Needle
Epidermis Vessel wall
Lumen of vein
Pam uses her hands as tourniquet for Joe, who inserts his heroin-filled needle at too-steep an angle. Photo: Greg Scott
Structure of the vein and illustration of ideal needle insertion — a 15 degree angle and toward the heart (with, not against, the flow of venous blood as it returns to the heart). 9
The Gloom and Doom of RISK One night last summer I was preparing to teach a safer injection session at the west side Chicago CRA outreach site where I’ve been volunteering for the past 11 years. A veteran participant, “Johnny,” noticed me preparing injection supplies for the teaching session and asked what I was doing. I told him that I was preparing to teach a session on the risks of drug injection and how to change injection technique to reduce that risk. His reply hit me like a skid of paving stones:
receive (and often internalize) every day from friends, loved ones, social control authorities, etc. Perhaps it’s time for an inversion of the risk-reward quotient with regard to formulating the basis for intervention. How did I respond to Johnny’s challenge? Well, I stood there nodding dumbly for at least a full minute. Then an image came to mind: “leaky veins.” “Well, let me put it this way,” I began. “One of the things I teach is that you should insert the needle at a 15 degree angle, which is really shallow compared to how most people do it.” Here I showed him the picture above. “Now, most people go in way too steep, like they’re stabbing themselves,” I continued. “Yeah, and . . . ?” he replied. “Well, if you do that, then the needle goes through the top side of the vein, you get a flash of blood in the syringe but before you know it, you lose the flash and have to pull back out a little bit, and then you get it again.” Johnny enthused, “Yeah, that happens to me all the fucking time, like almost EVERY time I shoot!” I carried on: “Okay, so check this out . . . the vein’s like a hose, right?” He nods. “So when you go in too fast and too steep and you make TWO holes in the vein, one on the top and one on the bottom, what do you think happens when you do finally shoot the dope into your system?” Johnny looked at me, then back at the picture, and then exclaimed: “The shit leaks out the other side!” he
Aw man, not another “and here’s another way you can get sick and die” infomercial. You know we hear this shit all the time, right? Don’t you think we already know that just doing this is bad for us? That’s the main reason that I shoot dope in the first place. The thrill. Don’t be a Dr. Killjoy, man. There’s enough of them kind of doctors already in our faces. Why don’t you try somethin‘ else for a change – tell me how I can get more good, not how I’m gonna feel more bad. Johnny’s absolutely right: The vast majority of safer injection interventions invoke the “gloom and doom” of disease/infection risk as the principal motivating factor. At a fundamental level, most SI programs carry a threat: “If you don’t follow these practices, you will suffer.” This sort of message arguably dissipates and rapidly loses steam amidst the cacophonous barrage of negative messages that PWIDs
8 Fall 2011 Issue 16
bellowed. “Exactly. You got yourself a leaky vein. A little bit of your shit leaks out the other side, which means you’re only gettin’ $7 or $8 out of that $10 bag you just bought, so the rush won’t be as strong and the high won’t last as long. Not to mention the fact that having two holes is worse for you health-wise than having one hole.” At this point an awkward staring contest ensued. After what seemed like a 10-minute stare-off, Johnny broke out a grin: “Leaky motherfuckin’ veins. You actually taught me somethin’, Doc. See, that’s what I’m talkin’ about. We need useful information. Enough of the scare tactics. I mean, you’re still tellin’ me about bad health and shit, but this is different because it’s, like, dope fiend useful.” Over the next few weeks of field work, I noticed the “leaky veins” idea taking on a life of its own. What started as an improvised repackaging of an old message became a social marketing campaign. And it was rooted in the quest to maximize pleasure, not minimize risk. It’s time for SAPs to consider alternate, pleasurebased “frames” for their safer injection protocols. For injection drug users, principal concerns – which can serve as excellent intervention message frames – include maximizing the rush and the total quantity of drug entering the body, increasing the length of time that their primary veins remain accessible, and reducing the visibility of stigma-precipitating track marks.10