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Opportunities to learn and barriers to change: crack cocaine use in the Downtown Eastside of Vancouver Boyd, Susan; Johnson, Joy L; Moffat, Barbara Nov 17, 2008

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchOpportunities to learn and barriers to change: crack cocaine use in the Downtown Eastside of VancouverSusan Boyd*1, Joy L Johnson2 and Barbara Moffat3Address: 1Studies in Policy & Practice, University of Victoria, Canada, 2NEXUS, School of Nursing, University of British Colombia, Canada and 3Nursing and Health Behaviour Research Unit, School of Nursing, University of British Columbia, CanadaEmail: Susan Boyd* - scboyd@uvic.ca; Joy L Johnson - joyjohnson@exchange.ubc.ca; Barbara Moffat - Barb.Moffat@nursing.ubc.ca* Corresponding author    AbstractIn 2004, a team comprised of researchers and service providers launched the Safer Crack Use,Outreach, Research and Education (SCORE) project in the Downtown Eastside of Vancouver,British Columbia, Canada. The project was aimed at developing a better understanding of theharms associated with crack cocaine smoking and determining the feasibility of introducing specificharm reduction strategies. Specifically, in partnership with the community, we constructed anddistributed kits that contained harm reduction materials. We were particularly interested inunderstanding what people thought of these kits and how the kits contents were used. To obtainthis information, we conducted 27 interviews with women and men who used crack cocaine andreceived safer crack kits. Four broad themes were generated from the data: 1) the context of crackuse practices; 2) learning/transmission of harm reducon education; 3) changing practice; 4) barriersto change. This project suggests that harm reduction education is most successful when it isinformed by current practices with crack use. In addition it is most effectively delivered throughinformal interactions with people who use crack and includes repeated demonstrations of harmreduction equipment by peers and outreach workers. This paper also suggests that barriers toharm reduction are systemic: lack of safe housing and private space shape crack use practices.In 2004, a team comprised of researchers and service pro-viders launched the Safer Crack Use, Outreach, Researchand Education (SCORE) project in the Downtown East-side (DTES) of Vancouver, British Columbia, Canada. Thepurpose of the SCORE project was to develop a betterunderstanding of the harms associated with crack cocainesmoking and to determine the feasibility of specific harmreduction strategies. A significant harm reduction compo-nent of the project included the distribution of safer crackkits. The findings for this paper are derived from 27 qual-itative interviews conducted in 2007 with women andThe SCORE project was ultimately aimed at providingharm reduction services to women and men. The projectwas dedicated to ensuring that everyone who uses crackand lives in the DTES has access to equipment and educa-tion that will help them to incorporate safer crack usepractices. At the outset, one of the many questions we hadrelated to how crack cocaine users access and utilize edu-cational information about illegal drug use and harmreduction. We were also interested in knowing how crackcocaine users themselves reduce drug-related harm.Published: 17 November 2008Harm Reduction Journal 2008, 5:34 doi:10.1186/1477-7517-5-34Received: 24 June 2008Accepted: 17 November 2008This article is available from: http://www.harmreductionjournal.com/content/5/1/34© 2008 Boyd et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 12(page number not for citation purposes)men who use crack cocaine and who had received safercrack kits.SCORE drew from critical, feminist and harm reductionresearch on illegal drug use in constructing the researchHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34project and analyzing the research data. The project wasalso informed by community-based research perspectives.The following sections include background on critical andfeminist drug research, harm reduction perspectives,methodology and project background, safer crack kits anddistribution, and research findings. We conclude by high-lighting social factors that shape crack use and learningopportunities. The project findings contribute to existingharm reduction literature and are expected to be of benefitto practitioners working in the area of harm reduction.Critical and Feminist Drug ResearchEarly critical drug research shifted the field of drugresearch. Rather than law officers or social workers, healthprofessionals, or media people reporting on the lives ofpeople who use illegal drugs, critical drug researchersadopted an ethnographic approach – privileging the voiceand perspective of people who use drugs themselves inorder to better understand their behaviour and concerns[1,2]. Later feminist ethnographic research explored howillegal drug use is gendered [3]. Critical and feminist drugresearch is especially useful for those seeking to under-stand social and cultural factors that shape the lives ofpeople who use legal and illegal drugs. It privileges thesubjective experiences of people who use drugs and pro-vides insight into social learning related to minimizingharm and informal social control.Most significant for this paper, critical and feminist drugresearchers emphasize qualitative interviews as a method-ological tool that successfully brings to light how peoplewho use drugs learn and make sense of the drugs they con-sume and the social environment where they use them.Howard Becker's early 1963 ethnography makes clear thatdrug use and learning is shaped by sociohistorical, cul-tural, and social-psychological variables [2]. Drugresearcher Norman Zinberg outlined how "set and set-ting" shape drug use. "Set," comprised of people's atti-tudes and their expectations, can be just as important, ormore important, than the pharmacology of a drug inshaping a user's long-term relationship with a particulardrug. "Setting" refers to the physical, cultural, and socialenvironment in which a drug is used. These variables arenot separate and distinct; rather they interact with oneanother [4].Zinberg explained that the experience of drug use is alsoshaped by both formal (the law) and informal social con-trols, rituals, and the transmission of knowledge. Heinvestigated how informal knowledge is transmitted, stat-ing that it is a "crucial factor in the controlled use of anyintoxicant" [4] (p. 14). Zinberg argued that rituals andinformal controls provide opportunities for learning howsafety. Informal controls apply to all drug use, for exam-ple, "don't drink till 5" and "don't bogart that joint" arefamiliar refrains. In addition to the concept of informalrituals and social control mechanisms that people whouse drugs employ, drug researchers note that drug availa-bility and access to drug paraphernalia (such as needleexchange) have a significant impact, especially on thelives of people who use illegal drugs, as do the criminalsanctions that shape drug use and services [1,5-9]. Theseconcerns also shape the lives of people who use crack inthe DTES.In their extensive ethnography, which included 267 life-history interviews with heavy cocaine users (includingcrack) in northern California, Waldorf, Reinarman, andMurphy found that for these users "there is no centralclearinghouse for such illicit information .... and crackusers are left to their own folk-experimental devices fortesting tools or techniques" [10] (p. 113). They also dis-covered that there was no "uniform progression or pat-tern" of cocaine use and that their participants were byand large no different than other "ordinary citizen [s]"(i.e., who held jobs and have families); this "normality""turns out to be theoretically crucial" [10] (p. 10). Theyconcluded that what keeps "many heavy users from fallinginto the abyss of abuse, and what helps pull back thosewho do fall, is precisely this stake in conventional life" [10](italics in original, p. 10).Critical and feminist drug researchers have long pointedout that there is much "historical evidence suggesting thatreducing harm and offense...is more likely through thedissemination and internalization of the informal socialcontrols of user culture than through the formal socialcontrols of the state [11] (p. 408). Thus, it is imperative tounderstand the user culture and to work with them along-side community organizations in order to create bettereducational material, avenues for education, and access toharm reduction equipment. This was very much in keep-ing with the vision of the SCORE project.Harm ReductionAlthough there are some different views about harmreduction, for example some conventional critics have co-opted the term to include sending people who use illegaldrugs to prison to reduce risk to themselves and society,for the purposes of this paper, "harm reduction" isdefined as providing practical, non-judgmental servicesthat seek to minimize drug-related harm to both the indi-vidual and society. In addition, prohibition and socialand economic inequality are seen as contributing to harm[6,8]. Harm reduction advocates state that " [a]dversehealth, social and economic consequences of drug use"Page 2 of 12(page number not for citation purposes)to control the consumption of legal and illegal drugs andtechniques of use and knowledge about equipment andcan be effectively decreased without "requiring decrease indrug use" [12] (p. 1698). Diverse, low, and high thresholdHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34services that are culturally appropriate have been createdin and outside of Canada [13]. Prioritizing of needs andeducation are also central goals. Harm reduction pro-grams differ from conventional abstinence-based treat-ment. Abstinence is not the primary goal of the harmreduction model; rather, abstinence is one of many variedoptions that can be offered. Drug use is understood asbeing non-static and can range to include a variety ofmethods of expression, including casual, dependent,functional, controlled, and dependent use. Furthermore,not all drug use is negative, nor is all addiction negative.Problematic or negative use is recognized as stemmingfrom social factors and individual trauma; however, this isneither determined nor static [14].Responding to political and social factors, and shifts inillegal drug availability and use, people who use illegaldrug users themselves, health, and service providers con-tinue to adapt their services to meet the needs of thosemost affected. Harm reduction advocates recognize theimportance of moving towards a health and human rightsmodel where social factors are brought to the foreground[15]. Furthermore, people who use illegal drugs are con-sidered to be essential partners and experts at all levels ofplanning and practice [16]. Thus, we adopted a bottom-up approach to our harm reduction project, and membersof the SCORE team worked in partnership with individu-als who used crack [8].In many ways, critical drug research perspectives andharm reduction practice draw on similar theoretical phi-losophy. Both perspectives recognize that those mostaffected by policy, and engaged in drug use, have insightsto share about their lives. Both perspectives are interestedin people's relationships with drugs and are non-judg-mental about drug use in itself. Furthermore, both per-spectives account for the social and cultural context inwhich drug use occurs. And finally, both perspectives rec-ognize that humans have historically used drugs tochange consciousness and that "zero tolerance" or a"drug-free" world is impossible and unrealistic. In thisway, drugs are neither seen as bad nor good; rather, peo-ple use drugs for a variety of reasons – most often drugsare consumed for pleasure, to heal and sustain health, andfor spiritual and religious reasons. However, people alsouse drugs to enhance physical performance, work, andschool output; to alleviate hunger; to reduce pain and suf-fering (both physical and emotional); and as a strategy tocope with violence, dislocation, and colonization[6,14,17]. Critical drug research and harm reduction stud-ies attempt to highlight how drug use is shaped by per-sonal and larger societal and cultural factors.cities, now referred to as harm reduction programs; how-ever, these services were less effective than they could havebeen due to one-on-one needle exchange and limitedaccess and hours. In the case of methadone, punitive andever-changing policy also limited its effectiveness [5,18].Following years of advocacy by health and communitygroups including activists, especially by VANDU and therelease of the Report on the Task Force Into Illicit NarcoticOverdose Deaths in British Columbia [19], a public healthemergency was declared in 1997 by Dr. John Blatherwick,the Chief Medical Health Officer of the Vancouver Rich-mond Health Board, in response to increasing numbers ofoverdose deaths and infection for Hepatitis C and HIV inthe area [20]. In 2001, the City of Vancouver's drug strat-egy, described in A Framework for Action: A Four-PillarApproach to Drug Problems in Vancouver, was adopted byCity Council [21]. The City drug strategy recommendedactions across the four pillars of prevention, treatment,harm reduction, and enforcement. It also recommendedthe opening of the first supervised safer injection site inNorth America in the DTES. The facility, Insite, opened in2003.Programming that supports safer injection drug use prac-tices such as access to sterile syringes and water and theimplementation of a supervised injection site have beenimplemented in Vancouver [21]. In the DTES, harmreduction program planning has primarily focused oninjecting drug use and the reduction of blood-borne infec-tious diseases such as HIV and Hepatitis C. Nevertheless,various infectious diseases have been associated withcrack use. The scarcity of quality crack pipes (such as Pyrexpipes, which are more heat resistant and less likely tocrack than glass pipes) and their cost leads to repeated useof glass pipes that are cracked and split. Split and crackedpipes increase the likelihood of cuts to the hands and lips[22-24]. In addition, many people who smoke crack sharetheir equipment, thereby increasing their risk for infection[24-26]. Small and Drucker outlined some of the healthrisks that individuals who use crack are exposed to due toinadequate harm reduction equipment [9]. Among otherrisks, they noted how inadequate filters, such as Brillo,pose health risks to people who use crack because parti-cles break off, putting users at risk for cuts to their lips aswell as associated pulmonary problems [9,27].There is also evidence of infections related to crack use.Hepatitis C (HCV) and Human immunodeficiency virus(HIV) have been associated with crack use in epidemio-logic studies [23,28-31]. A recent study confirmed theplausibility of HCV transmission through sharing crackpipes when HCV was identified on a crack pipe [32]. Inaddition, a recent outbreak of pneumococcal pneumoniaPage 3 of 12(page number not for citation purposes)Harm Reduction in the DTESIn the late 1990s, Canada had methadone maintenanceprograms and needle-exchange services in place in somewas identified in the DTES [33,34]. A substantial propor-tion of these cases were noted to be people who wereusing crack regularly, leading to the proposition that shar-Harm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34ing crack paraphernalia was an efficient means of spread-ing pneumonia. The pneumonia outbreak generated highuse of intensive care beds in the city, significant mortality,and a massive vaccination program [34]. The extent of theoutbreak illustrated the precarious health status of peoplein the DTES or in contact with this community. In 2007and 2008, there were also outbreaks of tuberculosis inpersons who use crack in BC [33,35].Originally a safer crack cocaine smoking room wasplanned for the Insite project; however, to date it has notbeen implemented. Few services provide supportuniquely for people who use crack, and there is less harmreduction information, education, services, and access tosafe equipment in the DTES [9,25]. Furthermore, "pov-erty, violence, exploitation, discrimination," and "ongo-ing trauma" intersect with and influence health concernsexperienced by individuals who use crack in the DTES,especially women [33]. Of note, a 2006 SCORE survey (of126 women and 80 men) conducted prior to kit construc-tion and distribution in the DTES suggested a high inci-dence of daily and weekly crack smoking practices, use ofBrillo (98.4%), split pipes (43.7%), and sharing pipes(46.8%) [25]. The findings reinforced the need for lessharmful non-injection drug-using equipment, includingPyrex stems, metal screens, mouthpieces, and woodenpush sticks, as well as further exploration of learningopportunities and barriers to change that resulted from kitdistribution. The qualitative interviews were an attempt tobetter understand this from the perspective of those whohad received safer crack kits.Methodology and backgroundThe SCORE project was conducted in the DTES of Vancou-ver, British Columbia. It is one of the poorest neighbour-hoods in Canada. It has been estimated thatapproximately 16,000 people live in the DTES and thatwomen comprise 38% of this population [36]. The DTESis a very diverse neighbourhood: 40% of its residents areAboriginal, and another 20% are East Asian or Latino/a[37]. The DTES has a "high concentration of social prob-lems, including poverty, mental illness, drug use, crime,survival sex work, high HIV/Hepatitis infection rates,unemployment and violence" [38] (p. 5). A number ofsurveys in the DTES indicated that crack use has becomeincreasingly common over the past 10 years. The actualprevalence of use depends on the population surveyed. In2003–2004, the Community Health and Safety Evalua-tion project [39] recruited over 3,500 people within theDTES to participate in a survey on health-related ques-tions. About 28% reported frequent crack use, and over50% had used crack [39]. In a study of youth in custody inBC aged 14–19 in 2006, 60% reported ever using crack,Survey (VIDUS) found that crack use in a group of injec-tion drug users in Vancouver almost doubled from 32% in1997 to over 60% in 2004 [41]The project drew from community-based research per-spectives that aim to create social change and to give backto the community [42]. This methodological approachtakes into account the lives of those who are acted upon –without erasing their experiences. A number of critical andfeminist researchers advance community-based researchas an approach that acknowledges that research partici-pants are sources of knowledge about themselves andtheir communities; therefore, they have much to contrib-ute [43,44]. The 2005 Canadian HIV/AIDS Legal Networkpaper, "Nothing about us without us." Greater, meaningfulinvolvement for people who use drugs: A public health, ethicaland human rights imperative," provided important guid-ance for inclusion of people who use illegal drugs [16].The team was comprised of DTES community workers,research assistants, and faculty with backgrounds in nurs-ing, health care and epidemiology, criminology/sociol-ogy. The team worked in collaboration with the SaferCrack Use Coalition of Vancouver (SCUC), a group com-prised of community outreach workers, women and menwho used crack cocaine, and health care providers, as wellas the SCORE's Women's Advisory Committee (SWAC),comprised of four women selected from a women's sup-port group run by the Vancouver Area Network of DrugUsers (VANDU). Our intention was to provide an alterna-tive model of research by including community inputfrom the conception, to the planning, implementation,and writing about the project [25].MethodsAlthough major components of the SCORE projectfocused on women, men were also participants. Theresearch activities included participant observation over athree-year period, field notes during the kit-making ses-sions, and cross-sectional surveys regarding health con-cerns and general drug use practices. These researchactivities surrounded the construction and distribution ofnon-injection harm reduction kits for crack use. Towardsthe end of the project, qualitative interviews were con-ducted.The sample for this paper includes 27 qualitative inter-views with women and men who use crack cocaine andwho had received a harm reduction kit (17 women, 1transgendered person, and 9 men). All interviews tookplace in the DTES. Interviews ranged from 15 to 45 min-utes in length. The participants were between 19 to 55years of age. Most of the women and men interviewed forPage 4 of 12(page number not for citation purposes)with females significantly more likely than males to haveused [40]. In addition, the Vancouver Injection Drug Userthe study were living in extreme poverty and currentlyused or had a recent history with crack use. IntervieweesHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34were recruited by SCORE members and staff from variouslocations throughout the DTES, including drop-in centres,women's housing facilities, emergency shelters, and com-munity health centres. The drop-in locations were chosenstrategically to enhance women's and men's access to serv-ices offered by these agencies. Participants were paid a $10honorarium for their time and expertise, in keeping withpractices of other health and social science research in theDTES and elsewhere; all were offered a safer crack kit.The team developed an interview guide in which partici-pants were asked about the first time they had receivedsafer crack kits, the contents of the kits (what worked,what did not), changing crack use practices, and accessingcrack kits. The questions were open-ended, and partici-pants were encouraged to identify issues that theybelieved were relevant to their experience with safer crackkits and crack use.Prior to the interview, interviewers reviewed the consentform with participants, and issues surrounding confiden-tially and anonymity were communicated. Recordedinterviews were transcribed, and all identifying informa-tion was removed; transcribed interviews were thenreviewed by the research team and coded. The transcriptswere analyzed drawing on a method of constant compar-ison and questioning, a bottom-up, back-and-forth reflec-tive process where "interpretation" informs the researchprocess, including the coding process; thus, themes wereidentified not only through the interview schedule butfrom the data, and interviewing ceased upon reaching sat-uration [45,46].Safer Crack KitsAfter consulting other harm reduction programs in Can-ada regarding the contents in safer crack kits, the SCOREteam chose to include in each kit the items listed below.Decisions about the type and quantity of items took placethrough a process of consultation with people who usecrack in Vancouver, as well as members of the projectadvisory teams, SCUC, and SWAC. The rationale for pro-viding each of these items follows below. In total, approx-imately 14,000 kits were assembled during kit-makingsessions (see Table 1).Over the course of the project, the kits were distributedthrough peer-delivered on-foot outreach or through anexisting outreach van to persons in the DTES. All of theoutreach teams distributed between 25 and 100 kits eachshift. The process of distribution included handing outkits, demonstrating how to put the brass screens into thepipe and how to attach the mouthpiece properly. Therewas information provided on why screens should be usedinstead of Brillo. The teams also talked with people aboutthe risks of sharing equipment and made referrals tohealth agencies when possible. The teams used a tallyTable 1: Kit contents and rationale for inclusionKit Item Rationale for InclusionPyrex Stems • Compared to conventional glass, they are stronger and less brittle.• They are less likely to explode, break, or chip and last longer than do glass stems.• Their inclusion reduces likelihood of the use of other, less safe options.Mouthpieces (a four-inch rubber tube) • For use at one end of a stem to prevent direct contact with broken or hot pipes.• A personal mouthpiece minimizes exposure to communicable disease when a pipe is shared.Wooden Push Sticks (chopstick) • For the purpose of packing and positioning the filter or screen inside the stem.• Wooden push sticks do not chip stems, unlike metal counterparts that are used frequently (e.g., coat hangers, car antenna).• Given that plungers of syringes were also being used for this purpose, providing a wooden push stick decreased the use of syringes and subsequent littering of needles and syringes.Condoms • Since crack use is associated with high-risk sexual behaviors (i.e., buying and selling sex), condoms are integral to promoting safer sex.• Many women in the DTES who use crack support themselves through sex work; women need easy access to condoms.Bandages: • These were included to protect broken skin, promote healing, and minimize exposure to infection (self and others).Alcohol Swabs • Promoted the use of clean equipment (e.g., pipes, mouthpieces) and a means of cleaning wounds.Screens (Brass tobacco pipe screens) • They are less likely to break apart than steel wool or "Brillo.1"• Unlike Brillo, brass filters are not coated with potentially toxic substances.Lighter • Smoking crack requires applying consistent heat to the pipe.• Using matches is more likely to result in burns and the inhalation of sulphur.Information cards • Two cards were included in the kits: 1) The Tip card covered harm reduction information for people who use crack, and 2) The Resource card outlined information on health and drug services in the DTES for people who use drugs.Page 5 of 12(page number not for citation purposes)1 The term "Brillo" used here and in the remainder of the document is the street term for the steel wool used as a filter on the inside of the crack pipe.Harm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34sheet to record how many kits were given out, the numberof people who received demonstrations and education,what referrals were made, and the gender of kit recipients.The one-on-one interviews following kit distribution pro-vide insight into crack cocaine practices among some indi-viduals in the DTES of Vancouver.The findingsThe findings point to the many challenges inherent inproviding education and changing drug use practicesamong individuals who use crack. This was particularlythe case for people who had a long history with crack use.Based on the interview data, we describe key findings,beginning with a description of the context of crack use.Crack use practicesThe interview data revealed that the ways crack wassmoked was shaped by the realities of people's lives. Inorder to understand how the kits were used, we must firstconsider this context. For example, many participantsindicated that they often smoked in small groups and thatthis often necessitated the sharing of equipment, (i.e., apipe). Due to a lack of private space and safe housing, thelocation for crack use for most participants was outdoors,e.g., on the streets and in alleys. One female participantnoted:Because a lot of the time if women are on the street and theyjust want to have a toke and warm up.As a result of smoking crack in such open and publicspaces, many talked about the need to be vigilant in orderto avoid the police, which further contributed to a need tosmoke crack in a hurry. One participant focused on theimportance of being discrete with paraphernalia andremaining vigilant in her surroundings. She was particu-larly concerned that the push stick in the kit was too long:It [the push stick] is a bit long for somebody who's trying tokeep things out of sight. I noticed that if I am transportingsome paraphernalia from one place to another and I haveto get there fast and I don't want anybody noticing, I don'twant the police to notice this stick hanging out of my pocket,it gets seen, right?Most of the people we interviewed also spoke about need-ing to get high and being in a hurry to do so. Continuingto use Brillo for many was based on the belief that Brillowas easier to handle especially when in need of a "hoot."As one person stated, "We're not thinking about safety whenwe want [to use], we're just thinking about our dope. We needa toke." There was a particular concern that using screenswould be awkward and would disrupt preferred practices.to play with it" [inserting screens]. The context of people'sday-to-day lives necessitated some degree of adaptability.Participants described how crack use practices variedaccording to circumstances. They often illustrated a prac-tical approach to their use. In the following quote one par-ticipant describes the utility of sharing and why an extramouthpiece is a good idea especially for street involvedwomen:The two mouthpieces is really good because then they cankeep one to use if people want to use their pipe, and they dolend it out because a lot of women don't have a lot ofmoney. And if somebody is using their pipe, they get to keeptheir resin, and that's how they stay high all day, right? Soif they lend their pipe out all day long and have an extramouthpiece to put on for other people to use, then they canswitch mouthpieces. I think that's a great idea.Their ability to adapt the use of the harm reduction mate-rials was noteworthy. One woman described how sheused condoms for smoking crack.You know how people share it when they're mouth to mouthblowing the smoke in, it's the same thing with a condom.You blow the smoke in there and suck it back. Same thing,"seconds," that's what I use the condoms for.While many did not consistently use harm reductionapproaches when they smoked crack, their practices sug-gested an underlying concern about limiting harms. Forexample, one participant commented:I don't use the mouthpiece, if I do, if I'm using somebodyelse's [pipe], then I use a mouthpiece.We also found, not surprisingly, marginalization shapedcrack use and learning opportunities. In particular, a lackof private space (affordable housing) and visibility shapedcrack use and the experiences of participants in the DTES.As noted, the participants in this sample often smokedcrack outside and in small groups. Sharing of pipes iscommon, and safety concerns related to violence, fear ofarrest, and rip-offs keep users on the move. It follows thatequipment that is time-consuming to use and difficult towork with remains a challenge to promote when "time" isa rare commodity. A sense of urgency to use crack set inthe context of a lack of private space to use and busy daysfilled with volunteer work, participation in projects forresearch stipends, doctors' appointments, hustles toobtain drugs, food, and shelter limit learning opportuni-ties and encounters with safer crack kit distribution teams.Learning/Transmission of harm reduction educationPage 6 of 12(page number not for citation purposes)One woman indicated that she was in too much of a hurrywhen she was trying to get high and stated, "I didn't wantIn this section of the findings, we explore the ways inwhich educational information was conveyed thatHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34resulted in learning about harm reduction and safer crackuse. The interviews with kit recipients were an opportu-nity to explore how such information had been transmit-ted and how learning about the safer crack use items hadtaken place at the time of the kit distribution and demon-strations. During the course of our analysis, it was clearthat much harm reduction education information wasconveyed by watching others' practices with crack use, aswell as during informal interactions with other peoplewho use crack.As mentioned, demonstrations were an important part ofthe process of kit distribution; some participants wereopen to this mode of receiving harm reduction informa-tion. After observing a demonstration that involved theuse of the brass screens, one person was receptive to tryingthe screens at home. Based on her comment, there hadbeen a clear message that this was a safer approach tocrack use. As a result of learning something "new," she inturn demonstrated a willingness to practice somethingthat was less harmful.Yeah, I know because I went home, and I was like trying it[to use screens]. You've got to always try something new,right? And if it's something that is better for me, then sureI'll do itFollowing crack pipe demonstrations, learning took placeby way of "hands-on" experience for many participants.During the interviews, a number of kit recipients com-pared their experiences with using Brillo to the use ofbrass screens; many, not all, indicated that they recog-nized that the brass screens were a safer option than wasBrillo.The screens are good because they don't burn like the otherones, like Brillo. And the Brillo, I've had caught in mythroat I don't know how many times. I've cut my fingerswith it [Brillo] trying to break it apart.As one person stressed, being "aware" of health issuesrelated to crack use had played a role in his own safercrack use practices; he indicated that this awareness waslargely a result of learning about safer crack use practicesthrough his involvement with the SCORE project. Simi-larly, being "aware" of the reasons for including differentitems was key. As an example, many participants sup-ported the idea of supplying mouthpieces in the safercrack kits. Although the actual practices associated withthese mouthpieces were not consistent, many participantswere "aware" of their valuable role in reducing harm.Other participants credited the impact of peers with theirwas conveyed "informally" through watching others. Onewoman indicated that she was using brass screens moreoften and remained receptive to continue to do so becauseof what "others" were saying.I've always used Brillo, but I'm finding that more people areusing screens, and they're telling me, and they are showingme, "You should be doing it" which I'm doing that moreoften than I used to...the screens are better for your lungs,and I have emphysema, so I should be using the screensmore often.Several participants explained how they engaged in talk-ing about harm reduction with other people who usedcrack. A few participants described how they gave certainkit items to others, namely the Tip cards. A few peopledescribed the Tip cards as "informative" and helpful inworking with others.I found them useful in explaining to people, because I usedto do outreach. And I participated in the harm reductionconference, so I'm fairly knowledgeable. So by my saying apiece of information but then having it backed up [on thecard], made it invaluable, right?One woman underscored the importance for others "tolearn" how to use the Tip cards and take the extra time tobe safer. In her interactions with others who used crack,she suggested how she emphasized that "there are reasonswhy they put it in there." Based on the interviews, it wasclear that educational information and learning aboutharm reduction education came from different sources.Changing practiceCrack use practices are difficult to change. One key to thesuccess of this project was helping persons who use crackincorporate safer practices into their lives as they saw fit.In the words of one person, the SCORE project involved"problem solving" that provided "an incentive to do a safermethod."Many participants emphasized the need for the availabil-ity of paraphernalia. If new materials such as screens werenot available, people would have little choice but to useold practices.Well, screens aren't very available and how often does crackkits come around? I think once I got one off the street. So ifthey had screens available, then maybe they would be usedmore.One participant emphasized that she had decreased thesharing of pipes because pipes had become more availa-Page 7 of 12(page number not for citation purposes)own learning about safer crack use; for some, information ble.Harm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34It's safer, you're not using all broken up pipes, and we're notsharing often. I know myself, now I'm not sharing my pipeslike I used to because of availability, right? And it enablesyou to have a new pipe almost every second day. And thenyou always have new hoses, new screens, so...and the thingyou know we have to worry about nowadays with all thesediseases that we could contact with old pipes, or sharing.Similarly another participant equated the availability ofequipment with safety.The benefit being that it's safer, you know, you're not usingall broken-up pipes, and we're not sharing. Often, I knowmyself now I'm not sharing my pipes like I used to becauseof availability, right?Some participants emphasized the link between havingtheir own pipe and changes in their own use.Well, it's safer, instead of like people buying used ones. Iused to buy used ones [pipes], and it was black [charredwith use].One person indicated that he was happy to have "a nicepipe" and that he no longer shared his pipe with anyone.The use of a mouthpiece was also connected to their avail-ability.Everybody uses mouthpieces if they're there, pretty well,especially now people are starting to get more involvedbecause it's a lot of sharing of pipes.It was clear that many of those we spoke with had devel-oped an awareness of the harms associated with crack usepractices. For example, although one participant experi-enced challenges using the screens, he noted that screenswere safer; for this reason, he made a change in how hesmoked crack.The screens when you use them and you heat them up, itcracks the pipe and especially in the cold, they heat up dif-ferently. The Brillo cools down kind of like that [snaps fin-ger for effect]. You can take the screens out and wash them,or change them. People don't like the screens. As I said, I'mnot a proponent of it, but no more black things spitting up,no more black tongues, um, I'm sure it will let me keep myteeth a couple of years.Some of the participants suggested that their new practiceswere becoming entrenched and were systematicallychanging the ways that they smoked crack.I mean I've been guilty of using whatever pipe was conven-sure I carry my own mouthpiece with me. And if it's ever anoption, I usually try not to share other people's pipes. If Iabsolutely cannot live without [sharing] it, then I'll havemy own mouthpiece at least to put on there. And I usuallycarry a couple of alcohol swabs with me actually too.Changes were unlikely to be sustained if they were per-ceived to be unsatisfactory. For example, one participant'sfirst experience using the screens was "disappointing,"which influenced her plans to use screens in the future.I just, I didn't get anything that I was hoping to get out ofit. It was really disappointing. Because I didn't do a lot ofcrack yesterday and to have, sometimes if you have someand you're starting fresh with something you've never triedand you use it, and you don't get what you are expecting,it's even more disappointing, so I was a little bit bummedout by that. I won't do that again because I've tried it withthe screens, and every time I'm disappointed.Some participants who adopted screens early on indicatedthat they preferred the taste of using the screens. Mostoften, the change from using Brillo to screens was gradualfor participants. Packing the pipe with the screens was askill that required practice.The participants who were changing their practicesreflected on what they had personally found helpful inorder to make changes that resulted in safer crack use,which involved incorporating what they knew about cer-tain items, such as the screens. "There is no such thing as safecrack, if I can minimize the damage, at least, then I'm on myway, right?"Some emphasized how important and helpful it was tohear the safer crack use message on a repeated basis frompeers and outreach workers in order to shift personal crackuse practices. One participant noted how she shared themessage about safer use with others.Well probably the more times you're told, the more timesthat people are encouraging you [to use more safely]. Youhave the van going around telling us, now that I have a con-cept, I will be telling people, you know, to make a change.Demonstrations with pipes and screens were also benefi-cial in terms of changing practices. As one participantnoted, this was a process that took time.She [outreach worker] showed me how to wrap, fold thescreen, basically once she showed me that, I still didn't lis-ten and use it. But after that, I started to, question the Brillomore. And she showed me, and you know, she just showedPage 8 of 12(page number not for citation purposes)ient and closest, whoever had whatever. And I was justlucky that I didn't catch anything from it. But now I makeme what was in there [the kit] and showed me how to useHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34the screen and that it was better for you. And I took heradvice in the end, it took me awhile.Another interviewee noted that it took him a couple oftimes to learn how to use the screens properly. Thus theparticipants illuminate how time and repeated demon-strations are key components leading to shifting practices.Barriers to changeThe interview data is illuminating with regards to barriersto changing established crack use practices. Access toharm reduction paraphernalia was crucial. However,many individuals articulated their resistance to changingtheir practice and were adamant that they were set in theirways and strongly attached to their own crack use prac-tices. Contributing factors to such practices were the inac-curate understanding of risks (i.e., what they knew ofharms), difficulty using certain paraphernalia (e.g., apply-ing mouthpieces and screens), and crack use couchedwithin the context of busy lives.Some individuals indicated that they had no intention ofchanging how they smoked crack. As one person noted,"I'm used to one thing, I don't change...don't even ask mebecause I won't change." At the same time, there was recog-nition that others might be receptive to changing. "Yeah,some people are open to change, but I'm not one of them." Par-ticipants, particularly those with a long history of usingcrack, suggested that they had firmly established crack usepractices and preferences. For some, personal practiceswere built on years of crack use. As one interviewee madeclear: "But I pretty much know like the dos and don'ts."One person was adamant that he would not change hiscrack use practice after years of doing it a certain way. Infact, he was offended by the idea that others, with presum-ably less experience, would show him "how to."Because it's almost like an insult to me because I've beensmoking crack for 13 years...12 or 13 years. For somebodyto demonstrate to me how to load a pipe would be disre-spectful in a way.Another person added, "I know all that shit already anyways,and you know, why would I need that?"Some people felt that they already knew harm reductionmessages and that they had "no use" for more harm reduc-tion information that was provided in the kit. One selfdescribed "long-term user" indicated that he know all the"in's and out's" and, along with a number of the partici-pants, did not read the information card provided in thekit. According to another individual, this educationalThose [cards] are for rookies, for those that don't know howto use a pipe, that's where you start learning because I'mnot going to teach you. I didn't read it, didn't care becauseI already know how to use a pipe.For some older participants, a combination of accumu-lated knowledge and pride accompanied their longevity aspeople who use illegal drugs. However, their assumedknowledge hindered learning opportunities. Moreover,some of their comments raise questions of how best tocommunicate harm reduction information to, and takeinto consideration, individuals with a long history of druguse.One significant barrier in conveying information withprinted materials was noted by several participants whowere not able to read the information they had received,either because they had difficulty reading or because theyneeded glasses. As one woman observed, a lot of people"out on the strolls" threw this material away because theywere "illiterate." As one person noted, there was "toomuch information" on the information cards she hadreceived.I don't understand that card. I don't read long things likethat. Because, like some people that, they didn't understandthat thing, and they couldn't read it. And some peoplemight need glasses like me. I need glasses, but I don't wearglasses. But people get their heads smashed in and get intofights and their glasses go flying. That's why people don'twear glasses down here.Paraphernalia that was awkward to use was a significantobstacle. A few people noted that the mouthpiece was dif-ficult to apply onto the pipe, which was a disincentive tousing it. One person complained, "I always seem to breakthe pipe when I'm putting the mouthpiece on." It was alsotime-consuming when there was urgency to use.Many people commented that, based on their experience,the screens were also problematic. This lessened the like-lihood of changing how they used crack. Screens were alsotime-consuming to insert compared to Brillo. As a result,a number of participants highlighted the challengesrelated to shifting crack use practices. For some, thescreens provided in the kits were far from ideal. They tooktime to insert, and it was thought by some people thatthey blocked the pipe easily. Although one intervieweefound the screens to be "perfect" because they "fit the pipes"well and they did not crack easily, a number of partici-pants stated quite simply that they preferred using Brillobecause they had always used Brillo. They offered anumber of reasons to support this preference. As one per-Page 9 of 12(page number not for citation purposes)information was only useful for people who were learningto use crack.son explained, "Brillo is still better than screens because itstops the oil from running through, whereas the screens, the oilHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34runs right through it." Not surprisingly, that participant'sresponses revealed that if equipment takes more time touse, is awkward to use, hinders consumption, or leads toloss of the drug, it is less likely to lead to changes in prac-tice.Finally, some interview data revealed the importance ofconducting face-to-face interviews. For some participants,initial responses to questions about crack use practicesfailed to fully capture their lived experience. They alsomade clear the benefits of face-to-face interviews whereparticipants have time to expand on and clarify their ini-tial response. For example, when speaking about sharingequipment, a number of interviewees initially said theydid not share. One man said: "I'm the only one that uses mypipe." However, he followed up by stating, "My girlfriend isthe only one that uses my pipe. So I don't bother sterilizing it."Another interviewee also responded, "I don't share my pipe,never have, well, I share it with my wife, but that's different,right?" The interview process facilitated a more nuancedunderstanding of individuals' crack use practices and shar-ing of equipment with intimate partners.DiscussionProviding harm reduction education was extremely diffi-cult given the context of people's lives in the DTES. At thesame time, the data points to some shifts in practice thatdid occur for some individuals. How can we best build onthe changes that did occur?The findings suggest that availability of equipment,repeated demonstrations, watching others, peer-to-peerlearning, and contact with distribution and outreachworkers provide avenues for users to learn about safercrack use while obtaining harm reduction equipment. Inaddition, the distribution of the kits provided contactwith people who use crack. The findings also suggest thatthere is room for improvement, such as providing better-quality screens and/or screens that are easier to use.We found that some long-time users in our sample werenot open to receiving educational information; therefore,opportunities for learning were difficult to provide.Assumed knowledge in personal crack use practices hin-dered learning opportunities for some people. At the sametime, it is important for outreach and peer-to-peer workersto acknowledge the personal experience and expertise ofthose with a long history of crack use. Those individualshave much to share, and drawing on their input wouldenhance learning situations in the future. In addition,similar to Fraser and Valentine's 2008 study, we suggestshifting the focus from "a critical look at the behaviours'of individuals 'to a critical look at the contexts' in whichexperience and the strategies that they create to surviveand to reduce harm. Some participants also made clearthat illiteracy and difficulty reading (due to needingglasses) limited the usefulness of Tip cards and writtenharm reduction information. Thus, it is imperative thatinformation also be provided through personal interac-tion, whether peer-to-peer or outreach as occurred in thisproject. In addition, education might be further bolsteredby pictures demonstrating safer crack use.The transmission of education and harm reduction equip-ment in Canada is also shaped by prohibitionist policy,which shapes the lives of people who use illegal drug (andthose who do not). Partially due to the criminal status ofcrack, people who use the drug are depicted as criminaland deviant, rather than as individuals in need of harmreduction education and equipment, treatment, andsocial support. Until 2001, 95 percent of the NationalDrug Strategy budget was earmarked for criminal justicerather than treatment and education [48]. Changes inCanada's Drug Strategy in 2003 brought about a bit morebalance, and harm reduction was included in the budget,and slightly fewer funds were allocated for law enforce-ment and crime control. In 2004–2005, federal DrugStrategy expenditures revealed that 73 percent of thebudget went to enforcement and 3 percent on harmreduction. Coordination and research received 7 percentof the budget; prevention, 3 percent; and treatment, 14percent [49] (p. 7). However, these small yet positiveshifts were temporal. With the election of a minority con-servative government in 2005, the national Drug Strategyhas been restructured without consultation with publichealth providers, organizations such as VANDU, or drugtreatment professionals. The National Drug Strategy hasbeen renamed the "Anti"-Drug Strategy and moved fromHealth to Justice; the 2007 Federal Budget and Crownspeech eliminated federal funding for harm reduction andgrants more funding for crime control efforts. In 2007, theInternational Narcotics Control Board, funded by theUnited Nations, proclaimed that safer crack kits, mouth-piece, and pipe distribution to "chronic users" in Vancou-ver and the rest of Canada should be eliminated becausesuch practices contravene existing UN drug treaties. Theycalled on the government of Canada to eliminate theseprograms and to close any existing safe injection sites [50](pp. 60, 61).A number of local and international critics note that theInternational Narcotics Control Board is out of step withthe rest of the UN on harm reduction and HIV/AIDS pro-gramming and aid. Critics also propose that the currentfederal government of Canada is out of step with provin-cial and municipal authorities, especially in VancouverPage 10 of 12(page number not for citation purposes)individuals live" [47] (p. 12). We wish to understand theeconomic and social barriers that people who use crackwhere established harm reduction practices have provento be both effective and widely supported [9]. Further, inHarm Reduction Journal 2008, 5:34 http://www.harmreductionjournal.com/content/5/1/34the arena of supervised injection facilities (SIF), there areconcerns related to the federal government's failure tosupport Insite, treatment of "scientific processes and evi-dence," and prohibitionist policy [9,51-53]. However, arecent Supreme Court of British Columbia decision sup-ported Insite. On May 27, 2008, Judge Pitfield ruled thatclosing Insite would contravene provincial access tohealth care and fundamental health care rights; to denysuch services are an infringement of the right to life, lib-erty, and security of the person granted in the CanadianCharter of Rights and Freedoms [54]. Two days after theruling, the federal government announced that theywould appeal the decision.Recent federal conflicts and initiatives create a more puni-tive environment than the pre-2001 Drug Strategy, espe-cially in its rejection of positive findings stemming fromharm reduction as public health initiatives. Current fed-eral policy also makes it more difficult to envision theopening of the safer crack consumption room at Insiteand support for safer crack outreach, equipment, and pro-grams. It also challenges the vision of the enactment ofsocial policy that assures that people's basic health, hous-ing, and support needs are met. Nevertheless, it is interest-ing to speculate how such a facility would impact on harmreduction practices with regard to crack use. For example,in a well-funded and resourced safer crack consumptionroom, if used, sharing would be entirely eliminated in thefacility (by virtue of the fact that it would be strictly for-bidden in the program and prevented through observa-tion). It is also worth noting that a SIF with a safer crackconsumption room may not require a Section 56 exemp-tion, and another facility may very likely be opened out-side of Insite (especially given that Insite is already at itsmaximum capacity).Critical drug research on illegal drugs illuminates howmarginalization is linked to harm. Waldorf, Reinarman,and Murphy's 1991 study of individuals who usedcocaine/crack found that having a "stake in conventionallife" helped to keep those with the heaviest consumptionfrom falling into negative addiction and harm [10] (p.10). The SCORE project focused on Canada's most mar-ginalized people who use crack in the DTES, and for manythere is little access to "conventional life." Rather, similarto key ethnographic and qualitative works analyzing thesocial and political contexts of the lives of people who usecrack [10,24,33,55,56], the lives of people who use crackin the DTES are shaped by social factors that are beyondtheir control: discrimination; prohibition; the role ofpolice in enforcement, arrest, and imprisonment; lack ofaffordable and secure housing; inadequate health careand treatment; stigma; violence; and inadequate socialThe SCORE project is dedicated to ensuring that everyonewho uses crack and lives in the DTES has access to equip-ment and harm reduction education that will help themto use more safely. In addition, the SCORE project exem-plifies the intersection between research and practice inthe community; we encourage others to consider suchalternative models.This paper highlights some of the ways that crack users arereceptive to using more safely, avenues for learning, andsocial barriers to change. It also highlights how much fur-ther we need to go in order to provide safe and reliableaccess to education, information, and equipment to peo-ple who use crack, especially marginalized people as inthis sample. This study suggests that harm reduction edu-cation is most successfully conveyed by watching others'practices with crack use, as well as during informal inter-actions with other people who use crack and repeateddemonstrations of harm reduction equipment by peersand outreach workers. The findings in this paper bring tothe foreground that the social context of crack users' livesin the DTES simultaneously shapes opportunities and actsas a barrier to learning. The safer crack kits made and dis-tributed through the SCORE project in the DTES providedavenues for learning, sharing, contact, and some shifts inpractice. As one participant noted, "The kits are really usefulbecause it gives us the sense that somebody cares."Competing interestsThe authors declare that they have no competing interests.Authors' contributionsSB is the lead author. All authors contributed to the paperand approved the final version of the paper.AcknowledgementsThis project was funded by the Health Canada Drug Strategy Community Initiatives Fund and by the Centre of Addiction Research of BC. We acknowledge the many women and men who have generously given their time to this project. We would like to thank the external reviewers for their insightful editorial comments.References1. Lindesmith A: Opiate Addiction Evanston, IL: Principia Press; 1947. 2. Becker H: History, culture, and subjective experience: anexploration of the social bases of drug-induced experiences.J Health Soc Behav 1967, 8(3):163-176.3. Rosenbaum M: Women on Heroin New Brunswick, NJ: Rutgers Uni-versity Press; 1981. 4. 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