Richard Pates

Injecting illicit drugs.

Injecting illicit Drugs is the third book in a new collection from Addiction Press. Addiction Press was set up with the express purpose of communicating current ideas and evidence in this expanding field, not only to researches and practising health professionals, but also to policy makers, students and interested non-specialists. These publications are designed to address the significant challenges that addiction presents to modern society. Injecting drug use is of major concern to both Western and developing nations, causing extensive associated harm at both individual and public health levels. This book provides readers with authoritative an practical information on injecting drug use and the health consequence of this behaviour. As an efficient route of drug administration, the sequelae of injecting illicit drugs can be particularly deleterious in nature. The chapters in this book trace the hazards for the drug injector and promote a harm reduction approach to minimise these risks. Socio-cultural issues are considered, such as the ritualisation of injecting behaviour. Lifestyle characteristics of the injecting drug user are also taken into account. Insights from the user perspective are reflected in the last chapter.

Towards An Holistic Understanding of Injecting Drug Use: An Overview of Needle Fixation

Aims. To establish the existence of needle fixation and provide a theoretical explanation for the phenomenon. Method. By searching published literature using electronic searches, consulting a National Drug Library (ISDD) and snowballing from reference lists in publications related to addiction. Findings. Needle fixation as a phenomenon has been mentioned in the literature since at least 1929 but there is only one published paper devoted to it. Needle fixation is a conditioned response but with a number of different secondary gains which maintain the practice. These include ritual, substitution of non psychoactive substances in the absence of drugs, pain, sexual pleasure and status. Conclusions. Needle fixation should be taken seriously because of the concern about blood borne viruses among injecting drug users and the need to reduce the practice of injecting. A greater understanding of the problem will help in treatment of injecting drug users.

The identification of needle fixation: The development of the NEFPRO, a clinical screening tool

Aim: This article describes the development of a scale to identify needle fixation. Design: A series of statements were developed from qualitative interviews with 24 injecting drug users. The content of the interviews was used to generate 74 statements that had relevance to needle fixation. The 74 statements were developed into a 74-point questionnaire and administered to 80 injecting drug users. These statements were refined to 14 relevant questions with pairs of questions relating to a particular activity. This had a Cronbach reliability of .70. Following identification of needle fixation by interview these questions were reduced to the final 10. Participants: A total of 137 injecting drug users from Cardiff and surrounding area were used for different stages of the development. Results: The resulting 10-point scale has a utility in identifying needle fixation in individuals with the problem and specifies the role that needle fixation plays for them. Conclusions: This scale may help with the treatment of injecting drug users by identifying needle fixation.

Special Issue on injecting, why is this important?

This is the second special issue on injecting published by the journal and it brings together a number of different papers from across the world. These include qualitative and quantitative research; an exploration of policy in an opinion piece and produces some fascinating information as well as raising other questions. We have gathered papers from Australia, Hungary, Uzbekistan, Northern Ireland and England and Canada. Injecting is a subject of interest to myself and I undertook research in this area and one thing I discovered that apart from some excellent ethnographers and anthropologists much of the published work on injecting has been on epidemiology and routes and risks of transmission of infection. There is still so much to learn about injecting, habits, patterns, myths etc. Injecting still carries with it the high risks of transmission of infection through poor hygiene, bad practice and lack of availability of sterile injecting equipment. For example, McCurdy et al in 2005, described the phenomenon of “flashblood, a practice undertaken by female injectors in Tanzania where it was believed that the deliberate injection of another’s blood would prevent withdrawal from opiates because of the small amount of opiates in the blood of the donor. This is of course an incredibly risky practice. Pates et al (2012) outlined the many diseases that may be spread by injecting. HIV and hepatitis are well known as possible consequences of sharing injecting equipment but the list included malaria, infective endocarditis, tetanus, botulism, necrotising soft tissue wounds, anthrax etc. These may be as the result of infected injecting equipment or the material that is being injected may be infected or that poor injecting techniques that result in open wounds vulnerable to infection. In addition to these risks there is also risk of overdose and damage to the veins and circulatory systems. Injecting remains and inherently dangerous activity but it still practised in most parts of the world where opiates or stimulants are injected. In this special issue we have tried to cover a variety of issues. Scott Hinton has extended the work on needle fixation presented in the last special issue. Needle fixation (the compulsive practice of injecting over and above the efficient delivery of the drug) and extends the knowledge on this important but neglected area of research. The need to understand this phenomenon is important if agencies are offering treatment to drug injectors. McElrath and colleagues from Northern Ireland present another paper on the practice of injecting by looking at the implications of peer injecting and the risks of the transmission of blood borne diseases, another welcome paper that examines some of the consequences of injecting in different contexts. ColinWisely has produced an excellent paper tracing some of the history of drug treatment but also raising the very current concern about getting drug users into recovery. As Wisely comments, recovery is often seen as beyond the capacity for injectors but should in fact be encompassed in treatment plans as early as possible.

A case of needle fixation

Needle ® xation is a phenomenon occurring in some injecting drug users who appear to ® nd the process of injecting per se, rewarding, in addition to the eVect of the drug that they are injecting. It may be seen as a compulsive need to inject. It is a phenomenon that is widely acknowledged and referred to among drug users and among those clinicians working with them, but is not widely found in the literature of injecting drug use. Prior to 2001 the only reference to be found via literature searches on the subject was by Levine (1974), who described two cases of women who appeared to inject themselves frequently in the absence of reward from the drug. One of them reported injecting, despite no longer gaining any eVect from the opiates she injected, and the other would inject tap water, often slowly in order to maximise the pain. Levine provided both behavioural and psychodynamic explanations for this behaviour. The behavioural explanation being that continued and increased self-injection, in the absence of continued reinforcement, could be seen as an instance of secondary reward conditioning, in which behaviour is directed towards a stimulus with no intrinsic utility that has been conditioned in the past by a biologically signi® cant stimulus. The psychodynamic explanation he suggested was that the continued injecting served as a substitute for sex. No other references attempting to explain needle ® xation could be found in the literature. Pates et al. (2001) revisited this subject in an attempt to gain further understanding of the phenomenon. They observed that there were mentions of needle ® xation present in literature and biography, in discussions of injecting or the treatment of drug users, but never as a subject in its own right. In trawling through the disparate literature that mentioned needle ® xation, they observed that a number of distinct phenomena were reported. These were that some individuals persevered with attempts to use the needle, even when a vein was not easy to ® nd, or that the ritual associated with injecting drug use reinforced the practice of injecting, and heightened the enjoyment. Some drug users also substituted the injection of inert substances or alcohol for drugs. They also hypothesised that some form of secondary reinforcement was occurring and that the reinforcers were sexual, an enhanced status among peers, pain, a high perceived level of injecting skills, or the reinforcement of selfharm. McBride et al. (2001) tested this with a series of interviews with 24 injecting drug users with a self-reported needle ® xation. They con® rmed that all these phenomena occurred and that there appeared to be diVerent reinforcers for diVerent individuals. Thus some would report sexual feelings associated with injecting and others the status associated with being a good injector or with pain, etc., but not all in the same individual. Some clinicians will dispute the existence of needle ® xation claiming it to be the excuse of the injector for not ceasing injecting (e.g. Al-Adwani 2001). The evidence from the disparate literature and clinical experience, however, is becoming compelling. In an attempt to develop a sound psychological theory of needle ® xation, further research work is currently being undertaken. This will be the subject of a separate paper. KL was interviewed as a pilot for the interview schedule for that research. This report is being presented because of the rich material that was produced during the interview which described many of the factors discussed by McBride et al., possibly for the ® rst time in one individual.

Desert island addiction books

This study aimed to discover the books that are perceived by acknowledged UK experts on addiction to be the most enjoyable and influential. One hundred and eighty questionnaires were sent by post to senior addiction specialists. Respondents were asked to list their eight favourite addiction books and the one that they felt had made the largest contribution to the field of addiction. Thirty-eight replies were received, listing 158 books in total. Many books were common to different lists but no two lists were identical. Academic, literary and biographical books were listed. Forty-one books received two or more nominations, of which 11 were selected four or more times. Five books were nominated more than once as having made the largest contribution to the field of addiction. It is possible to identify a number of books that might be described as ‘classic texts,’ which should form the basis of any addiction library or reading list.

Drug Trends in Wales

This paper describes the evolution of responses to drug related problems in Wales, from the first National Health Service in-patient admissions in the late 1960s until the publication of Forward Together, the Welsh Office strategy for drug and alcohol problems, in May 1996. Service developments are placed in the context of the available data about the nature and extent of drug use across Wales, the particular challenges faced, and the strategies adopted in Britain, in Wales, and at the local level.

Absinthe makes the heart grow fonder

It is curious that 87 years after absinthe was banned in France, the country where its production and consumption was greatest, it has become a trendy drink for young people in Britain. I know a number of young people who have been allured by the promise of the supposed hallucinogenic effects of absinthe. After imbibing a largish quantity of it they have ended up with bad hangovers, no hallucinogenic experience but a promise never to touch the stuff again. So what is it these young people are drinking and what relationship does it have to la fe e verte of 19thand early 20th-century France? Absinthe is certainly the stuff of mythology and an interesting part of the history of alcohol use in modern times. It has been celebrated in paintings by many famous 19thand 20th-century artists, including Manet, Van Gogh, Picasso, Daumier, Gaugin, Munch, Toulouse-Lautrec and so on. Probably the most famous àbsinthe’ picture is that by Degas entitled Dans un Cafe or L’absinthe. In this picture a couple sit in a cafe , him smoking his pipe and looking into the distance and her looking in a trance-like state with a glass of absinthe in front of her. It sums up the detached introspection of the absinthe drinker. It was also drunk by poets and writers, so that it had a bohemian reputation. Paul Verlaine and Arthur Rimbaud, the French symbolist poets, were absinthe drinkers, Verlaine particularly so in the latter years of his life, and Oscar Wilde, Edgar Allen Poe and other 19th-century writers were also regular imbibers. Was it drunk to help the muse along, as has been claimed of the 18thand 19th-century opium eaters? (We know, of course, that, without the talent, drugs and alcohol will not produce art and the drugs probably interfere with the artistic process.) La fe e verte, the green fairy, supposedly summoned by the consumption of absinthe, has been widely represented in 19th-century paintings and in the anti-absinthe posters of the abolitionists. It can also be seen in a wonderful painting in the Cafe Slavia in Prague, a city with a wealth of Art Deco buildings, and was even played by Kylie Minogue in the recent ® lm Moulin Rouge. An infamous case of murder occurred in Switzerland in 1905 when an agricultural labourer named Jean Lanfray killed his wife and two daughters. On the day he killed his family he had drunk two large glasses of absinthe and was then described as an absinthiste. The absinthe was seen as the cause of the murder. What seems to have been overlooked was that he had also drunk a number of brandies, a cre Á me de menthe, at least 2 litres of strong local wine and some strong home-made marc. The amount of alcohol he had drunk was prodigious, which was probably more signi® cant than the absinthe. This murder led to the call for absinthe to be banned in Switzerland, which it was in 1910 (Conrad 1988). It also had the reputation of leading to madness, madness of a certain kind called absinthism. What was the source of its reputation? Certainly it was a very strong drink, being something like 72% alcohol by volume compared with modern spirits which are generally sold at 40% alcohol by volume. One of the relevant constituents from wormwood, which gave absinthe its distinctive ̄ avour, was a substance called thujone, which has a chemical composition similar to THC, the active ingredient in cannabis (Conrad 1988). Thujone is a powerful drug when taken in large amounts and can cause convulsions. Conrad, in a fascinating book, describes the history of absinthe and it eventual abolition. In the appendix he describes the modern analysis of absinthe and says that the evidence concludes that it is not the thujone but the alcohol that caused the problems. He says that the amount of thujone consumed by Lanfray on the day he committed his murder was 30 times less than that required to make a rat shudder. In France absinthe was banned in 1915. This was as a result of increasing pressure from abolitionist groups concerned with the social effects of drinking strong spirits (an interesting comparison with gin consumption and the Gin Laws of the 1750s in Britain). There was also concern within the government because of the effect of absinthe on the troops and their ability to ® ght. Since then it has been banned in France and, I believe, in most of Europe. It never was banned in Britain, but never achieved the popularity it had in France. It is still apparently produced illicitly in parts of Switzerland, in the Val-de-Travers area where absinthe had been produced for over a hundred years before it was banned. Last summer I was in Pontarlier, a town in the FrancheComte region of France close to the Swiss border. This was the centre of the French absinthe industry until abolition. Wormwood was grown around the town and there were several distillers of absinthe here. I asked a local man who sold absinthe antiques (the paraphernalia of absinthe are collectors’ items) where absinthe like the original could be obtained. He was disdainful of the absinthe consumed by young British people, which is mainly imported from Eastern Europe. It is very strong, as was its forebear but tastes and looks nothing like the original. Absinthe is still made in Spain and my contact said that this was most like the original absinthe. It turns the same opalescent pale green Journal of Substance Use (2002) 7, 63–64