Risky use of acidifiers in drug injection preparation: implications for health harms and service provision in the UK

Magdalena Harris, Jenny Scott, Daniel Ciccarone, Rachel Brathwaite, Vivian Hope

Background
Venous access is priority for people who inject drugs (PWID). Damage and permanent scarring of peripheral veins can exacerbate health harms, such as skin and soft tissue infections (SSTI), and promote transitions to femoral and subcutaneous injecting. The use of acidifier, necessary to prepare brown heroin used for injection in Europe, can influence venous damage and SSTI risk. To reduce injecting related injury and associated consequences (e.g. sepsis, amputation, death) it is crucial to understand the interplay of environmental and practice-based risks underpinning venous damage among PWID.
Methods
We present questionnaire (n=260) and in-depth qualitative interview (n=30) data generated with PWID in London for the ongoing Care and Prevent study. Participants provided life history data and detail on injecting environments and drug preparation practices, including use of acidifiers.
Findings
Of the 260 participants 84% reported lifetime history of street homelessness. Of the 59% reporting an SSTI, half had been hospitalised for a related complication. Most (89%) injected heroin and/or crack cocaine, with 81% using citric as their primary acid for drug preparation. Overuse of acidifier was common; 68% reported using half a sachet or more when preparing a £10 bag of heroin, 29% one sachet or more. The normalisation of citric ‘burn’ and vein loss was prominent in qualitative accounts. Reports of unsafe liquids for injection illustrate additional harms; with one participant hospitalised for three months after using saliva as an injection solution.
Conclusion
Venous damage and chronic injecting-related problems are common to the experience of PWID, particularly the unstably housed. Overuse of acidifier and use of unsafe liquids are modifiable risk factors. In the absence of structural supports such as safe injecting facilities, there is an urgent need to revisit injecting equipment design and distribution in order to alleviate health harms and distress amongst the most marginalised.