Safer injecting information: Powder and crack cocaine
This fact sheet provides information for service providers on how to educate and support clients to inject powder cocaine and crack cocaine more safely. Cocaine is a stimulant. This means that it speeds the body up, which can increase heart rate, energy and alertness.
Injecting drugs comes with serious health risks. These can include vein damage, blood-borne infections like hepatitis C and HIV, and other blood, skin and heart infections. Injecting drugs also carries a risk of overdose or drug toxicity.
By using new, sterile equipment and adopting safer injecting practices, people who inject drugs can significantly reduce their risk of health issues. Providing access to harm reduction supplies and education helps support people to use drugs as safely as possible. It also opens the door to build relationships and provide referrals to other health and social services, including treatment services.
Always use new equipment
New equipment should be used for every injection and should not be shared or reused. Using new and sterile equipment for every injection is essential to minimize the risk of vein damage, blood-borne infections such as hepatitis C and HIV, and other complications like blood, skin and heart infections. The following equipment is recommended to reduce these risks and promote safer injection practices:
- Alcohol swabs: Used to clean the skin at the injection site before injecting
- Sterile needle and syringe: Available in different gauges, sizes and lengths
- Sterile cooker: A small container used to prepare drugs for injection
- Sterile water: Used to dissolve drugs into a solution for injection
- Vitamin C (ascorbic acid): Used to prepare crack cocaine, which needs an acidifier to help it dissolve into a solution
- Sterile filter: Used to remove solid particles from the solution when pulling it into the syringe from the cooker
- Tourniquet: Used to restrict blood flow, which helps to locate and stabilize the vein
- Post-injection dry swab: Used to cover and put pressure on the site after injecting
Safer preparation of powder or crack cocaine
The specific recommendations for safer preparation vary, depending on the drug being used. It is important to explain to clients the safer preparation practices for the drug they are using.
When preparing powder or crack cocaine for injection, it’s important that the drug is fully dissolved into a liquid to prevent vein damage and reduce the risk of infections and other complications. It’s also important to use sterile equipment to prepare drugs to avoid introducing viruses and bacteria into the body that can lead to serious infections.
Here are some drug preparation tips to provide to people who inject powder or crack cocaine to reduce their risk of infections and other health complications:
Hands and preparation surfaces should be cleaned with soap and water or alcohol swabs to reduce the risk of introducing germs into the body that can cause infections.
Any larger chunks of the drug should be crushed into a fine powder to help the drug dissolve. To do this safely, without introducing bacteria, a sterile cooker and the back end of a new syringe can be used.
Sterile water should be added from an unopened package into the cooker. The mixture can be stirred with the back end of a new syringe to avoid introducing bacteria and help the drug dissolve. Using sterile water will prevent infections caused by bacteria found in tap, bottled and boiled water.
[For crack cocaine only] A small amount of vitamin C powder (about half as much as the amount of drugs) should be added to the solution, to help the crack cocaine dissolve. Adding too much can cause vein irritation. Pharmaceutical grade vitamin C (ascorbic acid) is the safest acidifier for dissolving crack cocaine. Other acidifiers such as lemon juice and vinegar can cause vein irritation and lead to bacterial or fungal infections.
The solution should be heated in the cooker for at least 10 seconds, until it boils, and then let to cool. This will help it dissolve and reduce the risk of infections from bacteria or viruses that could be present.
A sterile filter should be dropped into the solution directly from the package without being touched, to avoid introducing bacteria. A new needle should be inserted carefully into the filter to draw the solution into the syringe, to remove any solid particles.
With the solution in the syringe, and the needle tip pointed up, the sides of the syringe should be tapped while the plunger is slowly pressed to remove air bubbles, reducing the risk of complications from injection.
Safer injecting of powder or crack cocaine
When injecting, it is essential to follow safer injecting practices to reduce the risk of health complications.
One key safer injection practice is ensuring the needle is in a vein. Injecting in an artery or surrounding tissue can lead to serious health issues. To prevent vein damage, the needle should be inserted slowly and smoothly at a shallow angle, with the needle hole facing up and pointed in the direction of blood flow back toward the heart. Proper placement can be confirmed with "flagging," which involves gently pulling back the plunger to check for the appearance of blood in the syringe. If no blood appears, the needle’s position should be carefully adjusted until it is correctly inserted into a vein. If the blood is pulsing and bright red, the needle is in an artery. Injecting into an artery can cause significant pain and bleeding that is difficult to stop. If this occurs, the needle and tourniquet should be removed immediately, and direct pressure should be applied to the area.
Here are some general safer injecting tips to reduce the risk of infections and other health complications:
Some places on the body are safer to inject into than others. Veins in the lower arm are generally safer places to inject. Veins near the torso or lower legs should be avoided if possible, and injecting near the face, neck, wrist, groin and thighs can be particularly dangerous.
A tourniquet should be placed four to five finger widths above the injection site to help locate veins and hold them in place. The tourniquet should be removed before injection. The proper use of a tourniquet reduces the risk of vein damage and infections.
The injection site should be cleaned with an alcohol swab and allowed to dry. This removes germs that can cause infections.
After injection, a clean swab should be held firmly on the injection site for 30 seconds to stop the bleeding. It is important to rotate injection sites to allow them to heal properly and prevent complications.
Used equipment should be disposed of safely to protect everyone. Placing it in a sharps container or hard plastic bottle and dropping it off at a harm reduction service ensures proper disposal.
Important info about safer use of powder or crack cocaine
Mixing different substances
There are risks with mixing drugs. Mixing different drugs can cause stronger or different effects than using either drug alone. Mixing stimulants like cocaine with opioids like fentanyl or heroin increases the risk of heart attack, stroke and overdose. Different drugs also stay in the body for different amounts of time. It is important for people to always start with a small amount and use caution when using multiple doses or mixing drugs.
Safer sex
Use of cocaine and crack cocaine is associated with sex that has a higher risk of passing HIV and other sexually transmitted and blood-borne infections (STBBIs). Safer sex supplies such as condoms, gloves, barriers and lube should be offered to help reduce the chance of passing these infections. People can be referred to a healthcare provider who can prescribe PrEP (pre-exposure prophylaxis), which is a pill that is used to prevent getting HIV. PrEP does not prevent any other infections.
Stimulant overamping
Signs of overamping from stimulant use may include rapid heart rate or chest pain, rigid or jerking limbs, skin feeling hot or sweaty, anxiety, agitation and hallucinations. If someone is overamping, they may need support to calm down, cool down and rest. Emergency medical attention is required if someone has crushing chest pain or seizures, if they go unconscious or if they are not breathing. Naloxone works only on opioids and does not reverse stimulant overamping, but it is safe to use and may help if an opioid overdose is suspected.
Overdose (drug toxicity)
When someone is using drugs purchased from the illegal supply, there is a higher chance of overdose or toxicity. People can try to prevent or prepare for an overdose by:
using with other people or at a supervised consumption site
starting with a small amount and increasing slowly
getting their drugs tested, if possible
carrying naloxone and knowing how to use it
Naloxone temporarily reverses an opioid overdose. A person may be having an opioid overdose if they are unresponsive or unconscious, have slow or no breathing, are snoring or making choking or gurgling sounds, have cold or clammy skin, and/or have blue or grey lips and nails.
Resources
Mapping the body: Choosing a vein for safer injection – CATIE
Responding to an opioid overdose, responding to stimulant overuse and overdose – CATIE, Toward the Heart BCCDC Harm Reduction Services
Harm Reduction Fundamentals: A toolkit for service providers – CATIE
Connecting: A guide to using harm reduction supplies as engagement tools – Ontario Harm Reduction Distribution Program
Best Practice Recommendations for Canadian Harm Reduction Programs – Working Group on Best Practice for Harm Reduction Programs in Canada
Acknowledgements
This resource is adapted from Connecting: A Guide to Using Harm Reduction Supplies as Engagement Tools by the Ontario Harm Reduction Distribution Program (OHRDP). CATIE also thanks the reviewers who contributed their expertise to this resource.