I’m quite a liberal NSP worker at heart; I’m happy to work with clients to get to where they want, how they want and at their own pace. That of course doesn’t mean I don’t do my best to get people thinking about reducing or stopping, but if they are going to inject I’ll work with them to do it as safely as possible. But today was one of those very rare times that I say to someone, “Look mate, just stop injecting”.
It’s only the second time I’ve been in a situation where I’m so at a loss with someone that the only way out is to say “stop” (and I’ve been doing this work for a fair few years now). The following article explains why I needed to say it and how we planned to make it happen.
One of my colleagues rang me to ask if I’d have a word with someone about their injecting sites, so I picked up an injecting guide (the red ‘Exchange Supplies’ one) and joined them in the one to one session.
After the initial introductions the client pulled up his sleeves to show what can only be described as a battle ground of scabs, abscesses, open wounds, swelling and scars. ·I promise that I’m not exaggerating when I say that not a part of his arm from elbow to wrist wasn’t affected. At least two abscesses were infected and in need of antibiotic treatment.
What was he doing wrong?
He said he was injecting about a bag of heroin a day on top of a small methadone script, plus the occasional shot of amphetamine when he was feeling low. I asked him how much of his injections were ‘skin popping’ (injecting just under the skin and not into a vein) and how many were just missed hits. He said he skin pops the amphetamine and often missed with the heroin. But during the conversation he also disclosed that:
- He chews his filters before using them (the mouth is full of nasty bacteria)
- He licks his needle before injecting (like I said, really nasty bacteria)
- He compulsively picks the scabs and wounds on his arm with hands that are in no way clean
- Uses tubs of acidifier that are large course grain rather than smaller sterile packets
- Rarely washes his hands or sites (he is sleeping rough so has limited access to facilities)
- Uses a tourniquet far too tightly
- Plus may other smaller issues of concern
Basically he was doing everything you shouldn’t do. Add to this the fact that his arms had no simple access points left and his legs had cellulitis. The only real thing he had going for him was his total reluctance to groin inject, which considering his poor technique would have been a disaster anyway.
I’d normally have no issues working with someone who had a few of these issues, but this guy had almost every bad practice. So I said it: “Stop injecting mate, you’re crap at it”.
Putting in a plan
Now, of course it’s rarely that simple, but luckily this guy had an appointment that day with the nurse prescriber so his keyworker agreed to liaise with her to get his medication increased and to get his wound looked at by one of the doctors with a view to some antibiotic treatment. I gave him advice on a move to smoking for any remaining need before his appointment and agreed to see him along with his keyworker at his next appointment to check how it’s going.
Sometimes the right advice to give is the hardest. Get a good relationship with local prescribers, there are times when the only harm reduction option left is script based. If you get on well with the prescriber then you’re in a better position to work as an advocate.