People who smoke crack cocaine endure a wide range of health-related issues. However, public health and wellness programming designed for this population is limited, particularly in comparison through programming for world who inject drugs. Canadian ideal practice recommendations encourage needle and also syringe programs (NSPs) to administer education about safer cracked cocaine cigarette smoking practices, distribute more secure smoking equipment, and carry out options for more secure disposal of supplied equipment.

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We conducted an online survey of NSP managers across Canada to estimate the proportions the NSPs that provide education and also distribute much safer smoking devices to civilization who smoke crack cocaine. We also assessed change in pipe distribution practices in between 2008 and also 2015 in the province of Ontario.


Analysis that data from 80 programs verified that the bulk (0.76) listed education to clients on to reduce risks associated with sharing crack cocaine smoking equipment and about when to replace smoking tools (0.78). The bulk (0.64) additionally distributed more secure crack cocaine smoking equipment and also over half of this programs (0.55) had actually done therefore for much less than 5 years. Amongst programs that distributed pipes, 0.92 spread the recommended heat-resistant Pyrex and/or borosilicate glass pipes. Just 0.50 the our complete sample reported the their program provides clients through containers for more secure disposal of offered smoking equipment. The most typical reasons for not distributing much safer smoking tools were not enough resources (0.32) and lack of customer demand (0.25). Ontario-specific sub-analyses proved a far-reaching increase in the proportion of programs distributing pipe in Ontario indigenous 0.15 (2008) to 0.71 (2015).


Our findings point to important efforts by Canadian NSPs to reduce harm among people who smoke crack cocaine v provision the education and also equipment, however there space still borders that can be addressed. Our research can administer guidance for future cross-jurisdiction studies to describe relationships involving injury reduction programs and provision of safer crack cocaine smoking education and also equipment.

Although the injury reduction philosophy that has actually moved forward in Canada, and also North America an ext broadly, is inclusive of people who consume a wide spectrum of psychoactive substances, yes, really programming has actually been much more focused on world who inject drugs. This is worrying from a public wellness perspective due to the fact that in Canada crack cocaine use is common among street-based people who usage drugs <1–3>. World who smoke crack cocaine report experiencing oral sores, cuts, and also burns that are associated to the use of improvised crack pipes fashioned out of hazardous glass and also metal products <4, 5>, and such injuries might facilitate infectious disease transmission when pipes space shared among users <6, 7>. Pipe share is also commonly reported, specifically when pipe are challenging to achieve <8–10>. Indeed, evidence shows elevated rates of hepatitis C virus (HCV), and also HIV and also other infectious diseases, among people that smoke crack cocaine <11–15>.

There are most likely various, and also some convergent, reasons why harm reduction programming for human being who smoke crack cocaine has actually lagged behind programming emerged for people who inject drugs. Injection medicine use has actually long been considered the riskiest type of drug use in terms of potential health-related risks and also as such public health and wellness authorities have prioritized services, specifically HIV prevention services, for civilization who inject medicine (e.g., <16>). Nonetheless, although human being who usage illicit medicine in basic are a socially marginalized group, human being who smoke crack cocaine frequently exhibit pronounced marginalization identified by, because that example, poverty, unstable housing or homelessness, and elevated rates of encounters v the criminal justice device (e.g., <1, 17–19>). The establishment of higher services for this drug-using populace has relied on added advocacy efforts. Injury reduction supporters in Toronto and Vancouver were among the first groups in Canada to recommend and begin distribution of much safer smoking tools to engage world who smoke cracked cocaine in programming <20, 21>. However, implementation the policies and interventions designed because that crack cocaine customers has likewise been hindered and also delayed through questions about the legality of the distribution of more secure smoking equipment and also related opposition indigenous police (cf. <19, 22–26>). In an effort to promote programming that addresses high rates of HCV amongst people who smoke cracked cocaine, Canadian best practice referrals encourage needle and syringe program (NSPs) and other injury reduction program to provide education on more secure crack cocaine smoking practices and also use of smoking cigarettes equipment; distribute more secure smoking tools (i.e., Pyrex and/or borosilicate glass tube or “stems”, mouthpieces, screens, and push sticks); and administer options for more secure disposal the used equipment <27>. Watch Fig. 1 for a photo of the complete set of these ideal practices pertaining to safer crack cocaine use. These evidence-based guidelines for more secure crack cocaine smoking cigarettes education and equipment distribution were arisen by a national, multi-stakeholder team (for a summary of the ideal practices team formation, composition, and collaboration, view <28>).


Managers that NSPs throughout Canada were invite to participate in an digital survey analyzing program policies and uptake of best practices. Eligible programs had those activate by a public health organization or other company contracted by their local wellness unit to provide needle/syringe distribution in any province or territory. We focused on these “core” programs connected with public wellness units and did not attempt come sample “satellite” NSP services (see <25>). To increase their reach, main point NSPs often engage other organizations to be satellite sites the can also offer NSP services. Trying come sample every NSPs consisting of satellite sites would have actually been a time-consuming effort and one that could not have included much worth as main point NSPs often provide their local satellite services with the necessary training (including policies and procedures to follow), supplies, and support (see again <25>). As there is no main registry of all NSPs in Canada, we developed an email address list using 3 approaches. First, we knew from best practices research study team members that three districts (Quebec, Ontario, and British Columbia) preserved their own an extensive and up-to-date perform of every NSPs (including regimen manager email addresses) for their particular regions. We acquired these lists for Quebec and also Ontario. An main from the western province of brothers Columbia opted the end of giving their email list stating the the burden of participation to be too an excellent for regional NSP supervisors who were at the time implementing new overdose avoidance programming. We did not have actually the time and also resources crucial to contact all public wellness units in brothers Columbia and then follow up through all NSPs in that province to acquire the requisite email addresses. Because that the remaining provinces where, in part cases, there to be a small number of programs and local supervisors knew each other, we asked the regional representative ~ above the ideal practices team to administer email contact information for NSP supervisors in their province. Lastly, because that the territories, the very first author contacted local injury reduction representatives and also a territorial ministry of wellness to identify NSP supervisors in those regions. The northernmost territory, Nunavut, walk not have an NSP. Utilizing these three approaches, we think that we captured the email addresses for supervisors of all operational main point NSPs in Canada, v the exemption of NSPs in brothers Columbia.

To encourage survey participation, us modified a technique by Dillman et al. <29> by asking team members that were affiliated in injury reduction policy and/or business provision in their regions to send come their local NSP supervisors an initial email “alert” to introduce the study and advise of upcoming invitations come participate. One to 2 weeks after these warns were sent, the very first author sent formal email invitations to potential attendees in each district and territory; these invitations consisted of a study information sheet through consent kind and a attach to the survey. 2 weeks after these invitations, potential entrants were sent the an initial email reminder about the survey. Two weeks after this reminders, us emailed potential attendees a last reminder about completing the survey. To administer incentive to get involved in the online survey, we available to all potential attendees an choice to get in a draw to victory for your program one of 20 gift cards precious $100CAD for a well-known coffee shop chain. Examine recruitment was staggered and the survey was open to participants native April 9 to respectable 4, 2015.

Participants to be asked inquiries (in Yes/No, many choice, Likert scale, and also open-ended formats) about their program characteristics, distribution of injury reduction materials, including safer crack cocaine smoking equipment, and other key topics determined in the ideal practice referrals <27, 30>. The questionnaire was arisen for an digital platform, FluidSurveys, and also was available in English and French. Please view Additional paper 1 that has English online survey message that is pertinent to the findings us report in this article. Prior to launching data collection, us pilot experiment the online survey with 5 program managers from various provinces and also modified some inquiries as per their feedback. The university of Toronto Research principles Board (REB) approved this study.

Data were downloaded, managed, and analyzed using SPSS (version 24). Specifically, us report frequency distributions and bivariate statistics come characterize the ratio of programs giving safer cracked cocaine smoking education and equipment distribution by NSPs. In addition, using data native an previously study that used the very same online survey approaches for Ontario <25>, we compared the relationship of programs in that district that dispersed pipes in 2008 versus 2015. Comparable data to be not obtainable for the various other provinces or territories.

Sample characteristics

We invite 125 NSP managers from throughout Canada to finish the online survey. A filter question established eight supervisors who were not eligible to participate due to the fact that their program did not proactively distribute needles at the time (our just study eligibility criterion). That the staying 117 potential participants, 104 at first responded come the survey; ~ above reviewing the data, we removed 24 surveys due to the fact that of incomplete data, leaving 80 surveys for these analyses. Table 1 presents routine characteristics. Throughout our results, us report the ratio of program reporting every characteristic or practice.

Provision of more secure crack cocaine smoking education

A majority of attendees (0.76) reported the their regime provides education and learning to clients on reduce risks linked with sharing crack cocaine smoking equipment. Further, 0.75 suggested that their regime provides education and learning on identify risks, such together cuts and also injuries, indigenous the usage of improvised smoking equipment (e.g., soda cans together makeshift pipes), and also 0.72 reported that they carry out education on how to use much safer smoking equipment.

Over 3 quarters of attendees (0.78) reported the their program staff recommend clients about when to change smoking equipment. In state of details instances when it is time to replace smoking equipment, 0.75 of supervisors reported the their regimen advises client to replace pipes and/or mouthpieces if these items have actually been supplied by everyone else; 0.74 recommend clients to replace their pipeline if that is scratched, chipped, or cracked; 0.71 advise clients to change mouthpieces that room burnt; and also 0.70 advise clients to replace the screen if the shrinks and also becomes loose in the pipe.

We inquiry participants about the layouts their programs use to provide education to clients around drug-related hazard behaviors and also practices. Given the general method in which us framed this questions, we cannot identify if and also where the responses pertain to shipment of education and learning on injection- or smoking-related behaviors, or both. V that caveat, we minimal these analyses to only managers who reported that their program gives education regarding how come use much safer smoking equipment (n = 58) and found that all reported that their program uses educational information pamphlets or brochures; 0.97 sell one-on-one counseling; 0.79 market demonstrations; 0.52 sell peer-delivered education; 0.38 market skills-building sessions or group education; and 0.09 usage instructional videos.

Distribution of much safer crack cocaine smoking equipment

When asked if their routine distributes “any” more secure crack cocaine cigarette smoking equipment, 0.64 of managers responded affirmatively. Of these participants, practically all (0.96) suggested that their program distributes pipes; over fifty percent (0.55) reported the their routine has distributed safer smoking tools for much less than 5 years, when 0.43 have done so for an ext than 5 years and the remainder did no know just how long their program has spread this equipment. The the programs the distribute pipes, 0.92 supposedly distribute the encourage heat-resistant Pyrex and/or borosilicate glass pipes, while 0.08 distribution pipes of one unknown type of glass. The proportions of managers who reported distribution of various other pieces of safer smoking equipment were as follows: 0.94 because that mouthpieces, 0.94 because that screens, and also 0.92 for push sticks. In addition to offering each item of recommended equipment separately, 0.86 suggested that your program uses pre-packaged kits containing pipes plus other safer cigarette smoking equipment. In short, most of the programs the distribute safer smoking equipment reported providing out the recommended species of pipes and a match of other safer smoking cigarettes materials. Just 0.50 the our complete sample reported that their program provides clients through containers for much safer disposal of offered smoking equipment.

Among participants who reported that their regime does not distribute much safer smoking devices (0.35), the two most commonly endorsed factors for no doing therefore were no enough capital (0.32) and also lack of customer demand (0.25). Just two entrants selected “opposition from legislation enforcement” together a reason. Six managers wrote additional reasons in their surveys and three that these suggested that their programs room seeking to implement much safer crack cocaine cigarette smoking equipment circulation and/or have received recent approval to do so.

When asked about distribution policies, 0.53 of supervisors who shown that their regimen distributes pipes reported no maximum on the variety of pipes that they will carry out to a customer at any type of one time; the staying 0.47 suggested that their regime sets a maximum. Reported borders ranged from one to 20 pipes per visit, despite most frequently participants (0.57) suggested that their program imposes a best of one or 2 pipes per client at a time. When asked why their program imposes borders on pipe distribution, 0.61 of these supervisors reported that this amount adequately meets client demand and also 0.52 report concerns about running the end of supplies. Several participants added more information to their surveys that argued that maximums space imposed because of concerns about clients offering their pipe on the street (e.g., “Some clients have actually been recognized to offer what they don’t use”). One participant included that a benefit of having actually a pipe limit is the it keeps clients that smoke cracked cocaine coming ago to their regimen for solutions (i.e., “to maintain continuity of call with the clients so that us can administer support, education, and also referrals”).

Influence of best practices on safer smoking education and distribution practices

Also as part of the virtual survey, we asked managers if they and also their staff had used the recent collection of national best practice references <27> to adjust and align program methods with stated evidence-based guidance. Just under half of entrants (0.49) reported that their program used the referrals to affect pipe distribution practices, 0.49 also did so to affect safer smoking education and learning practices, and 0.39 did so to affect other smoking devices (e.g., mouthpieces, screens) circulation practices.

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Ontario: much more programs distributing pipes over time

Finally, to research potential transforms in pipe circulation over time, us performed Ontario-specific sub-analyses and compared review data collected in 2008 <25> through data indigenous the 2015 survey. Evaluation showed a significant increase in the relationship of programs distributing pipes in Ontario native 0.15 to 0.71.