Norwegian intravenous drug abuse has increased dramatically. At the beginning of the 1990s, there were between 4 000 and 5 000 intravenous drug abusers, in the year 2001 the number was estimated to be between 10 000 and 14 000. Notwithstanding close to 40 years of contacts with injecting drug abusers, I have never understood the details of the injecting per se. I have been in drug dens, seen injecting drug abusers, but never observed the injections being performed. Only when I visited Norway, I had the opportunity of closely studying the various phases constituting the injecting of heroin.

In the public debate and in research it has been overlooked that many drug abusers, when preparing the drugs, thrust their syringes into the same solution, that the solution is filtered through cotton swabs or cigarette filters, that addicts often have ulcerated skin chaps, that the intravenous abuse of drugs most often is a collective activity performed in a contagious environment.

At the “Plata” in Oslo, an open square close to the Railway Station, I could follow the drugs trade and the injecting during two weekends. At Christmas time 2003 and in March 2004, I took approximately 300 photographs. The pictures show e.g. how the drug addicts manage “patients difficult to inject”, i.e. themselves. The injection technique is occasionally highly sophisticated, which is seen in the pictures. Puncturing the vena jugulars interna seemed to be ordinary business.

In Norway a distribution of syringes and needles through the “needle bus” started already in 1988. Today, the distribution is performed at special clinics all over the country. Approximately 2 million syringes are distributed only in Oslo. Norway has – just as Sweden – the goal of a “drug-free society”, but the actual development is in the opposite direction. In February 2005 the first injection room was opened.

The main drug in Oslo is the brown heroin, which – depending on quality – requires citric acid to be prepared. Rohypnol is appreciated as a supplement.

The Rohypnol tablets had a blue protective cover. In order to dissolve the active substance, the drug abusers sucked off the coloured cover, thus the turquoise colour of their teeth.

The drug trade went on day and night, however mostly during daytime. During the night it moved further up into the adjacent street Tollbugata, where syringes and needles and can be picked up anonymously in a kiosk-like operation, commonly called “the street kitchen”, open from 11 AM to 11 PM. In spite of hundreds of drug addicts moving around the area, the atmosphere was peaceful.

Most of them were fairly “drowsy” from opiates and tranquil, except when they experience a withdrawal or a difficult business transaction. The age of those present, I estimated to vary between 18 and 50 years, and most of them had progressed far into their drug careers. During the weekend, the clientele became younger, when youngsters from other parts of the country took the train to Oslo in order to buy illegal drugs.

Staff at the needle exchange station experienced a conflict upon turning away people under the age of 18, which is the age limit for receiving free needles. I think that when a youngster lingers in a clearly unsuitable environment such as the “Plata”, he or she is to be helped out of it. Young girls, and also young men, are sought after in drug abusing coteries. When they have become dependent upon a drug dealer, they turn into a real treasure chest. The girl and the boy are sent out to make money as prostitutes or to act as middlemen in drug selling or fencing. It is easier for a young, healthy person to hide his or her criminal intentions than it is for an addict scarred by drug abuse.

When it was time for injecting, a camp was set up at the Plata. Some addicts retreated into a parking garage or sat down under lorries down by the harbour a few hundred meters away. Most of the people of whom I took photos were injecting together with one or more partners, with whom the heroin was prepared and shared. The syringe and the needle were clean when they were taken out of the package. That was, however, not the case with the spoon or the cup, where the heroin was mixed; neither were the water, the citric acid, nor the Rohypnol, which was added to the heroin.

Practice makes perfect: when necessary one drug abuser helped another to locate veins hard to find. They would inject into the head, the neck, into arms and legs, everywhere blood could be drawn from a vein. When the veins would no longer serve, the injections were taken intramuscularly.

What conclusion?

Intravenous drug abusers after a while develop skin wounds and injection scars, and they are not particularly prim and proper. If they were to protect themselves against blood borne infections, the same way as we do in the medical services, they would need not only clean syringes and needles, but also clean mixing bowls, sodium chloride and protective gloves. Of course they would then neither dip the needles into the same solution, nor have unprotected sex.

The risk of infections spreading through paraphernalia was recently addressed in a study of injecting drug addicts. Even though the syringes and needles were handed out and collected by specially trained staff and most of the addicts never shared syringes, the frequency of hepatitis C increased in the group. The scientists’ conclusion was that the needle exchange program did not curb the hepatitis infection. Instead they called for “a culturally, sensitive behavioural intervention” in order to protect addicts from the infection (Sarkar K et al., The Lancet, vol. 361, 2003).

Their conclusions are well in agreement with my observations in Oslo.

The needle exchange programme is evidently not effective in stopping the spread of either HIV not hepatitis. If anything, the needle exchange programme is likely to be treacherous in creating a false sense of security.

There are probably only two effective methods of protecting the spread of infection. The most effective method is that the individual drug abuser becomes drug-free. The best effort by society in the short run is to support regular testing and counselling among active drug abusers.

Source: SFAI Tidningen, the Official Journal of the Swedish Association for Anaesthesia and Intensive Care, vol. 11, no. 2, May 2005. Tr. J.H.