One of the exercises I do when I'm delivering safer injecting training looks at the most common injecting sites and their associated risks. People are usually quite good at putting the different sites in some kind of order of risk, but when it comes to the feet they often underestimate the dangers.
Why would someone inject in the foot?!
OK, first lets understand what some of the drivers are for people to use this site for injecting. There is of course the most obvious one, not being able to find a suitable vein elsewhere. This can for many people be a way of avoiding a move to sites that are perceived as higher risk like the groin, which of course does show that someone is taking steps to keep themselves safer.
But there are other reasons people choose the feet, one that I keep coming across is that this is a hidden area so the track marks won't show on arms where family members/friends/treatment workers may see them. One thing is pretty sure though, people don't inject in the foot because it feels good.
Problems with the foot
The first one that really comes to mind is that the blood pressure in the feet is incredibly low. You can't get any further away from the heart (ie the 'pump') and you are fighting against gravity. This will effect the way the drug feels for a person (no real 'rush' with this one) but it will also mean you have an increased chance of things like abscess and problems with veins, healing is slower in the foot so missed hits turn into abscesses with a predicable regularity.
And those missed hits are common. Although there are some very tempting veins on the feet that at first glance seem big and juicy (Am I the only one who thinks of veins as juicy?) they are in reality quite thin veins with a tendency to burst if put under pressure. Not only that but they have a habit of rolling around when you try to put a needle in them, leading to more misses.
Another reason for the increased chances of infection in feet is the way that (for most people) they are kept enclosed in sweaty shoes and socks all day, this keeps wound hot and wet which makes it a great breeding ground for bacteria.
Advice for foot injectors
An obvious piece of advice would of course be to stop injecting in the feet, although for many people stuggling with vein access this may not at first seem possible. Take time to help people find veins elsewhere, show them how to use a tourniquet correctly (see my article on tourniquet use for tips).
This is also the ideal opportunity for people to exit injecting behaviors, support people to transition back to smoking, or encourage them to access treatment services (if people want treatment then do the assessment now, not give them an appointment for two weeks time).
Of course some people will want to continue injecting in this high risk area, if that's the case:
- Encourage them to take good thin needles (in the UK I'd always suggest a 30 guage nevershare syringe)
- Give advice on ways to minimize 'rolling' of the vein (this can be done by gently applying pressure beside the vein to reduce the area it can roll to)
- Give advice on injecting VERY slowly so they don't put the vein under stress
- If possible have a stock of clean dry socks that can be given to homeless injectors
The most important thing as always with people injecting in higher risk areas is to give them good advice and other options.
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.