Safe Inhalation Pipe Provision Study: Intervening to improve policy and practice for people who use crack in England.

Background:

Crack cocaine use is rising in the United Kingdom, with smoking the primary form of administration. Provision of safe inhalation equipment for crack cocaine is prohibited under UK law. Consequently, people who smoke crack cocaine have little reason to engage with harm reduction and specialist drug services.  Pipes used for crack smoking are often homemade and/or in short supply, exacerbating risks of viral transmission and respiratory complications. The SIPP (Safe inhalation pipe provision) study implements and evaluates an intervention providing crack smoking equipment and harm reduction training in three sites in England. This co-produced study aims to reduce health harms and increase service engagement among people who use crack,  providing evidence of impact to inform legislative review. 

Methods

Study components comprise: 1) peer network capacity building 2) a pre-and post-intervention survey at intervention and non-equivalent control sites; 3) a mixed method process evaluation and 4) an economic evaluation. Survey eligibility criteria is crack use (injecting or smoking) in the past 28 days. We report findings from baseline survey (n=734) and from the process evaluation, including intervention monitoring data and qualitative interviews with people who use crack (n=32) and service providers (n=10)

Results

The baseline respondents (n=734) were primarily male (70%), white (86%), with an average age of 42 years. Respiratory symptoms were commonly reported (60%, n= 437) including breathing difficulty, chest pain or coughing blood in the past 28 days, with 39% (n=272) reporting hospitalisation for a respiratory condition within the past 6 months. Women were particularly vulnerable to respiratory symptoms (66% vs 58%) and associated hospitalisation (44% vs 36%) compared to men. Use of homemade or repurposed pipes was common (69%) among those smoking crack (99%). Qualitative data highlighted how practices, such as scraping residue from plastic inhalers, contributes to respiratory risk. During the 6-month intervention period over 3,000 pipes were distributed, with services reporting engaging with 192 people who had never previously attended any drug treatment service. Engagements extended beyond crack pipe provision to the offer of psychosocial supports, viral testing and other health interventions.

Conclusions

Preliminary findings from SIPP highlight the value of crack pipe provision for enhancing service engagement and a high unmet need for respiratory health interventions among people who use crack, particularly among women. Provision of safer crack smoking equipment, accompanied by legislative change, holds potential for long term risk reduction amongst this underserved population.