"I inject less as I have easier access to pipes": Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed

Department of Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada.
The International journal on drug policy (Impact Factor: 2.54). 06/2008; 19(3):255-64. DOI: 10.1016/j.drugpo.2007.02.008
Source: PubMed


Among injection drug users (IDUs) in Ottawa, the capital of Canada, prevalence rates of HIV (20.6 percent) and hepatitis C HCV (75.8 percent) are among the highest in Canada. Recent research evidence suggests the potential for HCV and HIV transmission through the multi-person use of crack-smoking implements. On the basis of this scientific evidence, in April 2005, Ottawa's needle exchange programme (NEP) commenced distributing glass stems, rubber mouthpieces, brass screens, chopsticks, lip balm and chewing gum to reduce the harms associated with smoking crack. This study aims to evaluate the impact of this initiative on a variety of HCV- and HIV-related risk practices. Active, street-recruited IDUs who also smoked crack consented to personal interviews and provided saliva samples for HCV and HIV testing at four time points: 6-months pre-implementation (N=112), 1-month (N=114), 6-months (N=157) and 12-months (N=167) post-implementation. Descriptive and univariate analyses were completed. Following implementation of the initiative, a significant decrease in injecting was observed. Pre-implementation, 96 percent of IDUs reported injecting in the month prior to the interview compared with 84 percent in the 1-month, and 78 percent in the 6- and 12-month post-implementation interviews (p<.01). Conversely, approximately one-quarter of participants at both the 6- and 12-month post-implementation evaluation points reported that they were smoking crack more frequently since the availability of clean equipment--25 and 29 percent, respectively. In addition to a shift to a less harmful method of drug ingestion, HCV- and HIV-related risks associated with this method were reduced. Among crack-smoking IDUs sharing pipes, the proportion sharing "every time" declined from 37 percent in the 6-month pre-implementation stage, to 31 percent in the 1-month, 12 percent in the 6-month and 13 percent in the 12-month post-implementation stages (p<.01). Since distributing safer crack-smoking materials by a NEP contributes to transition to safer methods of drug ingestion and significantly reduces disease-related risk practices, other NEPs should adopt this practice.

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    • "For instance, public health programmes in various settings have sought to discourage pipe-sharing by distributing safer crack use kits (SCUK), which typically include crack smoking equipment such as Pyrex ® stems, mouthpieces, and brass screens (Strike et al., 2011). While these programmes have produced modest reductions in crack pipesharing (Leonard et al., 2008), as many as half of people who smoke crack in these settings continue to share pipes (Malchy et al., 2011; Ti et al., 2011). This may be in part explained by the difficulty of these interventions in addressing social-environmental factors operating within crack smoking settings (e.g., gendered power dynamics) that perpetuate crack pipe-sharing (Bungay et al., 2010), while increasing exposure to other harms (e.g., violence). "
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    ABSTRACT: Introduction: Many cities around the globe have experienced substantial increases in crack cocaine use. Public health programmes have begun to address crack smoking, primarily through the distribution of safer crack use equipment, but their impacts have been limited. More comprehensive safer environmental interventions, specifically safer smoking rooms (SSR), have been implemented only in select European cities. However, none have been subjected to rigorous evaluation. This ethnographic study was undertaken at an 'unsanctioned' SSR operated by a drug user-led organization in Vancouver, Canada, to explore how this intervention shaped crack smoking practices, public crack smoking, and related harms. Methods: Ethnographic fieldwork was undertaken at this SSR from September to December 2011, and included approximately 50 hours of ethnographic observation and 23 in-depth interviews with people who smoke crack. Data were analyzed by drawing on the 'Risk Environment' framework and concepts of 'symbolic', 'everyday', and 'structural' violence. Findings: Our findings illustrate how a high demand for SSRs was driven by the need to minimize exposure to policing (structural violence), drug scene violence (everyday violence), and stigma (symbolic violence) that characterized unregulated drug use settings (e.g., public spaces). Although resource scarcity and social norms operating within the local drug scene (e.g., gendered power relations) perpetuated crack pipe-sharing within unregulated drug use settings, the SSR fostered harm reduction practices by reshaping the social-structural context of crack smoking and reduced the potential for health harms. Conclusion: Given the significant potential of SSRs in reducing health and social harms, there is an urgent need to scale up these interventions. Integrating SSRs into public health systems, and supplementing these interventions with health and social supports, has potential to improve the health and safety of crack-smoking populations.
    International Journal of Drug Policy 01/2015; DOI:10.1016/j.drugpo.2015.01.015 · 2.40 Impact Factor
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    • "The prevalence of injecting crack use decreased (96% to 78%; p < 0.001), but was substituted by oral crack use. The overall prevalence of crack use paraphernalia sharing remained high (e.g., 80% or higher), while high-frequency crack paraphernalia sharing declined from 37% preto 14% post-SCUP initiative (p = 0.001) (Leonard et al., 2008). A pre-post study of a Vancouver SCUP program found an increase in finding access to 'safer' crack use paraphernalia, including pipes (p = .010), "
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    ABSTRACT: There are an estimated several million crack-cocaine users globally; use is highest in the Americas. Most crack users are socio-economically marginalized (e.g., homeless), and feature elevated risks for morbidity (e.g., blood-borne viruses), mortality and crime/violence involvement, resulting in extensive burdens. No comprehensive reviews of evidence-based prevention and/or treatment interventions specifically for crack use exist. We conducted a comprehensive narrative overview of English-language studies on the efficacy of secondary prevention and treatment interventions for crack (cocaine) abuse/dependence. Literature searches (1990-2014) using pertinent keywords were conducted in main scientific databases. Titles/abstracts were reviewed for relevance, and full studies were included in the review if involving a primary prevention/treatment intervention study comprising a substantive crack user sample. Intervention outcomes considered included drug use, health risks/status (e.g., HIV or sexual risks) and select social outcome indicators. Targeted (e.g., behavioral/community-based) prevention measures show mixed and short-term effects on crack use/HIV risk outcomes. Material (e.g., safer crack use kit distribution) interventions also document modest efficacy in risk reduction; empirical assessments of environmental (e.g., drug consumption facilities) for crack smokers are not available. Diverse psycho-social treatment (including contingency management) interventions for crack abuse/dependence show some positive but also limited/short-term efficacy, yet likely constitute best currently available treatment options. Ancillary treatments show little effects but are understudied. Despite ample studies, pharmaco-therapeutic/immunotherapy treatment agents have not produced convincing evidence; select agents may hold potential combined with personalized approaches and/or psycho-social strategies. No comprehensively effective 'gold-standard' prevention/treatment interventions for crack abuse exist; concerted research towards improved interventions is urgently needed. Copyright © 2015 Elsevier B.V. All rights reserved.
    International Journal of Drug Policy 01/2015; 26(4). DOI:10.1016/j.drugpo.2015.01.002 · 2.40 Impact Factor
    • "of crack pipes through public health services is associated with important benefits, such as reduced crack pipe sharing and drug injecting frequency, and increased contact with public health services [15] [31]. "
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    ABSTRACT: Introduction and AimsCrack pipe sharing is a risky practice that has been associated with the transmission of hepatitis C and other harms. While previous research has exclusively focused on this phenomenon among adults, this study examines crack pipe sharing among street-involved youth.Design and Methods From May 2006 to May 2012, data were collected from the At-Risk Youth Study, a cohort of street-involved youth aged 14–26 in Vancouver, Canada. Survey data from active crack smokers were analysed using generalised estimating equations logistic regression.ResultsOver the study period, 567 youth reported smoking crack cocaine and contributed 1288 observations, among which 961 (75%) included a report of crack pipe sharing. In multivariate analysis, factors that were associated with crack pipe sharing included difficulty accessing crack pipes [adjusted odds ratio (AOR) = 1.58, 95% confidence interval (CI) 1.13–2.20]; homelessness (AOR = 1.87, 95% CI 1.43–2.44); regular employment (AOR = 1.53, 95% CI 1.15–2.04); daily non-injection crystal methamphetamine use (AOR = 2.04, 95% CI 1.11–3.75); daily crack smoking (AOR = 1.37, 95% CI 1.01–1.85); encounters with the police (AOR = 1.42, 95% CI 1.01–1.99); and reporting unprotected sex (AOR = 1.95, 95% CI 1.47–2.58).Discussion and Conclusions The prevalence of crack pipe sharing was high among our sample and independently associated with structural factors including difficulty accessing crack pipes and homelessness. Crack pipe sharing was also associated with high-intensity drug use and a number of other markers of risk and vulnerability. Collectively, these findings highlight opportunities for health services to better engage with this vulnerable group and reduce this risky behaviour.
    Drug and Alcohol Review 07/2014; 34(3). DOI:10.1111/dar.12180 · 1.55 Impact Factor
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