Safe inhalation pipe provision (SIPP): protocol for a mixed-method evaluation of an intervention to improve health outcomes and service engagement among people who use crack cocaine in England.

BACKGROUND: Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact. METHODS: The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms. ANTICIPATED IMPACT: SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally. CONCLUSION: People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform. TRIAL REGISTRATION: ISRCTN12541454  https://doi.org/10.1186/ISRCTN12541454.

Risky injecting practices associated with snowballing: a qualitative study.

INTRODUCTION AND AIMS: Crack cocaine injecting is associated with a higher prevalence of sharing behaviours, increased rates of hepatitis C infection and a higher likelihood of homelessness. The limited available evidence on snowballing (co-injecting of heroin and crack cocaine) suggests that this is associated with an increase in risky injection practices. This study sets out to explore the views and experiences of a group of drug users who 'snowball', with a view to inform the improvement of harm reduction services for such clients. DESIGN AND METHODS: This is a qualitative interview study of 18 male and female homeless drug users attending a needle exchange service in Nottingham, UK. RESULTS: For all those interviewed, snowballing represented a communal activity which affected peer injection practices. The individual perceptions of the terms 'sharing' and 'splitting' affected the levels of concerns when snowballs were used with others. The study highlighted the importance of knowing current vaccination and screening history of injecting partners in order to manage risk behaviour when drugs are used communally. DISCUSSION AND CONCLUSIONS: Harm reduction services need to target information so it is meaningful and appropriate to those who engage in communal drug use.