Booting and Flushing: Needle Rituals and Risk for Bloodborne Viruses

Booting” and “flushing” are terms used to describe an injecting behaviour in which the plunger is pulled back and the fluid (mostly blood and perhaps blood only) is re-injected. The behaviour differs from “registering,” which occurs before the drug is injected. Booting/flushing can produce subcutaneous and venous damage, and increases the risk for the spread of blood-borne viruses when used equipment is passed on to other injectors. The purpose of the study was to explore the extent of flushing, the context of flushing and IDUs’ self-reported reasons for flushing. Data were collected through semi-structured interviews with 59 IDUs in Northern Ireland, who were recruited through various strategies. Respondents’ ages ranged from 22 to 50 years, and females comprised 34% of the sample. Mean length of injecting career was 8.3 years. A total of 46% reported flushing on a regular basis during some or most of the injecting career. The results showed that flushing occurs for different reasons, and in comparison to research conducted elsewhere, is not associated solely with cocaine or speedball injection. Interventions designed to reduce the extent of flushing must take into account the various reasons for the behaviour. Booting and Flushing McElrath 3 INTRODUCTION Injecting drugs is a process that involves a series of steps commencing with the preparation of drugs for injection (Grund, 1993), e.g., mixing the drug with water and at times other substances, such as citric acid. The process can differ depending on the particular drug that is injected (Bourgois and Bruneau, 2000), the form of the drug, e.g., Diamorphine, brown heroin (Strang et al., 2001), the amount of drug injected, subcultural and individual rituals associated with injection, and a host of other factors. Once the drug is prepared for injection, injecting drug users (IDUs) often engage in “registering” in which blood that fills the syringe is indicative that the individual has “found” a vein into which the drug will be injected. After the drug is injected, some IDUs will pull back the plunger again and then re-inject the fluid (Heimer and Abdala, 2000). Various terms are used in the literature to describe this behavior and in some studies, it is not clear whether the choice of term reflects the author’s preference or represents the vernacular of IDUs in the respective sample. The behavior has been referred to as “booting” in research conducted in parts of the US, Canada and Australia (Bourgois and Bruneau, 2000; Bruneau et al., 2004; Carruthers, 2003; Lamothe et al., 1993; Singer et al., 2000). US-based scholars also have used the term “kicking” (Greenfield et al., 1992) and “jacking” (Centers for Disease Control, 2004:2), although Caulkins et al. (1998) suggested that “jacking” refers to registering. Booting and Flushing McElrath 4 In various regions of the United Kingdom, IDUs often refer to the behavior as “flushing” (Black Poppy, 2004; McBride et al., 2001; Pates, 2001). Consistent with the vernacular used by IDUs interviewed for the present study, I also refer to the behavior as “flushing.” Registering and flushing occur for different reasons, and several if not most IDUs appear to engage in registering, i.e., the practice by which they ascertain that they have located a vein. In contrast, not all IDUs engage in flushing, which can produce venous and subcutaneous damage (Murphy et al., 2001). Flushing can contribute to the spread of bloodborne viruses, particularly when used injection equipment is passed to other IDUs. Flushing increases the likelihood that the needle and syringe will come into contact with infected blood (Abdala et al., 2004). In a simulated study of flushing (Heimer and Abdala, 2000), blood contaminated with HIV-1 was inserted into insulin syringes and then emptied. The syringes were stored for several days and the recovery of HIV-1 was assessed. The authors concluded that the high volume of blood associated with a simulated single flush, was one factor that contributed to the “survival” of HIV-1 in syringes over time. Some researchers have suggested that flushing occurs because IDUs perceive that drug residue remains in the syringe after injecting (Carruthers, 2003; Heimer and Abdala, 2000). Others have noted that IDUs flush in order to inject the drug “in a series of small injections” (Caulkins et al., 1998:32). Few studies have explored the reasons for flushing from the perspective of IDUs. One exception is a study by Greenfield et al. (1992) who examined the reasons for flushing among Booting and Flushing McElrath 5 31 IDUs residing in the US, who had injected heroin, cocaine and speedball in the six months prior to the interview. Respondents in the study were asked to simulate injection of the three drugs. In general, respondents in that study reported that flushing served to “enhance feelings” of the drug’s effects, particularly when simulating the injection of cocaine and speedball. The authors noted that “booting is not universal, but occurs only in a subpopulation of cocaine and speedball users” (Greenfield et al., 1992:107). Similar findings were reported in a San Francisco study whereby IDUs suggested that flushing enhances the rush when injecting cocaine (in Bourgois and Bruneau, 2000). Taken together, these studies suggest that 1) flushing is associated largely with cocaine injection, and 2) the behavior is perceived to enhance the effects of cocaine. Flushing brings more blood to the injection setting, thus the behaviour can increase the likelihood of transmission when blood is contaminated and other injectors are present. Transmission in these settings can occur when either flushers or non-flushers consciously or inadvertently pass on equipment to other IDUs, or when contaminated blood remains in the injection setting. A better understanding of the nature of flushing and the context in which it occurs can inform the development of effective interventions. In the present study, I explored 1) the extent of flushing among 59 current injectors residing In Northern Ireland, and 2) IDUs’ self-reported reasons for flushing. Booting and Flushing McElrath 6 METHOD Local context Research into injecting drug use in Northern Ireland commenced in the midto late-1990s. Prior to that decade, the limited data on heroin and injecting drug use suggest that there were very few heroin users or IDUs presenting for treatment to drug services or general practitioners. For example, a total of 35 persons were officially registered as “drug addicts” in 1985 and most of those persons were notified as heroin users (cited in Murray, 1994). It has been suggested that the wider political conflict in Northern Ireland contributed in part to the alleged low levels of heroin use and injecting drug use in the region during the 1970s and 1980s (McElrath, 2004). However, public health indicators of heroin and injecting drug use were limited during this time, and surveillance of blood borne viruses was limited to one source that reflected data collected through voluntary testing. Increases in heroin use and IDU in Northern Ireland were first noted in the mid1990s, and the estimated number of problem heroin users was between 695 and 1018 during the 12-month period, 1 November 2000 and 31 October 2001 (McElrath, 2002). These figures are low in comparison to other regions in the United Kingdom and the Republic of Ireland, however, they represent a substantial increase from previous years. Booting and Flushing McElrath 7 Progressive changes in drug policy commenced approximately six years after the initial reports of an emerging heroin outbreak. Pharmacy-based needle exchange was introduced in 2001 and substitute prescribing (methadone and high-dose buprenorphine) was implemented in 2004. At this writing, there is one drug outreach team (four members) that addresses the needs of IDUs and the team is confined largely to one area of Belfast, the largest city in Northern Ireland. Thus, although some harm reduction initiatives (e.g., substitute prescribing, pharmacy-based exchange) have been introduced in Northern Ireland, implementation has been slow in comparison to other regions of the United Kingdom and the Republic of Ireland. Procedures Data presented here were collected as part of a larger research project that addressed risk behaviours for blood borne viruses among 90 IDUs residing in Northern Ireland (McElrath & Jordan, 2005). Data were collected through faceto-face, semi-structured interviews that addressed issues relating to first and last injection, loaning and borrowing of injection equipment, “risk” scenarios, experiences with drug treatment, general practitioners and pharmacists, access to and utilization of needle exchange schemes, and related issues. Data collection commenced in December 2003 and concluded in September 2004. Two female interviewers were used, one of whom was the author. The second interviewer had access to and knowledge of the local heroin “scene.” Prior to data collection, the second interviewer was trained in terms of the interview Booting and Flushing McElrath 8 guide, ethical issues pertaining to confidentiality and anonymity and other issues relating to qualitative fieldwork. The interview guide was developed, piloted on the first five respondents and minor revisions were made throughout the study when we learned that questions were inappropriate or worded improperly. Interviews were conducted in university offices that offered a great deal of privacy, private residences, and semi-public areas. Primary measures Flushing Although the larger project focused on risk, and despite numerous drafts of the interview guide, we neglected to ask about flushing during the initial interviews. The first stage of data collection revealed that some IDUs were describing flushing behaviours (unprompted) and that some respondents reported flushing with opiates (namely heroin). We then revised the interview guide by adding questions about flushing. In all, 59 of the 90 respondents were asked about flushing and the data reported in this paper are based on the sub-sample of these 59 IDUs. During some interviews, respondents described flushing during a particular injection episode (often the last time that they had injected) and we used that opportunity to explore their reasons for flushing. In other interviews, we began with a general question, e.g., “Does the word flushing mean anything to you?” Most respondents had knowledge of the term: Booting and Flushing McElrath 9 “You got your vein. You know you’re in [observe blood in the syringe; registering]. Inject, depress the plunger and pull back again. The blood comes back again and you inject again. Yeah, I flush every time.” (30, male, age 30) Although the majority of respondents had knowledge of the term “flushing,” a few were unfamiliar with the word and some believed we were asking about “registering.” We then clarified to these respondents our meaning of the term, e.g., “Most people pull back the syringe to make sure they’ve found a vein. Other people pull back again and sometimes loads of times – that’s flushing.” Once we clarified our meaning of the term, we asked respondents the extent to which they flushed. Respondents who reported flushing were asked to explain why they flushed. Loaning and borrowing injection equipment The interview guide included several questions that attempted to measure the number of times that respondents had engaged in the loaning or borrowing of injecting equipment in the past 30 days, e.g., injected with a needle that had been used by another IDU, provided a used filter to another IDU. We found that these questions generated confusion during the interviews, particularly for respondents who had injected with different people during the 30-day period. We concluded that these quantitative measures of risk had low levels of validity among respondents in our sample, thus we subsequently used a qualitative approach when asking about these behaviours. We found that in many Booting and Flushing McElrath 10 interviews we had to “tease out” whether respondents had loaned or borrowed used equipment by discussing various injection settings and episodes in the 30day period prior to the interview, or by asking people to describe in detail their recent injection episodes. In the end, we concentrated solely on whether respondents had engaged in the loaning or borrowing behaviours during the 30day period and abandoned our quest to determine the number of times that the behaviours had occurred. Sample and recruitment The criteria used for interview eligibility were 1) 18 years or older and 2) injection of one or more drug (excluding insulin or other substance that was prescribed for injection) within the 30 days prior to the interview. Several methods were used to recruit respondents for interviews. First, announcements of the study were distributed within pharmacies that offered needle exchange and placed on notice boards in venues where current injectors might frequent, e.g., health centres, in or near the offices of general practitioners. Second, information about the study was distributed by drug outreach workers, community workers and through “street sources” who had access to IDUs. Third, persons who completed an interview were asked to refer friends and acquaintances to the study. For ethical reasons we tended to avoid asking for referrals from persons who were attempting to “get clean” because some of these people wished to distance themselves from the wider injecting community. We monitored referrals carefully and generally did not permit more than three or four referrals from any one Booting and Flushing McElrath 11 respondent. Fourth, targeted sampling approaches were used to recruit females in particular and to ensure that interviews were conducted with respondents from each of the four health board areas in Northern Ireland. Finally, midway into the data collection stage we distributed copies of the study announcement to various drug treatment facilities in Northern Ireland. This strategy was not used until the latter stages of the study so to increase the likelihood of recruiting out-oftreatment IDUs (in the end, a total of 12% of study participants were recruited through drug treatment settings). The use of multiple sources of recruitment had two potential advantages. The procedure: 1) increased the probability of recruiting more people into the study, and 2) increased the potential for sample diversity. Ethical procedures Full ethical approval was granted by the Queen’s University Medical Ethics Committee. Informed consent was obtained from participants before the interview commenced and the anonymity of respondents met that consent was obtained verbally. Respondents were paid £20 for a completed interview. About half of the interviews were taped and subsequently transcribed by the first author. Very detailed notes were taken during the remainder of the interviews. Audio tapes were secured outside the jurisdiction until they were transcribed, and then they were destroyed.