We called recently for the development of ‘safer groin-injecting interventions’ targeting UK groin (femoral vein) injectors, alongside interventions to prevent transitions to groin injection [1]. Zador challenges this proposal, highlighting the serious health risks associated with groin injection, and arguing that groin injection is avoidable and cannot be carried out safely [2]. We acknowledge the serious health risks of groin injection. Our work highlights the harm produced by this practice and a consequent urgent need for harm-reducing interventions in response [1,3].

Surveys indicate that groin injection is the norm among injectors in many UK cities, especially in areas linked with crack-heroin ‘speedball’ injection [3,4]. Crucially, drug injectors will initiate and persist with groin injection in the face of serious health complications and despite warnings of clinical dangers [1,5]. Many UK drug agencies have avoided advice-giving in relation to groin injection for fear of reinforcing or encouraging it. In arguing against the development of harm-reduction interventions on groin injection, as does Zador, we miss the opportunity for reducing harm, as well as related costs associated with injection site wounds and treatment, among a considerable proportion of UK injectors who are groin injectors. Like other high-risk drug use behaviours, we need a hierarchy of prevention and harm-reduction approaches.

Clearly, safer groin-injecting interventions need to go beyond the provision of ‘safer injecting pamphlets’ to include the active engagement of injectors about the risks of groin injecting with the aim of discouraging this practice by promoting the use of lower-risk alternative injecting sites. Supervised drug consumption rooms and injectable opioid treatment clinics are uniquely placed to provide in situ and individually tailored safer injecting advice, and their use is associated with improvements in injecting technique and injecting hygiene [6,7]. In the United Kingdom, this level of intervention is available to only a minority of injectors in injectable opioid maintenance trials. We also proposed, as have others, the inclusion of specialist nurses in low-threshold drug services, including syringe exchanges, who could train groin injectors in peripheral venipuncture techniques [5], as well as provide advice on injecting site hygiene and wound care. Such interventions are worthy of pilot evaluation. Peer-delivered interventions which aim to reduce modelling of groin injection and which promote social norms supportive of using peripheral injecting sites, akin to those developed to prevent and reverse transitions in relation to injecting per se, could also be piloted [8–10].

We need to be pragmatic in how we respond to the health harms of everyday drug injecting. It is perhaps inevitable that there is a gap between that which is theoretically ‘safer’ or ‘safest’ and that which occurs in practice. Part of the function of harm-reducing interventions is to bridge this divide. The supervised drug-injecting episode, described by Zador and experienced by a small minority in the United Kingdom, may be qualitatively different from the lived experience of day-to-day injection experienced by most [2]. Our study emphasizes the everyday situational factors mediating groin injection [1]. We retain our position that the extent of vein damage associated with speedball injection combined with normative shifts towards groin injection in some UK locations warrants a hierarchy of intervention responses. This includes reducing the harms of injection among those—sometimes a majority—who continue to groin inject regularly.


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  2. References
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