Training Guide

Getting Off Right: A Safety Manual for Injection Drug Users

Getting Off: The Basics of Safer Injection

 

This chapter covers:

• Taking Control
• Mainlining (Intravenous Injection)
• Hierarchy of Safety for Choosing Intravenous Injection Sites
• Veins vs. Arteries
• Veins vs. Nerves
• Exercises for Improving Vein Visibility
• Some Tips for “Getting Veins Up”
• Muscle-Popping (Intramuscular Injection)
• Skin-Popping (Subcutaneous Injection)

This section of the manual presents information on proper injection technique (intravenous, intramuscular, and subcutaneous injection).

As  important  as  preparing  your  drugs  as  cleanly as possible is injecting them as safely and as carefully as possible.

This section of the manual presents information on proper injection technique (intravenous, intramuscular, and subcutaneous injection). In addition to mastering proper injection technique, folks who inject intravenously regularly must also be sure to practice good vein care, and everyone who injects should be aware of the various things they can do—like rotating injection sites—that will help them avoid infection and maintain good health.

 

TAKING CONTROL

It is extremely important for people who inject regularly —particularly those who are physically dependent—to be able to prepare and safely inject drugs on their own.  People may take advantage of you when they know that you rely on them for getting off.  You deserve to have control over your body and what you need to do for yourself! Learn how to safely and properly inject yourself!

 

Learning how to inject properly, like mastering any other complicated activity, takes practice. After a while, you will no doubt be able to hit veins you’ve never used before on the first try, causing minimal trauma to the injection site and leaving a tiny puncture wound that barely bleeds. You will develop ‘a feel’ for where your veins are and how you need to position and insert your needle in order to get a good hit.

Perhaps the safest way to learn how to inject is to have someone who knows what they’re doing teach you. An experienced injector can walk you through the process of injecting, or perhaps even demonstrate it, and prevent you from making any dangerous mistakes. If possible, find someone who you trust to mentor you through this process. And talk with other injectors about the various tips and wisdom about injecting they’ve picked up over the years.

 

Hopefully, there are things in this manual that will be new and helpful even to those of us who have been injecting for a long time. However, reading about how to inject and actually doing it are two different things. If you are new to injecting, we can only caution you to read this manual thoroughly before you begin and to go slow and be aware of everything you’re doing. If the risk of injecting drugs seems too dangerous after you’ve read this booklet, deciding not to administer drugs via injection is a harm reduction response that we whole-heartedly support.

 

 M A I N L I N I N G ( INTRAVENOUS INJECTION ) 

Intravenous injection (mainlining), or injecting a substance directly into the bloodstream through a vein, is one of the fastest ways to deliver a drug into your system. It is also the riskiest method to use in terms of overdose (as compared to sniffing, smoking, or oral administration) because the entire dose enters the body all at once and very quickly. Injecting intravenously usually gives the user a “rush” that many people report to be extremely pleasurable, a sensation that does not occur with intramuscular or subcutaneous injection. While each injection method carries its own risks, mainlining is arguably the riskiest since it creates a direct opening between the bloodstream and the outside world. Heroin, cocaine, and amphetamine are three drugs that are commonly administered intravenously.

 

CHOOSING AN INJECTION SITE 

People who inject drugs often have one or two favorite places to inject—sites that feel the most comfortable, are easy to access, and where you almost always get a clean hit on your first try. While it may seem awkward at first, it is important to learn how to inject in other places that may not seem as comfortable or accessible on your first couple of tries. If you keep injecting in your favorite spots over and over without letting the veins repair themselves they will become leaky, making your shot less satisfying and harder to hit; could become seriously infected; and will eventually collapse or scar so badly that they become altogether unusable and interfere with circulation. So, it is very important to rotate the sites you use to inject. Try to use a new site for each new injection and go back to sites you’ve already used only after they’ve had time to rest and repair themselves.

 

In addition to learning to inject in new places, it is also important to learn how to inject with either hand so that if the veins on one side of your body need a rest or are otherwise unusable, you’re able to inject into the veins on the other side of your body—even if you need to use your non-dominant hand to do it. The next time you’re in withdrawal and really need to get off but can’t find a vein in your usual spot, you’ll be thankful you taught yourself how to inject into the other arm!

 

CLEANING THE INJECTION SITE 

Any time you inject intravenously, you risk pushing bacteria, fungi, and any other infection-causing microbes that are on your skin directly into your bloodstream. It is therefore extremely important to thoroughly clean your injection site prior to getting off. Alcohol pads work well for this purpose, but be sure to wipe in only one direction and not in a circular motion which will cause the dirt and germs to stay on your skin. Rubbing alcohol, hydrogen peroxide, or plain old soap and water or any other type of cleaning agent or disinfectant also work fine. Be sure not to touch the injection site with your fingers after you’ve cleaned it. Routinely cleaning the skin prior to injection is one of the most important things you can do to reduce your risk of endocarditis, blood poisoning, and similar infections (discussed in chapter 3).

 

TYING UP 

Use gravity to bring blood to the limb you’re going to use to inject before applying your tourniquet (tie): swing or hang your arms, make a fist, etc. Tie your tourniquet in such a way that it can be easily removed if necessary. Try to secure ‘rolling’ veins like those in your forearms before you inject into them. Finally, be sure not to leave the tourniquet on for too long. If you feel your limb becoming numb or notice it turning blue, undo your tourniquet and don’t retie it until you’re ready to inject.

 

INSERTING YOUR NEEDLE 

Insert the needle into your vein with the needle bevel (opening) facing up, at a 15 to 35 degree angle, and always in the direction of the heart. The more perpendicular the needle is to the injection site, the greater chance you have of sticking the needle through the vein instead of into it. (See illustration on following page.)

 

REGISTERING 

Once you think you’re in a vein, pull the plunger back to see if blood comes into the syringe. If so, and the blood is dark red and slow moving, you know that you’ve hit a vein. You can now untie your tourniquet and proceed to inject your drugs. If no blood or only a very tiny amount of blood comes into the syringe when you pull back, you’re not in a vein and will have to untie your tourniquet, pull your needle out, and try again. If you proceed to inject without being properly positioned in a vein, you’ll be putting your drugs into the tissue surrounding the vein, under the skin, or some other place. It will probably be painful and become swollen, and the effects of your drugs will come on much more slowly. You also risk abscess formation and other possible problems.  

If there’s too much blood in your shot to tell if you’re properly registering, split the shot into two and dilute each half with water. If the plunger of your syringe is forced back by the pressure of the blood and it is bright red, frothy, and ‘gushing,’ you may have hit an artery.  Stay calm and slowly draw the syringe out and elevate the limb. 

Some people like to ‘boot’ their syringe after they’ve injected their drugs—that is, pull back the plunger, draw blood into the syringe, and re-inject it. Some injectors like to do this several times, ostensibly to rinse out any drug solution that remains in the syringe. Because of all the blood involved, you might want to refrain from booting if you know you’re going to be cleaning your needle and syringe and allowing someone else to use it. Be sure to thoroughly flush your needle and syringe with water after booting if you plan to re-use it at a later time, so that blood doesn’t clog the needle.

 

PULLING OUT 

After you’ve successfully injected your drugs, carefully pull the needle out of the injection site at the same angle at which it went in. (To minimize bruising, you should have untied your tourniquet before you injected your shot.) Apply pressure to the injection site to stop any bleeding. If you’re getting off in a public place, it is a good idea to have some tissue, gauze, or Band-Aids around so you don’t get blood all over your clothes. Don’t use alcohol pads on a fresh injection wound: alcohol will cause it to bleed more, not less.  

 

MISSED SHOTS & AFTERCARE 

Don’t apply creams, salves or oils you use to treat your track marks or bruising until the injection wound has begun to close (a couple of hours after injecting) otherwise you might cause an infection. Treat missed shots (those that ended up somewhere other than in your vein) immediately with a warm water soak or compress to reduce the likelihood of irritation and abscess formation. Warmth will open the capillaries and bring disease-fighting white blood cells to the affected area.

 

MAINLINING COCAINE 

Cocaine has a numbing effect on the veins and causes them to constrict (shrink), so if you’re shooting coke, you should be extra careful to register properly and make sure you’re in a vein before you inject your drugs. Also, chances are that if you’re shooting coke, you’ll be injecting many times in a short period of time with perhaps only several minutes between each injection. This can be traumatic on the veins and the surrounding tissues, and result in a lot of bleeding.

• Try to use a sterile, sharp needle for each injection;
• make sure you keep your injection equipment separate from anyone else’s you’re getting off with;
• and try to give the area a good rest for a few days.

You may experience some pain and swelling after such intense activity.

 

MAINLINING CRACK 

Because crack comes in a solid form (rock), it is necessary to dissolve it first. The safest way to do this is with powdered citric or ascorbic acid–ask your local syring service program or health food store where to find it. Avoid lemon juice or vinegar, as these can lead to serious infections.

To dissolve crack: put crack and citric or ascorbic acid (about a pinch to a slab) in the cooker; add plenty of water; mash and mix well.  Try to only use as much acid as you need, since extra will dissolve your drugs, and acid can be very hard on your veins.  

 

SHOOTING SPEED 

Because speed is often cut with such dangerous chemicals, it is very important not to miss your shot. Skin-popping speed can be very painful, may cause an abscess, and will take a long time for the body to absorb. If you get the shakes after doing a few shots, it may be helpful to have a friend inject you if you are not using alone. Because the quality of speed varies so dramatically, a tester shot is a good idea.

 

HIERARCHY OF SAFETY

for Choosing Intravenous Injection Sites 

The following is a breakdown of possible intravenous injection sites, beginning with the safest options and moving toward the least safe ones.

ARMS: Arms, first upper then lower, are the safest sites for injecting. You should be careful to secure the ‘rolling’ veins in the forearms before you inject into them. Arms are also good if you’re concerned about hiding your injection or track marks (although wearing long sleeves in the summer can be a drag!).

HANDS: Hands are somewhat less safe than arms because the veins are significantly smaller and more delicate and therefore more likely to bruise or become damaged. Circulation is also slower in the hands, causing healing to take longer. If you’re getting off in your hands, be sure to use the thinnest needle possible (highest gauge) or, if you can find one, a butterfly needle. Be vigilant about rotating the sites, and keep in mind that it is difficult to conceal injection marks and bruises on the hands.

LEGS: Circulation in the legs may be poor, especially in people who don’t use theirs a lot. Veins in the legs are more likely than those in the arms to develop clots that can obstruct circulation and eventually break off and lodge in the lungs or heart. Also, damaging the valves in the leg veins is more serious than damaging those in the arms since they play a greater role in getting blood back to the heart.

FEET: As with the hands, the veins in the feet are generally smaller than in other parts of the body, and close to nerves, cartilage, and tendons which you want to avoid hitting when you inject. Because they are farther from the heart than the veins in the hands, arms, and legs, blood circulates more slowly in the foot veins and they therefore require more time for healing and repair. In addition, foot sweat and dirty socks act to prevent wounds from healing and increase the chance of infection from bacteria.

GROIN: The femoral vein in the groin area is a large and fairly easy vein to access, but its location near the femoral nerve and the femoral artery make it quite a risky place to inject. Among the three, the femoral vein is located closest to the groin, with the artery and then the nerve located as you move outward. If you’re going to inject into the femoral vein, first locate your femoral artery— where you do not want to inject—by finding the pulse. Then move a short distance toward the inside of your leg to find the femoral vein. Because it lies fairly deep, you will probably not be able to see it but will have to inject into it without seeing where the vein is.

NECK : The jugular vein in the neck is the riskiest place to inject because it lies very close to the carotid artery, a major blood vessel that brings blood directly to the brain. Accidentally hitting the carotid artery could be fatal, and damaging the jugular vein in any way can interfere with blood circulation to the brain.

 

SAFEST INJECTING LOCATION: THE ARM

(Numbered in order of safety) 

 

LOCATION OF VEINS IN HAND:

Know Where You’re Hitting

 

 MORE TIPS FOR CHOOSING AN APPROPRIATE INJECTION SITE 

• Taking proper care of the veins in your arms and other safer locations will prevent you from having to shoot up in more dangerous ones.
• You should avoid using veins that are tender, hardened, or inflamed until (and if) they heal. Warm compresses and the use of appropriate creams can help speed the healing process.
• The larger and more visible the vein, the easier and safer it usually is to hit. Deep veins are harder to hit, and trying to access them increases your chance of hitting a nerve or artery in the process. On the other hand, it may be difficult to keep a needle properly positioned in a very shallow vein, causing you to accidentally skin-pop your hit.
• Areas that are farthest from the heart, like the hands and feet, heal the slowest and have the poorest circulation. Areas nearest to the heart (like the groin and the neck) have veins that are located near major arteries and nerves which, if accidentally hit, can cause serious, life-threatening damage.
• Injecting near a bone increases the chances that swelling and pain will occur.

 

VEINS VS. ARTERIES 

You always want to inject into a vein and never into an artery. Veins are blood vessels that carry blood from the extremities of the body back to the heart and lungs where it becomes re-oxygenated. Veins have no pulse, and the blood they carry is a deep, dark red because it is low in oxygen. Arteries carry blood rich in oxygen from the lungs and heart to all the other parts of the body. Arteries have a pulse, and the blood in them is bright red and frothy. Arteries are located deeper in the body than veins and so are not visible as many of your veins are.

 

You’ll know you hit an artery if: 

• The plunger of your syringe is forced back by the pressure of the blood.
• When you register, the blood in your syringe is bright red and ‘gushing.’ Blood in veins is dark red, slow-moving, and “lazy.”
• It hurts differently from your usual injections

You can avoid hitting an artery by:

• Never injecting where you feel a pulse.
• Injecting only into surface veins and not trying to hit those that lie deeper.

What to do if you hit an artery: 

• Untie your tourniquet and pull your needle out immediately.
• Raise the limb above your head to stop the bleeding, if possible.
• Apply firm pressure to the wound for at least 10 minutes.
• If bleeding continues, apply a bandage or cloth wrapped very tightly around the wound and seek medical attention immediately. The loss of blood from hitting an artery can be life-threatening if it’s not stopped.

 

Veins vs. Nerves 

Unlike some veins, nerves are not visible from outside the body, although you will definitely know if you’ve hit one while injecting because you’ll experience extreme pain and no blood will enter the syringe when you pull back to register. You may feel an electric “burn” along your limb.

 Hitting a nerve can be very dangerous and result in paralysis or the loss of a limb. It’s a good idea to know where your major nerves are so that you can avoid them when getting off.  

 

Exercises for Improving Vein Visibility

If you’re the athletic type, engaging in the following activities can help make your veins more visible from outside the body.

• Push-ups, pull-ups, and other exercises that strengthen the arms
• Weight-lifting, particularly bicep exercises
• Squeezing tennis balls
• Wrist curls

 

Some tips for “Getting Veins Up” 

If you’re having difficulty locating a vein to inject into, you might want try one of the following:

• Put a warm compress on your injection site for five or ten minutes to help bring a vein to the surface. When you’re cold, it can be very difficult to access a vein. (If you’re getting off in a bathroom or somewhere else where there’s not a lot of heat, don’t unroll your sleeve or uncover your injection site until you’re ready to inject.)
• Lower your arms below your heart or swing them in a circle.
• Lightly slap the injection site.
• Wrap your limb in Saran Wrap for a few minutes. This traps the heat and causes veins to rise to the surface.
• Caffeine and nicotine can both constrict veins. Try injecting before you’ve had your first cup of coffee and/or cigarette. If you have had a cup of coffee or a cigarette, wait about 30 minutes to try injecting again.
• Remain calm. It can be extremely frustrating to be unable to get a hit, particularly if you’re in withdrawal. Chances are getting upset will only increase your difficulty, so take a few deep breaths and start over again in a calmer state of mind.

 

 MUSCLE – POPPING ( INTRAMUSCULAR I N J EC T IO N ) 

Some drugs, including injectable steroids and hormones, must be injected into a muscle instead of a vein, but heroin and other opiates can also be administered using this method. The physical and psychoactive effects that result from an intramuscular injection of a drug come on much more slowly than those of an intravenous injection (half an hour to forty-five minutes versus almost immediately), although the overall, cumulative intensity of the effects and the experience are virtually identical. Also, the “rush” that is produced when drugs like heroin are administered intravenously is not experienced by individuals who inject intramuscularly.

Most if not all of the infection control and other safety precautions intravenous drug injectors should follow also apply to individuals who inject drugs intramuscularly. Muscle-popping produces much less bleeding than intravenous injection, if any at all, but the risk of transmitting viruses and other blood-borne bacteria as a result of needle-sharing is as serious as it is with intravenous injection. In addition, muscle-poppers are at high risk for abscess formation, especially if what they inject has any particles in it whatsoever. When muscle-popping, it is extremely important to inject only a solution that is as particle-free as possible.

Many of the substances that require intramuscular injection come pre-prepared in liquid form. To prevent contaminating your entire supply (especially if you’re sharing it with someone else), be sure to use only a sterile needle and syringe when drawing the liquid up from the bottle in which it’s stored. Muscling speed or cocaine is very painful and dangerous, and is likely to cause an abscess.

 

CHOOSING AN INJECTION SITE 

The buttocks, thighs, and upper arms are the three best sites, respectively, for intramuscular injection. The best is in the deltoid, the muscle on your upper, outer arm where your shoulder and your arm meet. If injecting into the butt, mentally divide each cheek into four equal sections and inject into the top right or top left outer section of each cheek. You can also use the front surface of your thighs about six inches above your knee to about six inches below your hip, or the outer surfaces of your upper arms between your shoulder and your elbow. Always be careful to avoid nerves, blood vessels, or bones, and rotate injection sites to avoid bruising, abscess formation, and the like. It is not uncommon for your muscle to be sore for a few days after an injection.
 

CLEANING THE INJECTION SITE 

Be sure to carefully clean the injection site prior to injecting (see ‘Mainlining’ section above for more detail).

 

INSERTING THE NEEDLE 

Try to relax the muscle prior to injection. This will result in a less painful injection and may prevent the soreness you usually feel the following day or two. When injecting into a muscle, insert the needle in one quick stab straight into the injection site at a 90° angle to the body. Nearly the entire needle should enter the muscle. You definitely want to draw your plunger back slightly to make sure no blood comes into the syringe. If blood does appear, you’ve hit a blood vessel and need to pull out and try again. Inject your substance slowly.

 

PULLING OUT 

Pull your needle out in the same direction and angle at which you inserted it. Because you injected into a muscle, there should be little if any bleeding. You might want to apply a Band-Aid in any case to prevent infection. Massaging the area lightly for a few minutes will help the drug absorb and reduce the pain.
 

MUSCLING HORMONES 

Hormones are to be injected only into the thigh or buttock muscle. When injecting, be careful of nerves, veins, and bones. The buttock is the most common place people inject. You can switch buttock cheeks to avoid bruises and sores. After you inject into these muscles, you might be sore for a day or two.

Do not inject more than the prescribed amount; it will not speed up your treatment process. You can cause serious liver damage and increase the risk of blood clots. Blood clots can appear in the veins of the legs and can travel to the lungs; this is called Pulmonary Embolism, which can be fatal. People who smoke cigarettes and inject hormones are more likely to develop Pulmonary Embolism. (This section taken from Positive Health Project’s “Safety Guidelines for Injecting Hormones.”)

 

 S K I N – P O P P I N G ( S U B C U T A N E O U S I N J E C T I O N ) 

 

Skin-popping is the injection of drugs between the body’s skin and fat layers. Like muscle-popping, the effects of your drug will come on much more slowly than if you’d injected it intravenously, and you will not experience a “rush.”

Skin-poppers should follow all of the infection control and other safety precautions that intravenous and intramuscular injectors should follow. Although like with muscle-popping, skin-popping results in little or no bleeding at the site of the injection, the risk for bacterial or viral infection is real if injection equipment is shared or drugs are not prepared and injected hygienically. Also, skin-poppers are at greatly increased risk for abscesses, especially if injecting crushed pills or another solution with particles in it. When skin-popping, it is critical to use only a solution that is as particle-free as possible.

 

CHOOSING AN INJECTION SITE 

The upper and lower arms and legs are probably the best locations for skin-popping.

 

CLEANING THE INJECTION SITE 

As always, thoroughly clean the injection site with alcohol, soap and water, or other disinfectant prior to injection.
 

INSERTING THE NEEDLE 

Slide the needle under your skin at a shallow angle, 15° to 45°  at  the  most. Inject  no  more  than  1⁄2   cc  of  liquid  (half  of  the volume of a 1 cc syringe) to form a little bubble under the skin. If  your  hit  is  more  than  1⁄2   cc, inject  into  two  or  more  sites. The bump from the solution you injected will slowly decrease as the liquid is absorbed into the body, and should disappear completely within a few hours. Skin-popping can be uncomfortable, and the bump you create may hurt a bit. If you skin pop where the skin is loose, pinch the skin between your thumb and forefinger and put the needle into the skin you’ve pulled up.

 

PULLING OUT 

Pull your needle out in the same direction as it went in. There should not be much bleeding at the injection site when skin-popping, but you might want to apply a Band-Aid to prevent infection.