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Opiate users’ experiences of injecting

Opiate users’ experiences of injecting. Nicoletta Voutsa, Shamil Wanigaratne and Alyson J Bond National Addiction Centre Institute of Psychiatry, KCL. Routes Oral Sublingual Intranasal – snorting Inhalation – chasing Subcutaneous Intramuscular Intravenous. Reason Drug used

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Opiate users’ experiences of injecting

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  1. Opiate users’ experiences of injecting Nicoletta Voutsa, Shamil Wanigaratne and Alyson J Bond National Addiction Centre Institute of Psychiatry, KCL

  2. Routes Oral Sublingual Intranasal – snorting Inhalation – chasing Subcutaneous Intramuscular Intravenous Reason Drug used Social environment Desired effects Reasons for chosen route of administration

  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 fixation47% 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* N=NEFPRO 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. Results:Characteristics 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 (n=28)

  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 drug’s 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.“I’d rather have a fix than have sex.” - Pleasure mentioned in association with stimulants “Heroin is a loving cuddle. Injecting crack, that’s orgasm.” “Rush of amphetamines is like climax.”

  20. Characteristics of needle fixation • Flushing - 26/28 “To make sure the gear is in the vein.” “It’s just like you’ve done it and you’re 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 butonly 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 it’s not the needle, it’s 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 I’ll 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

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