healthmedicinet

Drugs used

All participants in both cities reported injecting heroin from Afghanistan. Kulob
is approximately 70 km from Afghanistan, and Khorog is situated on the Tajik side
of the Panj River, which separates Afghanistan and Tajikistan. The price of a gram
of heroin cited by the majority of respondents in Khorog was 50 Somoni, the equivalent
of $10 US. In Kulob, the average price of heroin was 50 Somoni, approximately $10
US, a gram. However, participants reported that prices in Kulob often fluctuate, and
higher purity heroin may sell for 100 Somoni ($20 US) per gram. There was a general
perception that the heroin currently being sold in both cities was not as pure as
the heroin that was available in previous years. This may reflect an actual decline
in the quality of heroin, or their perceptions may be clouded by nostalgia. Several
participants reported that the drug sellers adulterated heroin with zopiclone or diphenhydramine.
Zopiclone is from the same family of drugs as Lunesta (eszopiclone) and Ambien (zolpidem).
Diphenhydramine is an antihistamine, which reports indicate has been mixed with heroin
and injected in other settings 24]. Participants in Kulob reported that some PWID add diphenhydramine to heroin after
they purchase it to potentiate the effects of the heroin when there is a shortage.

“If heroin is pure, it will carry you away until the morning, you won’t feel sick.
But there is shortage of [good quality] heroin now, that’s why they shoot it [mixing
with medicines].” (FGD#3, Kulob)

Several participants in Khorog reported that some PWID inject “khanka” (i.e., acetylated
opium). They said “khanka” is produced by adding acetic anhydride to opium. However,
“khanka” injection is relatively uncommon now because heroin is readily available
in Khorog. Some participants in Kulob reported injecting “synthetic heroin” in the
past. One participant described the difference in the appearance of heroin and “synthetic
heroin” as follows:

“Usually heroin has no glitter, but that one glitters like glass, it is a substitute,
you buy it for the same money, the price is the same.” (FGD#1, Kulob)

They reported that this “synthetic heroin” was sold on the market several years ago
and was associated with a higher risk of overdose. No one was sure of the chemical
composition of this “crystal heroin.” Most participants reported that they would only
buy it if regular heroin was not available.

One participant in Kulob reported that some people who inject heroin inject eye drops
that contain tropicamide to relieve withdrawal symptoms if they cannot get heroin.
However, no other participant mentioned it, so this practice did not appear to be
widespread in Kulob or Khorog at the time these focus groups were conducted.

Factors that influence the characteristics of needles and syringes that are used and
preferred

Most of the participants differentiate the needles by length and thickness; nobody
mentioned needle gauge as the way to distinguish between the needles. Many participants
distinguish needles by the color of the needle hub and according to volume of the
syringe the needle usually comes with (e.g., the needle of a 2-ml syringe, the needle
of an insulin-type syringe etc.). Needle hubs are color coded by gauge. However, in
a previous study, we found that the color coding is not consistent across all manufacturers
17].

Quality of needles

Participants prefer needles that are sharp and that are securely attached to the plastic
hub. Needles are mass-produced, and all manufacturers occasionally produce needles
that are defective. These defects include needles that are dull, bent, or poorly secured
to the plastic hub when they leave the manufacturer. Most PWID prefer needles that
are sharp because they are less painful, and they do less damage to veins. The proportion
of defective needles from the NSP in Khorog seemed to have increased recently.

“Well, they are blunt, expired. Before, when it started, everything was ok, beautiful,
needles were clean and fine, not expired, and now, recently, they are all blunt and
of low quality. OK, but if we don’t take it, then what we will shoot with?” (FGD#8, Khorog)

Several participants reported that when some needles are reused multiple times, the
connection between the needle and the needle hub fails, and the needle detaches and
remains in their arm following the injection. Although this seems to be a relatively
rare occurrence, it seems to make an impression on PWID when it happens as described
by a participant from Khorog.

“The needle does not break; it just comes out of there, out of the plastic thing.

Old ones, expired ones.” (FGD#8, Khorog)

Needle length

Needle length varied depending on the injection site/vein. Medium-length (25 mm) needles
were preferred by those participants who inject into cubital (i.e., forearm or elbow)
veins. Some of the participants mentioned that they use 25-mm needles for injecting
into the neck. Longer (32 mm) needles are used for injecting into the groin or femoral
veins. Some participants reported that PWID combine 2-ml syringes with larger needles
from 5- or 10-ml syringes to inject into the groin as illustrated in the following
quotes.

“Those who shoot in veins, they use 25 [mm needles], and there are people who shot
into groin, that use 32 [mm].” (FGD#10, Khorog)

“If someone has large veins, good veins, he would use small [needles]. And those,
as someone said, hopeless ones, who shoot into groin, they hit with [needles from]
5-ml [syringes]. If there are no veins, only tiny veins are left, he would use insulinka
[needles from insulin-type syringes].” (FGD#5, Kulob)

“I take these 2-ml [syringes], but would attach a longer needle, the blue one or the
black, long one, which [syringe] had those? Was it 10-ml? So this kind of needle,
I buy them, will tear [the package] off, I throw [the barrel] away, will take its’
needle and will attach it to a 2?ml [syringe].” (FGD#6, Kulob)

Longer needles are also preferred by those who inject intramuscularly or into deep
(central) veins

“…yes, [intra]muscular, so [the solution] will not go under the skin. Because, if
[the needle] is [short], [the solution] will go under the skin.” (FGD#8, Khorog)

“It will not work then, it is too short, it will reach only so much, will not reach
central veins. So I would use [a needle from a] 2-ml one… it can reach the central
veins…].” (FGD#5, Kulob)

Using longer needles to inject in shallow veins raises the risk of going all the way
through the vein and into tissue beneath the vein. In some instances, this may cause
bruising and discomfort, and in other instances, it may lead to abscesses or other
soft tissue infections. So, most PWID try to avoid using longer needles to inject
into shallow veins.

Needle gauge

As noted previously, the gauge of a needle is its outside diameter. The diameter of
the bore of needles of the same gauge may vary depending on if the eedle is thin walled or thick walled. Higher gauge (i.e., thinner) needles are preferred
for injecting in the smaller veins of the arms or hands. In particular, a needle from
the insulin-type syringe (also called a “capillary” needle) is very popular for injecting
into thin veins (referred to as capillaries by some of the participants). Some participants
mentioned that insulin-type needles can be used for injecting into the surface veins
in arms and hands by PWID who have good veins, including those who recently started
injecting. PWID often combine the needle from an insulin-type syringe with a barrel
from a 2-ml syringe.

“If someone has visible veins, he would, of course, use insulinka, it has a small
needle.” (FGD#8, Khorog)

“I have these [insulin-type syringes], it has a thin needle, why do you use them,
so the vein does not burst, no blood gets deposited there. [Insulin-type syringes],
they have very small needles, so with that, it is a little bit easier with it. You
check [if the needle is in the vein], you inject, smoothly. Say, I have no large veins,
lost them, so I use insulinka for thin veins.” (FGD #4, Kulob)

These needles are also preferred by those who want to avoid visible needle puncture
marks on their skin, which may reveal that they inject drugs. Injecting with thin
needles from insulin-type syringes is also less painful.

“… it is better with that [needle from an insulin-type syringe], because it will not
leave needle traces, needle marks…No bruises.” (FGD #3, Kulob)

“…I just hit with insulin-[type syringe], so it does not hurt.” (FGD#5, Kulob)

Participants reported that PWID often use thicker needles when they are injecting
in larger veins. They reported preferring thicker needles if they were injecting more
viscous fluids that are difficult to inject through a thin needle. Similarly, participants
reported that PWID who have trouble with their blood clotting and clogging the needle
prefer thicker needles because they do not clog as easily. Participants in both cities
reported these issues as described in the following quotes.

“Those who use a filter, they can use thin ones, it won’t [get clogged] thanks to
filtering. For us it won’t work, because most just shake [drug mixture inside the
syringe], so it is not good for us.” (FGD#5, Kulob)

“With the brown [hub] needles, say, when you draw the blood in, if you are a bit late,
it can get clogged.” (FGD#4, Khorog)

“[Needles from insulin-type syringes] or others, 46 ^th , 25 ^th , if you use them, they get clogged, it happens…” (FGD#7, Khorog)

In general, needles longer than 25 mm tend to be thicker because long thin needles
bend too easily. PWID who inject in femoral veins or other deep veins require long
thick needles to reach the vein without bending.

Needle hub opacity

Several participants reported that they preferred needles with translucent plastic
hubs over needles with opaque plastic hubs. With a translucent hub, PWID can see the
blood when it is still in the needle hub. With an opaque hub they have to draw blood
all of the way into the barrel of the syringe as described in this quote from a participant
in Khorog.

“…you would draw blood back and will not see it, you won’t know if the needle is there
[in the vein] or not.” (FGD#12, Khorog)

Drawing more blood into a syringe increases the possibility that the blood may clot
and block the needle. As blood disperses through the drug solution, the solution begins
to look like blood. This can be problematic if the needle moves slightly during the
injection process, and more blood needs to be drawn into the syringe to confirm that
the needle is still in a vein. Opaque needle hubs also make it impossible to tell
if there is blood trapped in the hub of the needle after rinsing a syringe with the
needle attached. With an opaque needle hub, the only way to determine if blood is
still in the needle hub is to remove the needle and look into the hub. These factors
may increase the risk of blood borne disease transmission if needles with opaque needle
hubs are shared.

Syringe barrel capacity

Participants reported that the barrels of 1-ml syringes are long and thin. Using these
syringes, it is difficult to operate the plunger with one hand when injecting volumes
of fluid much greater than 0.5 ml. A participant from Khorog described the problem
as follows:

“[The insulin-type syringe] is somehow inconvenient, it is small and thin, and it
is easier with a 2[ml], with this one, it is easier to handle it with one hand.” (FGD #12, Khorog)

When injecting into a vein in an arm or hand, it is essential to hold the syringe
steady with two fingers and a thumb and operate the plunger with the index finger
and the middle finger.

Some homemade drugs require injecting volumes of fluid greater than 2 ml. Also, when
PWID are preparing drug solutions for more than one person, they may use 5-ml syringes.

Syringe design (permanently attached or detachable needle)

Many PWID reported preferring syringes with detachable needles over syringes with
permanently attached needles. In some instances, this was because the maximum barrel
capacity of syringes with permanently attached needles in Tajikistan is 1 ml. As noted
previously, the barrels of most 1-ml syringes are long and thin. This makes them difficult
to manipulate with one hand if a PWID is injecting more than 0.5 ml of fluid, and
most PWID in Tajikistan inject at least 1 ml of fluid. In addition to not being available
in the appropriate barrel capacity, participants reported several other reasons for
preferring detachable needles. If a detachable needle clogs, it is relatively easy
to remove it and replace it with another needle. With detachable needles, the needle
can be removed, and the tip of the syringe nozzle can be placed directly on the filter.
The bore of the syringe nozzle is much larger than the bore of a needle, which allows
even high viscosity solutions to be drawn up relatively rapidly. Another potential
benefit that was not mentioned is that removing a needle when drawing the drug solution
into the syringe virtually eliminates the risk of dulling a needle by accidentally
jamming it into the bottom of the mixing vessel (e.g., cooker, spoon).