Can We Make Crack Cocaine Smoking Safer?
In this article, we address the new evidence-based recommendations for distribution of safer crack cocaine smoking equipment.
What Is Crack Cocaine?
Crack cocaine is a stimulant that has been converted from powder cocaine into a rock crystal. When the rock crystal is heated to a high temperature, it melts and quickly vapourizes, and can be inhaled ("smoked"). It produces a short but intense high. Crack is also ranked highly in terms of the harms (physical, dependence and social) associated with its use.5
How Many People Who Smoke Crack Cocaine Have HIV, Hepatitis C or Hepatitis B in Canada?
Studies across Canada show elevated rates (compared to the general population) of HIV among people who smoke crack cocaine. Prevalence rates of HIV reported among people who smoke crack cocaine in Canadian settings range from 19% in Vancouver to 6% in Toronto to 11% in Ottawa.6-8 These rates are all substantially higher than among the general Canadian population (0.2%).9 However, numbers from Toronto included some people who used to inject drugs, although no one had injected in the previous 6 months.
While HIV transmission risk remains higher through sharing injection equipment compared to smoking crack cocaine, research has not determined the cause of infection for people who have histories of both injecting drugs and smoking crack cocaine. Possible causes of infection are the sharing of injecting or smoking equipment and unsafe sexual practices. There is a need for more research to better understand the specific HIV transmission risk of smoking crack cocaine.
In terms of hepatitis C, a study was able to isolate hepatitis C genetic material (RNA) on a used crack pipe;2 other studies have found that hepatitis C can survive on a variety of surfaces from seven to 28 days.10,11 Therefore, we know there is potential for crack pipes to spread hepatitis C. Studies across Canada show elevated rates of hepatitis C among people who smoke crack cocaine. Prevalence rates of hepatitis C among people who smoke crack cocaine in Canadian settings range from 37% in Ottawa to 43% in Vancouver to 29% in Toronto.6-8 These rates are all substantially higher than among the general Canadian population (0.7%).12
Although the evidence is limited, there is also potential for the transmission of hepatitis B, other sexually transmitted infections, tuberculosis, and pneumonia among people who smoke crack cocaine.13-26
What Is the Link Between Pipes and HIV and Hepatitis C Transmission?
Pipes for smoking crack cocaine can be crudely constructed from items such as glass bottles, soft drink cans, plastic bottles, car aerials or metal pipes. When makeshift pipes are used to smoke crack cocaine, the hot, jagged surface can cause injuries to the hands and mouth, including oral inflammation, cuts, burns and sores. Blood from these injuries may end up on the pipe. HIV or hepatitis C virus contained in the blood can then be passed along to the next person using the pipe. It is hypothesized that through this mechanism, people who smoke crack cocaine are at an elevated risk of acquiring HIV and hepatitis C.1,2,8,27
Sharing of Pipes
Evaluations of safer smoking supply distribution programs across Canada have documented sharing of crack cocaine smoking equipment.28-33 Pipe sharing has also been reported in other Canadian studies of people who smoke crack cocaine.34-37
Many factors can influence pipe sharing, including smoking in small groups and intimate partner relationships. In addition, allowing others to use a pipe means that the owner can collect the "resin" or residue that collects on the inside of a pipe and smoke it.38 People who smoke crack cocaine who have difficulty accessing pipes are also more likely to share.30,39 Crack cocaine is sold as small "rocks," making it difficult to divide into smaller pieces; this may contribute to sharing of smoking equipment among people who pool their money to purchase drugs.
Several Canadian studies report high frequency of smoking episodes (for example, one to 70 episodes per day).1,20,33,34 Impaired memory, lack of restraint and poor risk assessment due to heavy use may also lead to the sharing of drug use equipment and risky sexual practices.4
Can We Reduce the Harms of Crack Smoking?
While NSPs are well-established programs for HIV and hepatitis C prevention across Canada, programs that distribute safer crack cocaine smoking equipment are fewer in number and some parts of the country lack these programs altogether. Many safer crack cocaine smoking equipment distribution programs struggle to sustain funding and some have been subject to intense community opposition.35,40,41
New evidence-based recommendations for safer crack cocaine smoking equipment distribution have been developed by a multi-stakeholder team, the Working Group on Best Practice for Harm Reduction Programs in Canada, as part of Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 1.42 In a previous Prevention in Focus article, we discussed the Best Practice Recommendations project and the evidence that supports the recommendations for needle distribution.
This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
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