How to Know if Someone Is Shooting Up Drugs: 12 Signs of IV Drug Use

The clearest signs someone is shooting up drugs are track marks, unexplained wounds or bruises over veins, long sleeves in warm weather, and paraphernalia like syringes, burnt spoons, cotton balls and tourniquets. Behavioral changes such as secrecy, nodding off, money problems and pulling away from family often show up alongside them.

Injecting drugs, also called IV drug use or “shooting up,” sends a substance straight into the bloodstream. The effect hits within seconds, which is why many people move to injection after smoking, snorting or swallowing stops working. It is also the most dangerous way to use. Today’s street drug supply is contaminated with fentanyl and animal sedatives like xylazine, so a single injection can cause an overdose or a wound that won’t heal.

If you’re worried about someone you love, this guide explains what to look for, what the signs mean and what you can do next.

Key takeaways

• Track marks usually appear on the inner elbow and forearm, but people also inject into the hands, feet, legs, neck and groin to hide them.
• Paraphernalia often includes needles, bent or burnt spoons, cotton, lighters, belts or shoelaces, and small baggies.
• Much of the injected drug supply contains fentanyl. Keep naloxone (Narcan) on hand; it is sold over the counter.
• Injection drug use is a sign of a serious substance use disorder, and it is treatable.

If someone is unresponsive, breathing slowly or not at all, or has blue or gray lips, call 911 now and give naloxone if you have it.

Why Do People Start Shooting Up?

Most people don’t start out injecting. They move to it as their substance use gets worse. Common reasons include:

• Tolerance. Over time the body needs more of a drug to feel the same effect. Injecting delivers nearly the whole dose to the brain within seconds.
• Speed and intensity. A swallowed pill can take 15 to 45 minutes to work. Smoking takes seconds to minutes. Injection produces the fastest, strongest rush.
• Cost. Because less of the drug is wasted, injecting can feel like a way to make an expensive habit last longer.
• Avoiding withdrawal. For people dependent on opioids, the goal often shifts from getting high to simply not feeling sick.
• Social exposure. Many people first inject with a partner or friend who already does.

None of this means the person doesn’t care about their health or their family. Substance use disorder changes the brain’s reward and decision-making systems, which is why people keep using despite serious harm. Understanding that makes it easier to respond with concern instead of anger.

What Drugs Are Commonly Injected?

Almost any drug can be injected, though none can be injected safely. The drugs most often injected in the U.S. today are:

The biggest change in recent years is the drug supply itself. Fentanyl now drives most U.S. overdose deaths, and xylazine has spread into the opioid supply across the country.^[8] People who inject often have no idea what is actually in what they bought.

Physical Signs Someone Is Shooting Up

Behavior can be hard to read because every drug affects people differently. The body is more reliable. Injection leaves marks, and many of them are hard to hide for long.

1. Track Marks

Track marks are the most recognizable sign of IV drug use. They are lines of puncture marks, scabs, bruises or scars that form along a vein after repeated injections. In one study of people who inject drugs, 92 of 100 participants had visible track marks.^[1]

What Do Track Marks Look Like?

• Fresh marks: small red or dark dots, often in a line over a vein, sometimes with a scab, bruise or swelling around them.
• Repeated marks: a darkened, raised line running along the path of a vein, from about a centimeter to several inches long.
• Older marks: faded pink, purple, brown or white scars that can look like stretch marks or old burns.
• Skin darkening: patches of darker skin around and along the injected veins.^[1]

Where Track Marks Appear

The inner elbow and forearm are most common. As those veins scar, or when someone is trying to hide their use, they may inject into the back of the hands, between fingers or toes, feet, ankles, behind the knees, thighs, groin or neck. Marks in hidden places are a sign the person has likely been injecting for a while.

2. Covering Up

Long sleeves or pants in hot weather, wristbands, makeup over the arms, or refusing to change clothes in front of others can all be attempts to hide marks.

3. Bruising and Swelling

Unexplained bruises, especially on the arms, hands and legs, and swollen hands, legs or feet are common. Swelling can come from missed injections, damaged veins or poor circulation. People who inject into their legs tend to develop more severe vein disease.^[3]

4. Skin Infections and Abscesses

Every injection breaks the skin. Shared or reused needles and unsterile water carry bacteria into the body. Look for red, warm, painful areas, pus-filled lumps (abscesses) or spreading redness (cellulitis). Untreated infections can spread to the blood, bones or heart.^[1]

5. Xylazine (“Tranq”) Wounds

Xylazine wounds look different from ordinary abscesses. They often start as dark blisters with irregular edges, then turn into a hard, dry black crust (eschar) and can deepen into open ulcers. They can appear on the arms or legs even where the person didn’t inject.^[4] Anyone with these wounds needs medical care quickly.

6. Collapsed or Scarred Veins

Repeated injections inflame and scar the vein walls until the vein closes off. Collapsed veins can look sunken, hard or rope-like, and the person may spend longer searching for a usable vein. Over time, injection can cause lasting vein damage, especially in the legs.^[3] A doctor can confirm vein damage.

7. Skin Popping Scars

Some people inject under the skin (“skin popping”) or into a muscle (“muscling”), often after their veins are too damaged to use. This leaves small, round, sunken scars, hard lumps under the skin, or clusters of circular marks on the arms, thighs or buttocks.^[2] These scars are considered a hallmark of injection drug use and can remain for years.^[1]

8. Signs of Intoxication or Withdrawal

With opioids, look for pinpoint pupils, heavy eyelids, “nodding off” mid-conversation, slurred speech and itching. With stimulants like meth or cocaine, look for dilated pupils, fast talking, jaw clenching, not sleeping for days and weight loss. Opioid withdrawal looks like a bad flu: sweating, chills, runny nose, yawning, diarrhea, goosebumps and anxiety.

IV Drug Use Paraphernalia

9. Finding Injection Supplies

People who inject need a specific kit, and finding these items together is a strong sign. Check rooms, cars, bags, shoeboxes, makeup cases and bathroom cabinets for:

• Syringes, needles or orange needle caps
• Spoons or bottle caps that are bent, blackened or burnt on the bottom
• Lighters, candles or small torches
• Cotton balls, cigarette filters or cotton swab tips (used to filter the drug)
• Belts, shoelaces, rubber tubing or hair ties (used as tourniquets)
• Small baggies, balloons or folded foil with powder or residue
• Small water bottles, vials or alcohol wipes
• Citric acid or lemon juice (used to dissolve crack cocaine or some heroin)
• Blood spots on sleeves, sheets, tissues or bathroom surfaces

Some of these items, like sterile syringes, may come from a syringe services program. That means the person is using, but also that they are taking steps to stay alive, which is a good starting point for a conversation.

Behavioral Signs of Injection Drug Use

Physical signs are more specific, but behavior often changes first.

10. Secrecy and Isolation

Locking doors, spending long stretches in the bathroom, disappearing for hours, getting defensive about their room or phone, and pulling away from family and old friends.

11. Money, Work and Legal Problems

Asking to borrow money often, missing cash or valuables, selling belongings, losing a job or falling behind at school, and new trouble with police.

12. Changes in Health and Routine

Noticeable weight loss, poor hygiene, frequent “flu” symptoms, sleeping at odd hours, missing appointments and losing interest in things they used to enjoy. Mood swings between calm or sedated and irritable or anxious often track with using and withdrawal.

One sign alone doesn’t prove someone is injecting. Several signs together, especially a physical sign plus paraphernalia, are a reason to act. Learn more about the signs someone needs rehab.

The Dangers of Shooting Up Drugs

Injection carries more risk than any other way of using drugs:

• Overdose. The full dose reaches the brain at once, leaving no time to react if the drug is stronger than expected or contains fentanyl.
• Hepatitis C and HIV. Sharing needles, cookers, cotton or water spreads blood-borne infections. The CDC has linked rising hepatitis C rates and HIV outbreaks to injection drug use.^[7]
• Endocarditis. Bacteria, including MRSA, can travel to the heart and infect its valves, a life-threatening condition that often needs surgery.^[5]
• Sepsis and bone infections. Untreated skin infections can spread through the bloodstream.
• Chronic vein disease. Damaged veins can cause long-term swelling, skin changes and leg ulcers.^[3]
• Severe wounds. Especially with xylazine in the supply.^[4]

Signs of an Overdose

An opioid overdose can happen within minutes of injecting. Watch for:

• Unresponsive or can’t be woken up
• Slow, shallow or stopped breathing; gurgling or snoring sounds
• Blue, gray or ashen lips and fingertips
• Pinpoint pupils
• Cold, clammy skin and a limp body

A stimulant overdose looks different: chest pain, very high body temperature, a racing heart, agitation, confusion or seizures.

What to Do in an Overdose

1. Call 911. Florida and most other states have Good Samaritan laws that offer some legal protection to people who call for help during an overdose.
2. Give naloxone (Narcan). Spray one dose into a nostril. If there’s no response in 2 to 3 minutes, give a second dose.
3. Support breathing. If you’re trained, give rescue breaths.
4. Put them in the recovery position on their side so they don’t choke.
5. Stay with them. Naloxone can wear off before the drugs do, and the overdose can return.

Naloxone does not reverse xylazine, but always give it anyway, because xylazine is usually mixed with fentanyl.^[8] Narcan nasal spray has been approved for sale without a prescription since 2023, and many health departments hand it out free.^[9] Read more about what to do during a fentanyl overdose.

What to Do if You Think Someone Is Shooting Up

• Don’t wait for proof. If you’ve seen several signs, it’s reasonable to act.
• Keep naloxone in the home and learn how to use it.
• Know about harm reduction. Syringe services programs and fentanyl test strips lower the risk of infection and overdose while the person is still using. Staying alive keeps the door to recovery open.
• Get medical care for wounds or fevers. Infections from injecting can become emergencies quickly.
• Plan a calm conversation and have treatment options ready before you talk.

How to Talk to a Loved One Who Is Injecting Drugs

How you start the conversation matters more than having the perfect words.

• Pick a calm moment when they’re sober and you’re not angry. Avoid confronting them right after you find something.
• Lead with concern, not accusation. “I’ve noticed bruises on your arms and I’m scared for you” lands better than “I know you’re using.”
• Use “I” statements and describe specific things you’ve seen.
• Listen. Ask what’s been going on and let them answer without interrupting.
• Offer a next step, such as a call to a treatment center or a doctor’s visit, rather than an ultimatum.
• Set boundaries you’ll keep, like not giving cash, while making it clear you’ll always help them get treatment. Here’s how to support a loved one without enabling them.
• Take care of yourself. Support groups like Al-Anon, Nar-Anon and SMART Recovery Family & Friends help families cope.

If they refuse help, don’t give up. Many people accept treatment after several conversations. A professional interventionist can also help your family plan a structured conversation.

Treatment for IV Drug Addiction

Injection drug use usually points to a severe substance use disorder, and that calls for a full continuum of care:

• Medical detox. Withdrawal from opioids, especially fentanyl, can be intense. Medical detox keeps the person safe and comfortable and manages wounds, infections and other health issues.
• Medication for opioid use disorder. Buprenorphine, methadone and naltrexone reduce cravings. Methadone and buprenorphine are linked to a significantly lower risk of death after an overdose.^[6]
• Residential treatment. Living on-site removes access to drugs and gives the person time to stabilize, heal and learn new coping skills.
• Therapy. Evidence-based approaches like cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT) and trauma therapy address the reasons behind drug use.
• Dual diagnosis care. Depression, anxiety, PTSD and other mental health conditions are common and need to be treated at the same time.
• Family therapy and aftercare. Ongoing support, alumni programs and relapse prevention planning help recovery last.

Frequently Asked Questions About IV Drug Use

What are the first signs someone is shooting up?

Early signs include small red puncture marks or bruises on the inner arm, wearing long sleeves in warm weather, spending long periods alone in the bathroom, and finding needle caps, burnt spoons or cotton balls.

What do track marks look like?

Fresh track marks look like small red or dark dots in a line along a vein, often with bruising or scabs. Over time they become a raised, darkened line, and older marks fade into pink, purple or white scars.

Where do people hide track marks?

People often inject in less visible spots such as between the fingers or toes, the tops of the feet, behind the knees, the thighs, the groin or the neck. They may also cover marks with clothing, tattoos, makeup or bandages.

How long do track marks last?

Fresh marks can heal in days to weeks if injecting stops. Repeated injection in the same spot causes scarring that can be permanent, though it often fades with time.

What is skin popping?

Skin popping is injecting a drug under the skin instead of into a vein. It leaves small, round, sunken scars and hard lumps and carries a high risk of abscesses.

Can you shoot up without leaving marks?

Not for long. Even careful injection causes puncture wounds, and repeated use leaves bruises, scars or vein damage. Some people hide marks by injecting in less visible places.

What do xylazine (tranq) wounds look like?

Xylazine wounds often start as dark blisters, then form a hard black crust and can deepen into open ulcers. They may appear away from the injection site and need prompt medical care.

Does Narcan work if someone injected fentanyl?

Yes. Naloxone (Narcan) reverses fentanyl and other opioid overdoses, though more than one dose may be needed. It doesn’t reverse xylazine or stimulants, but you should always give it in a suspected overdose.

What should I do if I find a needle in my home?

Don’t recap it or touch the tip. Pick it up by the barrel with gloves or tongs, place it in a hard plastic container with a lid, such as a laundry detergent bottle, and ask a pharmacy or local health department how to dispose of it.

Is IV drug addiction treatable?

Yes. Medical detox, medication for opioid use disorder, residential treatment and therapy help people stop injecting and recover. Treatment with methadone or buprenorphine also lowers the risk of overdose death.

Get Help for IV Drug Use at Mandala Healing Center

If you’ve noticed signs that someone you love is shooting up drugs, you don’t have to figure out the next step alone. Mandala Healing Center in West Palm Beach, Florida, offers medical detox, residential treatment and dual diagnosis care for people struggling with fentanyl, heroin, meth and other drug addictions. Our team can also help families plan how to approach a loved one and verify insurance coverage.

Call 866-922-3654 to speak with an admissions specialist, or contact us online. The call is free and confidential.

You can also reach the free, confidential SAMHSA National Helpline at 1-800-662-4357, or call or text 988 if you or your loved one is in crisis.

References

1. Dhillon SS, Kaur T, Bala N, Mankaranpreet. Clinico-epidemiological aspects of cutaneous lesions in injecting drug users visiting an oral substitution therapy centre in Northern India: a cross-sectional study. Dermatol Pract Concept. 2022;12(4):e2022154. https://pmc.ncbi.nlm.nih.gov/articles/PMC9681189/
2. Saporito RC, et al. Recognizing skin popping scars: a complication of illicit drug use. Cureus. 2018;10(6):e2726. https://pmc.ncbi.nlm.nih.gov/articles/PMC6070054/
3. Pieper B, et al. Impact of injection drug use on distribution and severity of chronic venous disorders. Wound Repair Regen. 2009. https://pmc.ncbi.nlm.nih.gov/articles/PMC2748060/
4. Vaile JR, Connolly WC, Zavitsanos AP, et al. Xylazine-associated wounds: a scoping review of clinical presentation and management. Adv Skin Wound Care. 2026;39(4):E185-E193. https://pubmed.ncbi.nlm.nih.gov/42007753/
5. Lorson WC, et al. Microbial epidemiology of infectious endocarditis in the intravenous drug abuse population: a retrospective study. Infect Dis Ther. 2019. https://pmc.ncbi.nlm.nih.gov/articles/PMC6374230/
6. Larochelle MR, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018. https://pubmed.ncbi.nlm.nih.gov/29913516/
7. Centers for Disease Control and Prevention. HIV/HCV health advisory. April 24, 2015. https://archive.cdc.gov/emergency_cdc_gov/han/han00377_1719330601.asp
8. Centers for Disease Control and Prevention. Xylazine: clinical management and harm reduction strategies for patients. https://www.cdc.gov/overdose-resources/search/pages/CDC_Xylazine-Clinician-Fact-Sheet.html
9. U.S. Food and Drug Administration. FDA approves first over-the-counter naloxone nasal spray. March 29, 2023. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray

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Clinically Reviewed

Mandala Clinical Team

This page was prepared by Mandala Healing Center and reviewed by our clinical team, the licensed medical and behavioral health professionals who provide detox and treatment at our West Palm Beach facility. We review it regularly so it reflects current clinical guidance.

Last reviewed: November 2, 2026

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