Heroin-gel capsule cocktails and groin injecting practices among ethnic Vietnamese in Melbourne, Australia.
ABSTRACT Evidence of harms associated with temazepam gel capsule injecting among injecting drug users in Australia led to its withdrawal from manufacture in Australia. Subsequently, diphenhydramine gel capsule injecting was identified among a subset of ethnic Vietnamese injecting drug users.
Observational fieldwork around an active street-based illicit drug marketplace together with targeted purposive sampling enabled 66 ethnic Vietnamese injecting drug users to be recruited for in-depth interview.
Data revealed that the injection of gel capsules increases exposure to non-viral infections. Analysis of participant interviews show how participants have established their own ways of reducing these harms including thinning the drug solution by jacking regularly during injection. Controversially, femoral vein administration of diphenhydramine-heroin cocktails was also seen as a harm reduction strategy by participants.
Health education campaigns to address the potentially negative consequences of gel capsule groin injection will not be successful unless health workers and policy makers work with drug users and incorporate local understandings and meanings of risk in health promotion activities.
- [show abstract] [hide abstract]
ABSTRACT: Pleasure and its pursuit provide the key explanatory frame in this ethnographic analysis of temazepam injection among a set of drug injectors who enthusiastically embrace high-risk practices. The foregrounding of pleasure challenges key assumptions of harm reduction: namely, the 'rational' subject and the privileging of health as a universal good. In this paper I problematise the concepts of pleasure and conventional understandings of rationality. Interrogating these concepts through the actions and accounts of temazepam injectors, I argue that the model of the subject implicit in harm reduction does not sufficiently account for their everyday social practices. The paper draws on ethnographic research among heroin user/sellers of Vietnamese ethnicity in a local Australian heroin marketplace. Temazepam was used in combination with heroin to enhance the experience of intoxication. Intense intoxication was desired for the pleasurable bodily sensations and emotional feelings it produced. The transgressive and dangerous nature of the practice added to its pleasure. Injection of temazepam capsules was also one of the practices constituting as well as expressing central social and cultural processes of heroin use in this particular social field. Despite embodied awareness of the harms associated with temazepam injection, these people were prepared to sacrifice 'health' for the pleasures they perceived to be afforded by injecting the gel capsules. My ethnographic analysis suggests that if harm reduction is to respond to high-risk practices such as these, then attention needs to be paid to the pleasures people derive from their practices, and to the social and cultural values these constitute and express.The International journal on drug policy 12/2007; 19(5):367-74. · 2.54 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Temazepam capsules have become a popular choice for benzodiazepine injection by injecting drug users, and serious vascular and tissue damage leading to ulcers and gangrene can result. We compared the self-reported benzodiazepine injecting behaviour of 91 heroin users with their Pharmaceutical Benefits Schedule (PBS) records for the preceding 5 years. We found that individuals prescribed PBS temazepam capsules were more likely to report injecting benzodiazepines than individuals who had either not been prescribed PBS temazepam capsules or had been prescribed PBS temazepam tablets. These results provide empirical support for the argument to limit the prescription and supply of temazepam capsules in Australia.Drug and Alcohol Review 07/2003; 22(2):153-7. · 1.55 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: This paper discusses research findings on non-biological risk factors associated with illicit drug use. There is an established body of North American research in this field, and a growing European literature. We find that there is an interplay of individual and environmental factors associated with drug use, with the permeation of their interactions potentially limitless. Within the behavioural science literature, we identify three main analytical dimensions for understanding ‘risk factors’. These are: ‘intrapersonal’; ‘micro-environmental’; and ‘macro-environmental’. We note that it is not new to emphasize drug use as a social activity, involving social interactions within particular social environments, but that, despite this, the balance of focus in research tends towards ‘extra-environmental’ or ‘individualistic’ interpretations. We emphasize that future research is best oriented towards generating data of practical value for the development of interventions rather than attempting to delineate causative factors. The failure of most risk factors research rests in its incapacity to capture the variety of social and environmental influences on drug use, and the relevance of these for developing socially appropriate interventions. In addition to recognizing the importance of targeting interventions towards ‘high risk’ populations and ‘high risk’ forms of drug use, we emphasize throughout the importance of the ‘risk environment’ in mediating patterns of drug use.07/2009; 10(4):303-329.
International Journal of Drug Policy 20 (2009) 340–346
Contents lists available at ScienceDirect
International Journal of Drug Policy
journal homepage: www.elsevier.com/locate/drugpo
Heroin–gel capsule cocktails and groin injecting practices among ethnic
Vietnamese in Melbourne, Australia
Peter Higgsa,b,e,∗, Robyn Dwyerc,b, Duyen Duongb, My Li Thachb, Margaret Hellardb,
Robert Powerd, Lisa Mahere
aDepartment of Epidemiology and Preventive Medicine, Monash University, Australia
bCentre for Epidemiology & Population Health Research, The Burnet Institute, Australia
cNational Drug Research Institute, Curtin University of Technology, Australia
dThe Centre for Harm Reduction, The Burnet Institute, Australia
eViral Hepatitis Epidemiology and Prevention Program, National Centre in HIV Epidemiology and Clinical Research, UNSW, Australia
a r t i c l ei n f o
Received 19 December 2007
Received in revised form 26 May 2008
Accepted 29 May 2008
Gel capsules injecting
Street drug market
a b s t r a c t
Background: Evidence of harms associated with temazepam gel capsule injecting among injecting drug
users in Australia led to its withdrawal from manufacture in Australia. Subsequently, diphenhydramine
gel capsule injecting was identified among a subset of ethnic Vietnamese injecting drug users.
Methods: Observational fieldwork around an active street-based illicit drug marketplace together with
targeted purposive sampling enabled 66 ethnic Vietnamese injecting drug users to be recruited for in-
Results: Data revealed that the injection of gel capsules increases exposure to non-viral infections. Anal-
ysis of participant interviews show how participants have established their own ways of reducing these
harms including thinning the drug solution by jacking regularly during injection. Controversially, femoral
vein administration of diphenhydramine–heroin cocktails was also seen as a harm reduction strategy by
Discussion: Health education campaigns to address the potentially negative consequences of gel capsule
groin injection will not be successful unless health workers and policy makers work with drug users and
incorporate local understandings and meanings of risk in health promotion activities.
© 2008 Elsevier B.V. All rights reserved.
Studies of injecting drug users (IDUs) in Melbourne during the
late 1990s and early 2000s confirmed that heroin–temazepam gel
capsule injecting was directly associated with injection-related
harms such as vascular damage (Aitken & Higgs, 2002; Fry &
Bruno, 2002). Regular heroin–gel capsule1cocktail injecting has
been identified in ethnic Vietnamese heroin-using populations in
Melbourne (Kelsall, Higgs, & Crofts, 1999; Kelsall, Higgs, Hocking,
of injection-related harms (Dobbin, Martyres, Clode, & Champion
De Crespigny, 2003; Feeney & Gibbs, 2002), the Australian Pharma-
∗Corresponding author at: The Burnet Institute, GPO Box 2284, Melbourne 3001,
E-mail address: email@example.com (P. Higgs).
1References to gel capsules in the paper include generic names (temazepam;
Local terms are italicised in the text.
ceutical Advisory Council (a consultative forum providing advice
to the health Minister) recommended that temazepam gel cap-
sules be restricted to an authority script which required doctors to
obtain permission before issuing a subsidised prescription (Breen,
Degenhardt, Bruno, Roxburgh, & Jenkinson, 2004). Within 2 years
had ceased in Australia (Zimmer, 2005).
late 1980s in the United Kingdom, partially as a response to reports
that the injection of liquid from temazepam capsules (sometimes
with heroin as a cocktail) was associated with increased HIV risk
(Klee, Faugier, Hayes, Boulton, & Morris, 1990), liquid-filled cap-
sules were replaced with semi-solid gel capsules, ostensibly to
& Strang, 1999). Temazepam in gel form was withdrawn several
years later in response to continuing evidence of harms among
injectors (Ruben & Morrison, 1992; Strang, Griffiths, Abbey, &
in the purchase and injection of diphenhydramine gel, an antihis-
tamine sleep-aid, available over-the-counter (OTC) in capsules at
0955-3959/$ – see front matter © 2008 Elsevier B.V. All rights reserved.
P. Higgs et al. / International Journal of Drug Policy 20 (2009) 340–346
pharmacies (Matheson, Bond, & Pitcairn, 2002; Pates, McBride, Li,
& Ramadan, 2002; Roberts, Gruer, & Gilhooly, 1999). Despite pub-
lished reports that suggested diphenhydramine had a low abuse
potential (Jaffe et al., 2004), Thomas, Nallur, Jones, and Deslandes
(2008) found evidence of its misuse.
Among Melbourne-based ethnic Vietnamese heroin injectors,
a similar increase in the use of diphenhydramine gel capsules
– locally known by their Australian brand name, Unisom – also
occurred as a direct outcome of the reduced supply and subse-
in 2003 (Hellard et al., 2006), at least monthly injecting of heroin
in combination with either temazepam gel capsules or diphenhy-
dramine gel capsules was reported by 28% of ethnic Vietnamese
heroin users. Apart from a 2006 study which found that 71%
of other participants recruited in Melbourne reported injecting
heroin–diphenhydramine cocktails in the month preceding inter-
view (Dwyer et al., 2007) there are no other published reports of
Combined heroin and gel capsule (temazepam and/or diphen-
hydramine) injecting has become a common practice among a
sub-group of ethnic Vietnamese injectors who are regular par-
ticipants in an active street-based drug market located in the
Melbourne suburb of Footscray. This environment has been pre-
viously associated with high levels of drug-related harm (Aitken,
Moore, Higgs, Kelsall, & Kerger, 2002). In this paper we explore the
emergence of the injection of diphenhydramine gel capsules in this
population. The first section explains the origins of this practice
with a focus on the street scene, as well as describing the transi-
tion from temazepam to diphenhydramine injecting. Secondly, we
present data on the practice of groin injecting and its links with
benefits of diphenhydramine injecting are presented. Finally, we
document localised harm reduction strategies employed by par-
ticipants to minimise the perceived harms associated with this
Data were collected between January 2004 and June 2007 as
part of a larger study investigating culture and risk among IDUs
of Vietnamese ethnicity in Melbourne (n=84). Participants were
eligible for the study if they reported injecting drugs in the pre-
vious 6 months and were recruited through snowball sampling
based on street and social networks (Watters & Biernacki, 1989).
fieldwork observations. Data include field notes based on obser-
vations and conversations with drug market participants, and
transcripts of in-depth interviews with ethnic Vietnamese heroin
users. Interview participants were reimbursed $AUD20 for time
and travel expenses. Interviews lasted between 15 and 45min and
were digitally recorded and transcribed. Informed consent was
obtained from all participants and ethical approval for the study
was obtained from the Department of Human Services (Victoria)
Human Research Ethics Committee and the Monash University
Standing Committee on Research Involving Humans.
Data analysis followed the general tenets and principles of
grounded theory (Strauss & Corbin, 1990). Field note and interview
transcripts were read and re-read and emerging themes discussed
and refined by the authors to develop an initial coding scheme.
Data were formally coded by the first and senior authors using
derived themes. Data from 62 participants, all of whom reported
injecting heroin in combination with diphenhydramine gel cap-
are pseudonyms. Twenty-one participants were interviewed on
more than one occasion (range 1–5 interviews); participants were
aged between 18 and 40 years (median age 27 years); and women
constituted one-quarter of the group (n=16). Participants reported
injecting heroin–diphenhydramine cocktails for an average of 29
months (range 6–96 months), and over 75% reported a combined
heroin–diphenhydramine cocktail as the last drug injected.
Origins of diphenhydramine injecting
increased and widespread injection of Unisom by ethnic Viet-
namese heroin injectors in the Footscray street scene. The
well-documented disruption to the heroin supply in Australia in
late 2000–early 2001, produced a general increase in temazepam
use (Fry & Bruno, 2002) among heroin injectors. In Melbourne, the
practice was particularly prevalent among ethnic Vietnamese and
suggested that its continuation was, in part, accounted for by eth-
nic Vietnamese injectors’ position in the heroin marketplace. Many
among this group supported their heroin use through street level
dealing. By supplementing heroin with temazepam, participants
had more heroin available for resale. During 2003–2004, when
restrictions on temazepam resulted in reduced availability of the
gel capsules, ethnic Vietnamese injectors in Footscray began sub-
stituting temazepam with diphenhydramine as a ‘back-up’ drug.
Heroin availability remained generally stable, although fieldwork
indicated there were regular short-lived interruptions to supply.
In a study of temazepam and heroin injection conducted in this
same drug marketplace (Dwyer, 2007), ethnic Vietnamese heroin
users drew a direct link between the heroin shortage and their use
of temazepam. When heroin was in short supply and purity was
low, temazepam was used as a supplement to increase feelings
of intoxication. In our study, some participants made similar link-
ages between periods of reduced availability and the injection of
simultaneously occurringconditionsledto the
[Why did you start injecting Unisom?] Because of that drought.
Not the first drought in 2000, but the most recent one now
[August 2006]. Because of that. Someone said ‘have a whack
with this [Unisom]’. (Luong, male, 20 years)
Unisom were generally mixed with heroin—typically a single
capsule per injection. Participants reported being taught how to
inject gel capsules by friends:
him. I was short [didn’t have sufficient money] that day and if
you’re hanging [craving heroin] then you’re like just looking for
anyone you know who can afford to shout. It was lucky. Like,
that day he has some Unisom as well and tells me to ‘Try this, it
makes it last longer’. So I did, and it gets you more tired and so
you are phe [intoxicated] longer. (Cuong, male, 22 years)
While Normison was only one of three brands of temazepam
speaking Vietnamese, they used the word trung (egg) because the
capsules are the same shape as eggs. The word trung was also
used when referring to Unisom. Both temazepam and Unisom
were also referred to as thuoc ngu (Western sleep medicine). This
categorisation of drugs from two different drug classes – benzodi-
P. Higgs et al. / International Journal of Drug Policy 20 (2009) 340–346
azepines and antihistamines – into the same general class of ‘sleep
medicine’ meant that they were considered commensurate. Qual-
itatively, people described the drug action effects of normies and
unis as similar, but with normies being the ‘stronger’ of the two.
The sensations and feelings participants had learnt to associate
learnt to draw out from the range of possible diphenhydramine
macologically different, the gel capsule formulation makes the
tine which participants also strongly identified with the injecting
of gel capsules.
Kinh was in the mall today and I overheard him ask some of
the regulars if they know anyone who wanted to buy normies.
It was clear from the bright blue contents in his hand that he
was selling Unisom. I asked him why he called them ‘normies’
when they weren’t, and he replied that the “gel caps mean we
mix them up the same as the normies. That’s why I call them
that.” (Field notes, 15 June 2006)
During the research period, boxes of eight Unisom cap-
sules (each containing 50 milligrams (mg) of diphenhydramine
hydrochloride) sold through pharmacies for $AUD12 to $AUD15.
By the middle of 2006, growing awareness among pharmacy staff
chases had become severely limited, especially for participants in
[Can you get them over the counter?] No. Asians can’t get them.
If Asians ask for it, they [pharmacists] think it’s a drug. (Hung,
male, 23 years)
Right now a lot of people are getting it [Unisom], so it’s going to
get harder. The chemists are catching on, so pretty soon they’re
going to stop selling them. Actually, a couple of days ago my
friend tried to get it and the pharmacist said ‘We’ve run out’.
(Tri, male, 21 years)
The unusual practice of requiring a prescription for an OTC
drug emerged as a result of government campaigns educating gen-
eral practitioners and pharmacists about the potential misuse of
macies were asking for photo-identification and allowing only one
box a week to be purchased without a prescription.
Our participants primarily obtained their Unisom gel capsules
from black market sources. Involvement in heroin distribution
placed them in contact with Unisom suppliers—usually Anglo-
Australians looking to purchase heroin. This meant participants
could swap heroin or pay cash for Unisom, which commonly sold
for $AUD10 each or $AUD20 for three capsules. Most participants
ited time to spend waiting in doctors’ surgeries hoping they could
convince a doctor to write them a prescription. For this group, ‘doc-
tor shopping’ was not an option and their position as street level
dealers enabled them to buy what they needed:
I can’t be bothered with it you know. My English not that good,
so it’s hard when you go to the Aussie doctor. The Asian one
more okay. But you still have to have a long story, and then,
sometimes, they not give it to you anyway. So I stopped [going
to the doctor for this] a long time ago. (Kinh, male, 39 years)
There seems to always be someone out looking to selling unis
[Unisom] and then, if not, we can always ring Anna, then she
delivers to us here. (Khuyen, male, 24 years)
quality of temazepam transactions on entering the Footscray
drug marketplace in 2003. Although diphenhydramine had largely
I was surprised to see Thao out there today looking to buy Uni-
som. Everyone she went past, she had to ask if they had any.
After about half an hour, an older guy, who is here regularly,
came through the mall with two boxes. He got swamped, sold
out in less than five minutes, but Thao was first in line so she
got her two for $20. (Field notes, 6 July 2006)
I lost the veins in my arms and moved to the neck, then to the
leg, and now I use in the groin. (Cao, male, 27 years)
Coinciding with the transition from injecting heroin to inject-
ing heroin–gel capsule cocktails, participants in this study also
reported switching from injecting in their arms to injecting in their
groins. Our data suggest several interrelated reasons for this prac-
tice. Firstly, normie injecting among some of this group, prior to
the reduction in quality and supply of heroin in late 2000–early
2001, meant that many participants had already switched (Aitken
& Higgs, 2002). Participants reported that damage to their usual
injecting site meant a different vein was required:
I just don’t want to use the hands all the time. They gets blocked
up. And for safety reasons. [What do you mean by safety?] From
blockage mainly, you know what I mean? They collapsed. I
couldn’t use them any more. With the gel, it was just three or
four times, then they collapse. (Huy, male, 21 years)
I used it in the groin because I couldn’t use it in my arm. That’s
the only reason why. If I could use it in my arm, I wouldn’t be
using my groin. (Tuyet, female, 26 years)
In describing how groin injecting has become increasingly nor-
malised for some IDUs in the United Kingdom, Rhodes et al. (2006)
and Rhodes, Briggs, Kimber, Jones, and Holloway (2007) outline
five reasons for this practice, all of which were also reported by
participants in our study. These include ‘the sure shot’; speed and
is done while finding a vein; and acceptable and normalised use of
this vein (Rhodes et al., 2006, p. 166). Participants in the current
study reported that the main reason for using their femoral vein
was the high likelihood of, and swiftness in, finding the vein:
These guys [pointing to her friend Phuoc] are expert at that
[injecting into the groin]. They just, like, take one shot and they
Others reported previously experiencing frustration over the
length of time it took to administer injections because of poor
Other veins just take too long. Sometimes you’re lucky [finding
the vein], just takes five minutes. Sometime ten minutes, some-
P. Higgs et al. / International Journal of Drug Policy 20 (2009) 340–346
times takes a couple hours. That’s why I swap, I don’t want to
waste too much time. (Vinh, male, 29 years)
Participants reported certainty and consistency by switching to
injecting into the groin:
[W]here you’ve been going in, you have the scar and then, you
female, 21 years)
The relative speed and convenience of groin injecting may be
particularly attractive to street-based injectors exposed to a high
risk of disruption and/or arrest (Rhodes et al., 2006). Some par-
ticipants also valued the discretion afforded by groin injecting,
allowing them to conceal their injecting from families and the
Because I don’t want using that one [the arm]. Too many people
can see it, cops, my mum, you know. (Nhon, male, 26 years)
It was common for younger participants (those aged under 25
years) to report making the transition to groin injecting soon after
initiating injecting, as Diep explained:
About a month and a half [to move to groin injecting]. Because,
like, I was using the Unisom for that and the veins in my arms
just collapsed. [Just from Unisom?] From the Unisom. Just that
one thing, everything just all collapsed. (Diep, female, 21 years)
As injection of heroin in combination with gel capsules had
been widely practiced within this social group for at least 8 years,
many new injectors were quickly exposed to the practice of ‘cock-
tail’ injection. This contrasts with older injectors who commenced
injecting prior to the introduction and diffusion of gel capsule
injection. Younger, newer injectors were therefore more likely to
commence groin injecting sooner, as it was a common feature of
the injecting repertoires of their social milieu. Rhodes et al. (2006)
also highlighted such normalisation of groin injecting.
While rare, some participants injected their first gel capsule via
It was the first time, and they say to me, at that time they say, ‘If
you use the vein [in the arm], you lost a vein. Better to use this
one [groin]’. (Ly, male, 23 years)
For most participants, groin injecting had become the most
efficient and preferred way to inject, although they could still be
flexible when required:
[A]lthough I usually do it in the groin, she injected for me on
my neck. It’s just there wasn’t a big fit [25 gauge long needle] so
she used a small one [27 gauge 1ml syringe] to do my neck for
me. [What was it like injecting in the neck?] It was really good.
The rush was really good. Stronger, because it goes straight up
to your brain or something. I don’t know what it is. The feeling
is different. (Huong, female, 22 years)
Perceived risks and benefits
& Rosenthal, 1999). We have evidence to suggest that by moving
from the arm to the groin, some injectors subjectively experience
a more ‘intense’ rush:
It’s quicker and it’s more intense. Sometimes, it’s like, I’m push-
ing in half the mix [drug solution] and I can feel it already.
(Quynh, female, 26 years)
The larger diameter of the femoral vein meant that participants
could inject more volume of drug solution and could do so more
confidently and quickly, which may indeed have resulted in a more
of a more intense ‘rush’ were clearly an important factor in sustain-
ing and promoting the practice of groin injection.
Many participants in our study reported direct experiences
of harm and, additionally, were aware of others’ experiences of
heroin–diphenhydramine cocktail injection. The first and most fre-
quently reported benefit was the increased intoxication and longer
induced by the cocktail:
It’s the same taste but then it’s just a lighter, milder stone. And
it gets warmer, you know what I mean, in your body. The unis
come up straight away, rush straight up. With gear alone, then
it’s just sometimes [that you experience the rush]. It depend on
your habit, do you know what I mean? Unis gives you an extra
high in a way. (Trieu, male, 33 years)
As with all opiate-dependent people, participants in the current
drawal. Our participants reported that injection of heroin–Unisom
cocktails enabled them to avoid withdrawal, or hanging out, for
longer periods, especially when the quality of the heroin was poor
or they were trying to save money by using less. However, some
participants also reported hanging out for Unisom:
If I have unis, then I have to have gear. Without them [Unisom],
I just don’t use [heroin]. (Hung, male, 22 years)
[Can you use the gear without unis at all?] No, not really. If some
days, if I’ve got the gear and haven’t got uni, I’m still hanging out
for the uni. (Hien, female 28, years)
Participants had both first-hand and indirect experience of
not flush back into the syringe when drawing back the plunger),
localised skin and soft tissue infections, deep vein thrombosis
(DVT), or systemic infections such as endocarditis.
then 2 days later I got locked up in custody. The nurse from the
cells cleaned it up and stuff like that. [And is your groin alright
now?] No, it’s gone. I’ve haven’t tried [using] it again. Maybe
it like my arm, it’s blocked, got a blood clot. It got swollen up
double size what it is normally ... I get so scared when I see and
hear all this stuff. (Trinh, female, 31 years)
Graphic evidence of these injuries was referred to by some
local health and welfare workers as the normie shuffle—the char-
acteristic limp of those of Vietnamese ethnicity who used their
groin for injecting. Diverse accounts of the causes of these
harms were related by participants, and uncertainty existed
about whether these harms were directly related to Unisom
injection or to the practice of groin injecting. Some felt that
these injuries were a direct result of the injection of gel cap-
P. Higgs et al. / International Journal of Drug Policy 20 (2009) 340–346
sules, both historically with temazepam and currently with
[And what happened? Why did you stop?] It collapsed. I couldn’t
use it anymore. With the gel, it was just three or four times with
normies, then they collapse. (Huy, male, 21 years)
Unisom gel capsules:
That’s just the bad habit of the uni. You can use [inject] it some-
where [in one part of the body] but it explode somewhere else,
you know what I mean. It’s like, [you] use in your arm, your
hand, but the infection, it can be anywhere else. It can congeal
somewhere else. It can be anywhere, my neck, my fingers, it
can be anywhere. That’s why people say it’s very dangerous for
the Unisom because when it goes into your blood system it still
congeals and it can congeal anywhere. (Diep, female 21 years)
tions’ was not commonly articulated by participants in this study.
Diep was one of several participants who had been hospitalised as
a result of injecting complications. Her explanations were based
on information provided by medical staff. Unfortunately, informa-
tion provided by health professionals was not always accurate or
relevant to participants:
what caused my blood clot. The doctor didn’t even know what
Unisom was, and so instead of him giving me information on
DVT or Unisom injecting, he gave me a handout on buprenor-
phine injecting. (Quynh, female, 26 years)
Although Quynh reported that she had explained to hospital
staff that she had been injecting diphenhydramine–heroin cock-
tails, and that her symptoms (leg swelling) had been previously
misdiagnosed as a spider bite, she claimed that she was not given
the information she required to reduce risks of further complica-
Other participants believed that it was the use of the femoral
vein, together with Unisom, which resulted in these problems:
[Why don’t you use it on your groin?] I had a bad experience with
the other one, the yellow one [Normison], a few years ago. [That
time when you had the bad experience, that was in your groin?]
Yeah, I missed and everything swelled up and you get that bad
taste and not just the bad taste, you feel like shit. (Tuyet, female,
Other recognised risks of groin injecting included the widely
reported hazard of missing the vein and injecting into the nearby
femoral artery. The associated pain was described by Diep:
When you play [inject] down here [the groin], two kind of veins,
one is an artery and one’s a capillary, or whatever. And so, you
have to find the black blood – that’s how we know. With our
knowledge, or education, we call it the black [vein] and red
[artery] blood. So we have to look for the black blood, the darker
blood. If you get the red blood, it really hurts. [So you’ve done
that?] Yeah, it just really, really hurts. Basically, I was holding
my leg, I was in such pain, you know. You know how you have
to kneel when you’re basically doing it [injecting in the groin],
and I was just basically holding my leg like this because I was in
so much pain. It really hurts when you get that red blood. (Diep,
female, 21 years)
Indigenous harm reduction practices
harm rather than a reduction in drug use per se (Lenton & Single,
1998). While not using the term ‘harm reduction’, participants
in this study articulated specific strategies which, they believed,
reduced the harms associated with injecting heroin–Unisom cock-
The most common strategy articulated in interviews involved
the actual technique of injecting, where participants would mix
and dilute the drug solution with blood, believing the warmth of
the blood made the gel solution easier to inject:
Once I’m in, I would push a quarter, and another quarter, and
when I’m down to the last quarter – [I jack] back and forward,
back and forward. [How many times?] About three or four times
until get more blood mixed into it. Since it’s a gel-based liquid,
I want it to pump around my veins properly, instead of it just
being clogged up in one place, as you can die from that. (Luong,
male, 20 years)
Luong believed that by ‘pumping’ the heroin–Unisom solution
into his veins slowly and gradually he could avoid obstructed veins
or DVT; he was clearly aware that serious health complications
could arise from clots and blockages. Huy described a similar pro-
cedure, and explains how, in his opinion, using his groin helped to
reduce potential harms:
When I inject, I just pull out more blood and because there’s a
lot more blood in the groin than the arm, so I can do that. (Huy,
male, 21 years)
As an associated harm reduction strategy, participants also
reported using more water to mix the cocktail solution than would
be the case with heroin alone. This reduced the viscosity of the
affected the types of injecting equipment favoured by participants.
As described in the field note below, Khuyen and Nhon used both
3-ml syringes and 23-gauge needle tips, as well as 1-ml syringes
with 27-gauge needle tips.
Khuyen and Nhon had just picked up [bought their drugs]. They
invited me [Peter] to come with them, and over the next 20
minutes I watched them preparing their shots [injections]. The
whole process was complicated, with each person having their
individual role. Nhon was cutting up [breaking up the required
amount of heroin from a larger supply] and then mixing the
heroin in the fit [needle and syringe] wrapper, whereas Khuyen
prepared the Unisom gels. Khuyen started by melting the bright
blue capsule, which he had pushed onto a 23 gauge needle at
the end of 3ml syringe, with a cigarette lighter flame. It was
all new equipment. Picking up the prepared 3ml syringe, Nhon
then used a 1ml syringe and front-loaded them. They each had
about 40 lines (0.4ml) of dissolved heroin mixture. They shook
the contents furiously to mix it, and then both squatted and
simultaneously injected into the right side of their groins. (Field
note, 19 June 2004)
The 3-ml syringe enabled participants to use a range of nee-
dle sizes. The 23-gauge (larger bore needle) was considered best
for extracting the gel from the capsule, while either a 25-gauge
P. Higgs et al. / International Journal of Drug Policy 20 (2009) 340–346
or 27-gauge (smaller bore needles) was preferred for injecting. All
these needle sizes were available from the local needle and syringe
[And how do you get it [the heroin solution] into the two syringes?]
It starts off in one small fit [1ml syringe], and then we put it
into two. We just got two new clean fits [3ml syringes] already
loaded with uni, then we open them [take the needle tip off],
and then just squirted through the front. (Minh, male, 29 years)
divided by back-loading the syringe.
Some participants clearly saw injecting via the groin as a harm
reduction strategy, finding that the size of the femoral vein made
injecting the heroin–gel capsule cocktail easier, particularly as the
viscous heroin–gel capsule combination required slower injection.
Participants could also use both hands when injecting, making the
process more stable:
I can hold it straight and steady much better when I shoot in
down there [groin]. It [the needle] just seemed to fall out too
easy when I inject in my arm. (Quynh, female, 27 years)
Additionally, the relatively larger diameter of a femoral vein
meant that it did not become obstructed as quickly as veins in
the arm, and made it possible to sustain the practice of injecting
heroin–gel capsule cocktails.
The injection of gel capsule preparations appears to increase
exposure to injecting related non-viral harms. Those identified in
this study, both from participants’ direct experiences as well as
boses. Like our participants, we are uncertain if this greater harm
is due to gel capsule injection, groin injecting or a combination of
Our study also has several limitations. Sampling involved
recruiting from an active street-based drug market and a major-
ity were involved in street-level dealing, meaning participants may
not be representative of all ethnic Vietnamese heroin users. It may
also be the case that participants were unable to remember events
accurately and that post hoc reasoning may also have been used to
justify participants’ behaviour.
Transitions from smoking to injecting heroin have been doc-
umented among ethnic Vietnamese in Melbourne and Sydney
(Maher et al., 2001; Sargent, Maher, Higgs, & Crofts, 2001; Swift,
Maher, & Sunjic, 1999). In this study we documented transitions
from injecting in the arms to injecting in the groin, and identi-
fied a shift from injecting heroin to heroin mixed with gel capsules
(Normison succeeded by Unisom).
Our study identified previously undocumented injection prac-
tices. For ethnic Vietnamese participants, the development and
expansion of street drug markets led to the evolution of a street-
based using culture (Maher & Dixon, 1999; Maher, Dixon, Hall,
& Lynskey, 1998). The settings or environments in which peo-
ple inject drugs constitute an important dimension of the risks
associated with their use (Rhodes, 2002; Rhodes et al., 2003).
Several studies have associated public injecting with increased
harm, including overdose, physical violence, spatial displacement
and risk of blood-borne viral infection (Maher & Dixon, 1999;
McKnight et al., 2007). The risk environment of the current study
site (Aitken et al., 2002) clearly influenced the harms associated
with heroin–diphenhydramine cocktail injection and, in particular,
administration using the femoral vein.
Participants were aware of the potential harms associated with
their injecting practices and identified attempts to reduce them,
including “jacking” or “booting” during administration in order to
dilute the drug solution (by mixing it with blood). Participants also
reported vascular damage and described specific routines, such
as replacing needles after preparing the gel capsule but prior to
injecting the cocktail, to minimise further damage.
Somewhat controversially, groin injecting was perceived by this
group as a harm reduction strategy, helping to minimise both the
risk of arrest by speeding up the process of injection and the
risk of “blocked” or obstructed veins. This conflicts with medical
McCarroll, Donovan, Rashid, & Kling, 1989), although there is some
recent debate as to whether groin injecting can be done safely
(Miller, Lintzeris, & Forzisi, 2007; Zador, 2007). Although most par-
ticipants were aware of the health-related consequences of groin
injecting, the narratives presented here suggest that from the per-
beyond health-related harms, a point made by Maher et al. (1998)
in relation to perceptions of ‘risk’ and blood-borne viruses.
A recent paper by Rhodes et al. shows how among injectors
in six English cities the groin has become a “normative, rational
and socially acceptable injection site” (Rhodes et al., 2006, p. 166).
injecting was conceived as a pragmatic response to the demands of
heroin–Unisom cocktail injection and the structural impediments
of a heavily policed, street-based injecting environment. Despite
a regular supply of heroin, participants in the current study com-
monly injected heroin mixed with diphenhydramine gel capsules.
This was because of the increased and sustained euphoria experi-
enced but also because the drug cocktail was believed to be more
effective than heroin alone in alleviating opioid withdrawal. This
paper has described participants’ understandings of the positive
and negative effects of this phenomena, highlighting the specific
strategies they used to increase drug sensation and mediate the
harms of vascular obstruction and opiate withdrawal.
Despite attempts to reduce the prevalence of gel capsule
injecting via regulatory mechanisms, such as the removal of the
Normison formulation from the Australian market, this group
of injectors appears likely to continue this practice. Attempts
to reduce the harms associated with diphenhydramine injecting
ing equipment and protective practices, including hand washing.
Education, including peer-based education, designed to increase
anatomical awareness and encourage the use of multiple injection
associated with injection-related injuries including systemic infec-
2007). Structural interventions such as supervised injection facil-
ities should also be considered for this group. Finally, indigenous
attempts to reduce the harms associated with groin injecting in
this context, including reducing the viscosity of the cocktail solu-
tion by diluting it with blood and extra water, provide useful entry
points for health workers seeking to engage this group.
The authors thank the participants in this study who gave their
time to be interviewed. We also thank Rebecca Winter, Stuart
Armstrong, the Open Family youth outreach team and the Health
P. Higgs et al. / International Journal of Drug Policy 20 (2009) 340–346
public health scholarship and a post-doctoral fellowship. Robyn
Dwyer was supported by a National Drug Research Institute Post-
graduate Research Scholarship. Lisa Maher and Margaret Hellard
are supported by a National Health and Medical Research Council
tre in HIV Epidemiology and Clinical Research is core funded by the
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