Download Revisiting safer injecting

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