The following was taken from the latest Clinical Update. To view the full clinical update by Euan Lawson, please register to become a Premium Member.

Harris M, Scott J, Hope V, Wright T, McGowan Catherine, and Ciccarone D. Harm Reduct J. 2020;17:24. Available open access here.

The study used a questionnaire with 455 people and in-depth qualitative interviews in 32 people who inject drugs in London as part of the Care and Prevent study. They found that a high proportion of the survey reported a lifetime history of street homelessness (70%) and nearly two-thirds had suffered bacterial infections with 30% of people requiring hospitalisation. The quality of accounts provide the most revealing detail here. They told stories of people using very unsafe, if not outright dangerous injection practices in semipublic spaces. They had difficulties accessing sterile water and ended up using water from toilet cisterns, puddle water and even, horrifically, saliva. We all know that there is a requirement to add water in the preparation of heroin and crack cocaine. The water is needed to dissolve the heroin and get it into solution. This stage needs some heat and that does help kill micro-organisms in contaminated water. However, those in the study who described their process for preparing snowballs used some cold water, the ‘cooler’, before adding the crack cocaine, and putting them at particularly high risk of bacterial and fungal infections.


I am beginning to suspect I would read a shopping list if it was written by Magdalena Harris who has generated some of the best research in the harm reduction field in recent years. Here’s another study to add to a growing list of essential research that will change your practice. The brilliance of this study, much like the most recent paper on acidifier is, is it takes something that none of us give much thought to and puts in the context of people who inject drugs (PWID). So, here’s the key message if you are not doing this already: start having conversations about access to clean water and harm reduction advice about the cold water phase to help reduce devastating infections. 

Typically of Harris and the team they are not satisfied with simple academic discourse and practical measures are tied in. The legal regulations were amended in June 2005 and drug treatment services are permitted to supply water for injection to PWID. Harris and colleagues point out that there was a maximum size of 2ml that can be supplied and the Medicines Act was amended in 2012 to allow the supply of 5mg ampoules. However, the distribution of these is limited due to cost and fears of HCV infection through shared ampoules. (Particularly when the ampoules are glass raising anxiety about cuts and increased potential for HCV transmission.) The authors also flag up the 2019 Exchange Supplies water risks poster for display in needle and syringe providers. And check out their excellent description of a prototype street injecting kit addressing cost constraints but maximising harm reduction. Great stuff.

Clinical Update edited by Dr Euan Lawson