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Difficulty accessing crack pipes and crack pipe sharing among people who use drugs in Vancouver, Canada Ti, Lianping; Buxton, Jane; Wood, Evan; Zhang, Ruth; Montaner, Julio; Kerr, Thomas Dec 30, 2011

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SHORT REPORT Open AccessDifficulty accessing crack pipes and crack pipesharing among people who use drugs inVancouver, CanadaLianping Ti1,2, Jane Buxton3,4, Evan Wood2,5, Ruth Zhang2, Julio Montaner2,5 and Thomas Kerr2,5*AbstractBackground: Crack pipe sharing can increase health risks among people who use drugs, yet the reasons forsharing these pipes have not been well described. Therefore, we sought to identify the prevalence and correlatesof crack pipe sharing among a community-recruited sample of people who use illicit drugs in Vancouver, a settingwhere crack pipes are provided at low or no cost.Findings: Data for this study were derived from two prospective cohorts of people who use drugs: the VancouverInjection Drug Users Study (VIDUS) and the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS).Multivariate logistic regression was used to identify factors independently associated with crack pipe sharing.Among 503 crack users, 238 (47.3%) participants reported having shared a crack pipe in the previous six months.Having acquired a mouthpiece in the last six months (adjusted odds ratio [AOR] = 1.91; 95% confidence interval[CI]: 1.31 - 2.79) and difficulty finding new pipes (AOR = 2.19; 95%CI: 1.42 - 3.37) were positively associated withpipe sharing. Binge drug use (AOR = 1.39; 95%CI: 0.96 - 2.02) was marginally associated with sharing pipes.Discussion: There was a high prevalence of crack pipe sharing in a setting where crack pipes are distributed atlow or no cost. Difficulty accessing crack pipes was independently and positively associated with this behavior.These findings suggest that additional efforts are needed to discourage crack pipe sharing as well as increaseaccess to crack pipes.Keywords: crack cocaine smoking, injection drug use, harm reduction, sharing drug paraphernaliaIntroductionCrack cocaine use continues to be associated with var-ious health-related harms. Injuries such as blisters, sores,and cuts on the lips and gums are common among peo-ple who smoke crack [1], and crack use has been asso-ciated with hepatitis C virus (HCV) and humanimmunodeficiency virus (HIV) infection [2,3]. There isevidence suggesting that injuries to the oral mucosa pro-mote the transmission of HCV when crack smokingparaphernalia are shared between individuals with orallesions [4]. However, in the case of HIV, the transmissionpathways have not been determined and may reflect ele-vated syringe sharing or unsafe sex among crack users[2,5]. Other studies have pointed to crack use as a poten-tial mode for the transmission of other infectious diseasesincluding tuberculosis [6,7]. However, increasing accessto crack pipes may reduce the frequency of injecting andby extension, blood-borne disease transmission amongthis population [8].There is growing support for programs that facilitateaccess to sterile and safer crack smoking paraphernalia[8,9]. However, these programs remain controversial, andin Canada a number of these programs have been shut-down in response to concerns expressed by policy makersand the public [10,11]. Despite these developments andthe high prevalence of crack cocaine use in settingsthroughout North America [2,12,13], little is known aboutwhy people who smoke crack continue to engage in riskybehavior such as crack pipe sharing. Further, althoughpast research has revealed that problems with access to* Correspondence: uhri-tk@cfenet.ubc.ca2British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the articleTi et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:34http://www.substanceabusepolicy.com/content/6/1/34© 2011 Ti et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.sterile syringes can drive syringe sharing in settings wherelarge needle exchange programs operate [14], little isknown about the relationship between crack pipe accessand crack pipe sharing. Therefore, we sought to investigatecrack pipe sharing and access in Vancouver, Canada, a set-ting where crack smoking is prevalent and where crackpipes are provided at no or low cost.BackgroundVancouver has experienced a massive growth in crack useover the past decade [12]. According to the 2010 CanadianAlcohol and Drug Use Monitoring Survey, the prevalenceof crack cocaine use in BC (6.9%) is higher than in anyother province [15]. A study in Vancouver demonstratedthat among a sample of drug-using participants, dailycrack use increased from 7.4% in 1996 to 42.6% in 2005.In the same study, crack use was independently associatedwith several characteristics, including sex work involve-ment and unstable housing [12]. Crack cocaine smokinghas also been associated with the acquisition of HIV infec-tion among people who inject drugs (IDU) in the city [2].Locally, crack smoking paraphernalia, including Pyrexpipes, plastic mouthpieces and wooden push sticks, areprovided through the BC Centre for Disease Control(BCCDC). A mouthpiece made of clear vinyl tubing isused as an attachment for crack pipes as a means of redu-cing risks for blood-borne disease transmission and otherharms [16]. Wooden push sticks are used as an alternativeto plastic syringe plungers, which are often used whenpacking a screen into a pipe [17]. Distributing woodensticks helps reduce the likelihood that melted plastic isinhaled and also prevents the misuse and discarding ofsyringes [17]. Crack pipes in the form of hollow glasstubes are available at some harm reduction distributionsites in Vancouver at no or low cost, but are not univer-sally available for free throughout the city. Local storesalso sell crack pipes in areas where crack smokers live orcongregate.MethodsData for this study were derived from two prospectivecohorts involving people who use drugs: the VancouverInjection Drug Users Study (VIDUS) and the AIDS CareCohort to evaluate Exposure to Survival Services(ACCESS). The methods for these studies have been pre-viously described [18,19]. In brief, beginning in May 1996,participants were recruited through street outreach andself-referral in the Greater Vancouver Regional District.VIDUS eligibility criteria included having injected illicitdrugs at least once in the previous month. ACCESS elig-ibility criteria included being HIV-positive, and havingused illicit drugs other than cannabinoids in the previousmonth. At baseline visit and semi-annually thereafter,participants complete an interviewer-administeredquestionnaire and provide blood samples. The question-naire elicits information about socio-demographic charac-teristics, drug use and other behavioral patterns, income-generation practices, engagement with medical and addic-tion treatment services, law enforcement encounters, andother experiences with the criminal justice system. Ateach study visit participants were provided with an honor-aria ($20 CAD). The study has received ethics approvalfrom the University of British Columbia/ProvidenceHealth Care Research Ethics Board. The present analyseswere restricted to participants who reported smokingcrack cocaine in the last six months, and were seenbetween December 2010 and May 2011. We selected themost recent follow-up period due to recent changes to thecrack pipe distribution program in Vancouver. Specifically,we wanted to characterize current rates of sharing amongthis subpopulation in the wake of these programmaticchanges. The collection of these data is being used toinform program development for crack users.For the present analyses, we used univariate and multi-variate logistic regression, with the outcome being havingreported crack pipe sharing in the last six months. In thisinstance, crack pipe sharing referred to either crack pipeborrowing or lending. Variables considered included: med-ian age, gender, living in the Downtown Eastside (DTES)of Vancouver (yes vs. no), frequency of crack use (≥ onceper day vs. < once per day), having acquired a mouthpiece(yes vs. no), difficulty accessing crack pipes (yes/sometimesvs. no), smoking crack in public (always/usually vs. some-times/occasionally/never), and binge use of non-injectiondrugs (yes vs. no). All behavioral variables refer to beha-viors in the past six months. The variable “having acquireda mouthpiece” referred to obtaining a sterile mouthpiecefrom sites distributing crack pipe supplies. Additionally,the variable “difficulty accessing pipes” referred to whetherparticipants found it difficult to obtain new crack pipeswhen they needed them. “Binge use of non-injectiondrugs” referred to whether the participant used non-injec-tion drugs more than usual. To examine bivariate associa-tions, we used the Pearson c2 test. Fisher’s exact test wasused when one or more cells contained values less than orequal to five. We then built a multivariate logistic regres-sion model to identify independent predictors of crackpipe sharing by including all variables that were associatedwith the outcome at the p ≤ 0.10 level in bivariate analyses.All p-values were two-sided. As a subanalysis, we askedparticipants to specify where they acquired their crackpipes.ResultsIn total, 503 drug users reporting crack cocaine smokingin the past six months participated in this study, includ-ing 181 (36.0%) females. These participants represented61.1% of the total number of participants who wereTi et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:34http://www.substanceabusepolicy.com/content/6/1/34Page 2 of 5recruited into both VIDUS and ACCESS cohorts for thisstudy period. The median age of participants was 46years (range = 23 - 72 years). In total, 238 (47.3%)reported having shared a crack pipe in the last sixmonths. As well, 63.6% were active injection drug usersand 60.6% reported having been in alcohol or drug treat-ment in the past six months. As indicated in Table 1, fac-tors significantly and positively associated with crackpipe sharing included having acquired a mouthpiece, dif-ficulty accessing crack pipes, and binge use of non-injec-tion drugs. Additionally, age was negatively associatedwith pipe sharing (all p < 0.10).As indicated in Table 2, in multivariate analyses, factorsthat remained positively associated with crack pipe shar-ing included: having acquired a mouthpiece and difficultyaccessing crack pipes (p < 0.05). Participants reportedaccess to crack pipes through a variety of sources, includ-ing: street (new) (39.4%), corner store (29.8%), a druguser-run organization (25.6%), and local health programs(8.2%). As well, a number of participants (9.9%) reportedacquiring used pipes from the street.DiscussionIn the present analyses, we found a high rate of crackpipe sharing among illicit drug users in Vancouver, withjust under 50% of participants reporting crack pipe shar-ing in the previous six months. Those participants whoreported sharing crack pipes were more likely to reporthaving recently acquired a mouthpiece and to haveexperienced difficulty accessing pipes.Our findings are consistent with previous studiesreporting high rates of crack pipe sharing among peoplewho smoke crack [8]. Although there is limited evidenceconcerning the impact of programs that target cracksmokers, a study in Ottawa, Canada reported positiveoutcomes from distributing crack-smoking paraphernalia,including a decline in the frequency of pipe sharing [8].Given the health risks associated with pipe sharing andour finding that difficulty accessing pipes was associatedwith sharing, increasing access to crack pipes has poten-tial to reduce the transmission of infectious diseases aswell as injuries to the oral cavity via use of makeshiftdevices [4,6].Table 1 Bivariate analyses of factors associated with crack pipe sharing among people who smoke crack cocaine (n = 503)Shared a crack pipe in the last six months n (%)Characteristic Yes238 (47.3)No265 (52.7)Odds Ratio (95% CI) p - valueAge≥ 46 years old 116 (43.8) 149 (56.2) 0.74 (0.52 - 1.05) 0.09< 46 years old 122 (51.3) 116 (48.7)GenderFemale 84 (46.4) 97 (53.6) 0.94 (0.66 - 1.36) 0.76Male 154 (47.8) 168 (52.2)Living in DTESYes 157 (45.4) 189 (54.6) 0.78 (0.53 - 1.14) 0.20No 81 (51.6) 76 (48.4)Frequency of crack use*≥ once per day 99 (51.6) 93 (48.4) 1.32 (0.92 - 1.89) 0.13< once per day 139 (44.7) 172 (55.3)Acquired mouthpiece*Yes 162 (54.9) 133 (45.1) 2.12 (1.47 - 3.04) < 0.01No 76 (36.5) 132 (63.5)Difficulty accessing pipesYes/Sometimes 78 (63.4) 45 (36.6) 2.38 (1.57 - 3.63) < 0.01No 160 (42.1) 220 (57.9)Smoke in public*Always/Usually 53 (52.0) 49 (48.0) 1.26 (0.82 - 1.95) 0.29Sometimes/Occasionally/Never 185 (46.1) 216 (53.9)Binge drug use (non-injection)*1Yes 127 (53.8) 109 (46.2) 1.65 (1.15 - 2.36) < 0.01No 106 (41.4) 150 (58.6)DTES: Downtown Eastside of VancouverCI: confidence interval*Activities/events in the last six months1Note that counts for binge drug use do not add up to n = 503 due to 11 missing responses (n = 492).Ti et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:34http://www.substanceabusepolicy.com/content/6/1/34Page 3 of 5Recent efforts have been made by BCCDC to distri-bute mouthpieces province-wide. Mouthpiece distribu-tion provides a point of engagement for crack smokerswho may not inject since many may not have been con-nected with harm reduction services otherwise [16]. Inthe event where crack pipes are unavailable, and sharinga pipe becomes inevitable, mouthpieces can alleviate therisk of injuries and infections associated with pipe shar-ing. Consistently, our findings showed a positive associa-tion between mouthpiece acquisition and sharing crackpipes, indicating that many people who smoke crack arepracticing safer smoking methods. However, it is unclearwhether individuals are using their own mouthpiecewhen sharing pipes. Given the lack of evidence describ-ing the negative health consequences from sharing amouthpiece, future research should focus on examiningthe different health risks between individuals who shareand do not share mouthpieces.This study has limitations. First, because of the cross-sectional design, determining a temporal relationshipbetween exposure and outcome is not possible. Second,both VIDUS and ACCESS cohorts are community-recruited non-randomized samples of IDU and HIV-posi-tive drug users and therefore our findings may not be gen-eralizable to all crack cocaine users in local or othersettings. Third, from this study, it is not clear whether theparticipants are using their own mouthpiece, sharing amouthpiece, or not using a mouthpiece at all when theyare sharing crack pipes. Lastly, the data collected wereself-reported and may be subject to reporting biases.In summary, we found that crack pipe sharing is com-mon among people who smoke crack in Vancouver. Diffi-culty accessing pipes and having acquired a mouthpiecewere positively associated with crack pipe sharing.Although many cities worldwide, including Vancouver,have succeeded in providing harm reduction paraphernaliafor IDU, similar services for people who smoke crack arenot as readily available [20]. Our findings suggest thatadditional crack pipe distribution efforts are needed toaddress the risks and harms associated with crack use.AcknowledgementsThe authors thank the study participants for their contribution to theresearch as well as current and past researchers and staff. We wouldspecifically like to thank Deborah Graham, Tricia Collingham, Carmen Rock,Peter Vann, Caitlin Johnston, Steve Kain, and Calvin Lai for their research andadministrative assistance, and Dr. Robert Hogg for facilitating access to theBritish Columbia Centre for Excellence HIV/AIDS Drug Treatment Programdata.Funding for this study was provided by the US National Institutes of Health(R01DA021525) and the Canadian Institutes of Health Research (MOP-79297,RAA-79918). Thomas Kerr is supported by the Michael Smith Foundation.Julio Montaner is supported by the Ministry of Health Services and theMinistry of Healthy Living and Sport, from the Province of British Columbia;through a Knowledge Translation Award from CIHR; and through an Avant-Garde Award (No 1DP1DA026182-01) from the National Institute on DrugAbuse, at the US National Institutes of Health.Author details1Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, Canada. 2British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada. 3Epidemiology Services, British Columbia Centre for Disease Control,655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada. 4School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver, BC V6T 1Z3, Canada. 5Department of Medicine, University ofBritish Columbia, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada.Authors’ contributionsThe specific contributions of each author are as follows: LT and TK wereresponsible for study design; RZ conducted the statistical analyses; LTprepared the first draft of the analysis; All authors provided criticalcomments on the first draft of the manuscript and approved the finalversion to be submitted.Competing interestsDr. Julio Montaner has received grants from, served as an ad hoc advisor to,or spoke at various event sponsored by: Abbott, Argos therapeutics, BiojectInc., Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho, Merck Frosst, Pfizer, Schering, Serono Inc.,TheraTechnologies, Tibotec, and Trimeris. Other authors declare that theyhave no other competing interests.Received: 21 November 2011 Accepted: 30 December 2011Published: 30 December 2011Table 2 Multivariate logistic regression analyses of factors associated with crack pipe sharing among people whosmoke crack cocaine (n = 503)1Variable Adjusted Odds Ratio (AOR) 95% CI p - valueAge(≥ 46 years vs. < 46 years) 0.80 (0.56 - 1.17) 0.25Acquired mouthpiece*(Yes vs. No) 1.91 (1.31 - 2.79) < 0.01Difficulty accessing pipes(Yes/Sometimes vs. No) 2.19 (1.42 - 3.37) < 0.01Binge drug use (non-injection)*(Yes vs. No) 1.39 (0.96 - 2.02) 0.08CI: confidence interval*Activities/events in the last six months1Χ2 (Likelihood Ratio Test) = 35.68; p-value = < 0.01; R2 = 0.07Ti et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:34http://www.substanceabusepolicy.com/content/6/1/34Page 4 of 5References1. Porter J, Bonilla L: Crack Users’ Crack Lips: An Additional HIV Risk Factor.Am J Public Health 1993, 83(10):1490-1491.2. 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Health Canada: Canadian Alcohol and Drug Use Monitoring Survey.Ottawa, ON: Office of Drugs and Alcohol Research and SurveillanceControlled Substances and Tobacco Directorate, Health Canada; 2010.16. British Columbia Harm Reduction Strategies and Services: Crack PipeMouthpieces: Questions and Answers. Vancouver: BC Centre for DiseaseControl; 2010.17. British Columbia Harm Reduction Strategies and Services: Crack Pipe PushSticks: Questions and Answers. Vancouver: BC Centre for Disease Control;2010.18. Buxton J, Kerr T, Qi J, Montaner J, Wood E: Public crack cocaine smokingand willingness to use a supervised inhalation facility: implications forstreet disorder. Subst Abuse Treat Prev Policy 2011, 6(4).19. Palepu A, Milloy M, Kerr T, Zhang R, Wood E: Homelessness andAdherence to Antiretroviral Therapy among a Cohort of HIV-InfectedInjection Drug Users. J Urban Health 2011, 88(3):545-555.20. Haydon E, Fischer B: Crack Use As a Public Health Problem in Canada:Call for an Evaluation of ‘Safer Crack Use Kits’. Can J Public Health 2005,96(3):185-188.doi:10.1186/1747-597X-6-34Cite this article as: Ti et al.: Difficulty accessing crack pipes and crackpipe sharing among people who use drugs in Vancouver, Canada.Substance Abuse Treatment, Prevention, and Policy 2011 6:34.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTi et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:34http://www.substanceabusepolicy.com/content/6/1/34Page 5 of 5


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