The injection of medications and the development of intravenous infusions have saved countless lives since these tools of modern medicine were developed. It is hard to imagine medicine without them, yet they are of relatively recent origin. The first syringes were devised as tools by the ancient Greeks to drain abscesses rather than for injection of materials into the body. It is thought that a barber in Alexandria around 280 BC first used what was called pyulcos (pus-puller) in Greek. The earliest reference to the use of this technique and tool is in the first-century AD treatise Pneumatics, by Hero of Alexandria (Duffin, 1999). Alexander Wood, a Scottish physician, was first given credit for inventing the hypodermic syringe. Remarkably, his syringe, developed in 1853, was used to inject morphine for neuralgic pain control (Bellis, 2005). The association of injection with opiates thus dates back to the very start of injecting itself. The first mass-produced syringe was developed by the Becton-Dickinson company for the administration of the newly developed injectable polio vaccine, given to over one million American children, by Jonas Salk in 1954 (Bellis, 2005).
Injection as a route of drug administration provides some obvious advantages to medicine: doses can be measured precisely; the absorptive limitations of the skin, gut, or respiratory mucosa can be bypassed; and agents can be introduced directly into the bloodstream (in intravenous injection) for rapid distribution to target tissues. Indeed, "keeping veins open" (KVO) lines are used for precisely this reason - to allow rapid access to the circulatory system. But these tremendous advantages can be misused and can lead to grave complications. As the epidermal barrier of the immune system is effectively bypassed, unclean needles and syringes can result in direct inoculation of pathogens into the system. As such, risk of bacterial endocarditis in drug users, along with acquisition and transmission of classic blood-borne pathogens, including HIV, HCV HBV malaria, tetanus, and syphilis, is exacerbated in IDU. Further, the direct introduction of agents into the bloodstream means rapid intake and distribution of psychoactive agents to the brain - markedly increasing the speed and intensity of the "high," but also increasing the likelihood of overdose (with heroin) and dependence and/or addiction (with heroin, cocaine, methamphetamine, and other injectables). The greater efficiency of drug action with injected doses is one of the key drivers of transitions to injection from other less efficient means, like snorting, sniffing, or smoking drugs, and has been reported in multiple settings (Griffiths et al., 1994). As users become addicts and spend down their resources on drugs, the need to get the greatest effect from the drug used drives injection behavior. It should be clear that it is not the injection per se that leads to the most infectious disease risk for IDU; rather, it is the sharing of injection equipment with others.
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