APOTHICOM

A chacun sa couleur






Cookers


Types of cookers used


Cookers are used to mix and /or heat the solution to be injected. If sterile cookers are unavailable, drug users commonly use tea- or tablespoons or drinking cans (Scott, 2008). These items, being non-sterile, can contain bacteria or fungi, as well as residuals of other liquids. It is recommended to use sterile, single use cookers to prepare drug solutions.

The Stericup® is a sterile cooker that does not contribute to the contamination of the drug containing solution. Scott (2008) states that its fragile nature is an advantage of the Stericup. Reheated, it becomes flimsy, especially around the handle which will bend. This may prevent People Who Inject Drugs (PWID) to use it several times.


Cooker sharing


Cooker reuse is very prevalent amongst PWID (Debrus, 2008; Needle et al., 1998). Furthermore, depending on context, knowledge, culture and cooker-availability, cookers are shared by 16 to 65% of PWID (Cadet-Taïrou, 2012; Huo et al., 2005; Strike et al., 2010). Several studies found that this item is shared more frequently than other paraphernalia (Koester et al., 1990; Thorpe et al., 2002; Latkin et al., 2010; Strike et al., 2010); moreover, PWID tend to believe that cooker sharing is associated to a lower risk than syringe sharing (Latkin et al., 2010).


Cookers can be shared either for use by one person after another, or to prepare a solution for several people at the same time (batch preparation). The bigger the cooker is, the larger the risk of batch preparation. Care should be taken to provide the smallest cooker suitable for the preparation of a given drug (some drugs, mainly pills not intended for injection, need larger volumes to dissolve).

The Stericup has a capacity of 2.5 ml. Solutions of up to 1.5 ml can be heated in this cooker. The Maxicup® has a capacity of about 5 ml. Solutions of up to 4 ml can be heated in this cooker.


In addition to "deliberate" sharing (sometimes due to lack of equipment available at a given time), some situations may lead to confusion. The presence of large quantities of tools during group injection may, for instance result in confusion about their ownership, as may the fact of being under the influence of psychoactive drugs... A survey conducted in France (Debrus2008) showed that the vast majority (85%) of PWID has already injected in the presence of other injectors and 45% of them have ever had adoubt about the ownership of the equipment used. Distribution of tools with different colours can allow PWID to differentiate the material used. As reuse seems to be rather a rule than an exception, the colours will enable people to, at least, reuse their own material. The colours also provide a visual support of the message not to share any harm reduction tools.


The harms associated with cooker sharing


Blood born viruses (BBVs)


Shah et al. (1996) have detected HIV antibodies, DNA and/ or RNA on 14 to 54% of the used cookers they examined. Epidemiological research also showed an association between cooker sharing and HIV. Seropositive persons are more likely to have shared cookers than seronegative persons (Vlahov et al., 1997). The majority of the research done does not differentiate cookers from other paraphernalia such as filters and water for injection. Both McCoy et al. (1998) and Faran et al. (1998) found a strong association between the sharing of paraphernalia (cookers, water or filters) and HIV transmission.


Heating of the drug containing solution for more than 15 seconds may inactivate the HIV virus (Clatts ea, 1999). The same authors recommend the use of thin cookers that reach the inactivation temperature the fastest for any given combination of volume and heat source.


As for the HCV virus, Crofts et al. (2000) have shown the presence of this virus on used cookers. Doerrbecker et al. (2013) have shown that HCV can remain both present and infectious, even after rinsing.


The correlation between cooker sharing and HCV contamination has been confirmed by several epidemiological studies. Hagan et al. (2001) studied the sharing of cookers and filters (combined) and found an elevated risk for HCV seroconversion (adjusted relative risk of 5.9). Cohort studies found cooker sharing to be a strong predictor for HCV seroconversion (adjusted relative risk of 3.5-Thorpe et al., 2002; adjusted relative risk of 2.76 – Hagan et al., 2010). Pouget et al (2012), in a meta-analysis of 7 scientific publications on hepatitis C seroconversion in association to cooker sharing (including the above articles) found a relative risk of 2.42.


On the contrary to HIV, heating of the solution in a drug using context will not inactivate the hepatitis C virus (Song et al., 2010).


Other risks


Any non-sterile cookers (makeshift cookers or the reuse of cookers), even when they are not shared, can be contaminated by bacteria. Bacteria present in drug paraphernalia, when injected, can lead to life-threatening bacterial infections, including abscesses, cellulitis, bone and joint infections, or endocarditis (Gordon and Lowy, 2005).


Recommendations


The supply of single use cookers potentially reduces the transmission of BBVs and other infections and improves the hygiene of injection preparation. Strike et al. (2013) provide several recommendations which we have completed here: 

  • Provide individually packed, sterile cookers with a heat resistant handle.
  • To reduce contamination, a new sterile cooker should be used for every injection. Cookers should thus be distributed in the quantity requested by PWID, without limitation on the number of cookers distributed. One sterile cooker should be provided with every sterile needle.
  • People should be encouraged, but not be obliged to come back and dispose of their paraphernalia as bio-waste materiel at the needle exchange program.
  • Procedures to clean cookers can reduce the amount of pathogens present but will be unable to eliminate germs or virus at 100%.
  • Offer cookers of the size needed by the participants of your harm reduction program, and inform your clients on the differences and least harmful options.
  • Encourage people to use the smallest cooker possible (depending on the drug they inject) and advice to avoid or reduce batch preparation. The Stericup is smaller than the Maxicup and should be preferred if feasible.
  • Provide cookers which are thin to avoid reuse and to increase the temperature reached when the cooker is heated.
  • Provide cookers of different colours to remind clients that they are for personal use and to enable them to do so, even in confusing situations.
  • Provide harm reduction information on the use of cookers and the associated risks.
  • Provide other harm reduction tools such as syringes, filters, acids, sterile water for injection, alcohol pads…


References


Cadet-Taïrou A (2012) Résultats ENa-CAARUD 2010 - Profils et pratiques des usagers. Notes d'information SINTES, OFDT


Clatts MC, Heimer R, Abdala N, Goldsamt LA, Sotheran JL, Anderson KT, Gallo TM, Hoffer LD, Luciano PA, Kyriakides T (1999) HIV-1 Transmission in Injection Paraphernalia: Heating Drug Solutions May Inactivate HIV-1. JAIDS 22(2): 194


Crofts N, Caruana S, Bowden S, Kerger M.(2000) Minimising harm from hepatitis C virus needs better strategies.BMJ. 2000 Oct 7;321(7265):899


Debrus M (2008) Impact de nouveaux outils sur les risques de l’injection. Gestion des risques liés au saignement après l’injection. Prévention des risques de partage accidentel. www.apothicom.org/downloads/IMPACT%20DE%20NOUVEAUX%20OUTILS%202008.pdf


Doerrbecker J, Behrendt P, Mateu-Gelabert P, Ciesek S, Riebesehl N, Wilhelm C, Steinmann J, Pietschmann T, Steinmann E.(2013)Transmission of hepatitis C virus among people who inject drugs: viral stability and association with drug preparation equipment. J Infect Dis.207(2):281-187


Faran E, Archibald C, Razaque A, Sandstrom P (2009) Factors associated with an explosive HIV epidemic among injecting drug ysers in Sargodha, Pakistan. JAIDS. 51(1): 85-90


Gordon RJ and Lowy FD (2005) Current concepts. Bacterial infections in drug users. A review. N Engl J Med 353(18): 1945-1954


Hagan H, Pouget ER, Williams IT, Garfein RL, Strathdee SA, Hudson SM, Latka MH, Ouellet LJ. (2010) Attribution of hepatitis C virus seroconversion risk in young injection drug users in 5 US cities. J Infect Dis.201(3):378-385


Hagan H, Thiede H, Weiss NS, Hopkins SG. Duchin JS, Alexander ER (2001) Sharing of Drug Preparation Equipment as a Risk Factor for Hepatitis C. Am J Public Health.91: 42–46


Huo D, Bailey SL, Hershow RC, Ouellet L. (2005) Drug use and HIV risk practices of secondary and primary needle exchange users. AIDS Educ Prev. 17(2):170-184


Koester S, Booth R, Wiebel W (1990)The Risk of HIV Transmission from sharing water, drug mixing containers and cotton filters among intravenous drug users. International Journal on Drug Policy. 1 (6) : 28-30


Latkin CA, Kuramoto SJ, Davey-Rothwell MA, Tobin KE (2010) Social norms, social networks, and HIV risk behavior among injection drug users. AIDS Behav. 14(5):1159-1168


Pouget ER, Hagan H, Des Jarlais DC (2012) Meta-analysis of hepatitis C seroconversion in relation to shared syringes and drug preparation equipment. Addiction. 107 (6) : 1057-1065


McCoy CB, Metsch LR, Chitwood DD, Shapshak P, Comerford ST. (1998) Parenteral transmission of HIV among injection drug users: assessing the frequency of multiperson use of needles, syringes, cookers, cotton, and water. J Acquir Immune Defic Syndr Hum Retrovirol. 18 Suppl 1:S25-29


Needle RH, Coyle S, Cesari H, Trotter R, Clatts M, Koester S, Price L, McLellan E, Finlinson A, Bluthenthal RN, Pierce T, Johnson Y, Jones TS, Williams M (1998) HIV Risk Behaviors Associated with the Injection Process: Multiperson Use of Drug Injection Equipment and Paraphernalia in Injection Drug User Networks. Substance Use & Misuse. 33(12): 2403-2423


Scott J. (2008) Safety, risks and outcomes from the use of injecting paraphernalia. Scottish Government Social Research. 2008 (www.scotland.gov.uk/socialresearch)


Shah SM, Shapshak P, Rivers JE, Stewart RV, Weatherby NL, Xin KQ, Page JB, Chitwood DD, Mash DC, Vlahov D, McCoy CB (1996) Detection of HIV-1 DNA in needle/syringes, paraphernalia, and washes from shooting galleries in Miami: a preliminary laboratory report. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 11, (3), 301-306


Song H, Li J, Shi S, Yan L, Zhuang H, Li K (2010) Thermal stability and inactivation of hepatitis C virus grown in cell culture.Virology Journal 2010, 7:40


Strike C, Buchman DZ, Callaghan RC, Wender C, Anstice S, Lester B, Scrivo N, Luce J, Millson M (2010) Giving away used injection equipment: missed prevention message? Harm reduction journal. 7: 2


Strike C, Hopkins S, Watson TM, Gohil H, Leece P, Young S, Buxton J, Challacombe L, Demel G, Heywood D, Lampkin H, Leonard L, Lebounga Vouma J, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D, Tzemis D, Zurba N. (2013) Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: Part 1. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada.


Thorpe LE, Ouellet LJ, Hershow R, Bailey SL, Williams IT, Williamson J, Monterroso ER, Garfein RS. (2002) Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. Am J Epidemiol. 155(7):645-653


Vlahov, D, Junge B, Brookmeyer R, Cohn S, Riley E, Armenian H, Beilenson P (1997) Reductions in High-Risk Drug Use Behaviors Among Participants in the Baltimore Needle Exchange Program. Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology. 16 (5): 400-406



 
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