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Month: May 2017

Research Round Up 1: Acidity, Veins, and Heroin

Research Round Up 1: Acidity, Veins, and Heroin

Reviews of medical research relating to and/or informed by harm reduction

Moving back to Portland, one of the biggest shocks for me was how gnarly the wounds are here on injection drug users. I set up and ran a wound care program in Pittsburgh and rarely saw wounds that were as large and angry looking as is the norm out here. Why is this?

I originally assumed it was due to some different demographics of participants. Pittsburgh is a cheaper place to live and most of the folks we saw in Pittsburgh had housing and easy access to plumbing. This is not something I could necessarily assume with participants at PPOP. So I thought- maybe it’s a hygiene thing- like people aren’t able to clean well enough and have less access to sanitation, and thus have a higher rate of exposure to infections. Another thing I noticed was that people in Pittsburgh were way more obsessive about pre-cleaning with alcohol pads- people took tons of alcohol pads per week, like everyone. Here at PPOP, some people don’t like alcohol pads at all, other people have emphasized about cleaning the site afterwards, and in general it just seems like less of priority for folks (on a side note, in my opinion cleaning with alcohol prior to injection, for at least 12 seconds, may be the simplest, cheapest, and most effective way of reducing infection risk). But this still didn’t quite explain the wound differences.

The big difference is this: in Pittsburgh, people are mostly using a tan powder heroin that cooks up easily in lukewarm water, no heating needed. In Portland the available heroin is black tar. I wanted to know if black tar heroin was worse for the veins- I did a little research and asked around online- from and there were several postings by people attesting to the harshness of tar heroin on their veins. I received the same info from people in harm reduction networks (thanks Lee!! thanks Alice!).

And then I found a couple of research articles spotlighting on the connections between different forms of heroin and skin and soft tissue infections. The article, titled Fire in the Vein: Heroin acidity and its proximal effect on users’ health (Ciccarone, Harris 2015), discusses the various types of heroin on the global marketplace and notes connections between increased vein damage along with increased heroin acidity. They measured both brown and tan heroin and both were acidic, though the brown heroin significantly more so than the tan. Unfortunately, they were unable to measure tar heroin in this study, though they did note that cities where tar heroin is common had a much much higher rate of skin and soft tissue infections. Of interest for tar heroin users, they note that the spores of the clostridium bacterium may be activated by the heating process necessary to make tar heroin shootable, thus increasing infection rates (especially with missed shots or with improperly injected muscling shots, as clostridium tend to thrive in areas with low blood flow- for example shots in fatty tissue and not in true muscle). On the other hand, they also note that the necessary heating of tar heroin may have helped reduce the spread of HIV infections within the drug using community.

Another idea, not addressed in this article, but that occurred to me, was that overdose is not at quite the epidemic levels here as it is in Pittsburgh, and I’m curious if this is another protective aspect of tar heroin? Is it more difficult to cut with fentanyl? Anyone have any ideas?

Regardless, the article is easily readable to medical and non-medical people alike, presents a lot of different ideas and recommendations, and is definitely worth your time. It’s available to read for free here.

The second article (Summers, Struve, Wilkes, and Rees, 2016)specifically focused on the powder heroin found on the east coast (in this study- Boston) and the west coast’s tar heroin (in this study- Sacramento). This research mainly sought to show correlation between tar heroin, skin and soft tissue infection, vein loss, and non-venous injection habits (eg- muscling and skin popping). It will probably come as no surprise that there is a correlation- the researchers found that people who inject tar heroin were seven times more likely to develop abscesses, and lost, on average, two more injection-site veins in six months than users of powder heroin. This article does not speculate at what it is about tar heroin that does this, whether it is the tarry form itself or a particular substance used as a cutting agent. Recommendations for decreasing the injection burden associated with tar heroin should sound familiar to PPOP’s participants- increased access to clean injection equipment, supervised injection facilities, and “supply chain interventions”- a consumer revolt! I would also note that increased injection hygiene education and increased early infection interventions would also help.

Ciccarone, D., & Harris, M. Fire in the Vein: Heroin acidity and its proximal effect on users’ health (2015). The International Journal on Drug Policy, 26(11), 1103–1110.
Summer, P.J., Struve, I.A., Wilkes, M.S., & Rees, V.R. Injection-site vein loss and soft tissue abscesses associated with black tar heroin injection: A cross-sectional study of two distinct population (2016). The International Journal of Drug Policy, 39(2017), 21-27.
Research Round Up: Intro

Research Round Up: Intro


Reviews of medical research relating to and/or informed by harm reduction

Prevention Point Pittsburgh, Western Pennsylvania’s only aboveground harm reduction clinic, offers a variety of services- needle and works distribution, naloxone distribution, overdose prevention training, and rapid hepatitis C testing. In 2013 I’d been volunteering at Prevention Point fairly regularly for about three years. I was also a new nurse.

Over the years there I had repeatedly heard that the organization wanted to establish a wound care program. With one year under my belt working in an oncology/medical ICU, I had encountered lots of wounds, I had done a lot of wound dressings, and had read lots of reports and recommendations from the wound and ostomy nurses. I didn’t actually know a lot about wound care, but I thought- I could learn, right? So this began a long and bizarre journey into researching wounds and wound care specific to people who inject drugs (PWIDs).

I assumed that there would be some straightforward guides to wound care available on, like, amazon. There are some wound care guides and textbooks, but ultimately they are pretty vague, mostly about different types of dressings and brands, and make almost no mention of wounds related to injection drug use. Through my hospital’s library I had access to a lot of academic journals and research articles, and I found that there was not very much written on this subject (though I am happy to say that research is growing quickly). Gathering a body of knowledge about injection drug use wounds sent me to the far corners of medical research- including the Journal of Foot and Ankle Surgery, the Archives of Surgery, and Emergency Radiology. But also turned me on to some consistently good research publications like the International Journal of Drug Policy, and the American Journal of Public Health. And it’s probably not a big surprise that a lot of the best research out there is being done overseas. I amassed a small textbook of articles, typically with a very narrow focus (e.g.- How to Treat Arterial Ulcers in the Groin), and these, as a whole, started to develop a more complete idea about best practice relating to wound care for PWIDs.

All of this is to say, that there’s a lot of good information out there- not only for practitioners of wound care- but also for people who inject drugs. However, a lot of this information is difficult to access without being in school, or having professional or academic credentials. So, I hope to use this space to give updates on new research on all things related to keeping yourself and your veins healthy when injecting drugs.



Signs Signs Everywhere

Signs Signs Everywhere

If you were in Portland following the presidential election it was hard not to notice some signs that were popping up everywhere. Printed by letterpress and mostly hanging in store windows they read:






In a public environment that had become overcome by hate and fear- I understood trying to inject some gentleness and solidarity into the world. It is a kind and compassionate statement made bold.

On the other hand I’m a 43 year old native of heavily gentrified north and northeast Portland, and as I saw these signs up and down Killingsworth, Alberta, and Mississippi streets- I started wondering what it really meant to be safe in these places. I thought about the history of this city, and the history of gentrification and race and violence here. I thought about people calling the cops on shoplifters. I thought about people with money with outdoor seating, eating sushi, while black teenagers are lined up and patted down across the street. And I thought- do people selling $300 vintage backpacks really stand with me? Am I really safe in a high end taxidermy and museum goods shop? Will they record me on video? Will they even let me use the bathroom? And if ICE or the cops come charging down the street, will these stores take people in, shelter, and feed them?

The longer I saw these signs, the more I thought about alternatives. In the early 80s there was a lot of hysteria around kidnapping. I remember when I was growing up that there were houses around town with signs up for kids that said something like ‘safe place’,  and I think these signs were set up by the city and churches- places/homes that kids could run to if they were scared. What if new signs in Portland came out explicitly against ICE or the police? Would that mean something more?

And then, honestly, I’m just kind of contrary- so it’s hard not to look at something and tear it apart in my head. One morning when I was sick, I sat down in front of the computer and worked up a photoshopped alternative to the ‘YOU ARE SAFE HERE’ signs. I did it with PPOP in mind, thinking of our fixed site on Saturdays. I thought about the quiet times up there, later in the day (after all the bulbs are gone!), when participants come and are just hanging out. I like those times, people use the space, sip coffee, lounge on the couches, charge their phones, and just look relaxed. Like they’re in a place that stands with them and where they are (relatively) safe. Like they are in a space where they’re not constantly criminalized or on the run.
I emailed these images to Sam and was rewarded a couple weeks later when he put them up at the PPOP fixed site. It was a real pleasure to watch people up there notice the signs, and then do a double take as they realized how the text had been altered. Anyway, these are the posters, feel free to use, reuse, adapt, mock, and change.

There’s a high res version of this poster (for printing) here.