All You Wanted to Know About Needles But Were Afraid To Ask

09Aug10

To get a hit, an injecting drug user (IDU) has to get the needle right between the vein walls of the injection site.  To make sure that the needle is in the right location, this IDU has to pull the plunger back to see if the syringe is filling with blood.  This process is called aspirating in health care circles, and flaggingamong people who use injecting drugs.  As soon as the blood gushes into the syringe it means that the needle is in the right place and the injecting drug user pushes the plunger and completes the injection.

Between 1993, when I injected my first hit of morphine, and 1998, all needle exchange programs in Ontario distributed 28gauge BD syringes.  For those who don’t know about gauges and other syringe terminology, here is a brief syringe 101.

For our purposes, the syringe has 3 main parts:

  1. 1. The Plunger
  2. 2. The Barrel, and of course,
  3. 3. the needle

1) The PLUNGER is a long, thin rod that fits snugly inside the barrel of the syringe.  It easily slides up and down to either draw the liquid (drugs, blood, etc…) into the barrel or push the solution out of the barrel through the needle.

The plunger has a rubber seal at the lower end to prevent leakage.  The rubber seal lines up with the digits on the barrel to measure the correct amount of liquid/drugs/solution.

The ease with which the plunger is pushed into and pulled out of the needle is called “The Action of the Needle”.  The action of a needle is important for many reasons.  The easier the action, for example, the less likely the needle will move in your vein and get out of it while you’re shooting up.  So, overall, you are less likely to miss a shot if you’re using a syringe that has a smooth action.

But something always has to give: generally speaking, the smoother the action, the less resistance, and the less suction.  Therefore, although the plunger is manipulated easily, the blood isn’t sucked up as strongly.  Because resistance and the action of the plunger are inversely related, the smaller the barrel, the more resistance there is, and the harder the action becomes.  So ½ cc syringes generally have harder action.

PARTS OF A SYRINGE

2) The BARREL is the long, thin chamber that holds the fluid.  The barrel is marked with lines to measure the number of fluid units

For intravenous drug use, barrels usually come in two sizes: ½cc  and 1cc.   ½cc syringes take up to 500mg or 50 units of fluid.  Whereas 1cc barrels contain up to 1 cubic centimeter, or 1000 cubic millimeter or 100 units of fluid, ½ cc barrels contain up to, as you may have guessed it, ½ cubic centimeter, or 500 cubic millimeters or 50 units of fluid.   Of course there are syringes with much larger barrels – but these are generally bulky and inconvenient for intravenous drug use.[1]

Smaller barrel syringes are more compact and generally easier to manipulate.  For novice injection drug users, these needles are easier to flag and shoot; unfortunately, if you don’t have good veins, these syringes fill up very fast and become cumbersome to use.  This is one of the reasons why ½cc syringes are not very popular among veteran IV drug users.

3) The NEEDLE is a short and thin metal covered with a fine layer of silicone that allows it to puncture the skin easily and with less pain.

Most needles are divided into three parts (below), but insulin needles (the ones distributed by needle and syringe distribution programs) come attached to the barrel and have two parts:  The shaft and the bevel.

PARTS OF A NEEDLE

When you pick up a syringe, three numbers stick out:

1) its Size,

2) its Gauge, and

3) its length

The Gauge and Length have to do with the needle, and the size has to do with the amount of load the barrel can take.

For example, when you read 1cc, 27G X ½’, the 1 cc means that the barrel can take 1 cubic centimeters, or 1000 cubic milimiters, or 100 units of fluids.

The Gauge is the THICKNESS of the shaft of the needle.

The smaller the Gauge, the thicker the shaft.

A 27G needle is thicker than a 28G or 29G needles.

The length of the needles you pick up at harm reduction or needle  and syringe distribution programs in the west are half a centimeter long (except for detachable needles which are usually used for steroids and some pharmaceutical drugs).  There’s a lot of confusion about the length of needles among some injecting drug users.

Many users mistake the Gauge of a needle for its length. Sometimes, when I offer a 27G syringe to a service user, s/he declines my offer on the premise that the needle is too short.  Instead, s/he opts for a 29G syringe.  Only after bringing the 2 needles side-by-side have I been able to convince folks that the length of both needles are identical – and this is true for all the needles that are distributed at the COUNTERfit harm reduction program or any other needle distribution program in Ontario (again, except for detachable needles which are usually used intramuscularly and come in various lengths, predominantly 1′ and 1½’).

The gauge of a needle is one of the most important factors when choosing a syringe.  As stated earlier, the gauge is the thickness of the needle shaft and the “bigger” the gauge, the thinner its shaft.  In Canadian harm reduction/needle distribution programs, needles come between 27G and 29G.

Let’s try one more time to read the size of the 1cc, 27G X ½’ syringe:

1 cc means that the barrel can take 1 cubic centimeters, 1000 cubic millimeters or 100 units of fluids.

27G means that it’s the thickest needle available in Canada for intravenous drug use, and

½’ stands for the length of the needle being 0.5 inches or apx. 1.1 centimeters long.

Like I did when I started injecting needles, most injecting drug users believe that it’s better and easier to use the thinnest needle – hence the popularity of 29G BD Hypodermic Insulin syringes.  To repeat myself, this belief is based on 2 things:

1) Thin needles do less harm to one’s veins, and

2) It’s easier to get a thin needle into a vein (and thus it’s easier to flag).

I will argue that thin needles do not necessarily cause less vein damage, nor do they make flagging easier.

For one, during the manufacturing, storing, distributing, and using stages, thinner needles get damaged much easier than their thicker counterparts.

Last year, I conducted my own research around needle tip damage.  I did this because COUNTERfit staff were receiving all kinds of complaints about blunt needles.  Initially, I tried to solicit the help of the manufacturers.  But both Terumo and BD wanted serial and lot numbers to conduct their own investigations.  Unfortunately, these info are registered on the boxes of the offensive syringes – and many injecting drug users don’t get their syringes in boxes. So, for a while, we couldn’t get the necessary explanation for our service users.

And when service users don’t have all the information, rumours take a life of their own – and rumour had it that needle & syringe programs in Toronto were distributing 2nd hand, refurbished syringes.  So, we had to quickly disperse these unfounded rumours and find out why so many needles were dull, blunt, or damaged.

If the community is meaningfully involved in research, we call it Community-Based-Research.  I was involved in my own research both as a researcher and as a subject and I’m uncertain if Community Based Self-Serving Research would be the proper name of my investigation.

During my research, I injected my own drugs by using one-hundred 28G Terumo and one-hundred 28G BD needles.  I was flabbergasted when approximately 25% of the Terumo syringes and 30% of the BD were blunt at first injection.

At second injection, the Terumos became blunt a little faster than the BDs; however, at first injection, the undamaged Terumo needles seemed sharper and smoother at the point of injection.  Also, Terumo needles have much smoother action than BDs.  So, at first injection at least, Terumo needles were superior to BDs.  But if the person has bad veins, the BDs seem kinder to both skin and vein during subsequent injections.  I know, I know, all the literature strongly recommends a new needle for every new injection.  Unless I’m using detachable needles, that recommendation is totally unrealistic, wasteful, and unworkable.  There is no way that I, or any other injecting drug user is going to backload into a new syringe when he or she can’t find a vein at first, second, or even fifth injection.  It’s too wasteful – the user will lose some of the drug while re-inserting the plunger into the new needle.  I’ve lost entire fixes trying to backload in ideal environments.  Imagine when one is shooting up in a washroom, or against time.

Getting back to my research, I assessed ‘damage’ as soon as there was excessive surface tension at the point of puncture. An undamaged needle almost glides into skin and muscle during injection.  During my own research, damage to the tip of a needle was sometimes so bad, I could feel (and almost hear) the needle making a hole both at the borders of skin and vein.  For example, the needle wouldn’t puncture my skin unless I applied more force, and when it finally broke through, it did so in a sudden and jerking motion – which was also painful.  And I had to apply more force yet again to get through the wall of my vein and again the bevel would tear through in a jerking and sudden manner, causing even more pain (not to speak of the squeamish feeling I got when I felt my vein tear).

As I wrote earlier, when a needle is undamaged, there’s almost no pain during the puncturing stage[2] — the needle simply slides in.  A high gauge (or thin) needle is extremely vulnerable to have its bevel damaged.  Even if the needle hasn’t become blunt at the manufacturing stage, many injecting drug users mix their drugs with the tip of their needles, damaging them.  Virtually all injecting drug users have to apply the bevel of their needles on the filter in their spoon or cooker to suck up their fix into their syringe (see photo).  Many damage their needle during this stage.

DRAWING FIX INTO SYRINGE

Further damage incurs when injecting drug users aren’t able to get a vein[3] at their first injecting site.  When they inject again using the same needle – as most veteran injecting drug users do – the bevel gets damaged.  Below are photos of bevels before and after injection. Imagine having to use the same needle over and over again.  I am not sure what the gauge of the needles are in the photo.  But the thinner the needle (or the bigger the Gauge), the more the damage.

BLUNT/REUSED NEEDLES PICTURES

I consider myself as an expert injecting drug user.  I teach people inject, and anyone who has a hard time finding a vein comes to me for help.  Friends and an ex-partner offer all kinds of incentives to be around when they’re injecting – because they have a hard time getting a vein on their own, and I am seasoned in that particular job.

I’ve been injecting drugs since 1993 and doctors and nurses are amazed at the amount of veins I’ve been able to find in my arms.  Not only do I use surface veins, I’ve been able to hunt most of the intermediate veins in my arms too.[4]

Having said that, veteran injecting drug users like me seldom get a hit at first injection – it sometimes takes me anywhere from 1 to 70 injections to get a vein.  For people like me, rotating veins is not a practical option. Instead, I use the thickest available needle to inject the least amount of times.

But thicker needles are not for veteran injecting drug users alone.

Venous blood is thick and becomes even more viscous as soon as one starts to inject cocaine or other stimulants.    Thinner needles often cannot aspirate (flag) venous blood easily, especially after a few cocaine injections.  So, the shooter goes from vein to vein trying to find one with enough pressure to push blood into the barrel.  Whereas, a person may have been successful in her/his first flagging attempt if s/he was using a thicker, 27G  or a smaller gauge syringe.

Also, when using pharmaceuticals (pills, patches, etc), some of these are viscous (thick fluid) or there is so much gunk that any needle that’s thinner than 27G will get clogged.  Even if the needle doesn’t get clogged and you were able to get the solution into your syringe, your plunger may jam during injection.  For these reasons, I believe it’s better to use a thick gauge than a thin one –because with a thicker gauge, you’ll probably get your fix after one injection attempt, while with a thinner needle, you may have to inject over and over again until you can get your fix into your vein. I prefer to inject once with a thick needle and get my fix, rather than injecting a dozen times with a thin needle before I can get high

So, again, what is the best needle for you?

Generally speaking, if you have good veins and are using cocaine, heroin, or any drug that dissolves easily in water, a 28G, 1CC or ½CC syringe is ideal provided the needle hasn’t become blunt during the manufacturing or the shipping and handling processes.

If you have bad veins like me, you should not be using anything thinner than 27G syringes, and the barrel shouldn’t be smaller than 1cc.  You need the bigger barrel because the amount of the fix will get larger as you move from site to site[5].

If you’re using pharmaceuticals, you got to use 27G X 1CC syringes.  You want 1CC because you will need space for lots of water.

If you have tiny hands, or are a novice user, you may want to try ½CC syringes whenever possible.  When shooting up cocaine, for example, you don’t need to use more than 20 units of water.  So, a ½cc syringe would be more than enough; besides, it’s easier to flag and shoot with a tinier syringe.

My favourite syringe used to be the 27G X 1CC Terumo.  I prefered Terumo to BD for several reasons:

1) In Toronto, at least, we have no access to 27G BD syringes – all BD syringes are 28 to 29G.

2) The action of Terumo syringes are far superior to the BD – try the following experiment:  Pull out the plungers of two 28G 1cc Terumo and BD syringes until both are at the 100 units mark[6]. Hold both syringes from the middle of their barrel, bring the plungers of both syringes back to back, and push them against each other.  The first plunger that reaches to 0 units wins the race (is the one with the better action).  At least 90% of the time, the Terumo wins this race.

3) According to a Terumo salesperson, their needles are coated with silicone more liberally than the needles of BD syringes.  This makes Terumo needles superior in terms of puncturing the skin (it goes in smoothly and with less pain).  On the other hand, this also makes Terumo needles become blunt faster than its BD counterparts.  So, for one-time injection, Terumo hurts and damages less; however, if you have to use your needle for another injection, BD hurts and damages less.

I now use 26G detachable needles because these are very difficult to damage.  Unfortunately, I haven’t been able to find them in non-detachable syringes; however, in partnership with The Works, Toronto Public Health’s needle exchange program, COUNTERfit is now looking to find non-detachable 26 G syringes.  I think these are far superior than the 27 or 28 gauge of BD or Terumo syringes.  Some of COUNTERfit service users have sought even more radical solutions by using 25G syringes and they swear these are better than any other needle they’ve used.  By the way, in terms of public health, detachable needles don’t make sense:  used detachable needles have much more dead-space and can carry much more viruses and bacteria in case someone shares.

Have I confused you enough?  If you’re an injecting drug user and want to find out the best needle for you, you must experiment with them.  Unfortunately, most needle & syringe programs offer one brand and one size of needles.  In countries where governments fund or subsidize needle & syringe programs, the price of syringes is not the item that breaks the bank.  Ask your program to provide you a choice.  At COUNTERfit, we provide safer injecting kits that contain syringes of different makes and sizes so that our service users can choose the ones that work best for them.  After all, harm reduction programs exist to minimize the harms associated with injection, and using the proper syringe is one of the best ways of doing  just that.

[1] There are also smaller barrels, but these too are rarely used for injection drug use[2] Of course, it depends where I’m injecting.  For example, injecting into a nerve or a ‘burned’ vein, the puncture will be painful anyway; even then however, a damaged needle will cause additional pain.  Injection sites incur 1st to 3rd degree burns when I miss a shot filled with ascorbic acid, for example.  Missed speed as well as drugs with certain adulterants will cause similar burns.

[3] Getting a vein means getting blood into the syringe.  Remember, injecting drug users flag their needles to make sure they’re in a vein

[4] There are three layers of vein:  1) the surface or “superficial veins” are the veins used by almost all injecting drug users;  2) the intermediate veins lie between the superficial veins and 3) the deeper, “profound veins”.

[5] Even when you don’t get a vein, every time you flag, a little amount of blood is sucked into the barrel.  Sometimes, you do get a vein, but lose it when the needle moves.  If the barrel of the syringe is small, you want have enough space to flag unless you’re prepared to jettison some of the fix.

[6] You an use other gauges, as long as both needles are of the same specifications in terms of Gauge, barrel size, and needle length



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