Opiate users experiences of injecting

1
Opiate users experiences of injecting

• Nicoletta Voutsa, Shamil Wanigaratne and Alyson J
  Bond
• National Addiction Centre
• Institute of Psychiatry, KCL

2
Reasons for chosen route of administration

• Routes
• Oral
• Sublingual
• Intranasal snorting
• Inhalation chasing
• Subcutaneous
• Intramuscular
• Intravenous

• Reason
• Drug used
• Social environment
• Desired effects

3
Reasons for change of route or continued injecting

• Transition from chasing to IV 39
• Reverse transition rare 16 (Griffiths et al
  1994)
• Some clients on maintenance treatment continue to
  inject
• WHY?
• Effectiveness - maximise effect rush
• Economy - value for money

4
Persistence against the odds

• IV route associated with increased harm
• Users develop tolerance to pleasant effects quite
  quickly - only 8 report buzz
• (Sell Zador 2004)
• WHY PERSIST ?
• Seeking to recapture lost effect?
• Process more important than the drug
• needle fixation 47 gave this as the reason for
  injecting methadone syrup (Robinson et al 2000)

5
Definition of needle fixation

• Repetitive puncturing of the skin with or
  without the injection of psychoactive drugs via
  intravenous, subcutaneous, or intramuscular
  routes, irrespective of the drug or drugs
  injected or the anticipated effects of the drug
• (Pates et al 2001)

6
Theory of needle fixation

• Conditioning
• Needle Drug Pleasure
• Needle Pleasure
• Secondary gains
• RitualN
• Injecting skill status and self-esteem
• PainN (self-harm)
• Sex substituteN or pleasureN
• NNEFPRO subscales shows difference between
  groups

7
Characteristics of needle fixation

• Behavioural manifestations of needle fixation
• Repeated flushingN
• Perseverance in the absence of veins
• SubstitutionN
• Division of doses
• Loss of control/ Compulsion
• Fear ? philia for needles
• Also - Preference for injectingN

8
Aims of Current Study

• To investigate opiate injectors reasons for
  injecting
• To assess the incidence of needle fixation
• To investigate the relationship between needle
  fixation dependence, craving, self-harm,
  obsessional features

9
Methods of Current Study

• Cross-sectional design
• 3 outpatient specialist drug clinics situated in
  South London
• Current or previous IV opiate users using
  treatment facilities
• Both quantitative qualitative measures

10
Measures in Current Study- Quantitative

• Needle Fixation Profile (NEFPRO)
• Ritual Pain Sex Flushing Substitution
  Preference
• Obsessive Compulsive Injecting Scale
• Self-Harm Inventory
• Severity of Dependence Scale
• Maudsley Addiction Profile
• Maudsley Obsessive Compulsive Inventory

11
Measures in Current Study - Qualitative

• Semi-structured interview
• Drug and injecting-related information
• Why do you inject?
• Do you enjoy injecting?
• Elaboration on features of needle fixation

12
ResultsCharacteristics of sample

• N 28
• Age 37 8 y
• 22 (79) male
• 21 (75) single
• 2 (7) employed
• 26 (93) on maintenance treatment

13
Average number of days of substance use during
the past month (n28)
14
History of heroin use

• 24 (86) currently injecting
• Heroin main drug injected in all users
• First use 20 5 y (75 smoked)
• Mean transition time 27 25 months
• Mean period of injecting 9.6 9 y

15
Scores on questionnaires

• Questionnaire Mean (SD)
• Needle fixation profile 25 (7)
• Severity of dependence scale 11 (3)
• Obsessive compulsive injecting scale 17 (7)
• Self-harm inventory 6 (4)
• Maudsley obsessive compulsive inventory 12 (5)

16
Correlations between NEFPRO and other
questionnaires

• Questionnaires NEFPRO
• Severity of dependence -.176
• Self harm behaviours .402
• Craving for injecting -.110
• Obsessive compulsive features .049
• Period of injecting .489

17
Items of NEFPRO correlating with SHI

• I inject water if there are no drugs available
  .590
• Injecting water has a calming effect on me
  .529
• I flush blood before/ after injecting .442
• I flush blood even if there are blood clots.
  .529
• Injecting has become a substitute for sex .521

18
Incidence of needle fixation

• 1/28 participants scored above the NEFPRO cut-off
  of 35
• No participants fulfilled the criteria of needle
  fixation in the interview
• none were currently injecting inert substances
• none were injecting without anticipation of the
  drugs effects
• No evidence to support secondary gains

19
Secondary gains of needle fixation

• Ritual - recognised as important but only in
  order to get the drug
• Skill - most judged skill by the state of their
  veins but were not positive Junkies are low
  life.
• Pain - seen as necessary or discounted After the
  pain gonna come pleasure.
• Sex - Substitution - No comparison. Id rather
  have a fix than have sex.
• - Pleasure mentioned in association with
  stimulants Heroin is a loving cuddle. Injecting
  crack, thats orgasm. Rush of amphetamines is
  like climax.

20
Characteristics of needle fixation

• Flushing - 26/28 To make sure the gear is in the
  vein. Its just like youve done it and youre
  doing it again psychologically.
• Perseverance in the absence of veins - another
  route would not have the same effect I would
  look for hours and hours.It was already in the
  needle. I had to find a vein.
• Substitution - water alcohol but only when
  experimenting or for a placebo effect
• Division - prefer one dose for maximum effect

21
Characteristics of needle fixation

• Loss of control no evidence The good feeling
  of the drug and having some control over it.
• Fear 14 claimed fear but only 2 had avoided
  needles
• Preference for injecting over drug no evidence
  I was just as addicted to the needle as I was to
  gear. I mean its not the needle, its the
  effect.

22
Needle fixation

• 14 mentioned the term spontaneously
• 3 to deny it
• 4 felt they knew someone
• 5 to describe themselves
• None of these reported injecting without
  anticipation of the drug effects

23
Reasons given for injecting

• Effectiveness
• Economy
• Speed of onset
• Most equated drug taking with route
• The hardest thing about stopping injecting is
  the way you associate taking the drug - you
  inject, 3 seconds later you feel it.
• Still seeking the rush
• If I inject, maybe, maybe, maybe Ill get
  something.

24
Conclusions

• Injecting is likely to be maintained by the
  presence of the rush through an intermittent
  reinforcement schedule
• Needle fixation may be one aspect of self-harm
• There may be a difference between opiate and
  stimulant injectors
• Needle Fixation may represent a phase that some
  users go through when they first start to inject