It's a standard question on most assessments in drug services, asked in lots of different ways. "How often do you inject?", "Number of injections per day?" etc.
But, why ask it? And how would a worker react if someone was really honest about the answer?
Why ask it
In some ways we ask because it's taken as being a marker of how severe someone's drug habit may be. For instance, someone who injects twice a day is clearly better off than someone who says they inject four times a day. Good NSP workers may also use it as a discussion point for harm reduction interventions like vein care, blood borne virus (BBV) interventions, or talking to people about the amount of equipment they need.
But sadly the usual situation is that very little is done with information once it's given other than adding a number to a page.
Average injections per day
The average number is thought (in the UK) to be around three per day, at least that's what we're told... but is this really the case?
Estimates put the amount of time between someone's first initiation into injecting to the first time they attend an NSP at around the 2 year mark. By this time there is often significant damage done by poor injecting technique (flushing, not avoiding valves etc), and this has an effect on how successful someone's injecting may be.
I was talking to one young injector a week or so ago who told me that on a good day it 'only' takes him 4 or 5 attempts to inject, another person I spoke to recently said it can sometimes be 2 hours of trying before they get a vein, and in their frustration they often just 'skin pop' it (we calculated that they would have pierced the skin up to 60 times in those 2 hours). In both these cases the person had initally stated they inject four times a day.
This is obviously a major issue to the person injecting as the damage from even just the blunting of the needle will help to accelerate vein damage leading to collapse. You also have to take into account that because of the time being taken there is an issue of blood clotting in the needle, both people mentioned above also talked about re-filtering the solution to get rid of these clots, but some people just inject them which can lead to problems like pulmonary embolism.
We have to increase worker and service awareness of this issue, it's no good just having "Injections per day" on an assessment, we need to delve deeper. I'm currently writing a new assessment tool which asks "Number of successful injections per day" as well as "Average number of attempts per injection"
But how can we better raise awareness, the obvious answer is better staff training, but for me it's about better communication between worker and injector. If you're a worker it's your duty to be asking about his stuff, and even more importantly if you are an injector you need to be telling the workers at the NSP what the real situation is. It's no good just letting them carry on believing that you just inject three times a day if you are stabbing yourself with a needle 20 to 30 times a day.
How can we use this
The good news is that from a workers point of view this is a great opportunity for talking about route transitions, after all if someone is spending a frustrating hour trying to find a vein, jabbing this often, and having to re-filter the drug repeatedly, they would have been far better off just to smoke it on the foil in the first place.
Even if it's only for one of their '4' injections a day.
Nigel Brunsdon is the owner of Injecting Advice.com. He's been working in harm reduction since the 1990's, although he's previously a frontline needle programme worker he now spends most of his time developing online resources for drugs workers and users.