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 bluelight.com and drugs-forum.com 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.