distributing drug solutions, such as “backloading,” have been recognized as forms of “indirect” sharing that put people at risk of exposure to bloodborne pathogens. In the case of “backloading,” the drug solution is drawn up into one syringe and distributed to other injectors by flushing a measured amount of the solution into the back of other syringes. Injectors who receive the drug mixture could be exposed to pathogens in the syringe used to divide the solution.

New injection drug users are at increased risk of infection with bloodborne pathogens because they lack control of the injection process. Until people learn how to inject themselves, new injectors must yield control of the injection process to more knowledgeable injectors. Often, new injectors lack their own equipment and must use syringes provided by others, some of which may have been used previously. In some cases, new injectors may turn to “injection doctors” who specialize in performing injections for a fee in money or drugs.

For a variety of reasons, women who inject drugs may be at higher risk for infection with bloodborne pathogens. In some injection settings, women are at increased risk of exposure to pathogens because they often assume subordinate roles relative to men. Hence, women are often likely to inject after men, sometimes reusing the same syringe or other injection paraphernalia.

The complex relationship between injection drug use and sexual behavior sometimes places women at increased risk of infection with bloodborne pathogens and sexually transmitted diseases (STDs). At the most general level, women, as well as men, who inject drugs are often more likely to engage in riskier sexual behavior because the drugs injected alter consciousness and influence decision-making. As such, depending on the particular drug(s) injected, some users may be more likely to have sex with a higher number of people, with people less well known to them, and without using barrier protection. In the case of women who inject heroin, in particular, prostitution often becomes one of the few available means to make the money needed to purchase daily supplies of the drug. Women injectors who engage in sex work have increased chances of being exposed to HIV, hepatitis, and other STDs through high-risk sexual behavior (high number of anonymous partners; unprotected sex). In the case of other drugs, cocaine and methamphetamine injections are known to increase libido in many individuals and are often associated with high-risk sexual practices. Delayed ejaculation associated with methamphetamine and cocaine use, for example, often leads to prolonged periods of vaginal or anal sex. This may place women as well as homosexual men at greater risk of infection with bloodborne pathogens due to the abrasion of tissues, if condoms are not used properly.

A variety of drug abuse treatment services are available for injection drug users. For opioid-dependent injectors, methadone detoxification or maintenance is one of the most common methods of treatment. Established therapeutic drugs for cocaineand methamphetamine-dependent injectors are not available at this time. Women who inject drugs often have more difficulty accessing drug abuse treatment services compared to men. For example, women with children are often unable to participate in treatment services because they lack alternative child care resources. In summary, injection drug use affects women’s health in multiple ways, depending in part on the drug(s) used.

SEE ALSO: Acquired immunodeficiency syndrome, Harm reduction, Heroin, Sexually transmitted diseases, Substance use

Suggested Reading

  • Carlson, R. G. (2000). Shooting galleries, dope houses, and doctors: Examining the social ecology of HIV risk behaviors among drug injectors in Dayton, Ohio. Human Organization, 59(3), 325-333.
  • Friedland, G. (1989). Parenteral drug users. In R. A. Kaslow & D. P. Francis (Eds.), The epidemiology of AIDS: Expression, occurrence and control of human immunodeficiency virus type 1 infection (pp. 153-178). New York: Oxford University Press.
  • Howard-Jones, N. (1971, January). The origins of hypodermic medication. Scientific American, 96-102.
  • Koester, S. (1996). The process of drug injection. In T. Rhodes & R. Hartnoll (Eds.), AIDS, drugs and prevention: Perspectives on community action (pp. 133-148). London: Routledge.

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