Safer crack-smoking resources as a viable addition to comprehensive harm reduction programs for reducing HIV and HCV transmission

Harm reduction programs that consist of clean needle exchange, bleach kits and safe injection instructions for people who inject drugs (IDUs) are recognised as vital and necessary HIV and hepatitis C prevention strategies.

Many of the programs, however, are not adequately addressing harm reduction strategies to combat the growing evidence documenting potential HIV and hepatitis C transmission through the multi-person use of apparatuses to smoke crack. This lack of attention to harm reduction methods for crack users might change as a result of Lynne Leonard’s enlightening presentation at the Sixteenth International AIDS Conference in Toronto. Leonard and colleagues from the University of Ottawa demonstrated that distributing safer crack-smoking resources in a needle exchange program could decrease the frequency of engagement of sharing crack-smoking equipment, establish contact with previously unengaged population at risk, and actually decrease the frequency of injection drug use.

Leonard contends that “aside from a few local community initiatives, very few health authorities in Canada have implemented an integrated strategy to support crack smokers in taking control of their own health by providing resources to reduce the harms associated with smoking crack.” To validate the utilisation and health benefits of free and readily available safer crack-smoking resources, 550 active IDUs who reported smoking crack in the past six months were enrolled in the study. Interviews detailing crack use, sharing of crack-smoking equipment, frequency of such sharing, and injection drug using activities were conducted with study participants at four time points: six months before the implementation of the initiative, and at one month, six months, and twelve months following the implementation of the initiative. Through the Safer Crack Use Initiative, kits containing glass stems, rubber mouthpieces, screens, and other harm reduction resources, including condoms and water-based lubricant, were distributed by the city’s needle exchange program (NEP). Leonard not only showed detailed photographs of the safer crack-smoking kits, but brought many of them with her and offered them complementary to interested audience members after the session.

At baseline, 39% of the study participants reported chronic burns, cuts or blisters on the lips and inside the mouth. These conditions are a direct result of users haphazardly constructing crack-smoking devices from metal tubing used alone or lodged into plastic containers and aluminum soda pop cans. When the crack is smoked, heat is conducted intensely and swiftly through the metal pipe and can result in cuts, burns, blisters and open sores on the mouth, lips and gums.

Uptake of the initiative was considered to be “immediate, high and sustained” with 80% of crack-smoking IDUs at one and six-months and 87% at twelve-months post-implementation reporting collection of crack-smoking kits from the NEP. The sharing of crack-smoking equipment declined significantly, especially in those reporting sharing “every time” they smoked. The amount of participants who reported sharing “every time” decreased from 37% at six-months pre-implementation, to 31% one-month post-implementation and then finally to 13% twelve-months post-implementation (p

There was a significant rise in the frequency of smoking crack following the availability of crack-smoking equipment with 29% reporting more crack-smoking after twelve months of the initiative. Leonard was quick to point out that, although this finding “may initially appear to be a dream come true for critics of harm reduction measures -that providing resources encourages uptake of the behavior, we were able to document a significant decline in injecting behavior.” Indeed, the study documented a 40 % decrease in the frequency of injecting drugs since the availability of crack-smoking equipment. This fact, Leonard contends, is “evidence of transitioning from a higher risk method of drug use to one with somewhat lower risks.”

At the press conference following the presentation, Leonard noted that at the end of the twelve-month evaluation period, “over 4,400 contacts had been made with crack smokers….people who had previously had no contact with harm reduction recourses.” She concluded her remarks with an appeal for the implementation of crack-smoking harm reduction initiatives, saying that “the results of this evaluation document the urgent utility of replicating this safer crack-smoking initiative as one component of a comprehensive harm reduction strategy of other needle exchange programs.”