Vitamin C (ascorbic acid) is a weak organic acid which is used as an acidifier. It comes as a white powder that can be dissolved in water to form a mild acidic solution. It is available in waterproof sachets of 300mg.
Why do injection drug users use acidifiers?
Crack cocaine and ‘black tar’ (or ‘brown’) heroin are usually sold as solid crystals (rock) or powder; to inject them, the user must dissolve them in an acidic solution. Most powered, ‘white’, heroin does not require an acidifier to dissolve it in water. Common acidifiers include vitamin C, citric acid, lemon juice, and vinegar1, 2,3.
What are the problems with lemon juice and vinegar?
Lemon juice and vinegar are commonly used because they are widely available1. However, they are much harsher acids, causing more pain, irritation, and damage to the veins. Repeated damage causes veins to collapse2. A drug user may then start using more dangerous veins4, such as veins in the neck or groin, that are near major arteries. If a major artery is pierced accidentally with a needle, life-threatening blood loss can occur3. Vinegar and lemon juice may also be contaminated with bacteria or fungus. These may lead to life-threatening infections including abscesses, cellulitis and heart infections5, or eye infections causing blindness6,7.
How is vitamin C used?
The smallest amount of ascorbic acid is used to dissolve the drug in order to keep vein damage to a minimum. In a stericup or ‘cooker’ (see Cookers Q and A), the drug is combined with sterile water. Small amounts of vitamin C are added until the drug is fully dissolved. For crack, the amount of vitamin C required is about ¼ the size of the rock; however for crack and brown or black tar heroin, the amount of vitamin C needed to fully dissolve the drug varies with the purity of the drug. Heroin may be heated until the drug is fully dissolved. Crack may also be heated, but should not be boiled. Once the packet of vitamin C is opened, any left over should be thrown away, so that it does not become contaminated and cause an infection.
Why does BC Harm Reduction* Strategies and Services provide ascorbic acid?
Medical-grade vitamin C is the safest acidifier. It causes the least damage to the veins, is non-toxic, and is sterile, reducing or eliminating the harms associated with other acids2. Acidifiers are commonly shared when supplies are limited or difficult to access8. Shared acidifiers, like shared needles and other injecting paraphernalia, may transmit infections such as hepatitis C or HIV between users9,10. Single-use vitamin C packs should be available to all who need it and in a quantity to ensure sufficiency for each injection. Providing safe supplies to people who inject drugs creates a way to engage hard-to-reach and under-serviced populations in health care and social services. No studies have found that providing safe supplies makes people more likely to engage in harmful drug use.
How can vitamin C packets be ordered?
Vitamin C packets can be ordered by harm reduction distribution sites which are approved by the appropriate regional health authority. The harm reduction supply requisition form available online at the BCCDC website should be used and the vitamin C ordered at the same time as other harm reduction supplies. The completed form is faxed to BCCDC.
More information about the Canadian best practice recommendations for ascorbic acid distribution can be found here.
*See Health File #102a: Understanding Harm Reduction in the BC Health Guide for a definition of harm reduction.
1 Garden J, Roberts K, Taylor A, Robinson D. Evaluation of the provision of single use citric acid sachets to injecting drug users. Edinburgh: Effective Interventions Unit, Scottish Executive Drug Misuse Research Programme, University of Paisley. 2004.
2 Scott J. Safety, risks and outcomes from the use of injection paraphernalia. Scotland: Scottish Government Social Research. 2008.
3 Strike C, Leonard L, Millson M, Anstice S, Berkeley N, Medd E. Ontario needle exchange programs: Best practice recommendations. Toronto: Ontario Needle Exchange Coordinating Committee. 2006.
4 Darke S, Ross J, Kaye S. Physical injecting sites among injecting drug users in Sydney, Australia. Drug and Alcohol Dependence. 2001;62:77-82.
5 Gordon RJ, Lowy FD. Bacterial infections in drug users. New England Journal of Medicine. 2005;353(18):1945-1954.
6 Servant JB, Dutton GN, Ong-Tone L, Barrie T, Davey C. Candida endophthalmitis in Glaswegian heroin addicts. Report of an epidemic. Transactions of the Ophthalmological Societies of the United Kingdom. 1985;104:297-308.
7 Martinez Vazquez C, Fernandez Ulloah J, Bordon J, Sopeña B, de la Fuente J, Ocampo A, Rubianes M. Candida albicans endophthalmitis in brown heroin addicts: Response to early vitrectomy preceded and followed by antifungal therapy. Clinical Infectious Diseases. 1998;27:1130-1133.
8 Scottish Drugs Forum and Glasgow Involvement Group. Views from the street: Needle exchange users in Glasgow. 2004.
9 Shah SM, Shapshak P, Rivers JE, Stewart RV, Weatherby NL, Xin KQ, Page JB, Chitwood DD, Mash DC, Vlahov D, McCoy CB. Detection of HIV-1 DNA in needles/syringes, paraphernalia, and washes from shooting galleries in Miami: A preliminary laboratory report. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1996;14(3):301-306.
10 Thorpe LE, Ouellet LJ, Hershow R, Bailey SL, Williams IT, Williamson J, Monterroso ER. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. American Journal of Epidemiology. 2002;155(7):645-653.