how to know what drug was used from a cotton filter i found
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The filter of choice: filtration method preference amid injecting drug users
Harm Reduction Journal volume viii, Article number:xx (2011) Cite this article
Abstruse
Background
Injection drug employ syringe filters (IDUSF) are designed to prevent several complications related to the injection of drugs. Due to their small pore size, their use can reduce the solution'southward insoluble particle content and thus diminish the prevalence of phlebitis, talcosis.... Their low drug memory discourages from filter reuse and sharing and tin thus prevent viral and microbial infections. In France, drug users take admission to sterile cotton filters for 15 years and to an IDUSF (the Sterifilt®) for five years. This study was set up to explore the factors influencing filter preference amongst injecting drug users.
Methods
Quantitative and qualitative data were gathered through 241 questionnaires and the participation of 23 people in focus groups.
Results
Factors constitute to significantly influence filter preference were duration and frequency of injecting drug use, the type of drugs injected and subculture. Furthermore, IDU'southward rationale for the preference of 1 type of filter over others was explored. Information technology was constitute that filter preference depends on perceived health benefits (reduced harms, prevention of vein impairment, protection of injection sites), drug retentivity (low memory: meliorate high, protective mechanism against the reuse of filters; high retentiveness: filter reuse as a protective mechanism against withdrawal), technical and practical issues (filter clogging, ease of utilize, time needed to prepare an injection) and believes (the confidence that a clear solution contains less agile compound).
Conclusion
It was concluded that the factors influencing filter preference are in favour of alter; a shift towards the use of more efficient filters tin be made through increased availability, information and demonstrations.
Background
Drug preparations are commonly filtered past illicit drug users before injection in order to eliminate impurities of the drug containing solution. Several complications arising from injecting drug utilize depend on the characteristics of the filter used [1]. Amidst these is the introduction of insoluble particles into the blood stream. Various complications, ranging from pocket-size to severe, are associated with the intromission of these foreign bodies. At the site of injection, sterile abscesses, cellulites and ulcers can occur, which increase the risk of infection at these sites [2, 3]. Afterward injection, insoluble particles such as talc and cellulose will stay intact and move along with the claret stream, blocking the first vessels as well modest to pass. Repeated administration can thus lead to severe pulmonary and cardiac complications such equally talcosis [4–8]. People suffering from talcosis will experience moderate to severe dyspnoea, can develop cyanosis and even die [5, 9] This status tin have ane to several years to develop, simply one time present, the symptoms are irreversible and continue to develop despite of discontinuation of drug use [9]. Poor filtration has been suggested to be one of the adventure factors for the development of talcosis [10].
All filters used by injecting drug users (IDUs) will eliminate some of these particles, but non with the same efficacy. The size of the bulk of insoluble particles involved in the evolution of talcosis due to injecting drug employ is within the range of 9 μm to 23 μm (medium of 14 μm) [xi]. Cigarette filters, usually used by injecting drug users, eliminate less than half of all particles above x μm [12]. Injecting drug use syringe filters (IDUSF) accept been specifically conceived for drug use and are capable of eliminating the large majority of insoluble particles [13]. 3 IDUSF are currently bachelor: the Compet AG syringe filter (Compet AG, Switzerland), the "filter syringe" (Frontier Medical Group, Great britain) and the Sterifilt® (Apothicom, French republic). These IDUSF are non designed to sterilize a not sterile solution, but to promote single utilise of filters and to eliminate particles of over 10 micron, in accordance with the European Pharmacopeia concerning injectable preparations. Besides these IDUSF, several commercial filters called wheel filters are likewise capable of eliminating the majority of these particles [14].
Another important feature of a filter is its capacity to retain drugs, as the retention of a considerable proportion of the active compound tin can incite drug users to hold on to their filter and to reuse information technology later or even to share or sell it [15]. The conservation and reuse of filters puts IDUs at take a chance of bacterial and fungal infections, and filter sharing is a known risk cistron for hepatitis C transmission [16, 17]; sharing of paraphernalia other than syringes might even be a primal element in the ongoing hepatitis C epidemic. IDUSF are specifically designed to retain as little active chemical compound equally possible, without the necessity to add together extra rinses to the filtration process; this is susceptible to increase their acceptability and to reduce sharing.
IDUSF can thus substantially reduce some very common injection related Public Health issues, like the incidence of small vessel blockage and subsequent medical complications [12, eighteen].
As far every bit we are aware, France is the just country where an IDUSF is widely available, and free of accuse, at nigh all needle exchange programs (NEPs). These programs as well requite out sterile cotton filters (which are inside a sterile single use cooker given out equally a kit, the Stericup®). IDUs in this country thus take the choice between two sterile filters. Also these, some IDU utilise cigarette filters; other makeshift filters are rarely used in France. We depict hither a study which explored filtration method preference by IDUs who have access to these iii options and the influence of the drug existence injected on filter preference. The characteristics of the Sterifilt® are the following: it eliminates 99% of insoluble particles, and is additionally constructive at shifting the particle size distribution towards the smaller range, with approximately 95% of all particles nowadays later filtration measuring less than 5 μm [12]. This filter retains virtually no drug (0.02 ml), as opposed to cigarette and makeshift filters which retain nearly 0.thirteen ml [xiii].
Methods
Two complementary methods were used to gather both quantitative and qualitative information: a questionnaire and focus groups. A total of 241 questionnaires were filled in past IDUs visiting 10 different needle exchange programs in nine cities in France during 2009. The questionnaire explored housing, financial resource, frequency of injection, drugs injected during the last month and details on the last injection: drug injected, location, type of paraphernalia used and the reasons for using an IDUSF or not. The responses were collected past qualified drug workers afterwards a coming together with the study atomic number 82. Focus groups or expert groups were held with the objective of obtaining detailed qualitative information on filter preference, drug preparation techniques and opinions on Sterifilt®. A total of 23 people in 3 different cities participated in these groups. All participants injected illicit or pharmaceutical drugs and each reported having tried the Sterifilt® syringe filter at least in one case. Four of the participants had recently quit injection.
Quantitative analysis was conducted using EpiInfo half-dozen. The small numbers of people using cigarette filters obliged us to group these with the cotton wool filters into i category: "other filters" every bit opposed to IDUSF use.
Results and discussion
Participants and drug utilize
The participants' primary characteristics are briefly described in table 1. The group of participants under thirty contains more women (xl% versus xv%), they inject more often on a daily footing (74% versus 63%) and use more heroin (75% versus 45%) and cocaine (66% versus 55%) than their older counterparts. They as well alive more frequently with friends and other drug users in unstable housing and less often take stable resources.
The 4 drugs or pharmaceuticals virtually commonly injected are: buprenorphine (Subutex® and generics), heroin, cocaine and morphine sulphate (Skénan®) (table two). The mean number of substances injected during the final month by individual participants is 2.v.
Cocaine users are slightly younger (median 30 versus 34) and accept more precarious living conditions, they often alive in unstable housing and receive low or unstable financial resources. Morphine and buprenorphine users more often inject on a daily basis. The latter ones take a longer "career" as IDUs (sixteen years, versus 13 for morphine users and 9 for heroin or cocaine users). Morphine users more frequently experienced a bad hitting during the last 6 months (46% versus 31% for heroin or cocaine users and 19% for buprenorphine users).
Filtration
The majority of the participants (72%) employ the Sterifilt® on a regular basis ("always" or "ofttimes") with at least one of the substances they injected during the terminal month. 25% use this filter regularly with all drugs injected and 43% have used this filter for their final injection. When other filters are used, these are cotton filters in 56% and cigarette filters in 33% of the cases (The remaining 11%: no filtration, commercial cotton...).
Factors influencing filtration technique preference
Three factors were significantly associated with filter preference: the individual, the drug injected, and the urban center.
The syringe filter was used more often by people who inject oft (at to the lowest degree 2 to 7 days a week; p < 0.001). People who started injecting when this filter was already available were more probable to use it (p = 0.02).
The choice of the type of filter used was highly correlated across drug types for given individuals, suggesting that people accept the tendency to generalise their filtration technique to all the drugs they inject. Withal, an influence of the injected drug remains present: respondents were more than likely to filter their buprenorphine with an IDUSF and their cocaine with another filter than the other way around.
As for the drugs used during the last injection, we can distinguish 3 categories amongst the iv drugs most commonly injected in France:
The majority of the buprenorphine injectors (64%) used an IDUSF. The starch nowadays in these tablets gives ascension to several complications such equally the puffy mitt syndrome. Furthermore, complications at the injection site are more frequent among buprenorphine injectors [xix]. Their reduction seems to be the primary motive for Sterifilt® use amongst these injectors. This is partly due to the increased extent of information flow at NEPs on the injection of buprenorphine tablets and syringe filter use.
A 2d category includes heroin and cocaine, for which 39% versus 33% used an IDUSF. The primary statement for using syringe filters is the preservation of health; their use is facilitated past the relative lack of technical difficulties (e.g. the membrane hardly ever gets clogged by these drugs). The main arguments mentioned by this population for the connected use of cotton filters are the conservation and re-use of "old cottons" and the assumption that filtration of these drugs is less important than filtration of pharmaceuticals.
Finally, morphine sulphate capsules are almost always filtered using either cotton wool or cigarette filters (only 11% used an IDUSF), despite of the college frequency of "bad hits" found to be related to their injection. This preference is due to the grooming method by and large used to dissolve the morphine sulphate, which involves heating the solution before filtration, making it viscous so that even the cotton filter tin exist as well dense to filter it.
For those who use other filters, the bulk use the sterile cotton to filter buprenorphine, cocaine and heroin, while morphine sulphate injectors generally prefer a cigarette filter.
Substantial differences have been constitute between cities for filter preference, suggesting that local customs practices may take a meaning effect on filter preference (Figure ane). This is consistent with several studies which accept described the importance of peer influence on drug use [15, 20, 21].
Frequent Stérifilt ® employ during the last month per city in relation to the drugs injected. The percentage of IDUs who frequently ("always" or "frequent") employ the Sterifilt for each of the iv almost commonly used drugs in 9 dissimilar French cities.
For buprenorphine, the cultural influence on filter preference did not show meaning differences between cities (p = 0.i). These differences were quite big though (74% of the buprenorphine users in Beziers utilise a syringe filter, compared to only 40% in Paris), suggesting that the sample size might take been too low to obtain significance. Local filter preference differences are significant for the injection of heroin (3 levels, p < 0.0001), cocaine (iii levels, p < 0.001), and morphine sulphate (2 levels, p = 0.05).
Besides these factors, the questionnaires and focus groups revealed IDUs rationales for the preference of one filtration method over some other.
Reasons for non using a syringe filter
About of the reasons brought up for the employ of "other filters" concerned technical difficulties linked to the apply of the Sterifilt®. Scott [13] had as well observed that some IDUs discover the Sterifilt® difficult to use. Here, we explore which types of barriers are encountered.
Several participants mentioned that the membrane can get clogged, which is attributable to its small pore size, combined with a high density and insoluble particle content of the solution. Membrane obstruction is thus more than frequent with pill injection and particularly with the injection of morphine sulphate. This is due to the method used to ready Skénan® for injection: capsules are opened and the contained microbeads are crushed, h2o is added and the solution heated. Due to the gelatine contained in these microbeads, the process of heating produces a dumbo solution which clogs the filtering membrane. A participant of the Focus group in Toulouse illustrates this very well:
"I inject morphine sulphate every solar day (...). In the showtime, I heated to solution. I thus used a cotton filter, or more frequently a cigarette filter, because information technology was hard. I used a very small slice of cigarette filter, the smallest possible, otherwise information technology wouldn't get through."(male, age 26)
Grooming and filtration using a syringe filter can be slow. This tin exist an obstacle at two distinct moments:
When fitting the filter to the syringe, which takes some preparation and concentration.
"For me information technology's the speed, not the speed of filtration, which I believe is fast, but to fit the filter to the syringe. (...) I become through a lot of problem, especially when I have used a lot (of drugs) or when I shiver (...). You have to be very concentrated to fit the Sterifilt to the syringe". (male, age 41)
When pulling up the plunger. Due to the pocket-sized pore size, it takes some time for the solution to become through.
"I don't use the Sterifilt often. Filtration is irksome and takes too much time. When I don't take the time, I don't filter at all" (female, age 33)
The Sterifilt® might damage the needle. If a person is in a hurry, under the influence of drugs or in withdrawal while plumbing fixtures the Sterifilt® to the syringe, he or she might lack the concentration needed to perform this operation. The needle might then touch the plastic of the filter and thus get damaged.
"When I use a Sterifilt, I frequently damage a needle. As I don't apply drugs regularly, to limit my consumption, I just have two syringes when I programme to utilize. If I then damage the needle, I don't have spare needles. I thus prefer using a cotton filter." (male person, age 36)
Related to these technical difficulties is the fact that IDUs don't always have the fourth dimension, though some spoke about patience, to use this filter; especially if they are stressed or if they prepare their injection in a maladapted environment (public toilets, street).
"Filtration also depends on the context. Even though yous ever filter as you should, this is impossible if you have to inject in public toilets."(male, age 35)
Information technology is interesting to annotation that the data from the field, which suggests that the Sterifilt® is more than readily adopted by IDUs who have stable living conditions than by those who alive and utilize in the street, cannot be confirmed by the quantitative data. Though several participants, as here above, stated that some contexts are indeed less adapted than others, no correlation has been establish between precarious living conditions and Sterifilt® utilise.
Every bit the apply of a syringe filter changes the drug preparation ritual, for some, there never seems to exist an appropriate moment to endeavour out a new technique or tool. The perseverance of existing injecting practices tin can thus be a second major barrier to the apply of syringe filters.
Several presumptions about electric current practices may deed as a barrier to syringe filter use, such every bit the thought that someone's current filtration technique is efficient in eliminating particles, or that some drugs don't need filtration because no insoluble particles are visible in the solution. However, clear solutions are not always free of them, as some potentially harmful insoluble particles are invisible to the naked eye [22]. Cocaine and heroin filtration was believed to be of less importance because of the absence of tablet fillers such as starch and talc, and due to the lower prevalence of complications at the injection site (in France, complications at the injection site are more prevalent among buprenorphine users [19]).
"I only use the Sterifilt when my coke is very filthy" (male, historic period 39)
Others presume that the Sterifilt® is only meant for frequent injectors, a presumption reflected by the fact that frequent injectors utilize this filter more often.
"I don't use the Sterifilt often. I know it is better, just I don't employ drugs often, not daily. It is important for guys who inject every twenty-four hour period" (male, age 36)
Furthermore, some IDUs who inject an opaque solution for years can experience considerable difficulties admitting that their drug is completely water-soluble and that a transparent solution thus contains the aforementioned corporeality of agile compound.
"The cotton is more efficient, for the solution is white" (female, age 25)
Additionally, similar to the findings of Scott [13], IDUSF's depression drug memory can be considered as a disadvantage. Several respondents reported retaining cotton filters as a means to keep a pocket-sized corporeality of drug "for subsequently" and did non wish to change this behaviour. This conservation and reuse of cottons was associated with the injection of heroin, morphine sulphate and cocaine. These drugs are difficult to obtain and expensive; their consumption can be compulsive and/or shortage can readily induce withdrawal. Reuse of cottons was rarely mentioned past buprenorphine users.
"I always used the Sterifilt solely for Subutex (buprenorphine) (...). For heroin and cocaine, I had that erstwhile "craze" to utilise a cotton and keep it (...). I did it all: squeeze the last drop out of the filter using my hands, everything." (female person, age 32)
A concluding barrier to the employ of IDUSF was that they are non readily available everywhere. Though virtually all NEPs in France give them out, they are not attainable at syringe vendor machines or at pharmacies where 60 to 80% of all syringes are exchanged [23, 24]. This excludes IDUs who do not visit NEPs from beingness familiar with this filter, and influences its credence and habituation by other IDUs, as they do not have admission to it at each fourth dimension they commutation syringes.
"New injectors don't go to needle exchange programs (...). Habits from the get-go persist; Sterifilt should be given to new ones" (male, age 36)
Reasons for using a syringe filter
The two primary arguments reported by IDUs for using the Sterifilt® are the quality of filtration and more generally the role of this filter in the prevention of wellness problems.
Participants reported that solutions filtered by this IDUSF independent less "chunks", were cleaner and clearer. Buprenorphine users were particularly likely to draw these every bit advantages of syringe filters. Additionally, buprenorphine users mention specifically the removal of starch as an reward of syringe filters.
"Less deposit, less starch, cleaner" (male, age 30)
Secondly, similar to the findings of Scott [13], participants either state that they believe the Sterifilt® reduces drug related damage or that they have actually experienced a reduction in complications such as abscesses, bad hits, and phlebitis.
"I've had a phlebitis, that'due south the reason why I adopted the Sterifilt. Since, I don't have "pins and needles in my legs" anymore, less abscesses and no more phlebitis" (male person, historic period 36)
Respondents besides refer to the chapters of this filter to preserve the injection site. They state that when the solution is unintentionally injected into the soft tissue surrounding the vein, complications are less harmful and of a shorter duration.
"I use the Sterifilt to get rid of particles. When I miss my hit (the expression "a missed striking" refers to the deposit of the solution exterior the vein), I don't accept whatsoever abscesses any more" (male, age 48)
Furthermore, veins are described to recover more quickly when a syringe filter is used.
"Veins recover when you use the Sterifilt. You can't utilize it (the vein) for a couple of days, simply after that, you can reuse it" (male, historic period 39)
This may exist due to the reduction in the number of large insoluble particles in the solution and/or to the protection of the needle by the filter when information technology is appropriately fitted to the syringe. Indeed, this syringe filter covers the needle completely and thus prevents information technology from touching the inside of the cooker.
Most Sterifilt® users consider its depression drug memory as positive: they gain a better high considering there is virtually no loss of agile compound. This characteristic can also serve a protective office, removing the temptation to keep filters for later. Indeed, for some, even though they are aware of the risks and do non want to reuse filters, it is hard to throw abroad a filter containing 6 to 13% of the active compound. This tendency was also described by Scott [13].
"You gain in active production and y'all won't do the cotton fiber" (male, age 26)
Finally, several people familiar with its utilize described the Sterifilt® as piece of cake and quick to use.
Information technology is interesting to annotation that IDUs never mentioned the prevention of hepatitis C transmission through the reduction of reuse and sharing equally a reason for IDUSF use. It seems that, for individual users, local complications and vein damage are of more immediate concern, every bit they occur almost instantly afterward injection. As for pulmonary complications, most people are unaware of the link between injecting drug utilize, filtration methods and pulmonary problems, and may impute respiratory difficulties to infections or tobacco use.
Decision
IDUSF and other commercial syringe filters accept the chapters to considerably reduce harms associated with injecting drug utilize, such as complications at the injection site, and pulmonary issues due to the injection of insoluble particles, but also hepatitis C transmission through the reduction of reuse and sharing of filters due to their reduced drug retention. Several studies [thirteen, 14] take evaluated the efficacy of IDUSF or bicycle filters. Scott's research [thirteen] also included some questions on filter preference. However, to our knowledge, this is the first report exploring the factors and reasons for filter preference among injecting drug users in item. A improve understanding of factors and IDUs' motives influencing filter choice may assist drug workers to promote the utilise of less harmful filters. The unique French state of affairs of high availability of IDUSF and sterile cotton filters creates the opportunity to report these factors.
The results show three main factors influencing the filter of choice:
Individual drug users have the tendency to generalise their preparation method to all drugs used. Additionally, people who started injecting when the IDUSF filter already was available, utilise it more often, equally practise people who inject often.
The drugs injected. Three categories can be distinguished among the four drugs about commonly injected:
The majority of the buprenorphine injectors (64%) used an IDUSF during their terminal injection, mainly to reduce the frequent complications at the injection site related to the injection of this drug.
39% of the heroin users and 33% of the cocaine users used the syringe filter to preserve their health. The cotton wool filter on the other paw, is oft preferred for it allows "keeping some for after" in social club to foreclose withdrawal; furthermore, fine filtration of these drugs is ofttimes considered less important.
Simply 11% of the people injecting morphine sulphate used this filter, due to frequent technical difficulties, like membrane obstruction, which is, in its turn, related to the preparation method used for this drug.
Subculture and peer influence on preparation- and impairment reduction techniques were confirmed by a variation in local filter preference.
These three factors propose that positive modify is possible: influence of the individual and subculture, also every bit the relatively slow only stable progression of syringe filter utilize, advise that these behaviours can potentially be changed.
Harm minimization data will probably be more efficient if it addresses the advantages perceived past IDUs. Once understood, technical difficulties may get relatively less important. This report shows that the reduction of complications at the injection site is perceived as the chief advantage of syringe filters. The transparency of the solution, the reductions of abscesses and cellulites, every bit well as the preservation of veins are frequently referred to by drug users. The proceeds in agile compound due to low drug retention besides seems to exist an important upshot which, in addition, can be used as a protective mechanism against the re-apply and sharing of filters.
However, barriers remain for some users. Information technology is necessary to learn the technique to use this type of filter, filtration is relatively slow and the filter membrane may be clogged by cutting agents and tablet fillers. It is thus of import for needle exchange programs to provide frequent demonstrations, accompanied by the improvidence of appropriate information and prevention letters on the solubility of drugs and the harms associated to the injection of insoluble particles. The provision of information has been constructive in French republic, where information catamenia was full-bodied on buprenorphine employ; the bulk of its users accept adopted the IDUSF. Increased availability would probably also enhance IDUSF use.
Previous research has shown that drug users are preoccupied by their health and willing to alter their behaviour. To change preparation and filtration techniques, data should be full-bodied on the perceived advantages of new techniques; these will be more than disarming and able to promote modify.
Abbreviations
- IDU:
-
Injection Drug User
- IDUSF:
-
Injecting Drug Use Syringe Filter
- NEP:
-
Needle Exchange Program.
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Acknowledgements
Nosotros would similar to give thanks all teams who participated, investing their fourth dimension, knowledge and know-how to this report. The teams which passed the questionnaire: AIDES in Béziers, La Case in Bordeaux, AIDES in Lille, Ruptures in Lyon, AXESS in Montpellier, La Boutik "Réduire les Risques" in Montpellier, SACADOS in Orléans, Stride and the drib in of Espoir Goutte d'Or in Paris, AIDES Bearn in Pau, AIDES in Rennes and Espace Indépendance in Strasboug. The teams which organised the focus groups: ASUD in Marseille, ASUD in Nîmes and AIDES in Toulouse.
We would besides like to thank all people injecting drugs who took the time to participate in this study; without their fourth dimension, expertise and feedback, we would never take been able to deport out this report.
Finally, we would like to give thanks Nouria Gabelli, who is co-author of the French version of this study, too as Anne-Marie Ajuelos and Letissia Bierry for their reflexions on the French study report. We would also like to thank Dr. Peter Davidson of the University of California at San Diego for his revision of the first blueprint of this manuscript.
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Competing interests
Elliot Imbert is the inventor of the Sterifilt® and the chief stockholder of Apothicom Distribution. Lenneke Keijzer works at Apothicom, organisation which developed and sells the Sterifilt® as well equally the cotton filter. This enquiry was prepare and conducted by Apothicom in order to obtain a better understanding on filtration method preferences in a country where several filters are readily available; data which might be useful to adapt Apothicom's services or tools to IDUs practices.
Authors' contributions
LK and EI conceived and designed the study; LK implemented the study design, including data collection. LK performed the statistical analysis, wrote the manuscript and coordinated the revisions. Both authors revised the manuscript and read and approved the terminal draft.
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Keijzer, L., Imbert, E. The filter of choice: filtration method preference among injecting drug users. Harm Reduct J 8, 20 (2011). https://doi.org/10.1186/1477-7517-viii-20
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DOI : https://doi.org/10.1186/1477-7517-eight-20
Keywords
- Cocaine
- Heroin
- Buprenorphine
- Syringe Filter
- Inject Drug User
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Source: https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-8-20
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