Going into the groin: Injection into the femoral vein among people who inject drugs in three urban areas of England

Highlights

• 53% reported ever groin (femoral vein) injecting; 41% in preceding month.

• The most common reasons were “Can’t get a vein elsewhere”, “discreet” and “quicker”.

• Half first injected into the groin within 5-years of starting to inject.

• 1 in 10 started groin injecting at the same age that they started injecting.

• For some groin injecting may now be by choice, and not the last resort.

Abstract

Background

There have been increasing concerns about injection into the femoral vein – groin injecting – among people who inject drugs in a number of countries, though most studies have been small. The extent, reasons and harms associated with groin injecting are examined.

Method

Participants were recruited using respondent driven sampling (2006–2009). Weighted data was examined using bivariate analyses and logistic regression.

Results

The mean age was 32 years; 25% were women (N = 855). During the preceding 28 days, 94% had injected heroin and 13% shared needles/syringes. Overall, 53% reported ever groin injecting, with 9.8% first doing so at the same age as starting to inject. Common reasons given for groin injecting included: “Can’t get a vein elsewhere” (68%); “It is discreet” (18%); and “It is quicker” (14%). During the preceding 28 days, 41% had groin injected, for 77% this was the only body area used (for these “It is discreet” was more frequently given as a reason). In the multivariable analysis, groin injection was associated with: swabbing injection sites; saving filters for reuse; and receiving opiate substitution therapy. It was less common among those injecting into two body areas, and when other people (rather than services) were the main source of needles. Groin injection was more common among those with hepatitis C and reporting ever having deep vein thrombosis or septicaemia.

Conclusions

Groin injection was common, often due to poor vascular access, but for some it was out of choice. Interventions are required to reduce injecting risk and this practice.

Introduction

People who inject drugs (PWID) can have difficulty maintaining access to their peripheral veins (Harris and Rhodes, 2012). Problems with accessing peripheral veins may result in people making several injection attempts or using multiple areas of the body for injection (Darke et al., 2001, Harris and Rhodes, 2012, Maliphant and Scott, 2005). Injecting into central veins, such as the femoral vein (“groin injecting”), was generally regarded as the “last resort” for those who had no other options left, as a consequence of the vascular damage that can result after injecting over a long period of time (Darke et al., 2001, Maliphant and Scott, 2005, Rhodes, 1995).

In the United Kingdom (UK), groin injecting has gone from being an uncommon practice among PWID in the 1990s (Rhodes, 1995), to one which was reported by up to half of those surveyed in the mid-2000s (Maliphant and Scott, 2005, Rhodes et al., 2006). In part, this change may reflect an ageing cohort of PWID in the UK. However, for a few, injecting into the groin was reported to be occurring relatively soon after they had first started to inject, and for some, such as those injecting heroin and crack combinations, it may have become an “acceptable risk” (Rhodes et al., 2006, Rhodes et al., 2007). Increases in injecting into the femoral vein have been documented among PWID elsewhere. Recent reports indicate that 20% of those sampled in Seattle, USA, 31.5% of those sampled in Iran, and 34% of those sampled in Bangkok, Thailand, reported current injection into the groin or femoral vein (Coffin et al., 2012, Karimi et al., 2014, Ti et al., 2014).

Injecting into the groin may occur for reasons other than difficulties with vascular access elsewhere on the body. Injecting into the groin can be viewed as discreet – as the groin is a part of the body rarely seen by others – without clearly visible signs of injection such as ‘track marks’ (Coffin et al., 2012, Rhodes et al., 2007). In addition, groin injection can also be seen by PWID as being an ‘easy hit’ or as possibly giving a superior ‘rush’ (Coffin et al., 2012, Maliphant and Scott, 2005, Rhodes et al., 2007). This is because injecting into the femoral vein, due to the large size of this vein (which also allows the development of a sinus tract), is relatively simple and less likely to result in a missed ‘hit’ or having to repeatedly try to inject. Thus groin injection can be seen as both a discreet and a quick option.

Injecting into the femoral vein has been associated with a number of health problems (Coffin et al., 2012, Senbanjo and Strang, 2011); including damage to the vein and to the femoral artery, infections and circulatory problems. Health problems including deep vein thrombosis (DVT; McColl et al., 2001), abscesses (Mackenzie et al., 2000), chronic venous disease (Pieper et al., 2009), and necrosis of the femoral artery (Mullan et al., 2008) have been reported among those injecting into their groin. PWID are often unaware of the risks of developing these problems (Williams and Abbey, 2006) and often delay accessing services in response to injecting related problems (Hope et al., 2014b).

The few previous studies that have examined the extent of groin injection have had small sample sizes or had recruited using simple convenience sampling approaches, usually through healthcare settings. This study recruited a comparatively large sample of PWID from the community using respondent driven sampling (RDS), a form of structured chain referral sampling which aims to adjust for selection biases that may arise from convenience surveys (Heckathorn, 1997, Salganik and Heckathorn, 2004). This quantitative study purposively collected detailed data on current injecting practices, including groin injection, to examine the associations between injecting practice and the reasons for injecting into the groin. It also examined the medical complications associated with this practice. This paper describes (a) the extent of groin injection; (b) the reasons given for injecting into the groin; (c) the factors associated with current groin injection; and (d) the health harms associated with groin injecting.