Training Guide

Getting Off Right: A Safety Manual for Injection Drug Users

Potential Health Complications of Injection Drug Use 

Many, if  not  all, of  the  things  that  can  go  wrong during the process of preparing and injecting drugs fall into one of three categories: drug-related, technique-related, and hygiene- related mishaps. Because we’re forced to use blackmarket, unregulated drugs, we don’t have control over the quality or purity of the substances we use.  While we may not be able to do much about the actual drugs we use, we can work to improve our injection technique and hygiene which can have far-ranging effects on our health.

There are numerous and potentially very serious health complications associated with injecting illicit drugs, from injection-related injuries like tracking and bruising, to bacterial and fungal infections, from communicable diseases, to drug overdoses and other medical emergencies. This section of the manual describes some of the medical and health problems that can result from injecting drugs and offers suggestions for how to prevent them. Overdose prevention and survival are addressed in chapter four.


B A C T E R I A L , V I R A L , A N D O T H E R I N F E C T I O N S 



A “dirty hit” is a general term for a shot that makes someone sick or causes an abscess as a result of being contaminated with infection-causing microbes or toxic substances. Dirty hits can be caused by any number of things, such as:

  • contaminants in the water you used to dissolve your drugs;
  • bacteria, fungi, or other microbes from old cottons;
  • chemicals in a cigarette filter that was used to filter a shot;
  • adulterants or contaminants in the drugs themselves; or
  • not properly cleaning the skin prior to injection.

BACTEREMIA (bacteria in the blood) 

Bacteremia is when  bacteria entersthe blood- stream that can be caused by injecting with contaminated water, re-using old cottons, or failing to clean the skin prior to injection.

Early symptoms include chills, fever, and extreme fatigue. If you experience these symptoms, seek medical attention. Bacteremiacan be fatal!



Endocarditis is an infection of the heart valves  that is caused by bacteria, fungi, and other infection-causing microbes that enter the bloodstream during injection and build up around the valves of the heart, weakening them as well as other parts of the heart muscle. Endocarditis can eventually cause a heart murmur, as well as fever, chest pains, fainting spells, shortness of breath, and heart palpitations as well as congestive heart failure. Early signs include flu-like symptoms. It can be treated with antibiotics or antifungal agents if detected early, but requires several weeks, or months, of IV antibiotics and/or heart valve replacement surgery if not detected early. Endocarditis can be fatal if it goes untreated.



Tetanus is a bacterial infection that occurs when tetanus spores enter a wound and release tetanus bacteria, usually after a scab has already formed. The bacteria then enter the bloodstream and cause an infection, which is characterized by muscle spasms or rigidity, especially in the neck and jaw (tetanus is commonly called “lockjaw”). Tetanus is fatal if not treated.

Tetanus spores live in the soil and on rust, which is why a tetanus shot is recommended if you step on an old nail or other rusty object. Most local health departments offer free tetanus boosters, which will protect you from tetanus for five years, so you should r get one. If your needle, syringe, or other injection equipment is contaminated with tetanus spores due to dirt or rust, you could infect yourself. Skin-poppers and muscle- poppers are particularly susceptible to tetanus infection and should always use new, sterile equipment.


NECROTIZING FASCIITIS (Flesh-Eating  Disease) 

Necrotizing fasciitis is a bacterial infection commonly known as “flesh-eating disease” that enters the body through broken skin and then affects the surrounding tissue and nearby muscle. It can be transmitted by the exchange of blood during needle sharing, and has been traced to “black tar” heroin on the West Coast.

Symptoms of necrotizing fasciitis include increasing redness and swelling and extreme pain at the wound or injection site accompanied by a fever. This may look a few different ways, the flesh around the site of infection will be very red, swollen, with severe pain, and possible fever. . Over the course of days the skin can turn from red-purple to blue-gray and the skin could break down within 3-5 days. Since this infection is fatal, early treatment with antibiotics is crucial to survival, although even appropriate therapy does not prevent death in all cases. Wounds must be kept impeccably clean.

Always using new, sterile injection equipment; never sharing injection equipment; thoroughly washing your hands and clean- ing the skin prior to injection; and preparing your drugs on  a clean surface will all help prevent necrotizing fasciitis infections.



Wound botulism is caused by a bacteria that produces a toxin on the skin where a puncture wound is made and that eventually stops your breathing by paralyzing your muscles. Cases have been associated with the subcutaneous injection of “black tar” heroin on the West Coast. The source of the botulism could be the drug itself, a cut in the drug, dirty injection equipment, or contamination during the preparation process. Wound botulism can be prevented in the same ways as necrotizing fasciitis–by following excellent sterile technique when preparing and injecting your drugs.

Symptoms of wound botulism include droopy eyelids, blurred or double vision, and a dry, sore throat which may progress into difficulty speaking and swallowing, a weakness of the neck, arms, and legs, and difficulty breathing.

If untreated, wound botulism will cause death by paralyzing the muscles used for breathing. Early treatment for wound botulism is essential. If you  experience  any  of the  symptoms  listed  above,  seek   medical   attention   immediately. Treatment usually involves an antibiotic regimen and the draining of any abscesses or infected wounds.



Hepatitis is an inflammation of the liver that can be caused by certain toxic drugs, alcohol, or street drugs (iatrogenic or chemically-induced hepatitis); or that is the result of infection with a hepatitis virus (viral hepatitis). While there are numerous types of hepatitis viruses, hepatitis-B and hepatitis-C are the two that most frequently affect people who inject drugs, with hepatitis-A coming in third.

General symptoms of hepatitis include fatigue, loss of appetite, nausea, mild fever, and muscle aches, and if you smoke cigarettes, you may notice that they taste unpleasant. More severe symptoms of hepatitis include dark (tea-colored) urine, light-colored stools, and jaundice (a yellowing of the skin and the whites of the eyes).

HEPATITIS A ( “HAV”) is excreted in feces (shit) and spread by fecal-oral contact (feces-to-hand- to-mouth contact). Hepatitis A can be spread from contaminated food, water, hands, and eating utensils, for example, by a restaurant worker who didn’t wash their hands after using the bathroom and who then prepared food. There have also been outbreaks in places like encampments where people may not have access to running water for handwashing.  Unlike hepatitis B and  C, hepatitis A is not transmitted by blood-to- blood contact that occurs when needles or other drug injection equipment is shared, and is not generally spread through sexual contact unless rimming (oral-anal contact) is involved. 

Hepatitis A illness resembles the flu and can last from four to six weeks. It causes an acute (short-term) infection only and never develops into a chronic condition like hepatitis B or  C. You develop antibodies to hepatitis A after you’ve been infected with it, so your chances of ever getting it again are slight. A hepatitis A vaccine is available and is . a two-shot regimen, with the second injection taken 6 to 12 months after the first.

HEPATITIS B ( “HBV”) is spread through blood-to-blood contact of the kind that occurs when injection equipment is shared; contact with infected body fluids like semen, blood, vaginal fluids s; and from a parent to their infant at birth. Hepatitis B infection can be acute (short-term) and/or chronic (long-term); chronic HBV can cause serious liver damage, including cirrhosis (scarring), liver cancer, and death from liver failure. Hepatitis B is much more infectious than HIV, which means it is spread much more easily. It is one of the most important reasons people who inject should avoid sharing injection equipment of any kind.

A vaccine that will protect you against hepatitis B if you’re exposed to it is available, and all people who inject drugs should think about getting it . The vaccine involves a series of three intramuscular injections, with the second shot being administered 30 days after the first, and the third shot being administered 4 to 6 months after the second. The vaccine is safe and effective. If

you’ve had hepatitis B in the past, you’ve developed antibodies to it and will not catch hepatitis B again in the future and do not need the vaccine. You can get your blood tested to see if you’ve ever been exposed to the hepatitis B virus, and get the vaccine at your doctor, local Department of Health,, or even your syringe service program.

HEPATITIS C (formerly known as “non-A, non-B“ hepatitis and also referred to as “HCV“) is spread through blood- to-blood contact and is very infectious, which means you can acquire it quite easily if exposed to it. There are oral and blood tests available that detect whether or not you have antibodies to the hepatitis C virus in your blood, which, if positive, should be confirmed with a second test.  .  The only way to test whether or not you have the actual virus in your blood is by getting a confirmatory test which shows whether you have a current infection or not.  There is as yet no vaccine for hepatitis C, and antibodies are not protective—that is, they don’t make you immune to re-infection as with HBV. Currently, there is only prevention by avoiding blood-to-blood contact with use of sterile injection equipment, by not sharing injection equipment, and through safer sex.

Hepatitis C can either be chronic but asymptomatic (without symptoms, which means you barely even notice you have it), or chronic-active, which means disease will develop over a long period of time–several years or perhaps even decades.  Up to a quarter of people who become infected with HCV will clear the virus on their own and not develop chronic hepatitis C.  This does not mean you’re immune, or that you’ll be able to clear it if you’re re-infected.  People with active hepatitis C may have elevated liver function tests (LF Ts), fatigue, and jaundice, and active disease can result in cirrhosis, liver cancer, and ultimately liver failure, all of which can be fatal. The hepatitis C virus can be cleared from the body with medication,  and over time, the liver may be able to regenerate itself.  Regular testing helps to prevent hepatitis C from going unnoticed.   Hepatitis C is a serious health risk for people who inject drugs, many of whom have been exposed to the virus at  some point in their  lives.

In the past hepatitis C treatment was largely ineffective and had serious side effects.  Since 2013, there have been highly effective, all-oral, cures for hepatitis C.  Hepatitis C treatment can, and should, be available to everyone.  However, it may be difficult to access treatment based on where you live, your medical coverage, and your liver damage.    



Human Immunodeficiency Virus (HIV) is the virus believed to cause AIDS (Acquired Immune Deficiency Syndrome), an immune system disorder that causes the body to lose its ability to ward off infection and fight disease. HIV can be spread through the exchange of certain fluids (if they contain the virus).  These fluids are: semen (including pre-cum), vaginal,  and rectal fluids (during unprotected sex);  blood (via childbirth, the sharing of drug injection equipment or accidental needlesticks); and breastmilk.    

Blood-to-blood contact is one of the most efficient means of transmitting HIV from one individual to another, and the sharing or re-use of drug injection equipment is extremely risky in terms of HIV transmission. It is important to point out that injection drug use itself does not cause HIV; rather, HIV is transmitted (like hepatitis and other viruses) when infected blood from one individual is left in a needle, syringe, cooker, cotton, or water and injected into the bloodstream or body of a second individual who uses those same works. HIV from injecting drugs is therefore 100% preventable as long as you always use your own sterile works and never share them with anyone.

General symptoms of early HIV infection (soon after the point of transmission) may include a low-grade fever and fatigue. The longer a person has HIV and does not receive medication,, the more likely they are to develop one of the many bacterial, fungal, or viral infections, cancers, neurological disorders, or other conditions that affect people with HIV and AIDS.  There are numerous medication regimens including one pill version that can keep the HIV virus undetectable in the body HIV virus in the body so that you can live a regular lifespan.  

 In July 2012, the Food and Drug Administration (FDA) approved the use of tenofovir + emtricitabine (TDF/FTC), commonly known as Truvada, for HIV PrEP (Pre-Exposure Prophylaxis)  in adults who are at high risk for becoming HIV infected.  An uninfected person who might become exposed to the virus is provided a prescription for antiretroviral medications to prevent from becoming infected with HIV.   PrEP Eligibility includes: people who inject drugs and who share injection equipment, individuals who use stimulant drugs associated with high-risk behaviors, such as methamphetamine, and individuals who trade sex for money, drugs or housing.  PrEP is only for clients with a documented negative HIV test result.  HIV and STI testing, as well as blood tests to check on the liver, are repeated every three months. PEP (Post-Exposure Prophylaxis) is an option for individuals who have come in contact with fluids that may contain the HIV virus within the past 72 hours. Similar to PrEP, it is a course of antiretrovirals, but it is only taken for the month following the exposure.




Track marks are the scars that appear along the veins of someone who injects frequently and repeatedly uses the same  injection sites.


How a bruise is formed

Bruising occurs when blood leaks out from the vein under the skin in the process of injecting. Damage to the veins, including tracking and bruising, can be minimized or prevented altogether by practicing the following safer injection guidelines. (These are especially important for those individuals who are worried about family, friends, an employer, or someone else finding out about their drug use. Track marks are one of the most visible signs that you use.)

  • Use a new, sterile needle for every injection. Re-using needles, even once will cause them to dull.  Dull needles will cause trauma to the veins and surrounding tissue, cause a much larger puncture wound, and increase bleeding at the site.
  • Use the highest gauge (thinnest) needle you can find to make the smallest puncture wound possible.
  • Alternate and rotate your injection sites. Always try to inject at least one inch “up” from your previous injection site (for your arms, this means moving away from the hand and toward the shoulder, and for the legs, this would mean away from your feet and toward the hips).  Give your veins a chance to rest in between injections. Stay away from veins that are red or tender until they heal.
  • Always inject in the direction of the body’s blood flow (toward the heart).
  • Use a soft, flexible, easy-to-open tourniquet and remove it after you’ve registered but before you inject to help prevent bruising.
  • Use emollient-rich or antibiotic creams on injection sites once they’ve closed or scabbed over. Aloe vera gel and vitamin E oil are commonly-available and can help reduce the appearance of track marks.


Vein collapse occurs when veins close up due to repeated injections into the same site, repeated local infections, or trauma to the veins and surrounding tissues. Using barbed or dull needles can precipitate vein collapse. You know you have a collapsed vein when you can’t draw blood from it or when the vein “disappears.” Thrombosis is the formation of an obstruction of a blood vessel by
a blood clot. Don’t use veins that do not bend when pushed as they may have blood clots that can break off and lodge in the lungs or other parts of the body and cause serious damage.
You can avoid vein collapse by always rotating and alternating your injection sites and by injecting in the direction of the body’s blood flow (toward the heart). Using the same injection site over and over without letting the vein heal is one of the surest ways to cause vein collapse. Also, insert your needle at a 15 to 45 degree angle with the bevel of the needle facing upwards. Taking oral vitamin C may help your veins repair themselves and reduce bleeding and bruising. NEVER inject vitamin C, only swallow it.



Abscesses begin with redness, swelling, and tenderness at an injection site and develop into an infection with a hard, pus-filled core. Abscesses result from missed hits (injecting into the tissue surrounding the vein), injecting a solution with a lot of particles in it, not cleaning the injection site prior to injecting, re-using injection equipment, or skin-popping drugs like coke or speed that cause damage to muscle tissue and skin.
If you’ve just missed your shot and are worried about getting an abscess, ice the area immediately afterwards and raise the injection site for at least 30 minutes, if you can. This will not prevent an abscess if one is developing, but will help to ease the swelling. If any abscess does develop, switch from icing the area to heat.
If you notice a hard, warm lump developing at an injection site, apply warm compresses at least  three times a day to either make the abscess that is forming go away or come to a head (soften and fill with pus). If it comes to a head, you can get the abscess opened and drained at a hospital or clinic. If you experience fever, chills, extreme fatigue,  pain associated with an abscess, or a thin dark line moving from the abscess, seek medical attention immediately because you could have a blood infection. Pain in the groin or armpits (where your lymph nodes are)also means you most likely have an infection for which you should seek medical treatment.



If you’re unable or unwilling to seek medical care for an abscess, take the following steps:

  1. Clean the area with soap and water and dry it well  e sure to keep it as clean and dry as possible at all times.
  2. If the abscess is draining on its own (pus is coming out of it), let it continue to do so. Do not touch the abscess (except to clean it), squeeze it to extract the pus, stick your syringe into it, or inject above or below it.
  3. Keep the area covered with sterile gauze you can buy in a pharmacy, and change the dressing twice a day until the pus stops draining and at least once a day until the abscess is completely healed. Dressings that directly touch the wound should be dampened with sterile saline (which you can also purchase at a drug store) and then covered with dry gauze and tape. Properly dressing an abscess will help keep it free from further infection and speed healing.
  4. When removing the dressing, dampen the gauze that’s touching the wound so you don’t pull off newly formed tissue.
  5. Warm compresses and salt soaks will encourage the abscess to drain and promote healing. Do not soak or use a compress once the wound is open or draining. After the abscess has drained and scabbed over, antibiotic creams and preparations like aloe vera gel can be helpful.
  6. Let the area heal completely. If the abscess refuses to drain completely or pain and swelling persist, seek medical attention.

 If you do seek medical care to have your abscess drained, try to find a wound clinic where you can get your dressing changed on a regular basis and make sure the abscess is healing properly. If there isn’t a wound clinic available near you and you need your abscess drained, try a community clinic or emergency room.. If you do seek care for your abscess at the emergency room or a community clinic, know in advance that the doctor may cut into your abscess and scoop the pus out with their (gloved) fingers, and that they should provide you with lidocaine to numb the area. If they do not offer lidocaine, you are well within your rights to ask for it! Depending on what the infection is like, you may also be prescribed antibiotics. Try to take the full course of medication. And remember, although there are certainly no guarantees when it comes to people’s views about injection drug use, you deserve compassionate treatment and are allowed to advocate for yourself. 



An embolism is something such as air, fat, impurities, dirt, or other particles that can obstruct a blood vessel which results in the blockage of blood flow. Particles from injected pills that were not completely pulverized and clumps of bacteria are two examples of things that can cause emboli. Emboli can be extremely serious, particularly if they travel through the blood vessels to the heart or lungs or lodge in the small capillaries of the fingers, eyes, or toes where severe circulation damage can occur. The risk of emboli can be reduced by filtering out any particles in your shot 



We’ve got some tips for people who use drugs to access healthcare and advocate for yourself with healthcare providers – check out Quality Healthcare Is Your Right resource.