Citric acid and botulism infections

In the summer of 2000 there was an outbreak of Clostridium Novyii (a bacteria which can contaminate heroin that comes into contact with soil, and which gives off lethal toxins as it grows in the body).

During the outbreak concerns were raised about the possible role of using too much citric acid in the preparation of drugs for injection. This is because Clostridium Novyii grows best when there is dead tissue, and injecting too much citric is known to cause tissue damage.

These concerns although valid (injecting too much citric is a risk factor when people are injecting contaminated heroin), were partly responsible for the excessive caution around the supply of acidifiers and the resulting difficulty many injectors experienced until needle exchanges were able to supply it.

In January and February 2002 there was an outbreak of heroin contaminated with Clostridium Botulinum.

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Citric acid and anaerobic infections

Anaerobic bacteria
From time to time batches of heroin can become contaminated with spores of an anaerobic bacteria. There are many different types of spore forming anaerobic bacteria. Anaerobic means that they prefer environments with low or no oxygen. The fact they are spores means that they are tough and can survive for long periods (often in soil) until they find themselves in an environment in which they can grow.

Examples of this type of bacteria include literally hundreds of different types of clostridium organisms, tetanus and anthrax. These types of outbreak are rare and when they do occur will be limited by:

• The size of a contaminated batch
• The particular type of organism
• The way the drugs are used.

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Skin popping, IM injecting and 'misses'
Skin popping, intra-muscular injecting or missing a vein with contaminated heroin are particularly likely to result in the establishment of infections and should be avoided where possible. This is because oxygen levels are low in these areas and any tissue damage caused by the injecting process will make an infection more likely to take hold. If excessive acid is used in the preparation of drugs for injection, this in turn will increase the likelihood of tissue irritation and damage. It is therefore important that people only use enough acid to dissolve the drug.

Providing citric sachets during anaerobic bacteria outbreaks

Providing single use citric acid sachets is an important strategy for establishing and maintaining contact with injecting drug users, whilst promoting the message of always using the smallest possible amount of acid.

This message is reinforced by the fact that the sachets are single use, containing only about 100mg of citric acid and is strongly reinforced by written information on the sachets themselves and on the supporting literature.