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Injecting opioid tablets and capsules: Steps to safer preparing and injecting

This resource provides harm reduction information on how to prepare and inject prescription opioid tablets and capsules. Opioids slow down the body. They can cause relaxation, sleepiness, pain relief and euphoria.

Injecting drugs can lead to a range of health issues including vein damage, blood-borne infections such as hepatitis C and HIV, and other types of blood, skin and heart infections. Injecting drugs can also lead to overdose or drug poisoning.

Using new sterile equipment and other safer injecting practices helps to lower the chance of health issues for people who inject drugs. Providing education on safer injecting practices along with a range of free harm reduction supplies can support people to use their drugs as safely as possible.

Getting ready to inject opioid tablets and capsules

New equipment should be used for every injection and should not be shared or reused. This will reduce the chance of vein damage, blood-borne infections such as hepatitis C and HIV, and other types of blood, skin and heart infections.

The following equipment is recommended for injecting opioid tablets and capsules:

  • pill crusher (optional; see crushing methods below)
  • alcohol swabs
  • sterile needle and syringe
  • sterile cooker
  • sterile water
  • sterile filter
  • tourniquet
  • lighter (optional)
  • post-injection dry swab

Preparing opioid tablets and capsules for injection

Tablets and capsules need to be crushed into a fine powder to prepare them for injection. The more finely the drugs are crushed, the more easily they will dissolve in water. Beads must be emptied from a capsule before crushing. Using a sterile crushing method can prevent infections caused by bacteria getting onto the drugs.

Possible ways to crush tablets and/or capsule beads include:

  • Use a new sterile syringe and cooker. With the tablets or capsule beads in a new sterile cooker, use the back end of a new syringe to crush the drugs into as fine a powder as possible.
  • Use a pill crusher that has been wiped clean with an alcohol swab (and allowed to dry).
  • Use a folded piece of paper and a lighter (or something hard). Fold the paper and place the drugs in the middle. Use a lighter or other tool to rub and crush the drugs through the paper. Always use a new piece of paper to help prevent bacteria getting onto the drugs.

All drugs need to be turned into a liquid to be injected. Tablets and capsules contain fillers, waxes and other particles that can make them hard to dissolve completely in water, even after they are crushed.

Tablets and capsules can be dissolved in water alone, with or without heat (i.e., cooking). There are benefits and potential drawbacks to using heat.

The benefit of using heat is that it can reduce the chance of infections from certain viruses and bacteria that may be present. The potential drawback of using heat is that it can melt fillers and waxes found in tablets and capsules, which are then more likely to get past harm reduction filters and cause harm in the body. Heat can also make certain pills harder to inject.

There is a lower chance of injecting fillers and waxes when heat is not used. But there is a higher chance of infections caused by viruses or bacteria.

Whether heat is used or not, it is important to always filter the drug solution. This helps remove as many fillers, waxes and other particles as possible.

Service providers can give education on how to prepare opioid tablets and capsules for injection by sharing the following steps and information.

How to prepare opioid tablets and capsules for injection:

  • Wash hands and preparation surface with soap and water before handling harm reduction supplies. This can prevent infections caused by viruses and bacteria. Hand sanitizer or alcohol swabs can be used if soap and water are not available.
  • Add the finely crushed powder (from the crushed tablets or capsule beads) to a new sterile cooker.
  • Add sterile water from a new unopened package. Using sterile water will prevent infections caused by bacteria found in tap, bottled and boiled water. Tablets and capsules often need more water to dissolve properly, compared with other drugs.
  • The back end of a new syringe can be used to stir the mixture and help it dissolve. It may be necessary to add more sterile water and stir again to help the drugs dissolve.
  • If using heat, hold a lighter or other heat source under the cooker until the liquid bubbles, at least 10 seconds. Allow the liquid to cool, to help prevent vein irritation.
  • Drop a new sterile filter into the cooker directly from the package to ensure it remains sterile. Touching the filter with fingers can transfer bacteria into the drug solution.
  • Insert a new sterile needle into the flat end of the filter with the needle hole facing down. Ensure that the needle is not pushed through the bottom or side of the filter, as this can damage the needle tip.
  • Draw the liquid up into the syringe by pulling the plunger. Remove air bubbles by tapping the sides of the syringe with the needle tip pointed up and slowly pressing the plunger.

Steps to safer injecting

The following steps describe safer injecting practices for injecting any drug into a vein. Service providers working with people who inject drugs should offer education on safer injecting by sharing these steps and information:

  • Find a vein to inject into. Injecting in some veins is safer than others. Veins in the lower arm are always the first choice. Avoid veins near the torso or lower legs if possible. Injecting near the face, neck, wrist, groin and thighs can be dangerous.
  • If using a tourniquet, place it about four to five finger widths above the injection site. A tourniquet can help make veins bigger and easier to find and can hold them in place.
  • Clean the injection site with an alcohol swab then let the skin dry. This reduces the chance of bacteria getting inside the body and can help prevent skin, blood and heart infections.
  • Insert the needle slowly and smoothly into the vein. Point the needle in the direction of the blood flowing back toward the heart. To reduce vein damage, keep the needle at a shallow angle with the needle hole facing up.
  • Pull the plunger back until blood appears. This is called flagging and it ensures that the needle is inside the vein before injecting. If no blood can be seen, the needle may need to be advanced a bit further or withdrawn slowly and checked again.
    • NOTE: It is dangerous to inject into arteries. Arteries can be identified because they have a pulse and bright red blood. Veins have no pulse and have dark red blood. Injecting into arteries will hurt and can cause bleeding that is hard to stop. To stop the bleeding, remove the tourniquet and the needle and apply direct pressure to the area.
  • Once the needle is in a vein, it is best to untie the tourniquet before pressing the plunger. This reduces the chance of vein damage.
  • Press the plunger and inject slowly. If there is burning, stinging or pain, remove the needle and try again.
  • After injecting, remove the needle slowly and carefully.
  • Hold a post-injection dry swab or dry tissue firmly on the injection site for at least 30 seconds to stop any bleeding. Rotating injection sites will allow them to heal before another injection.
  • Put all injecting equipment in a sharps container or other hard plastic bottle, and drop it off at a local harm reduction organization for disposal.

Important info about safer use of tablets and capsules

Mixing different substances

There are risks with mixing drugs. Mixing different drugs can cause stronger or different effects than either drug alone. Mixing opioids with stimulants increases the risk of heart attack, stroke and overdose. Different drugs also stay in the body for different amounts of time. It is important to always start with a small amount, increase slowly and use caution when injecting multiple doses or mixing drugs.

Doing a “wash”

A wash involves adding water to a used cooker or filter. It is used to extract drug residues that remain in the cooker or filter after use. This practice is not recommended because used equipment is no longer sterile. Bacteria can grow in used equipment and cause infections when injected. Sharing a wash can also pass infections from one person to another. If a person is doing a wash, they should heat the drug solution for at least 10 seconds, until it bubbles. This can kill certain viruses and bacteria that could be present (like HIV) but not others (like hepatitis C).

Overdose/drug poisoning

When someone is using drugs purchased from the illegal or street supply, there is a higher chance of overdose or poisoning. People can 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

Safer substance use video series – CATIE

Mapping the body: Choosing a vein for safer injection – CATIE

Sharp shooters: Harm reduction info for safer injection drug use – 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

Acknowledgement

This resource is adapted from CATIE’s Safer Substance Use Video Series and Connecting: A Guide to Using Harm Reduction Supplies as Engagement Tools by the Ontario Harm Reduction Distribution Program (OHRDP). CATIE thanks the reviewers who contributed their expertise to this resource.