Safer injection guide

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Using and sharing injection equipment can be fatal.

Using and sharing injection equipment is a high-risk activity and is never safe to do in a non-medical context. This guide is provided for educational and harm reduction purposes only and we highly discourage users from engaging in this activity.

The above video is mostly accurate, but it is important to note that one should use distilled water over boiled water as it is considerably safer. Pure vitamin C should also be used within the mixture, which is not mentioned in this video.

Injection is the process of dissolving a compound in a liquid and drawing the resulting solution into a needle-tipped syringe for self-administration. Substances are typically either injected directly into the bloodstream via the veins (a practice known as intravenous or I.V. injection) or into the muscle tissue (known as intramuscular or I.M. injection).

More rarely, substances are injected in the flesh right under one's outer layer of skin and into the dermis itself: this is known as intradermal injection or "skin popping". Injecting into the subcutaneous tissue that surrounds the veins and arteries and lies under the skin is called "subcutaneous injection" or S.C. injection. Various classes of substances, like opiates, stimulants, dissociatives, benzodiazepines and psychedelics can be injected.

Injecting substances removes any bodily filtering mechanism and I.V. injection results in 100% bioavailability of a substance.[1] If the substance being injected is impure, there is a massive increase in harm potential of said substance. Even medical quality substances meant for injection carry inherent risks of infection and death.

A diagram showing the different angles needed for different types of injections

Risks and hazards

  • Risks of infection - The simple act of penetrating the skin with anything is a way to introduce bacterium and viruses directly into the body. One should be as sterile as humanly possible when injecting, making sure to use alcohol swabs to wipe the injection area before and after injection. There is also the risk of infection if the substance being injected is impure, adulterated, or unfiltered, which is extremely common. These substances do not pass any membrane for filtration, and any impurity in the substance will therefore be directly introduced into the body.[2]
  • Blood-borne diseases - Sharing needles with other users is the most obvious way to transmit a blood-borne disease or infection, but there are other less commonly thought of ways too. Using multiple needles in the same water supply can easily spread illness and disease. Sharing the same spoons and other equipment used to prepare the injection solution is also a way to contract a blood-borne illness such as HIV/AIDS or Hepatitis B & C.[3] The sharing injection materials page provides more in-depth information about the sharing of injection materials and the inherent risks of infection and disease that accompany it.
  • Increased risk of infection - People who inject are at an increased risk of bacterial infections such as MRSA.[4]
  • Re-using needles - Reusing needles is not advised for a number of medically relevant reasons. If upon injection the needle does not hit a vein or muscle tissue, only retry with that same needle one more time if needed. It is always best to use fresh needles every time one decides to inject because a needle is only meant to penetrate the surface of the skin once. After the first time penetrating the skin, the needle is dulled. Each additional time the needle is used it contributes to the dullness and harmful nature of the needle. Reusing the same needle can lead to greater risk of bodily injury and abscessed infections. Fresh needles can be found using needle exchange programs in the local area.
  • Abscessed infections - An abscessed infection is a collection of pus (usually caused by a bacterial infection) that has built up within the tissue of the body at or underneath an administration site.[5] If one notices an abscess forming following an injection, it is important that they seek professional medical help immediately because abscessed infections can lead to severe health complications and, not uncommonly, death. Abscessed infections are especially common when I.V. injecting into the feet, as the blood circulation in the extremities is poor and decreases the foot's ability to heal.
A diagram showing what an abscess looks like. If anything resembling an abscess occurs at an injection site it is imperative to seek medical attention immediately.
  • Injecting into the wrong tissue - Some substances need to be injected into certain types of tissue in order to be effective. For example, heroin has been shown to be most potent when IV'd and can be extremely harmful when injected into the subcutaneous tissue, while ketamine is typically IM'd. This is why it is so important that one makes sure their needle is correctly inserted into the vein before proceeding with an I.V injection.
  • Development of scar tissue - This is especially present with I.V. injection, but can occur with I.M. and S.C. injections as well. If the site of injection is not varied, scar tissue can develop and can impede further injections.
  • Increased risk of overdose - This is especially present with opiates, such as heroin. If one is injecting opiates, it is important to have naloxone available, if possible, as this can reverse the effects of an opiate drug overdose if administered quickly.[6] The risk of fatal overdoses rise sharply after a period of cessation and relapse, largely because of reduced tolerance.[7] To account for this lack of tolerance, it is safer to only dose a small fraction of one's usual dosage if relapsing after an extended break. It has also been found that the environment one is in can play a role fatal overdosing. In one scientific study, rats were significantly more likely to die after receiving their dose in an environment not associated with the drug in contrast to a familiar environment.[8]
  • Stroke Risk - Injecting into an artery and not a vein can be a potential cause of strokes and blood embolisms. This risk is especially present with I.V. drug use, when one misses a vein and injects into the artery instead. This is why it is important to make sure one is in a vein before I.V. injection. This risk increases with the use of uncommon injection sites such as the neck: the chemicals being injected might enter an artery and go straight to the brain, causing neurological problems and strokes.[9]
  • Nerve damage - Injecting into the muscle tissue during an I.M. injection, missing a vein during I.V. injection, and S.C. injecting can all present the risk of nerve damage. The needle may puncture a nerve and cause serious, painful, and possibly fatal bodily harm. This risk is especially present if injecting into the groin, as the femoral nerve located there controls leg and muscle movement - damaging this nerve can result in serious problems with mobility or even paralysis.[10]
  • Gangrene - If one injects into an artery or muscle tissue, a gangrenous infection may develop.[11]
  • Deep Vein Thrombosis - Deep vein thrombosis is a blood clot occurring in the deep arms of the legs and extremities, especially the legs.[12] This is a risk that is especially present with I.V. drug use into the groin are and the deep veins in the arm. Signs of deep vein thrombosis include; pain, swelling, redness, or tenderness of the leg or arm around the injection site. I.V. drug use leads to a higher rate of DVT in younger patients, with most DVT issues occurring in the groin area and the thigh.[13]
  • Hitting an Artery - One should always inject into a vein and never inject into an artery. One can differ between a vein and an artery by the following signs: Upon injection, when the plunger is pulled down the pressure of the blood in the artery will push it back up. The blood in the syringe is bright red, frothing and gushing versus the dark red and slow moving blood found within veins. You can avoid hitting an artery by never injecting where you feel a pulse and never trying to I.V. inject into deeper veins than those at the surface.

Materials and equipment

The full injection set up is shown above. The needle is the part that penetrates the skin, the barrel is the part that contains the drug solution, the plunger is pulled to check if one is in a vein and pushed down upon injection.
  • Milligram scale - It is vitally important to weigh out the substance one is going to inject to help mitigate the risk of overdose.
An IM needle differs from an IV needle in length.
  • Insulin syringe with I.V. needle - Used for I.V. injection, this type of syringe has a short needle meant to penetrate surface veins.
  • Syringe with I.M. needle - This type of syringe is used for the less common intramuscular (IM) injection. These needles are longer than the traditional insulin needles seen for IV use because it is designed to penetrate deep into the muscular tissue and deposit the solution there instead of in a vein.
  • Alcohol swabs - This is for sterilization before and after injection. Hydrogren peroxide or other disinfectants can also be used.
  • Sterile water - It is important to use deionized water or distilled water when injecting substances as tap water may contain harmful impurities. It is also important to change the water at a regular interval to prevent bacteria growth within the water. Placing a small amount (10ml max) in a shot glass and using this for IV/IM purposes is a good way to ensure a fresh water supply. Be mindful that using multiple needles in the same water supply can easily spread illness and disease. No other liquid substance should be added to the injection, even if it is supposed to increase the solubility of the drug in the water solution. Heat can be used to aid dissolution, but fruit juice or vinegar can lead to infections.
  • Micron filters or cotton filters - These are used to filter out solid impurities in the substance solution. A cotton filter is better than nothing, but a micron filter is considered to be the best. If one is using a cotton filter it is important to never re-use this cotton filter as it can harbor bacteria and cause severe health consequences known as "cotton fever."[14] This is due to the bacteria that grow in the moist conditions of the cotton filter - one should always dispose of their filters after a single use.
  • Vitamin C (ascorbic acid) - This can be added to heroin, crack and cocaine solutions to dissolve the substance. It is important that one does not use fruit juice or vinegar as these lead to greater risks of infection. Vitamin C powder can be found in packets online. Too much vitamin C will make the solution too acidic and can cause vein problems.[15]
  • A friend - If possible, do your best not to I.V./I.M. alone due to its high risk. The risk of overdose is significantly increased when injecting and having someone there to call the emergency services or give you medical aid, such as naloxone, can literally be the difference between life and death.
  • Soap - One should always wash their hands with soap and water before injecting. If soap and water are not available, alcohol-based hand sanitizer may be used, however, washing one's hands with soap and water is always preferable.
  • Elastic tourniquets or stockings - These can be used to "tie off", or make the veins more visible and accessible, during I.V. injection. These materials are better for skin than leather belts or other similar objects used to "tie off". Neckties, lubricated condoms, and socks can also be used. One should always use a slip knot when tying off so the tourniquet can be removed quickly if needed. The tourniquet should be removed immediately if there is a loss of sensation in the limbs or the limb discolors or turns blue.
  • Naloxone - If injecting an opioid, it is highly recommended that you have naloxone if it is available. Naloxone is a substance used to reverse the effects of opioids in an overdose. Many jurisdictions have programs to distribute naloxone for free or at discount prices to people who are in need of it. Naloxone may be available as a nasal spray under the brand name "Narcan" or as an autoinjector with voice instructions.

Procedure

In the interest of harm reduction, the use of any substance via I.V./I.M./S.C administration is not advisable from a health and safety point of view. It should be noted that I.M. administration is more commonly found when using substances like ketamine, while opiates (like heroin) and stimulants are typically administered intravenously.

It is extremely important to vary the administration sites of injections. The overuse of one particular injection site can lead to degradation of the tissue of the site. With I.V. use, this can lead to collapsed veins.[16] Once a vein has collapsed, it cannot be used again. In regard to I.M. injection use, there have been animal studies that show there is risk of permanent scarring and damage to the muscle tissue if the site is overused.[17]

It is extremely important to never inject pills as they contain pill binders that may congregate and cause blood clots and other serious bodily harm. This risk may be mitigated by the use of micron filters and extraction of the active pill ingredient, but it is not advised to inject pills of any kind. This issue is most often seen with pills that contain oxycodone. When crushed these pills may look safe to inject, but they may harbor pill binders and other materials that can clog up the veins and cause blockages in the bloodstream, resulting in circulation issues and kidney complications.[18]

I.V. injection

A diagram showing the angles that are optimal for I.V. injection. This image is from the "Getting Off Right Guide"[19]
A diagram showing the angles and positions of the body that may cause harm to the body when used for I.V. injection. This image is modified from the "Getting Off Right Guide"[20]
  • Administration sites - The most common administration site for an I.V. injection is in the body-facing side of the elbow, into the veins in the arm. The practice of injecting into extremities such as the hands, the feet, the legs, or even the pelvic area can lead to serious complications and bodily harm. The most dangerous places to inject are into the groin, the hands & feet, and the jugular veins in the neck. Injecting into the groin area is especially risky due to the femoral vein's location next to the femoral nerve and artery. The neck is the riskiest area to inject into because the jugular veins lie very close to the carotid artery, which can be fatal if injected into. Damaging the jugular veins can interfere with blood circulation to the brain. Also, veins in the legs are more likely than those in the arm to develop clots that can obstruct circulation and eventually break off and lodge in the lungs or heart, causing fatal bodily harm.
The safest injection sites for I.V. use are on the inside of the arm.
Dangers specific to I.V. drug use
  • Collapsed veins - After prolonged injection, thrombosis in the veins can occur. Thrombosis occurs when a vein’s blood flow is increasingly disrupted, creating blood clots in the lining of the vein. Eventually, the vein can become completely blocked by these clots, transforming the veins into scar tissue. This is commonly referred to as a collapsed vein.[21] To avoid this issue, the injection site should be rotated.
  • Direction of injection - One should always inject the substance towards the heart, not away from it. By injecting with the flow of blood you may avoid problems caused by creating scar tissue or clots which occur when injecting against the flow of blood in the veins [22]. If the substance flows towards against the heart, instead of away from it, it may lead to increased scar tissue and risk of infection.
Procedure
  1. Wash the hands with soap and water.
  2. Dissolve the chosen substance in water, being careful not to exceed the amount of water that the syringe can hold.
  3. Heat the solution up, sucking the solution into the syringe through the filter. Making sure that no air bubbles are present in the syringe barrel before the plunger is released is also of dire importance as air bubbles in the bloodstream can easily result in fatal injury.[23]
  4. Using a fresh needle, prepare the injection site with an alcohol swab.
  5. If using the traditional crook of the elbow injection site, one may need to apply pressure above the vein to make the vein stick out more. This is typically achieved through "tying off," which refers to the practice of wrapping a solid band or tourniquet around the upper forearm so that blood constricts and the veins become more visible.
  6. The needle will most likely have a bevel. It is important to angle the beveled edge away from the skin, so the point of the needle penetrates the vein and injects.
  7. Penetrate the skin at a 15 to 35-degree angle and always inject toward the heart.
  8. Once you have penetrated the skin with the needle, pull back on the plunger of the syringe. If there is blood present in the syringe, the needle has hit a vein and it is good to inject. If there is no blood in the syringe barrel or one feels a suck back, the needle is not in a vein; it is in subcutaneous tissue so do NOT inject! Repeat steps 1-5 until the needle hits a vein.
  9. Once the needle is in the vein, push the plunger down SLOWLY. It is highly advised not to rush the injection, especially if one is IVing a strong opiate, such as heroin.
  10. Once all of the solutions have been injected, slowly remove the needle and use a new alcohol swab to clean the injection site. There may be a little blood.

I.M. injection

  • Administration sites - Common injection sites for intramuscular injections include the buttocks, the arm, and the thigh.[24]
  • Needle length - It is important that one uses a needle that is longer than the I.V. needle in order to reach the muscle tissue.
  1. Wash the hands with soap and water.
  2. Wipe the injection site with an alcohol swab.
  3. To prepare the needle, hold the syringe with the dominant hand and pull the cover off with the other hand. Place the syringe between the thumb and first finger.
  4. Hold the skin around where the injection will be administered. With the free hand, gently press on and pull the skin so that it is slightly tight.
  5. Hold the syringe barrel tightly and use the wrist to inject the needle through the skin and into the muscle at a 90-degree angle.
  6. Let go of the skin with the other hand. Hold the syringe, so it stays pointed straight in. Pull back on the plunger a little to make sure the needle did not hit a blood vessel. The point of intramuscular injection is to inject within the muscle itself. If blood comes back into the syringe barrel, remove the needle immediately and do not inject. If possible, dispose of the needle and syringe and get a new one. When giving the second injection, use a different injection site than the first.
  7. Push down on the plunger to inject the solution. Do not push the plunger down hard and fast; some substance solutions may burn. Injecting at a slower rate reduces the pain.
  8. Once the solution is injected, remove the needle at the same angle as it went in. Re-swab the area of injection with an alcohol swab.

S.C. injection

Hold and pinch the skin to inject into the subcutaneous tissue.

Warning: This method of injection is uncommon and is strongly discouraged as the needle may break off in the skin, hit a nerve, or cause scarring, lumps, and other skin problems. Additionally, the risks of infection are greatly increased when using this method of administration.

  • Needle type - An I.V. or insulin needle length is suitable for this type of injection. Do not use a longer needle length as it can penetrate other types of tissue and cause medical problems.
  • Administration sites - The areas where S.C. injections can be administered in are the abdomen, the thigh, the lower back, and the upper arm.[25] It is important to vary the injection site to avoid infections or injuries. Seek immediate medical care if a rash develops at the injection site or swelling is present after injecting.
  1. Wash the hands with soap and water.
  2. Wipe the area where the injection will be administered with an alcohol swab.
  3. Hold the syringe in the dominant hand and grasp and pinch the skin where one will administer the S.C. injection.
  4. Inject the needle into the skin and slightly pull the plunger back. No blood should enter the syringe barrel to ensure that you are in subcutaneous tissue.
  5. Slowly inject the substance into the subcutaneous (skin) tissue.
  6. Remove the needle at the same angle that it entered and re-wipe the injection site with an alcohol wipe.

Cleaning up after injection

In order to prevent the spread of blood-borne diseases and bacterial infections, it is extremely important that one cleans up and disposes of used needles and syringe barrels properly. The needle and barrel of the syringe can hold old blood that can harbor viruses for days or even weeks.[26]

One should always re-cap their own old needle after injection to ensure that other people are not exposed to the old blood that still resides in the needle. The needle can and will cause accidental skin pricks that transmit disease. Do not let others re-cap someone's own used needle!

After the needle has been re-capped, it should be disposed of properly. Take the used needle and syringe to a medical waste/sharps disposal facility near you. Do not simply leave the needles lying around as this makes them available for re-use by others and is a possible vector for disease. Leaving needles lying around, especially if they are uncapped, also leads to an increased risk of accidental skin pricking which can cause injury, infection, or disease.

Aftercare

The injection administration site should be monitored for swelling, redness, or any other signs of infection. Seek medical attention from a doctor if you think the injection site may be infected or an abscess forms. An abscess may appear red, filled with puss, and hard and it may be a sign of a potentially serious infection. It is important to seek medical care immediately if persisting discomfort is experienced.

  • Getting tested - Regular STD tests and hepatitis B & C tests should be performed, especially if one suspects that they have injected with contaminated materials or has shared injection materials with others. Anonymous STD tests can be performed at local clinics or national organizations like Planned Parenthood.[27]
  • Proper Vein Care - One should avoid using veins that are tender, hardened, or inflamed until these veins have healed. It is important to take care of past injection sites, monitor them for signs of infection, and vary current injection sites.
  • Shooting Into the Wrong Tissue - If one misses an I.V. injection, it is important that the area is treated with a warm water soak or compress to reduce the likelihood of irritation and abscess formation. Warmth will open the capillaries and bring disease-fighting white blood cells to the affected area.

Legality

The injection of illegal drugs may lead to a higher risk of legal consequences. These consequences differ by country, state, and county. One should research the laws in their region before choosing to inject.

  • Needles and Syringes - Needles and syringes are illegal to possess without a prescription in some states and countries.[28]
  • Overdoses - If someone overdoses, the person who stays with them and calls emergency medical services will not be prosecuted. Do not simply leave a person who has overdosed to die out of fear of legal repercussions. The legal repercussions of staying with someone that has experienced drug overdose and calling emergency medical services vary by location.
    • In the United States, the states that have "good samaritan" laws (in varying degrees) protecting those that call EMS as of January 2016 are: Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oregon, Pennsylvania, Rhode Island, Tennessee, Vermont, Washington State, West Virginia, and Wisconsin.[29]
  • Naloxone - This life-saving drug is illegal to possess in some states, counties, or countries. Throughout the world, naloxone is not considered a controlled substance. In most countries, it is a prescription drug.
    • Australia: In Australia, naloxone is considered an over the counter drug and is available at most pharmacies.[30]
    • Canada: In Canada, naloxone kits are distributed in many emergency rooms and clinics.
    • United States: At a federal level in the USA, naloxone is a prescription drug. Many states have programs that make naloxone over the counter and available at request at most pharmacies. In the United States, most jurisdictions have programs to deploy naloxone to law enforcement and fire and rescue services. The states that have a naloxone access laws (in varying degrees) as of January 2016 are: Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington State, West Virginia, and Wisconsin.[31]
    • United Kingdom: In the United Kingdom, naloxone is considered a Prescription Only Medicine.

See also

External links

References

  1. Bioavailability of Drugs (howmed.net) | http://howmed.net/pharmacology/bioavailability-of-drugs/
  2. Arterial and venous cocaine plasma concentrations in humans: relationship to route of administration, cardiovascular effects and subjective effects. | http://jpet.aspetjournals.org/content/279/3/1345.short
  3. What infections can used needles or sharps pass on? (NHS.uk) | http://www.nhs.uk/chq/Pages/infections-from-used-needles-or-sharps.aspx?CategoryID=200&SubCategoryID=2001/
  4. What infections can used needles or sharps pass on? (NHS.uk) | http://www.nhs.uk/chq/Pages/infections-from-used-needles-or-sharps.aspx?CategoryID=200&SubCategoryID=2001/
  5. Abscess Infection Rates in IV Users | http://www.dermnetnz.org/topics/skin-infections-in-iv-drug-users/
  6. Overdose Prevention For Injection Drug Users (drugpolicy.org) | http://www.drugpolicy.org/resource/overdose-prevention-injection-drug-users
  7. Why Heroin Relapse Often Ends In Death - Lauren F Friedman (Business Insider) | http://www.businessinsider.com.au/philip-seymour-hoffman-overdose-2014-2
  8. Siegel, S., Hinson, R., Krank, M., & McCully, J. (1982). Heroin “overdose” death: contribution of drug-associated environmental cues. Science, 216(4544), 436–437. https://doi.org/10.1126/science.7200260
  9. 3 Potentially Deadly Spots to Shoot Up | http://drugabuse.com/iv-drug-abuse-3-potentially-deadly-spots-to-shoot-up/
  10. 3 Potentially Deadly Spots to Shoot Up | http://drugabuse.com/iv-drug-abuse-3-potentially-deadly-spots-to-shoot-up/
  11. Gangrene due to an intra-arterial injection | https://www.ncbi.nlm.nih.gov/pubmed/5057648
  12. DVT Information | http://www.medicinenet.com/deep_vein_thrombosis/article.htm
  13. Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3223775/
  14. Cotton Fever | http://www.heroinhelper.com/user/health/cotton_fever.shtml
  15. Safer injection (catie.ca) | http://www.catie.ca/en/practical-guides/hepc-in-depth/prevention-harm-reduction/safer-injection
  16. http://new.sfaf.org/tspsf/speedometer/shooters/vein_care.html
  17. Local tissue damage after intramuscular injections in rabbits and pigs: quantitation by determination of creatine kinase activity at injection sites (ncbi) | https://www.ncbi.nlm.nih.gov/pubmed/4036633/
  18. Injecting Pill Dangers | http://americanaddictioncenters.org/prescription-drugs/smoking-snorting-injecting/
  19. http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/ Getting Off Right Safety Manual (Harmreduction.org)
  20. http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/ Getting Off Right Safety Manual (Harmreduction.org)
  21. 3 Potentially Deadly Spots to Shoot Up | http://drugabuse.com/iv-drug-abuse-3-potentially-deadly-spots-to-shoot-up/
  22. Injecting Guide | https://www.anypositivechange.org/BVCSI_txtENG.pdf
  23. Embey, D. J., & Ho, K. (2006). Air embolus revisited-a diagnostic and interventional radiological perspective (bubble trouble and the dynamic Mercedes Benz sign). SA Journal of Radiology, 10(1), 3-7.
  24. What Are Intramuscular Injections? (healthline) | http://www.healthline.com/health/intramuscular-injection
  25. How To Give A Subcutaneous Injection (drugs.com) | https://www.drugs.com/cg/how-to-give-a-subcutaneous-injection.html/
  26. Safer injection (catie.ca) | http://www.catie.ca/en/practical-guides/hepc-in-depth/prevention-harm-reduction/safer-injection/
  27. STD Testing - Facts on STD Testing Procedures (Planned Parenthood) | https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/std-testing/
  28. Syringe and Needle Access in the USA | http://lawatlas.org/datasets/syringe-policies-laws-regulating-non-retail-distribution-of-drug-parapherna
  29. State Good Samaritan Laws in the USA | http://www.drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29.pdf
  30. http://www.abc.net.au/triplej/programs/hack/how-painkiller-use-becomes-a-heroin-addiction/7129964
  31. State Naloxone Laws in the USA http://www.drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29.pdf