Smoking crack out of a can

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Harm Reduction Journal volume 14Article : 17 Cite this article. Metrics details. People who smoke crack cocaine experience a wide variety of health-related issues. However, public health programming deed for this population is limited, particularly in comparison with programming for people who inject drugs. Canadian best practice recommendations encourage needle and syringe programs NSPs to provide education about safer crack cocaine smoking practices, distribute safer smoking equipment, and provide options for safer disposal of used equipment.

We conducted an online survey of NSP managers across Canada to estimate the proportions of NSPs that provide education and distribute safer smoking equipment to people who smoke crack cocaine.

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We also assessed change in pipe distribution practices between and in the province of Ontario. Analysis of data from 80 programs showed that the majority 0. The majority 0. Among programs that distributed pipes, 0. Only 0. The most common reasons for not distributing safer smoking equipment were not enough funding 0. Ontario-specific sub-analyses showed a ificant increase in the proportion of programs distributing pipes in Ontario from 0.

Our findings point to important efforts by Canadian NSPs to reduce harm among people who smoke crack cocaine through provision of education and equipment, but there are still limits that could be addressed. Our study can provide guidance for future cross-jurisdiction studies to describe relationships involving harm reduction programs and provision of safer crack cocaine smoking education and equipment. Although the harm reduction philosophy that has moved forward in Canada, and North America more broadly, is inclusive of people who consume a wide spectrum of psychoactive substances, actual programming has been more focused on people who inject drugs.

This is concerning from a public health perspective because in Canada crack cocaine use is common among street-based people who use drugs [ 1 — 3 ]. People who smoke crack cocaine report experiencing oral sores, cuts, and burns that are connected to the use of improvised crack pipes fashioned out of hazardous glass and metal materials [ 45 ], and such injuries may facilitate infectious disease transmission when pipes are shared among users [ 67 ]. Pipe sharing is also commonly reported, especially when pipes are difficult to obtain [ 8 — 10 ].

Indeed, evidence shows elevated rates of hepatitis C virus HCVas well as HIV and other infectious diseases, among people who smoke crack cocaine [ 11 — 15 ]. There are likely various, and some convergent, reasons why harm reduction programming for people who smoke crack cocaine has lagged behind programming developed for people who inject drugs.

Injection drug use has long been considered the riskiest form of drug use in terms of potential health-related risks and as such public health authorities have prioritized services, especially HIV prevention services, for people who inject drugs e. Nonetheless, although people who use illicit drugs in general are a socially marginalized group, people who smoke crack cocaine often exhibit pronounced marginalization characterized by, for example, poverty, unstable housing or homelessness, and elevated rates of encounters with the criminal justice system e.

The establishment of greater services for this drug-using population has relied on additional advocacy efforts. Harm reduction advocates in Toronto and Vancouver were among the first groups in Canada to recommend and begin distribution of safer smoking equipment to engage people who smoke crack cocaine in programming [ 2021 ]. However, implementation of policies and interventions deed for crack cocaine users has also been hindered and delayed by questions about the legality of the distribution of safer smoking equipment and related opposition from police cf. In an effort to promote programming that addresses high rates of HCV among people who smoke crack cocaine, Canadian best practice recommendations encourage needle and syringe programs NSPs and other harm reduction programs to provide education on safer crack cocaine smoking practices and use of smoking equipment; distribute safer smoking equipment i.

See Fig. These evidence-based guidelines for safer crack cocaine smoking education and equipment distribution were developed by a national, multi-stakeholder team for a description of the best practices team formation, composition, and collaboration, see [ 28 ]. Recommended best practice policies to facilitate smoking with a pipe — stem, mouthpiece, and screen — which is made from materials that are non-hazardous to health and have never been shared. As part of a national-in-scope evaluation of NSP practices and policies, the first of its kind that we are aware of in Canada, we conducted a survey of program managers to estimate the proportions of NSPs providing education and distributing safer smoking equipment to people who smoke crack cocaine.

For the province of Ontario, we used ly collected survey data [ 25 ] to assess if there had been a change in the distribution of safer smoking equipment over time. Managers of NSPs across Canada were invited to participate in an online survey examining program policies and uptake of best practices. To expand their reach, core NSPs often engage other organizations to be satellite sites that can also offer NSP services. Trying to sample all NSPs including satellite sites would have been a time-consuming effort and one that might not have added much value as core NSPs often provide their local satellite services with the necessary training including policies and procedures to followsupplies, and support see again [ 25 ].

As there is no central registry of all NSPs in Canada, we created an address list using three approaches. First, we knew from best practices research team members that three provinces Quebec, Ontario, and British Columbia kept their own comprehensive and up-to-date lists of all NSPs including program manager addresses for their respective regions.

We obtained these lists for Quebec and Ontario.

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An official from the western province of British Columbia opted out of providing their list stating that the burden of participation was too great for local NSP managers who were at that time implementing new overdose prevention programming. We did not have the time and resources necessary to contact all public health units in British Columbia and then follow up with all NSPs in that province to obtain the requisite addresses.

For the remaining provinces where, in some cases, there was a small of programs and local managers knew each other, we asked the regional representative on the best practices team to provide contact information for NSP managers in their province.

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Lastly, for the territories, the first author contacted local harm reduction representatives and a territorial ministry of health to identify NSP managers in those regions. The northernmost territory, Nunavut, did not have an NSP. Using these three approaches, we believe that we captured the addresses for managers of all operational core NSPs in Canada, with the exception of NSPs in British Columbia.

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To encourage survey participation, we modified a method by Dillman et al. One to 2 weeks after these alerts were sent, the first author sent formal invitations to potential participants in each province and territory; these invitations included a study information sheet with consent form and a link to the survey.

Two weeks after these invitations, potential participants were sent the first reminder about the survey. Two weeks after these reminders, we ed potential participants a final reminder about completing the survey. Study recruitment was staggered and the survey was open to participants from April 9 to August 4, The questionnaire was developed for an online platform, FluidSurveys, and was offered in English and French.

Please see Additional file 1 that contains English online survey text that is relevant to the findings we report in this article. Before launching data collection, we pilot tested the online survey with five program managers from different provinces and modified some questions as per their feedback. Data were downloaded, managed, and analyzed using SPSS version Specifically, we report frequency distributions and bivariate statistics to characterize the proportion of programs offering safer crack cocaine smoking education and equipment distribution by NSPs.

In addition, using data from an earlier study that used the same online survey methods for Ontario [ 25 ], we compared the proportion of programs in that province that distributed pipes in versus Similar data were not available for the other provinces or territories. We invited NSP managers from across Canada to complete the online survey. A filter question identified eight managers who were not eligible to participate because their program did not actively distribute needles at that time our only study eligibility criterion. Of the remaining potential participants, initially responded to the survey; upon reviewing the data, we removed 24 surveys because of incomplete data, leaving 80 surveys for these analyses.

Table 1 presents program characteristics. Throughout ourwe report the proportion of programs reporting each characteristic or practice. A majority of participants 0. Further, 0. Over three quarters of participants 0. In terms of specific instances when it is time to replace smoking equipment, 0. We asked participants about the formats their programs use to provide education to clients about drug-related risk behaviors and practices.

Given the general way in which we framed these questions, we cannot determine if and where the responses pertain to delivery of education on injection- or smoking-related behaviors, or both. Of these participants, nearly all 0. Of the programs that distribute pipes, 0. The proportions of managers who reported distribution of other pieces of safer smoking equipment were as follows: 0.

In addition to offering each piece of recommended equipment separately, 0. In short, most of the programs that distribute safer smoking equipment reported giving out the recommended types of pipes as well as a complement of other safer smoking materials. Among participants who reported that their program does not distribute safer smoking equipment 0.

When asked about distribution policies, 0. Reported limits ranged from one to 20 pipes per visit, though most commonly participants 0. When asked why their program imposes limits on pipe distribution, 0. Several participants added more information to their surveys that suggested that maximums are imposed due to concerns about clients selling their pipes on the street e. One participant added that a benefit of having a pipe limit is that it keeps clients who smoke crack cocaine coming back to their program for services i. Also as part of the online survey, we asked managers if they and their staff had used the recent set of national best practice recommendations [ 27 ] to change and align program practices with said evidence-based guidance.

Just under half of participants 0. Finally, to examine potential changes in pipe distribution over time, we performed Ontario-specific sub-analyses and compared evaluation data collected in [ 25 ] with data from the survey. Analysis showed a ificant increase in the proportion of programs distributing pipes in Ontario from 0. Our findings show that many NSPs in Canada offer safer crack cocaine smoking education and distribute equipment as recommended.

In Ontario, there has been a ificant increase in the of programs distributing crack cocaine pipes since These findings are encouraging given that crack cocaine smoking occurs in cities across Canada and increases in use have been documented in some locations e. However, there are important questions our study leaves unanswered or open for future investigations. Although we found that some programs reported using the national best practice recommendations to influence safer crack cocaine education- and equipment-related practices, due to the cross-sectional nature of our survey and how we worded specific questions, we cannot state whether or not dissemination of said recommendations led to the observed levels of education provision and any increases in equipment distribution by NSPs.

Overall, the evidence base supporting services for people who smoke crack cocaine is evolving and not as developed as that which supports harm reduction services for people who inject drugs—the latter backed by decades of research and recommended by international associations such as the World Health Organization [ 31 ].

More research is needed, for example, to solidify the linkage s between sharing pipes and HCV transmission [ 6 ]. That said, recent evidence demonstrates that access to safer smoking equipment can help to reduce health-related harm [ 32 ].

Research evidence is, nonetheless, one among numerous factors that impact health-related policy decisions. More work is needed to address other domains found to promote uptake of evidence-based recommendations, including nurturing champions of organizational change, organizational cultures that support innovation and leaderships that promote the use of evidence-based practice, and ensuring adequate funding streams for distribution and disposal of safer smoking equipment [ 3334 ].

Only two managers among those who said that their programs do not distribute pipes selected police opposition as an underlying reason. This finding seems consistent with from our larger evaluation study which show that the majority of NSP managers we sampled reported mostly positive relationships with their local law enforcement [ 35 ]. However, interpretation of this finding is difficult in light of other research that has reported policing practices to be a barrier to services deed for people who smoke crack cocaine e.

Police support and opposition regarding harm reduction programs are dynamic, though, for example, in Canada there are s that police perspectives on supervised injection facilities have changed in recent years, seemingly linked to the opioid overdose epidemic cf.

How police may view services for people who smoke crack cocaine and how those views are changing or may change are worthy of in-depth investigation. Lastly, although collection and safer disposal of used injection equipment is a core activity of NSPs, including providing clients with rigid, tamper-resistant, and clearly labeled sharps containers see [ 27 ] for evidence-based best practice recommendations regarding disposal and handling of used drug-use equipmentwe found that only half of all NSPs that we sampled provide clients with containers for safer disposal of used smoking equipment.

We know from anecdotal reports from members of the cross-regional, multi-stakeholder best practice team that cost can be a barrier and some programs already struggle to cover the costs of injection equipment disposal. The removal from circulation and safer disposal of used injection equipment have long been considered key elements of NSP strategies to reduce needle reuse and accidental needle-stick injuries which, in turn, reduce opportunities for infectious disease transmission [ 3839 ].

More research is needed to determine if disposal is similarly as important for reducing certain risks associated with crack cocaine smoking. In terms of study limitations, our findings may not be generalizable across all programs in Canada. One province with many NSPs and other harm reduction programs did not participate. It is also possible, though perhaps unlikely, that there are some programs that distribute safer smoking equipment and no injection equipment, and these would have been excluded from our survey.

Although not an ideal sample, we otherwise captured data from programs from all other regions, including the Maritimes and the northern territories, and are thus able to provide a highly unique snapshot of Canadian practices.

Our findings can provide some guidance for future, larger-sample investigations to describe and report on relationships involving harm reduction programs and safer crack cocaine smoking education and equipment. Our findings point to important efforts on the part of Canadian NSPs to help reduce HCV and other health-related harm among people who smoke crack cocaine through provision of education and equipment that aim to address such harm.

HCV is a preventable infection, and although at times challenging to implement harm reduction interventions, increased efforts are needed to reduce drug-related HCV risk in Canada and elsewhere in the world. Although beyond the scope of this article, we also stress that while client education and equipment distribution have a role to play in reducing such risk, ultimately improving the health and well-being of people who smoke crack cocaine requires much broader attention to social-structural factors—including social marginalization and drug law enforcement—that continue to disproportionately impact this population and drive much of their drug-related risk behaviors [ 40 ].

Social, health and drug use characteristics of primary crack users in three mid-sized communities in British Columbia. Canada Drug-Educ Prev Polic. Article Google Scholar. Predictors of crack cocaine initiation among Montreal street youth: a first look at the phenomenon. Drug Alcohol Depen. Modelling crack cocaine use trends over 10 years in a Canadian setting. Drug Alcohol Rev. Crack cocaine smoking and oral sores in three inner-city neighborhoods. J Acquir Immune Defic Syndr. Contemp Drug Probl. Hepatitis C virus transmission among oral crack users: viral detection on crack paraphernalia.

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Eur J Gastroenterol Hepatol. Article PubMed Google Scholar. Sharing of noninjection drug-use implements as a risk factor for hepatitis C. Subst Use Misuse. Crack pipe sharing among street-involved youth in a Canadian setting. Do crack smoking practices change with the introduction of safer crack kits? Can J Public Health. PubMed Google Scholar. Factors associated with difficulty accessing crack cocaine pipes in a Canadian setting. Smoking of crack cocaine as a risk factor for HIV infection among people who use injection drugs.

Smoking crack out of a can

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Education and equipment for people who smoke crack cocaine in Canada: progress and limits