Cookers

Types of cookers used

Cookers are used to mix and /or heat the solution to be injected. If sterile cookers are unavailable, drug users commonly use tea- or tablespoons or drinking cans (Scott, 2008). These items, being non-sterile, can contain bacteria or fungi, as well as residuals of other liquids. It is recommended to use sterile, single use cookers to prepare drug solutions.

The Stericup® is a sterile cooker that does not contribute to the contamination of the drug containing solution. Scott (2008) states that its fragile nature is an advantage of the Stericup. Reheated, it becomes flimsy, especially around the handle which will bend. This may prevent People Who Inject Drugs (PWID) to use it several times.

Cooker sharing

Cooker reuse is very prevalent amongst PWID (Debrus, 2008; Needle et al., 1998). Furthermore, depending on context, knowledge, culture and cooker-availability, cookers are shared by 16 to 65% of PWID (Cadet-Taïrou, 2012; Huo et al., 2005; Strike et al., 2010). Several studies found that this item is shared more frequently than other paraphernalia (Koester et al., 1990; Thorpe et al., 2002; Latkin et al., 2010; Strike et al., 2010); moreover, PWID tend to believe that cooker sharing is associated to a lower risk than syringe sharing (Latkin et al., 2010).

Cookers can be shared either for use by one person after another, or to prepare a solution for several people at the same time (batch preparation). The bigger the cooker is, the larger the risk of batch preparation. Care should be taken to provide the smallest cooker suitable for the preparation of a given drug (some drugs, mainly pills not intended for injection, need larger volumes to dissolve).

The Stericup has a capacity of 2.5 ml. Solutions of up to 1.5 ml can be heated in this cooker. The Maxicup® has a capacity of about 5 ml. Solutions of up to 4 ml can be heated in this cooker.

In addition to "deliberate" sharing (sometimes due to lack of equipment available at a given time), some situations may lead to confusion. The presence of large quantities of tools during group injection may, for instance result in confusion about their ownership, as may the fact of being under the influence of psychoactive drugs... A survey conducted in France (Debrus, 2008) showed that the vast majority (85%) of PWID has already injected in the presence of other injectors and 45% of them have ever had adoubt about the ownership of the equipment used. Distribution of tools with different colours can allow PWID to differentiate the material used. As reuse seems to be rather a rule than an exception, the colours will enable people to, at least, reuse their own material. The colours also provide a visual support of the message not to share any harm reduction tools.

The harms associated with cooker sharing

Blood born viruses (BBVs)

The presence of HIV has been detected on 14 to 54% of used cookers (Shah et al., 1996). In the field, the correlation between sharing cookers and HIV transmission has also been demonstrated. Seropositive persons are more likely to have shared cookers than seronegative persons (Vlahov et al., 1997). The majority of the research done does not differentiate cookers from other paraphernalia such as filters and water for injection. Both McCoy et al. (1998) and Faran et al. (1998) found a strong correlation between the sharing of paraphernalia (cookers, water or filters) and HIV transmission.

As for the HCV, Crofts et al. (2000) have shown the presence of this virus on used cookers. Doerrbecker et al. (2013) have shown that HCV can remain both present and infectious, even after rinsing.

A study measuring the HCV seroconversion among a cohort of 317 active Seattle residents who inject drug and who tested negative for HCV antibodies at recruitment, found that those who shared cookers and filters (but not syringes) had a relative risk of HCV seroconversion of 5.9. It was determined that 54% of HCV infections among this group were attributed to cooker and filter sharing.

Other risks

Any non-sterile cookers (makeshift cookers or the reuse of cookers), even when they are not shared, can be contaminated by bacteria. Bacteria present in drug paraphernalia, when injected, can lead to life-threatening bacterial infections, including abscesses, cellulitis, bone and joint infections, or endocarditis (Gordon and Lowy, 2005).

Recommendations

The supply of single use cookers potentially reduces the transmission of BBVs and other infections and improves the hygiene of injection preparation. Strike et al. (2013) provide several recommendations which we have completed here: 

• Provide individually packed, sterile cookers with a heat resistant handle.

• To reduce contamination, a new sterile cooker should be used for every injection. Cookers should thus be distributed in the quantity requested by PWID, without limitation on the number of cookers distributed. One sterile cooker should be provided with every sterile needle.

• People should be encouraged, but not be obliged to come back and dispose of their paraphernalia as bio-waste materiel at the needle exchange program.

• Procedures to clean cookers can reduce the amount of pathogens present but will be unable to eliminate germs or virus at 100%.

• Offer cookers of the size needed by the participants of your harm reduction program, and inform your clients on the differences and least harmful options.

• Encourage people to use the smallest cooker possible (depending on the drug they inject) and advice to avoid or reduce batch preparation. The Stericup is smaller than the Maxicup and should be preferred if feasible.

• Provide cookers which are thin to avoid reuse and to increase the temperature reached when the cooker is heated.

• Provide cookers of different colours to remind clients that they are for personal use and to enable them to do so, even in confusing situations.

• Provide harm reduction information on the use of cookers and the associated risks.

• Provide other harm reduction tools such as syringes, filters, acids, sterile water for injection, alcohol pads…

References

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