Getting Ready: Preparing Yourself & Your Equipment

This chapter covers:

Setting, Environment & Mood
Choosing Your Materials
Preparing Your Shot

Preparing for and planning your injection drug use (or any drug use) is one of the most important things you can do to achieve your desired results and to prevent potentially harmful mistakes from occurring in the process. Drug injection is a rather complex activity. There are many steps along the way where something can go wrong, but equally as many places where you can make the process safer. Before injecting, you should (1) assess the safety of your setting and evaluate your state of mind; (2) make sure you have the best materials you can get, and enough of them; and (3) prepare your drugs in the most sanitary way possible

Setting, Environment & Mood

Unfortunately, we don’t always have complete control over how we’re feeling when we want or need to get high or the circumstances under which we use. While we may not always be aware of it, where we use, who we use with (if anyone), and our state of mind when we’re getting high can all have an impact on injection safety.

WHERE YOU USE

Some places are safer for injecting than others, and you should always choose from among your options the safest one possible. The ideal location for injecting is one that is relatively clean, dry, warm, and well-lit, and where:

your chances of getting caught by the police are minimal
you feel comfortable that there will be no surprise interruptions or unwanted observers
you can take as much time as you need
you have adequate space for yourself and your equipment
you have access to a sink or other source of clean water
you are sheltered from the wind and weather.

All of these factors should be weighed against each other when choosing a place to get off. It is clear, then, that using in your own home (if you’re fortunate enough to have one) or the home of a friend is safer than using in a public bathroom. However, a public bathroom—particularly if it’s a single room with a door that locks—is usually safer than injecting in a place such as a public park or the stairwell of an apartment building. In general, but not always, indoor locations are safer than outdoor ones, and definitely preferable in terms of wind and weather.

If you’re injecting in a relatively public place, like a toilet stall in a public bathroom, try to make it look like you’re changing your clothes or freshening up. If you know you’ll have to be getting off in a location like this where there is no direct access to a sink, bring along a small bottle of water to mix your shot with (it’s probably a good idea in any case to make water a permanent part of the works you carry). Most importantly, always try to stay as calm as possible no matter where you’re injecting. While it can be nerve-wracking getting off in a pub lic or semi-public place or somewhere else where you’re afraid of getting caught, it’s important to keep your wits about you so that you don’t end up knocking over your shot, spilling your drugs, being unable to get a hit because you’re so nervous, or getting blood all over.

So, use common sense and planning when choosing a location to inject. If at all possible, wait to get off until you’ve found a place where you feel relatively comfortable and can minimize the risk of getting arrested. Make sure you have all the materials you need before you begin, and don’t assume you’ll always have access to water. Finally, be considerate of others—no one likes coming across a used needle and syringe in their apartment building or seeing bloody tissue in a public toilet, and there’s no reason they should have to.

WHO YOU USE WITH

Although it is not always (and for some people ever) desirable or possible to inject with someone else present, having another person around when you get high can be a safety net, particularly in terms of surviving overdose. For those who live alone, however, having someone else present every time you inject may be unrealistic; and some people simply prefer using by themselves. Another complication is that many of us use in secret for fear that we’ll be rejected or judged by those we come out to. It is important to try to put together a support system of people who know you use and who you can rely on for support or in case of an emergency. This may be easier said than done, however, and even though injecting drugs may have become a mundane activity for you, it is frequently shocking for non-users to learn that someone they know engages in this activity. Disclosing your use to the wrong person could add untold stress to your life, so make this decision carefully.

Try to make yourself available to other people who use drugs who may need support. If you’re worried that a friend may overdose, for instance, have them check in with you by phone after they get high to make sure everything is okay. And finally, avoid using with people you don’t like or who couldn’t care less about what happens to you if you were to overdose.

ASSESSING YOUR MOOD

The quality of any drug experience is determined not only by the drug itself (including factors like potency and purity), but also depends on how the drug is administered, the environment in which it is taken, and the mood or mindset of the individual at the time they take the drug. It is therefore important for anyone who is going to take a drug to assess their mood and mindset before they get high. You should always be aware of how you’re feeling prior to altering your consciousness.

Feeling relaxed, confident, and calm will help ensure that you will take your time to inject hygienically and properly. If you’re in withdrawal, panicked about getting high in a public bathroom, or otherwise anxious and upset, the chances of something going wrong increase. Take a few deep breaths and try to gain some composure before you begin to prepare and inject your drugs in order to prevent accidents and make sure you get a hit without harming yourself in any way.

CHOOSING YOUR MATERIALS

There are a lot of materials needed to inject drugs—what those of us who use refer to as our “works.” Ideally, the type of equipment someone uses to inject will be appropriately matched to the drug they’re using, where they plan to inject it, the condition of their veins (if they’re mainlining), and other factors. Unfortunately, people who inject do not always have regular, legal access to the materials they need and are frequently forced to make do with what they can get. This section of the manual discusses what materials are best for injecting drugs and how to usethem safely; and offers suggestions for second-best options when the safest equipment is for some reason unavailable.

NEEDLES AND SYRINGES

The needle and syringe is arguably the most important piece of equipment needed to inject drugs. Due to legal restrictions on possession and over-the-counter sale, it can also be the most difficult piece of equipment to obtain.

Needles and syringes are not all the same. It is important to find a needle and syringe that you feel comfortable with, so if you have the opportunity, experiment with different types, sizes, and brands of injection equipment until you’ve found the one that works for you. Or you may find that you’ll use different equipment at different times depending on what and where you’re injecting. Among the things you should consider when choosing a needle and syringe are:

NEEDLE GAUGE, which refers to the size of the bore or hole in the needle. With needles it is important to remember that the higher the gauge, the thinner the needle (and the smaller the hole). A 28 gauge needle (abbreviated 28G) is therefore thinner than a 25 gauge needle, which is in turn thinner than an 18 gauge needle. Most intravenous injectors use either a standard insulin set which typically has a 27G or 28G needle (and an orange cap), or a standard tuberculin set with a 25G needle (frequently referred to as a blue tip because of its color, but they can vary in color).

The smaller gauge needle you use, the smaller the puncture wound, and therefore the less opportunity for infection to occur. Using a smaller gauge needle is also likely to result in less bleeding. Intramuscular injections must be given with larger gauge needles (frequently 21G or 23G), and certain substances such as injectable steroids and hormones can only be administered intramuscularly. Intravenous injectors typically use needles no larger than 25G, and whenever possible, needle gauge should be matched to the size of the vein into which you’re injecting. If you’re using small, delicate veins like those in the hands, for instance, a thinner needle such as a 28G is the safest choice.

Drugs that are cut with a lot of impurities, like white powder or tar heroin, may clog the point of the syringe. The higher the gauge (therefore the thinner the needle and the smaller the hole), the more likely it is that the point may get clogged. This is particularly true with brown tar heroin.

NEEDLE LENGTH. Insulin needles are typically 1⁄2 inch in length and tuberculin needles are typically 5⁄8 of an inch in length— lengths that most people who inject intravenously find adequate if not ideal. A needle that is too short may miss your vein, and one that is too long may go right through it or be difficult to properly position. Longer needles are often appropriate for intramuscular injections. As inscribed on packaging, needle length appears after the gauge number: 28G1⁄2 refers to a 28 gauge needle that is 1⁄2 inch long.

BRAND. Most people who inject find that, if given the opportunity to try out different brands of needles and syringes, they will find one that they prefer over all others. Different manufacturers create needles and syringes of varying quality. Some brands of needles are more comfortable to inject with than others, and the plungers on some brands of syringes are easier to manipulate than on others.

ONE-PIECE SETS VERSUS TWO-PIECE, DETACHABLE SETS. With some types of injection equipment, the needle detaches from the syringe, resulting in two separate pieces. Standard insulin injection equipment is typically one piece, while tuberculin needles and syringes are often detachable. Detachable, two-piece equipment often has a larger reservoir above the needle in which a lot of blood can collect. If you’re using a two piece set, make absolutely sure the needle is securely fastened to the syringe so that it doesn’t detach while you’re injecting, causing you to lose your shot. Lastly, you might find that using a butterfly set—often used for drawing blood in hospitals —is helpful when getting off in the hands or feet, but this type of set can be difficult to obtain. (Ask your local exchange if they have any.)

SYRINGE SIZE. Standard insulin and tuberculin syringes are typically 1cc in size and are calibrated by .10 cc’s along the barrel of the syringe. Most people who inject find this size ideal and would rarely need use of a larger syringe, although some drug injectors like to use 1⁄2 cc syringes. Syringes other than 1cc in size may be difficult to obtain.

STANDARD, DETACHABLE, TWO – PIECE NEEDLE AND SYRINGE

Guidelines for Safer Injecting

As important as choosing an appropriate needle and syringe is how you use them. Below are some very important guidelines you should follow in order to make the process of injecting as safe as possible.

ONE SHOT= ONE NEW NEEDLE AND SYRINGE

In the same way that hospitals will use a needle and syringe only once and then dispose of it, this is the gold standard that anyone who injects drugs should also strive for. Needles dull quickly, even after just a few uses. Using dull needles causes unnecessary trauma to the veins and surrounding tissue, results in a larger puncture wound and increased bleeding, and is simply not as comfortable as using a new, sharp needle every time. Attempting to sharpen a needle (on a matchbook, for instance) is dangerous because it can create a burr on the needle that can cause significant damage to the veins, or weaken the point and cause it to break off in your vein.

Also, new needles and syringes are sterile as opposed to simply clean, which means they’re free of all biological matter that, if present, can cause infection. Using a new, sharp, sterile needle and syringe for every injection and then disposing of it is simply the safest possible way to go.

AVOID SHARING NEEDLES, SYRINGES OR OTHER DRUG INJECTION EQUIPMENT.

Blood or other matter that remains in a needle and syringe after someone has used it can be passed on to anyone else who uses that same injection equipment. The same applies to cookers, cottons and spoons. In this way, life-threatening viruses such as hepatitis C and HIV can be transmitted from one person injecting to another. The only definite way to avoid disease transmission of this sort is to never share needles, syringes, or other injection equipment.

It is therefore extremely important for every person who injects to have their own set of works, and an ample supply of needles and syringes so that they never have to share or re-use their own—but especially others’—injection equipment.

IF YOU ABSOLUTELY MUST SHARE NEEDLES, SYRINGES, OR OTHER DRUG INJECTION EQUIPMENT , BE SURE TO CLEAN IT THOROUGHLY BEFORE RE-USE.

If you find yourself in a situation where you must use someone else’s injection equipment or they must use yours, follow the cleaning instructions of this manual to reduce the likelihood of transmitting a blood-borne illness. Sharing injection equipment even after it has been cleaned is definitely a second-best choice because blood and other matter can remain in a needle or syringe even after cleaning with bleach. Cleaning needles and syringes is a complicated process that, even if done according to the best scientific advice currently available, is not a 100% fool-proof method of avoiding harmful bacteria, viruses, and other blood-borne pathogens.

FLUSH YOUR NEEDLE AND SYRINGE WITH WATER SEVERAL TIMES AFTER USE IF YOU PLAN TO RE-USE I T AT A LATER TIME.

While it is safest to use a new needle and syringe for every injection, if you know that you’ll have to re-use your injection equipment at some later time, be sure to flush it several times with cold or room-temperature water so that it doesn’t become clogged with blood or other matter. (see cleaning instructions on following page)

HOW TO CLEAN A NEEDLE & S Y R I N G E

As already mentioned, the only sure way for people who inject to avoid contracting blood-borne infections and diseases like hepatitis and HIV is to never use someone else’s works (including needles and syringes, cookers, cottons, or water) or let someone else use yours. Even though injection equipment might look clean to the naked eye, tiny amounts of blood can remain in the works which can result in infection.

If you find yourself in a situation where you absolutely must use someone else’s works or they must use yours, you can reduce the likelihood of disease transmission by carefully cleaning the equipment before it is used . Follow these instructions carefully:

Set out three cups or cookers, fill the first with cold water (hot water will cause any blood in the syringe or needle to clot, making it harder to remove), the second with undiluted household bleach (do not use splashless bleach, it is too thick and will not work properly) the third with cold water.
Draw up water from the first cup and rinse the needle and syringe with cold water. If you’re using a detachable needle and syringe, you might want to take the equipment apart to clean it more thoroughly. Be sure to discard the water you use to rinse the equipment.
Flush the needle and syringe with bleach from the second cup. Be sure to fill the syringe all the way up. Keep the bleach in the syringe for a full two minutes while shaking it. Discard the bleach.
Thoroughly rinse the needle and syringe with clean, cold water from the third cup to remove any remaining bleach. Discard the water.

If you do not have bleach, you can substitute hydrogen peroxide, a solution of dishwashing liquid and water, or rubbing alcohol. Use high- proof drinking alcohol, such as vodka or rum, if it’s all you’ve got.

Do not use soap or dishwashing liquid that has not been mixed with water — they are too thick and will get stuck in the syringe.

IMPORTANT: In order for bleach to kill hepatitis B that might be in the syringe and/or cooker, you must leave the bleach in the syringe and cooker for a full two minutes. It is unclear whether bleach kills hepatitis C, even after two minutes. This should also kill any HIV that might be in the equipment. (30 seconds is believed to do this.)

Be sure to clean the cooker with bleach if it’s going to be shared. Wash your hands and split whatever cotton you have in two before you use it–it’s virtually impossible to clean such a filter. And remember that sharing water is one of the most efficient ways to pass on or contract a virus or other infection-causing organism.

Rinse your equipment with cold water after you’ve used it in order to prevent any residual blood from clotting, especially if you plan to re-use it later.

If you purchase needles and syringes on the street, clean them before you use them: sometimes used equipment is re-packaged and sold as new. Do not clean equipment that is sterile; something that is sterile is as clean as you can get it, and “cleaning” it could actually contaminate it.

COOKERS AND SPOONS

Cookers and spoons are used to dissolve (cook up) powdered and solid drugs for injection.

If using a spoon, try to find one that is rounder and deeper than an average teaspoon or tablespoon—closer to the shape of a ladle—to decrease your chances of spilling your drugs. You might want to bend the handle to prevent the spoon from rocking or tipping over.
If using a bottle top or something similar, be sure you’ve removed any plastic or paper lining without scratching the cap’s finish.
You may want to fashion a handle for your cooker with a bobby pin, paper clip, bag twist tie, or something similar so that you don’t burn your fingers when cooking your drugs. Be sure the handle is securely fastened to the cooker so it doesn’t fall off, causing you to lose your shot.
Always make sure that your spoon or cooker is as clean as possible; like needles and syringes, it should never be shared with anyone else because doing so can transmit viruses and infections from one person to another.
Always place your spoon or cooker on a level surface and maneuver it carefully so that you don’t spill your shot.

COTTONS (FILTERS)

Most injectors draw their drug solution from a cooker or spoon into a syringe through some type of filter—most often a piece of cotton or other absorbent material. The filter acts to keep out particulate matter and other foreign objects you don’t want in your shot, and enables you to get just about every drop of the drug solution into your syringe so that none of it is wasted.

Make sure your fingers are as clean as possible before you tear off and roll up your cotton.
Clean, 100% cotton from a Q-Tip or cotton ball is the safest thing you can use to filter your drug solution. A small piece of tampon is not a recommended safe alternative because they contain chemicals that are not recommended for injecting.
Rayon and other synthetic fibers often don’t absorb liquid as well as cotton, and may prevent you from being able to adequately draw up all of your drug solution.
Cigarette filters are not safe to use since they contain tiny pieces of glass, and, if from a cigarette that has already been smoked, substances from the smoke that can be harmful if injected.
You might consider skipping the filter altogether if you have nothing safe to use.
Use a fresh cotton every time you shoot up, and as with needles, syringes, and cookers, never use someone else’s cotton or let them use yours; infections, bacteria, and viruses can all be transmitted through sharing cottons.
Many of us cook up our old cottons to squeeze what we can out of them when we have no more money for drugs. Some people may have heard that “cotton fever” is caused by a piece of cotton entering the bloodstream,but it is actually caused by fungi and bacteria that can live and grow in old cottons (which, because they are moist after use, provide ideal environments for microbes) when re-used at a later time. Cotton fever is an infection characterized by chills, sweating, fever, and other flu-like symptoms. It may go away on its own or, if it persists or worsens, require medical attention.

MIXING AND RINSE WATER

You’ll need water in which to dissolve your drugs and to flush out your needle and syringe after you’ve gotten off. It is particularly important for people with HIV, AIDS, or other serious health conditions to use the cleanest water you can find. Remember, you’re putting the stuff straight into your bloodstream!

Using sterile water to dissolve (cook) your drugs is your safest option. You can buy it at any drug store or pharmacy. This may also be available at your syringe service program in small ampules. DON’T buy sterile saline (salt water) because your drugs may not dissolve in it.
After sterile water, your next best option is using water that you boiled for at least 10 minutes and stored in a sealed jar. (Don’t use water that you boiled several days ago which has been sitting in a pot or kettle.)
If sterile or boiled water are not viable options for you, fresh, cold tap water or bottled water are the next best choices.
If you’re getting off in a location without a sink or other fresh water source, try to find a toilet and use the water from the tank (never use water from the bowl).
Using water from a stagnant (non- moving) source like a puddle or old tire can cause serious infections; instead, use water from a fire hydrant, stream, or other moving body of water (even water flowing in a gutter is safer than a puddle) if this is all you can find. THIS WATER CAN STILL GIVE YOU VERY SERIOUS INFECTIONS.
Be sure the glass or whatever you have your water in is clean. Don’t contaminate your entire water source by sticking a used syringe in it. Pour some water into another container if you want to rinse your syringe out, and always be sure to discard the water you use to flush your injection equipment so no one else accidentally uses it.
Sharing contaminated water can transmit viruses and bacteria. Make sure everyone’s got their own.
Finally, as mentioned above, you might want to get into the habit of carrying a little bottle of water as part of your works in case you need to get off in a place where there’s not a sink or other clean water supply.

TOURNIQUETS (TIES)

People injecting Intravenously usually need something to “ tie off ” with that will restrict blood flow and cause the veins to bulge out, making them more accessible for injection.

Elastic tourniquets (like the kind that are used in hospitals) or stockings are kinder to your skin than leather belts or similar ties. They’re also better at securing rolling veins like the ones in your forearm. Neckties, lubricated condoms, and socks are other items that, because they’re softer and more pliable than leather, make better tourniquets than a belt.
Use a slip-knot when tying up so that you can remove the tourniquet quickly if necessary (see illustration). Never leave the tie on for too long to prevent your circulation from getting cut off. If you lose sensation in your limb or notice it turning blue, remove the tourniquet immediately! If you’ve already tied up but need to re-cook your shot or transfer it to another syringe, take the tourniquet off and re-tie it just before you’re ready to inject. (See illustration on preceding page.)
Ideally, one should register, and then upon seeing blood in their syringe, remove the tie and inject. Some people like to inject and then remove the tourniquet because this causes a more intense rush. This could be dangerous because if you fall out, you will be unable to remove the tourniquet.

LIGHTER OR MATCHES

If you’re using tar heroin or crack, you’ll need something to heat your drug solution with in order to make it dissolve.

A gas stove works fine if you have access to one, although carrying your spoon or cooker to the stove after you’ve filled it may result in a spilled shot, so prepare everything at the (hopefully reasonably clean) stove.
Lighters produce a larger, hotter, easier-to-control flame than matches do, and can be ignited using only one hand. Also, a lighter won’t give off a sulfur smell like matches do, which could give you away if you’re getting off in a public bathroom.

OTHER HELPFUL MATERIALS

While the needle, syringe, cooker or spoon, cotton, tourniquet, and a lighter or matches are all necessary for preparing and injecting drugs, there are a few other materials it’s helpful to have if you can get access to them:

Alcohol pads are extremely helpful for cleaning an injection site prior to getting off to prevent bacteria and dirt on the skin from entering your bloodstream.
Antiseptic wipes are helpful for cleaning the injection site after getting off, since alcohol is too harsh for afterwards and slows down healing.
To prevent blood from getting all over your shirt sleeves or clothes—a situation that will require a lot of explaining if you’re at work or visiting a friend who doesn’t know you use—carry tissues or gauze with you and maybe even a Band-Aid to apply after you’ve gotten off.

PREPARING YOUR SHOT

Preparing your shot as sanitarily and hygienically as possible can help you avoid many illnesses and infections, some of which can be quite serious and require hospitalization (see chapter 3). Every time you inject, you’re creating the means by which bacteria and other infection-causing microbes can directly enter the body, and, if you mainline, the bloodstream itself. The skin is the body’s first immune system component, and we open ourselves up to potential infection every time we break it. That’s why it’s so important that the equipment and the process we use to shoot up is as clean and safe as possible.

FIRST STEPS

There are a few common sense things you should do before preparing and injecting your drugs.

First, if at all possible, thoroughly wash your hands with soap and water. Any bacteria or germs you have on your hands can contaminate anything you touch when preparing your drugs. At the least, rinse your hands with water, wipe them with an alcohol pad, or otherwise try to get your hands as clean as possible.
Inject your drugs in as clean a place as you can find and always try to use a level surface so you don’t tip anything over and lose your shot.
If they’re not brand new, make sure all of your materials are thoroughly cleaned, and don’t unwrap or uncap your needle and syringe—especially if it’s sterile—until you’re going to use it.
If you’re getting off with someone else, make sure each person’s equipment is clearly separate from yours so that accidental mix-ups and sharing don’t occur: needles, syringes, and water glasses all look the same!
Finally, calm yourself down if you’re upset for some reason. Consider whether smoking or sniffing a little bit of your drug will help you relax if you’re in withdrawal or otherwise freaking out.

COOKING YOUR SHOT

Powdered drugs must be dissolved into a liquid form before they can be injected—a process known as “cooking.” Different drugs dissolve differently. If you’re using something like injectable morphine or hormones that are already in liquid form, cooking is completely unnecessary. Some drugs will dissolve in water without being heated; some people cook their cocaine, for instance, while many more do not because it can clot when heated, mess up your shot, and clog your needle.

Though brown heroin will dissolve without an acid, heating it along with an acid like powdered vitamin C will help dissolve it more easily. DON’T USE LEMON JUICE because it can cause fungal infections that can damage the eyeball. Finally, pills must be crushed up or pulverized as finely as possible before being dissolved for injection. Many drug manufacturers now formulate their pills so that they’re not able to be dissolved in water at all, but just sort of clump up when you heat them. If you’re going to try to inject a pill, dissolve a small corner of it first so that you don’t waste the entire thing. And inject pills only as a last resort; injecting the particles from a pill can cause all sorts of problems, particularly abscesses. For this reason, you should avoid muscle-popping or skin-popping pills if possible . (see pages 41 and 44)

Ideally, your drug solution will be clear and particle-free. If it’s not, you may want to try to re-cook it, although sometimes street drugs contain cuts that will not dissolve no matter what you do. In this case, use your cotton to filter out as much of the cut as you can. Lastly, don’t re-cook a shot with a lot of blood in it as the blood can coagulate and clog your needle.

After you’ve cooked up your drugs, draw the solution into your syringe through your cotton. Tap out all the air bubbles and push the liquid to the tip of the needle.

DIVIDING DRUGS

If you’ve bought drugs with someone else, you need to ensure that everyone gets their fair share in a safe way. There are several ways this can be done:

The safest way to divide drugs is to split the powder or tar and have each person cook up their own drugs with their own materials.
If this first option is for some reason not acceptable, the drugs can be cooked up first (using sterile equipment!) and then divided (using sterile syringes!) after they’re in liquid form.
Backloading (Piggybacking): A single, sterile syringe can be used to draw up equal amounts of the liquid which can then be carefully squirted into the back of each person’s sterile syringe after the plunger has been removed. (See illustration on following page.)
Frontloading: The drug is carefully squirted into the front of each person’s syringe that still has the plunger in it but from which the detachable needle has been removed. (See illustration on following page.)
Always be sure any equipment you use to cook up and divide drugs is new (preferably sterile) or, as a second- best option, properly cleaned.

BACKLOADING ( PIGGYBACKING)

Remove the plungers from two syringes.

Using a third syringe, draw up the hit and empty half into each of the syringes.

Carefully replace both plungers.

FRONTLOADING

Photograph: Jean Paul Grund and Rene Overbeek from “Drug Sharing and HIV Transmission Risks: The Practice of Frontloading in the Dutch Injecting Drug User Population” (Journal of Psychoactive Drugs, Vol. 23(1), Jan.-Mar. 1991).