 In the medical community, we frequently are real happy with talking to people about stopping using. We are excited when they are sober and come to our clinics and talk to us then. We don't really have the same kind of comfort level of what to do when people are sick and using and actively using, and we see them in that moment. And since not everybody's ready to stop today or is able to stop today, that's really an opportunity where we could be doing more. When I have somebody in front of me that I'm working with who is actively using, I ask them lots of questions about the details of their use. So when I'm talking to somebody who's using cocaine regularly and I want to know what kind of acid are you using to break down the cocaine, they kind of look at me like, oh, you know what's up. And then we have much more of a conversation because that knowledge of how people are using is not widespread in our community. A lot of the folks that are using on the streets don't have a lot of trust with the medical community. And just by informing ourselves and being able to share that with folks, we open a doorway that can be leveraged for everything, all the stuff that we want in reducing harm and treatment and just primary care, getting people engaged so that they can get good health outcomes. Some people who use drugs may not be ready or able to stop using. Active drug use should never prevent a person from accessing health care services, education, or information, especially services to reduce health risks associated with substance use. Healthcare providers need to know how people use drugs to be able to counsel clients on reducing their risk of related harm. To counsel clients effectively on how to reduce harm, healthcare providers must understand the details of how clients inject, which means being comfortable talking about this topic. Drugs that are often injected include opioids, cocaine, and amphetamines. Drugs purchased illegally nearly always have an inactive adulterant, which can dilute the active ingredient in an unpredictable way, and can greatly increase the risk of harm for people who use drugs, including overdose. Many adulterants do not dissolve and can cause scarring of the lungs or heart valves when injected. What does injection drug use involve? Step 1. Before injecting a substance, it needs to be dissolved in a liquid. People dissolve drugs in any water they have access to, including water from the faucet, the toilet, a puddle, a bottle, or saliva. All of these water sources contain bacteria. The presence of bacteria can result in life-threatening infections. Therefore, clients should be counseled to use sterile water whenever possible. Tap water and bottled water are safe for alternatives if sterile water is unavailable. Step 2. A cooker is any object that is used to mix the drug in a liquid. A cooker can be a spoon, a bottle cap, or a cut-off bottom of a soda can. A cooker can foster bacterial growth if reused. Sharing cookers can result in the transmission of viruses such as HIV, Hepatitis B, or Hepatitis C. A new, clean cooker should be used for each injection. Disposable cookers are the safest. Sometimes heat is needed to dissolve drugs in a liquid, but this is not necessary for methamphetamines, and most powdered-street opioids available in the Northeast United States. Step 3. A filter is often placed in the cooker to remove powdered adulterants that do not dissolve in water. If a filter is not used, adulterants can block the needle preventing injection. Common filters include cotton balls, a part of a cigarette filter, or lint. Needle exchange programs often offer small cotton balls to use as filters. If a filter is rolled between the fingers, it can introduce additional bacteria. Step 4. The tip of a needle is placed in the filter, and the attached syringe is used to draw the dissolved drug up from the cooker. Sharing syringes carries the risk of spreading blood-borne diseases such as HIV, Hepatitis B, or Hepatitis C. Reused needles, even if not shared, can become another source of bacteria. A used needle can become dull and the tip can resemble a hook. Injecting with a dull needle can damage veins and promote scarring. Damaged veins in areas such as the forearms increases the likelihood that people will inject into riskier areas such as the neck. This carries a higher risk of deep tissue infection. Syringes are often available without a prescription at pharmacies or at needle exchange program centers. Clients should be encouraged to use the following steps when injecting. 1. Use clean items with every injection. 2. Use alcohol pads to reduce the presence of bacteria on the skin prior to injection. 3. Use a tourniquet to find and inject into preferred veins and avoid riskier injection sites. 4. Use powdered vitamin C to dissolve crack cocaine rather than vinegar or lemon juice, which are caustic and can lead to scarring of veins. In summary, to reduce the risks associated with injection drug use, use alcohol wipes, use sterile water, use a new filter, cooker and syringe for each injection. Use a tourniquet to find and inject into preferred veins and avoid riskier injection sites. Use powdered vitamin C to dissolve crack cocaine rather than vinegar or lemon juice.