Harm reduction is an approach to public health intended to be a progressive alternative to an approach requiring complete abstinence from drug use. While it does not condone the taking of illicit drugs, it does seek to reduce the harms arising from their use, both for the person taking illicit drugs and the wider community.
A prominent method for addressing the issue of disease transmission among intravenous drug users are needle exchange programs, in which facilities are available to exchange used injection equipment for safe sterile equipment, often without a prescription or fee. Such establishments also tend to offer free condoms to promote safe sex and reduce disease transmission. The idea is to slow disease transmission and promote public health by reducing the practice of sharing used needles. In countries where harm reduction programs are limited or non-existent, it is quite common for an IV user to use a single needle repeatedly or share with other users. It is also quite uncommon for a sterilizing agent to be used.
A philosophy of harm reduction promotes information and resources for IV drug users. General guidelines on safer injecting of various substances intravenously are typically based on the following steps:
The area for drug preparation should be cleaned with warm soapy water or an alcohol swab to minimize the risk of bacterial infection.
The equipment required involves new syringes and needles, alcoholic swabs, rinse eye drops as sterile water, filter (cotton or syringe filter like Sterifilt), tourniquet and a clean spoon or Stericup. In order to minimize the chance of bacteria or viruses entering the bloodstream, people are advised to wash their hands with soap and warm water. However, as people do not always have access to hot water and soap when they are injecting, the philosophy of harm reduction seeks to find the most realistic and reliable option that drug users will take: a process that takes much time or access to materiel is unlikely to be used frequently. Alcohol swabs are commonly distributed with injecting equipment, and while they are less effective than hand washing, their use is more effective than nothing. Any sharing of injecting equipment, even tourniquets, is highly discouraged, due to the high danger of transmitting bacteria and viruses via the equipment.
Sterile water is also recommended to prevent infection. Many needle and syringe programs distribute vials or ampoules of USP sterile water for this reason. Where sterile water is not obtainable, the harm reduction approach recommends tap water boiled for five minutes, and then allowed to cool.
Once the water and substance are combined in the mixing vessel, heat is sometimes applied to assist the mixing. Filtering is recommended by health services, as the mix can consist of wax or other non-soluble materials which are damaging to veins. Additionally, the injection of talc has been associated with pulmonary talcosis in intravenous drug users. Wheel filters are the most effective filters. 5.0 micron wheel filter (e.g. Apothicom Sterifilt), now shared in some needle-exchange programmes instead of cotton, is intended to get rid of the talc from prescription tablets like benzodiazepines, dextroamphetamine, methadone tablets, and other recreational drugs like MDMA. However cotton wool (with the risk of cotton fever) or tampons can be used, although to be more effective, several filtrations should be performed; cigarette filters should not be used due to the risk of fibres breaking off and being injected along with the solution, nor should filters of any sort ever be re-used, either as filters or in an attempt to recover drug material present, due to many risks, ranging from cotton fever to life-threatening sepsis.
Once the mix is drawn into the syringe, air bubbles should be removed by flicking the barrel with the needle pointed upwards and pressing the plunger to expel the bubbles that pool at the top. This is done to prevent injection of air into the bloodstream. The potential danger of an air embolism is often greatly overestimated by IV users; up to three CCs of air can be injected intravenously without causing complications, and time spent meticulously getting every minute air bubble out of the syringe would often be better spent ensuring clean conditions in general.
A tourniquet can be used to assist vein access. The tourniquet should not be on too tight, or left on for too long, as this causes the veins to swell and stretch. When injecting, the needle's bevel or 'hole' should face upward and be eased into the vein at a shallow angle between 10 and 35 degrees to minimize the risk of penetrating through the vein entirely. In order to prevent stress on the vein, the needle should be pointing towards the heart.
The plunger should be pulled back slightly (colloquially known as 'jacking back' or 'flagging') to ensure the needle is in the vein. Blood should appear in the barrel of the syringe if this is the case. This process is termed aspirating the needle or registering. When accessing a vein with unobstructed blood flow a "flashback," or sudden flash of red blood inside the needle tip, may occur spontaneously when the needle enters the vein. Because sudden appearance of blood in the needle/syringe alone does not guarantee proper needle placement (flashbacks can also occur when a needle passes through a vein completely, enters an artery inadvertently, or otherwise is extravasated), aspirating the plunger on the syringe is still considered a requisite step.
The tourniquet should then be taken off and the plunger gently pushed. After injection, a clean tissue or cotton wool should be pressed against the injection site to prevent bleeding. Although many people use an alcohol swab for this purpose it is discouraged by health services as the alcohol interferes with blood clotting.
Dispose of injecting gear using a 'sharps bin' if supplied. Other rigid-walled containers such as a bottle are recommended as a second best option.