Multiple injections per injection episode: High-risk injection practice among people who injected pills during the 2015 HIV outbreak in Indiana

Abstract Background Misuse of prescription opioid analgesics (POA) has increased dramatically in the US, particularly in non-urban areas. We examined injection practices among persons who inject POA in a rural area that experienced a large HIV outbreak in 2015. Methods Between August-September 2015, 25 persons who injected drugs within the past 12 months were recruited in Scott County, Indiana for a qualitative study. Data from in-depth, semi-structured interviews were analyzed. Results All 25 participants were non-Hispanic white and the median age was 33 years (range: 19–57). All had ever injected extended-release oxymorphone (Opana ® ER) and most (n=20) described preparing Opana ® ER for multiple injections per injection episode (MIPIE). MIPIE comprised 2–4 injections during an injection episode resulting from needing >1mL water to prepare Opana ® ER solution using 1mL syringes and the frequent use of "rinse shots." MIPIE occurred up to 10 times/day (totaling 35 injections/day), often in the context of sharing drug and injection equipment. Conclusions We describe a high-risk injection practice that may have contributed to the rapid spread of HIV in this community. Efforts to prevent bloodborne infections among people who inject POA need to assess for MIPIE so that provision of sterile injection equipment and safer injection education addresses the MIPIE risk environment.