Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency

Abstract

BackgroundInternationally, overdose is the primary cause of death among people injecting drugs. However, since 2001, heroin-related overdose deaths in the United States (US) have risen sixfold, paralleled by a rise in the death rate attributed to synthetic opioids, particularly the fentanyls. This paper considers the adaptations some US heroin injectors are making to protect themselves from these risks.MethodsBetween 2015 and 2016, a team of ethnographers collected data through semi-structured interviews and observation captured in field notes and video recording of heroin preparation/consumption. Ninety-one current heroin injectors were interviewed (Baltimore, n = 22; Chicago, n = 24; Massachusetts and New Hampshire, n = 36; San Francisco, n = 9). Experience injecting heroin ranged from < 1–47 years. Eight participants, who were exclusively heroin snorters, were also interviewed. Data were analyzed thematically.ResultsAcross the study sites, multiple methods of sampling “heroin” were identified, sometimes used in combination, ranging from non-injecting routes (snorting, smoking or tasting a small amount prior to injection) to injecting a partial dose and waiting. Partial injection took different forms: a “slow shot” where the user injected a portion of the solution in the syringe, keeping the needle in the injection site, and continuing or withdrawing the syringe or a “tester shot” where the solution was divided into separate injections. Other techniques included getting feedback from others using heroin of the same batch or observing those with higher tolerance injecting heroin from the same batch before judging how much to inject themselves. Although a minority of those interviewed described using these drug sampling techniques, there is clearly receptivity among some users to protecting themselves by using a variety of methods.ConclusionsThe use of drug sampling as a means of preventing an overdose from injection drug use reduces the quantity absorbed at any one time allowing users to monitor drug strength and titrate their dose accordingly. Given the highly unpredictable potency of the drugs currently being sold as heroin in the US, universal precautions should be adopted more widely. Further research is needed into facilitators and barriers to the uptake of these drug sampling methods.

“Am I gonna get in trouble for acknowledging my will to be safe?”: Identifying the experiences of young sexual minority men and substance use in the context of an opioid overdose crisis

“…Our study also revealed how similar protective and risk mitigation strategies are being taken up to reduce overdose risk, including a variety of behavioral interventions and accessing trusted drug supplies. These findings are consistent with other research that demonstrates how people who use drugs have a high degree of awareness and knowledge about overdose risk, as well as strategies to mitigate this risk [36,37].…”

“…Among people who use drugs more broadly, however, a growing body of literature has described the evolving harm reduction strategies used to mitigate overdose risk in the context of a highly contaminated drug supply. These strategies have included a breadth of behavioral changes, including not using substances alone (i.e., so that peers can assist in the event of an overdose), using one substance at a time, testing the potency of a substance by first using only a small amount, and using fentanyl test strips and other drug-checking technologies 1 to screen for fentanyl contamination in illicit drug compounds [34][35][36][37]. Recent studies have also demonstrated the important role that trustworthy sources of substances play.…”

When and how do individuals transition from regular drug use to injection drug use in Uganda? Findings from a rapid assessment

“…Non-medical use of drugs is an epidemic in many parts of the worl d [1][2][3][4]. They are taken into the human body in a wide variety of ways, including smoking, snorting or sniffing powder or solution (intranasal use), inhalation of the heated vapors ("chasing"), orally, and as anal suppositories ("plugging") or injected [5][6][7].…”

“…Of these, 10.6 million (range 8.3 million to 14.7 million) were people who inject drugs (PWID) [3]. While all methods of using drugs can be linked with social and health harms, injecting-whether intravenous, subcutaneous, or intramuscular, is the method of administration carrying the highest risk for multiple types of infections, overdoses, and their complications [5,[8][9][10][11]. Injecting drugs also carries high risk of human Immunodeficiency virus (HIV) and viral hepatitis transmission if sterile injecting equipment is not easily accessible and injecting equipment is shared among users.…”

Rapid Assessment of Injecting Drug Users (IDUs) in Nairobi and Mombasa counties, Kenya: A Respondent Driven Sampling Survey

“…While different methods of using drugs are associated with social and health harms, injecting -whether intravenous, subcutaneous, or intramuscular, carries the highest risk for multiple types of infections, overdoses, and their complications [37,38]. Injecting drugs also carries signi cantly higher risk of HIV and viral hepatitis transmission especially among users who don't have easy access to sterile injecting equipment and among those who share injecting equipment.…”