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INFORMATION FOR GENERAL PRACTITIONERS IN LOTHIAN No. 92 January 2004 Revisiting safer injecting Injecting drug users risk a diverse range of infectious diseases including viral hepatitis (A, B and C) and HIV. Increasingly clinicians are also seeing bacterial infections associated with injecting such as botulism, tetanus, necrotising fasciitis and severe wound abscesses. Other major risks of injecting include overdose of drugs, deep venous thrombosis, arterial embolism and subacute bacterial endocarditis. Infections arise from bacterial contamination of the injected drugs, from the sharing of injecting equipment or paraphernalia or from lack of hygiene when injecting. Promoting safer injecting as well as reducing levels of injecting amongst drug users and levels of sharing in those who continue to inject are important public health measures. Hepatitis C Hepatitis C (HCV) is the most prevalent infectious disease affecting those who inject drugs. − In Scotland to June 2002 (the most recent period for which figures are available) 14,390 diagnoses of HCV had been reported. − 90% of these cases, where route is known, are due to injecting drug use. − In 1999-00 the overall prevalence of HCV in the Scottish IDU population was 44% Sharing In 2002-03 it was reported to the Scottish Drug Misuse Database that 32% of injecting drug users in Scotland had shared a needle and syringe within the previous month. − 48% reported sharing spoons, filters and water - this can transmit HCV infection. (Risk of transmitting HBV or HIV when sharing paraphernalia only is negligible). − Many drug users are not aware of the risks of sharing injecting paraphernalia other than needles and syringes. Action The rising level of infections has led to many agencies reviewing the measures that are taken to reduce both levels of injecting and of sharing. Recent changes in policy and practice include: • increases in the number of needles and syringes given to clients at needle exchanges throughout Scotland • an outreach service on the streets distributing clean injecting equipment to the homeless • a major change in the law to allow needle exchanges to distribute citric acid and other injecting paraphernalia such as filters, water and spoons for injection in addition to needles and syringes. (Local implementation will depend on funding) • recommending tetanus–low dose diphtheria for injecting drug users who have not had 5 doses of tetanus vaccine • promotion of alternative routes for drug use including smoking and rectal administration as well as pathways to treatment options (through pharmacies and drug agencies) The Harm Reduction Team (HRT) Based at the Spittal Street Centre, this team has a remit to promote safer drug use in Lothian. The team runs a needle exchange at Spittal Street Centre and co-ordinates other needle exchanges throughout Lothian. A Low Threshold Methadone programme offers priority access to substitute medication for high risk clients e.g. those − using risky injection sites (neck, groin) − who are hep C or HIV positive − injecting more than four times daily − selling sex to fund their habit The HRT also runs the C-card condom distribution scheme, works with sex workers and provides training on relevant issues to professional workers throughout Lothian. Most people self refer to the HRT but referrals from professionals are also accepted. The Harm Reduction Team can be contacted on 537 8300. What can the GP do? • Ask all drug users, even those on a prescription, if they have recently injected any drugs. • Discuss the risks of injecting – highlight the risks of sharing equipment such as spoons, filters and water as many users will not be aware of this. • Advise against injecting into the muscle or under the skin. • Offer hepatitis B immunisation to all drug users (see Local AIDS sheet 89, July 2003). • Drug users with a history of injecting or currently injecting should be offered Twinrix (hep A & B) vaccine. • Check tetanus immunisation status –if in doubt immunise. • Discuss the possibility of testing for blood borne viruses. Remember all tests can be carried out on one sample (hep C, hep B, HIV). • Agree and review harm reduction goals with the patient to reduce the frequency and improve the safety of their injecting episodes. • Encourage current injectors to contact HRT where they will be offered advice on safer injecting, engaged on a needle exchange programme and offered assessment for substitute prescribing. • The HRT gives injectors ‘The Safer Injecting Handbook’. This booklet clearly describes the risks of injecting, alternatives to injecting and safer injecting practices. • Ensure patient knows whereabouts of nearest pharmacy or drug agency needle exchange. This sheet is published by Primary Care Facilitator Team (0131 537 8373) Back numbers on NHS Lothian intranet under Healthcare/Clinical guidance/Useful resources