Injecting heroin into a vein intravenous injectioninto a muscle intramuscular injectionor under the skin skin popping can quickly lead to addiction and major medical problems, including severe infections. Injecting heroin, which is also referred to as shooting up or slamming heroin, is a highly invasive way of using the drug.
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For almost all injecting drug users IDUsthe first site of injection is the arm. Although injection to sites other than the arm is associated with higher risks, literature is limited regarding this behavior. We aimed to determine the prevalence and associated factors of using IV access points other than the arm among a national sample of IDUs in Iran.
Data on socio-demographics, pattern of drug use, and injection-related behaviors were entered into a logistic regression to determine predictors of injection to sites other than the arm. From all participants, The other injection sites were the femoral venous sinus Using sites other than the arm for IV injection is linked to socio-demographics, drug use data, and injection-related characteristics that can be used by policy makers.
This information can be used for harm reduction planning. Intravenous IV access points can develop several local complications that may involve skin or vascular structure 1 — 9. These complications vary in severity from a simple erythema and pain, to necrosis, thrombophlebitis, vein sclerosis, and occlusion.
Following these complications, injecting drug users IDUs show interest in using other IV access points from an unusable vein to a new useable one 10 Clinicians, public health practitioners, and policy makers may use such information to protect the health of IDUs. Although we know that first injections often begin in the arm as the primary point for IV access 10there is lack of knowledge on trajectory of IDUs in using different IV access points.
According to the current literature, most IDUs begin their injecting practice using the arm and then gradually shift to other sites including forearm, upper arm, hand, neck, feet, leg, and femoral vein. The purpose of this study was to determine prevalence and associated factors of non-arm injection among Iranian IDUs using heroin.
Data came from the National Drug Dependence Survey that was conducted in and used a cross-sectional de. The main survey had a sample size of 7, performed by the research center for substance abuse and dependence at the University of Social Welfare and Rehabilitation Sciences. Some other manuscripts have been published from this database 12 The sampling strategy in treatment centers and prisons was random, but snowball in streets. The of samples taken from every province was proportional to the population of the province. Data were collected using a paper-based questionnaire that was the modified version of the one used in the national survey in Iran The questionnaire included 69 items in nine sections.
Participants were all heroin users with at least once daily heroin injections.
Drug injection to sites other than arm: a study of iranian heroin injectors
We entered the following data into our analysis: socio-economic data, drug use pattern, and injection-related data. Responses included the femoral venous sinus, groin, neck, and other sites. The study was approved by the ethical review committee of the University of Social Welfare and Rehabilitation Sciences.
Informed consent was obtained from all the participants after they had been verbally reassured that the information would be kept confidential, especially from the correctional system. Logistic regression was used for multivariable analysis. Participants had a mean age of First drug use and injection had begun at Injection duration was 6.
Sites other than the arm were reported to be the site of injection among From the above list of factors, the effect of injection duration and injection frequency on likelihood of shifting to other sites of injection was expected, as shift in IV access point occurs as drug injection progresses. That is, the shift in site of drug use may be a part of the natural history of drug injection. However, in the very limited pool of published evidences about pattern of IV access points, we could not find any evidence confirming or rejecting our findings about the association of being Sunni, family income, age at first drug use, or our outcome.
In contrast to our expectations, and opposite to the literature that emphasizes the role of low socio-economic status as a risk factor of poor health 15 — 18 and health risk behaviors 1920our study suggested that IDUs with higher family income may be at higher risk of shifting to using other IV access points.
Different from most of the literature, it was not lower age at first drug use 2122 but higher age at first drug use that was associated with higher risk of shifting from the arm to another injection site. Baldwin et al.
How heroin is injected and other ways it’s taken
Heavy drug use, during a critical period of neurobiological development, may also lead to dysfunction in memory and learning, inhibition, and executive functioning and neuronal activation, or even ultimately alterations in brain structure The use of injection sites other than the arm among IDUs is a major public health concern. Such behaviors are often associated with an increased risk of vascular complications such as deep vein thrombosis, leg ulcers, and vascular insufficiency.
In addition, in some sites such as the groin and neck, the close proximity to other organs poses the risk of inadvertent trauma to these sites Unfortunately, data is systematically scarce in this regard Within non-arm injection sites, the most frequent site was the groin.
According to the literature, among heroin IDUs, groin injection seems convenient, providing quick access, with little mess and less pain than smaller more awkward veins. The formation of sinuses over time facilitates continued use of the groin According to our findings, likelihood of non-arm injection increases by an increase in injection duration. Literature confirms that most IDUs begin to use other injection sites years after their first injection Injectors decide to shift to a new injection site when they believe the site is no longer accessible Based on harm reduction protocols, practices such as the rotation of injecting sites may prevent scar tissue occlusion, swelling, infections, and deep vein thrombosis among IDUs.
In addition, literature cites that IDUs believe that this rotation is both difficult and unreliable. The rotation of injecting to both arms needs using non-dominant hands, which might seem problematic to IDUs. Secondary to this perceived difficulty, IDUs find other IV access points as convenient, providing quick access, with little mess and less pain than ly used arm veins Non-arm injection is of interest because it is linked to high rates of local complications including tissue damage, infections, and deep venous thrombosis 10 Our recommendation to service providers is that site of injection is an important factor that should be asked about when a service is being delivered to an IDU.
Harm reduction services in Iran should include safe injecting trainings for IDUs.
This study sheds more light on the risk factors of transition to more severe injection sites. Of the factors, injection frequency and living status are modifiable, and can be considered as the target of prevention programs.
Injecting to sites such as the femur or neck should be strongly discouraged, because of the associated health hazards. These veins are at proximity of vital arteries. Missing the aimed vein may result in hitting the artery or nerves, which may cause major health problems for the IDU 28 Promotion of safe injection should be considered as a part of harm education programs, and may encourage the practice of safe injection among IDUs.
Such training programs can be delivered as a part of needle exchange programs. Safe injecting education programs may benefit from information about the motivations for transitioning to new IV access points.
We do not know whether training programs that enhance safe injection information among IDUs will increase the use of peripheral veins and decrease the use of risky injection sites such as neck and groin. IDUs should not be encouraged to use others for injection or injection facilitation, as presence of other IDUs at the time of injection may increase the risk of shared injection, which is linked to risk of blood-borne infections such as HIV. However, IDUs should receive information on health risks associated with transition to other access points for injections.
Not only may the findings of this research be of interest to the policy makers in Iran, but they may also benefit the global harm reduction community. Groin injecting is a neglected topic. Similar studies will shed more light on factors that are linked to similar practices among IDUs.
Information provided by this study is hoped to be used for the development of evidence-based safe injecting advice. Although Iran is a country that includes multiple ethnicities with unique cultures, we did not enter ethnicity to our analysis.
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Some participants were sampled using a snowball strategy, thus the are not generalizable to all Iranian male IDUs. This study did not enquire data on the pattern of transition between different injection sites. The study only included heroin users, thus further research is needed on individuals who inject drugs other than heroin. This study had a retrospective de.
Longitudinal studies are still required. Further work is needed to better understand the natural history of IDUs, especially their pattern of shift in IV access points. This behavior is attached to some socio-economic and drug-related characteristics.