Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London

Abstract

Background: The United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms. Methods: We generated questionnaire (n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices. Findings: A high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection.(Continued on next page)

Substance Use Disorders and COVID-19: Multi-Faceted Problems Which Require Multi-Pronged Solutions

“…First, drug and alcohol use are often communal (e.g., sharing blunts, smoking pipes, or syringes) and may contribute to the spread of COVID-19 ( 8 ). Second, many individuals with SUD have limited financial resources, unstable housing and limited access to clean water and soap increasing their risk of infection ( 8 , 9 ). Third, co-morbidities prevalent among people with SUD are associated with more severe COVID-19 symptoms, complications and fatalities and increase vulnerability to COVID-19 ( 3 – 7 ).…”

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Hostility, compassion and role reversal in West Virginia’s long opioid overdose emergency

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“…Christine described the difficulties of reusing syringes: … [T]hey get dull and they get spurs on the end of them and that’s what causes the big red marks that you see on people a lot, and causes abscesses and stuff… […] And then sometimes like where it’s not sharp enough of a point it won’t puncture the vein, so you would literally have to take it and stab your vein and then you have to hear that pop to know that you’re inside your vein… Several injections used extremely small amounts of water (10–15 units) because of beliefs that using more water reduced the overall dose strength. Due to cost constraints, sterile water was unavailable from the NSP which may have led to the substitution of other fluids, water sharing or using unsafe water sources [ 59 ]. Heating of heroin solution was not uniform, with many reporting that heroin did not require heat to go into solution.…”

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