Driving home a blunt message with a sharp instrument

 

I have written before of my phobia of needles. The sight of a dentist's local-anaesthetic syringe invariably induces a cold sweat and a feeling of light-headedness that stops just short of a faint.

Put me at the other end of the needle, however, and I become the swashbuckling, omnipotent and less than reassuring figure who informs his patients, "a little pinch, now" or, as one of them rather rudely replied, "just a little prick with a needle".

Hypodermic syringes were invented in 1848. Until the end of the first World War they were valuable medical instruments, hand-made by skilled artisans. In today's prices, each syringe cost the equivalent of £45 (€57). By 1930, two million were being mass produced each year, driven by mechanisation and a demand fed by the availability of insulin for the treatment of diabetes.

The greatest change in demand came when penicillin was manufactured on a wide scale during the second World War.

By 1964, penicillin represented more than 50 per cent of the market of all medical chemicals manufactured in the US - most human antibiotics were available only in injectable form, so a prescription for penicillin meant at least daily injections.

With the antibiotic era came a move away from reusable and sterilisable glass syringes to a less expensive single-use unit. As new, high-volume plastic manufacturing techniques developed, the production of disposable syringes soared and the cost plummeted.

Today, a small manufacturing facility can make 100 million sets a year for less than one and a half pence, or two cents, each.

Ironically, given the initial impetus for syringe production, few antibiotics given in the community are now administered by injection. Some doctors still give an initial dose by intramuscular injection, but most are happy to "front-load" a course of oral antibiotics, safe in the knowledge that the rates of absorption of modern medicines are so good that an equivalent blood level is now achievable via the oral route.

The manufacture and use of hypodermic syringes continues apace, however. Many modern medications are best given by injection. Insulin remains an injection-only drug and several anti-cancer drugs can be administered only into muscle, even after the patient has been discharged from hospital. And, of course, for those who are severely ill in hospital, the intravenous route remains the best and safest method of treatment.

The ready availability of syringes has also allowed more patients to be treated at home. For those who are terminally ill, the ability to deliver essential painkilling, anti-nausea and anti-inflammatory drugs through a syringe driver has revolutionised their home care. A syringe driver is a battery-driven device that slowly and steadily compresses the plunger on a syringe of drugs. When a needle is placed under the skin, it means a dying person is assured of a continuous and safe supply of morphine and other drugs.

On the downside, the ready availability of disposable syringes is a problem in drug abuse. In the hands of a desperate heroin addict, disposable becomes reusable. And in the case of groups of drug addicts, it becomes the highly dangerous practice of both sharing and reusing needles.

This has particular implications for less developed parts of the world, such as Russia. In the former Soviet Union, there are now between two and three million opiate injectors. There has been a rapid increase in HIV infection among heroin injectors in Russia, Ukraine, China, India and Pakistan.

The widespread practice of unsterile injecting poses a serious risk not only of spreading known infectious diseases, such as hepatitis C and HIV, but also of creating new ones. Yet another example of how something designed to do good can become an instrument of terror.

E-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie or leave a message at 01-6707711 ext 8511. He regrets he cannot reply to individual medical problems