Intranasal Mucosal Atomiser Devices: A Novel Harm Reduction Intervention

ABSTRACT

Introduction

Factors associated with diminished peripheral vein access, including age, prolonged history of injecting drug use and coadministration with other substances, are all increasing among people who inject drugs in Australia. This exposes individuals to increased risk of injecting related complications, including skin and soft tissue infection, neurovascular injury and deep vein thrombosis.

Case Presentation

Case 1 is a 48‐year‐old man with a 30‐year history of injecting drug use who presents with recurrent skin and soft tissue infections requiring hospitalisation, surgery and extensive wound care. Case 2 is a 40‐year‐old woman who has been injecting heroin since her teens, predominantly into the femoral vein. She has developed significant chronic venous insufficiency and severe venous ulcers. Both consumers were motivated to reduce their injecting‐related harms and were offered the use of an intranasal atomiser for heroin administration and reported both a positive use experience and an intention to continue to utilise the device.

Discussion and Conclusions

Intranasal administration of heroin via atomising device may be an effective harm reduction intervention. The efficacy of these devices is supported by evaluation within heroin‐assisted treatment programs, where they are associated with high rates of treatment retention, a favourable user experience and 50% fewer injection episodes. Harm reduction benefits of these devices require further evaluation but are likely to include reduced rates of infection and overdose. Given the potential benefits, as supported by the two cases reported here, intranasal atomisers should be further evaluated for inclusion within community harm reduction programs.

Key Points Summary

• Rates of some injecting‐related complications are increasing among people who inject drugs in Australia, alongside risk factors including ageing, prolonged history of injecting, and polydrug injection.

• There is a need to expand existing harm reduction interventions provided by needle and syringe exchange programs to better address and reduce the gamut of injection‐related complications.

• Intranasal heroin administration is supported by a similar pharmacokinetic profile to intramuscular injection and may have similar acceptability to intravenous use for some people who inject drugs.

• Intranasal atomisers may be an effective harm reduction intervention for injection‐related complications of drug use worthy of further evaluation in the harm reduction space

1. Introduction

Needle and syringe exchange programs (NSP) are a well‐established harm reduction intervention that has been in place for many decades, born during the HIV outbreak of the 1980s to reduce the rates of blood‐borne virus transmission among people who inject drugs [1]. Today, they are key structures within the range of available harm reduction services, providing not only sterile safer injecting equipment, but also opportunistic advice on safer use practices and pathways to access healthcare and treatment. Through this design, NSPs have been shown to significantly reduce the rate of blood‐borne virus transmission and other injecting‐related harms [1] and have been demonstrated to provide low‐barrier, non‐stigmatising and cost‐effective pathways to other health care for people who use drugs [2].

With advances in the availability of opioid agonist therapy (OAT), harm reduction services and medical care, there is an ageing population of people who inject drugs in many high‐income countries. In data from 2019, most people who inject drugs in Australia first began injecting in the 1980s and 90s [3]. As a result, since 2011, there has been a continuous increase in the proportion of people on OAT over the age of 50 in Australia [4]. Other factors that may contribute to poor peripheral venous access include poly‐drug injection and the coadministration of gel capsules such as diphenhydramine [5, 6, 7]. These cohorts may have increasingly difficult peripheral vein access and so progress to alternative injecting practices, such as intramuscular (IM) and subcutaneous injection, or begin to access higher‐risk areas such as inguinal veins [8]. This exposes individuals to an increased risk of injecting‐related complications such as severe infection, injury to neurovascular structures and deep vein thrombosis [9, 10]. Subsequently, although the number of people injecting drugs in Australia has progressively declined over recent decades, the burden of injecting‐related complications, predominantly skin and soft tissue infection, has increased in this population, which highlights the need for enhanced harm reduction interventions [11]. Furthermore, jurisdictions within Australia have observed an increased rate of heroin‐related overdose harms in the past decade, a trend which may be related to increased purity of street heroin observed over the same period, as high as 48% in some evaluations [12, 13].

In overseas jurisdictions, heroin‐assisted treatment (HAT) is increasingly utilised in individuals for whom conventional OAT has not been beneficial [14, 15]. However, in line with the above reflections, there are many for whom IV‐HAT is associated with either increased risk of complication or an unsatisfactory treatment experience (when inadvertently administered IM or subcutaneously) [14]. To reduce potential harms from HAT and to increase access and retention, intranasal (IN) HAT, utilising mucosal atomising devices, has been explored as an alternative mode of delivery [14, 15].

However, these devices have not yet been evaluated for a role in harm reduction outside of HAT programs. Moreover, they are not currently available at NSPs. We present here two cases with significant complications of long‐term and ongoing injecting heroin use who were identified for a trial of atomising devices as a non‐injectable route of heroin administration. We will also present a review of the literature supporting further evaluation and availability within existing harm reduction programs.

2. Case Report

2.1. Case 1

A 48‐year‐old man with treatment‐resistant schizophrenia (receiving fortnightly depot zuclopenthixol) and poorly controlled Type 2 diabetes (most recent HbA1c 12.3%) reports intermittent intravenous heroin use for more than 30 years. He accesses addiction and primary care through a community health service in Melbourne, Victoria which is co‐located with harm reduction workers and an NSP. Here, he receives Buvidal 128 mg monthly, continuing to use heroin two to three times per week. His long‐term injecting drug use has resulted in difficult peripheral venous access. Throughout 2025, he has been mostly unable to access his veins despite prolonged effort, instead administering heroin IM or subcutaneously. This has contributed to multiple skin and soft tissue infections requiring four hospital admissions for incision and drainage, multiple courses of oral antibiotics and twice‐weekly outpatient wound reviews.

To reduce his injecting‐related harms, he was provided with an intranasal atomiser device (Figure 1) and educated on its use. Street heroin was dissolved with sterile water to then be administered via the device. He reported a comparable experience to his current method of use, but with significantly improved ease and less discomfort. He was using the devices when unable to find an accessible vein to use, rather than utilising an IM injection. Access to the device led to a reduction in self‐reported injecting episodes and now several months after first use, continues to request devices when attending medical appointments.

FIGURE 1.

Intranasal atomiser device attached to a 3 mL Luer lock syringe. Heroin can be dissolved in sterile water and administered in an atomised solution intranasally.

2.2. Case 2

A 40‐year‐old woman who has been using IV heroin since the age of 16 and has been street homeless for the last 7 years. Her ongoing exposure to violence and experience of housing insecurity have limited her capacity to receive OAT. She uses up to half a gram of heroin per day.

She presents with a 24‐month history of worsening chronic bilateral lower limb wounds in the setting of venous insufficiency—a complication of long‐term femoral vein access due to lack of alternative accessible veins. Motivated to aid wound healing based on medical advice, she has instead been accessing small superficial upper body veins with increasing difficulty, often taking hours and frequently discarding drugs when unable to locate a vein.

While in hospital for wound care and treatment of infection, she continued to use heroin on the ward, though requiring a lot of time to secure a vein and with concern for management of patient sharps. On review by the addiction medicine consult service, she was offered the use of an atomising device. Upon first use, she reported a quick onset rush and intoxication. She was surprised by the degree of effect and was thrilled with the ease of use, so continued to use it while in hospital. She reports: ‘there are so many people like me with bad veins who could be using these’.

3. Discussion

As illustrated by Australian statistics and these cases, we have a need to expand access to and the range of interventions available within harm reduction services to reduce the rates of injecting‐related harms experienced by people who inject drugs with difficult peripheral venous access. Nasal atomising devices may represent a novel intervention for those who are experiencing increasing complication or difficult access for injecting drug use.

Initial findings from HAT programs overseas have shown that IN‐HAT is similarly acceptable to IV administration [16]. Pharmacological studies have displayed a similar peak plasma concentration and time to effect as IM administration [16, 17]. Although the peak plasma concentration of IM, and indeed IN heroin, is lower than when administered IV, when delivered at therapeutic doses within HAT programs, IN heroin is associated with a rapid onset of ‘rush’ and ‘heroin typical’ effects within 2 min [17]. Alongside a comparable subjective experience to IV use, participants in early studies cited advantages of IN‐HAT, including ease and convenience, reduced exposure to injecting‐related harms and reduced stigma [16]. In line with the accounts from our cases, reasons for choosing IN administration reported by participants in current HAT programs include deteriorated peripheral veins and a desire for a less harmful means of administration [15]. The acceptability of IN heroin is demonstrated by a reduction in injecting events of almost 50%, and high rates of treatment retention in HAT programs [15]. However, to date, atomisers have not been evaluated for use among people using street heroin.

While there is limited existing research exploring the role of IN heroin as a harm reduction intervention, the evidence relating to reduced harms from inhaling compared to injecting may be translated to this area. In one recent large cohort study, those who inhaled fentanyl experienced reduced rates of skin and soft tissue infection, infective endocarditis and non‐fatal overdose than those who were injecting [18]. The limited evidence that does exist outside of HAT programs for IN administration to reduce harms associated with IV heroin use demonstrates reduced rates of hepatitis C transmission and reduced overdose rates (supported by data from IN‐HAT, wherein no overdoses were observed) [15, 19, 20]. Reduced overdose rates are of particular relevance as Australia observes increasing purity of street heroin [13]. Additionally, IN heroin is unlikely to be associated with the risk of early and accelerated COPD seen among those who inhale heroin [21, 22]. Therefore, especially in those for whom IV access is no longer viable, intranasal atomising devices are likely to represent a positive use experience with reduced exposure to associated harm.

At present, intranasal atomisers are not funded or available at NSPs. While their costs when purchased directly from medical supply organisations would require funding, given the high costs associated with treatment of injecting‐related complications (which can be up to $8000AUD for uncomplicated skin and soft tissue infections) [23], an intervention that may reduce the rates of injecting drug use has significant potential cost and health benefits.

4. Conclusions

Here we present two cases, each with a long history of injecting drug use who have developed significant complications. Despite this, they continue to inject heroin regularly. When offered the use of an intranasal atomiser, both cases reported a positive use experience and a desire to continue to access the devices as a harm reduction tool for their heroin use.

People who are injecting drugs in Australia are increasingly vulnerable to injecting‐related complications, so there is a need to expand existing harm reduction interventions provided by NSPs to better address the gamut of injection‐related complications. Intranasal heroin administration is supported by a similar pharmacokinetic profile to IM injection and similar acceptability to IV use for some individuals. For these cases who were typically administering heroin IM due to lack of access, intranasal atomisers may be an acceptable and effective harm reduction intervention for injection‐related complications. Further research is needed to determine whether the experience of IN‐HAT translates reliably to the street heroin context and identify barriers to the uptake of this novel intervention. While the experience from HAT programs and pharmacokinetic studies generally supports a positive use experience for many individuals, concerns such as dose loss may be more prevalent in ‘real world’ use with street heroin and require qualitative evaluation of consumer experience.

Reflecting on the effectiveness of NSPs for access to harm reduction services, alongside the emerging role of IN heroin as a means of harm reduction, intranasal atomisers should be made available to consumers through NSPs as a core component of the suite of harm reduction interventions offered. Given the cost of the devices, funding would be required to make atomisers affordable within community harm reduction programs and to allow for peer‐developed education on their use. However, in view of the possible health and economic benefits by presumed decreased injection‐related complications, this could still be a viable intervention. While there is little existing literature exploring the role of nasal atomisers as a harm reduction tool outside of HAT programs, the potential benefit demonstrated in these cases mandates further research in partnership with harm reduction and peer organisations, as well as individuals accessing harm reduction services.

Author Contributions

D.M. conceived the idea for the case report. H.G. wrote the first draft of the manuscript and finalised the version for publication. T.N., M.L‐.J., S.C., D.M. and B.C. provided insight and contributed to the final version of the manuscript. S.C. and B.C. provided peer perspectives.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.