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December 6, 2011

Taking aim at crack cocaine

Reuel S. Amdur

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How can we minimize the impact of crack cocaine?

The drug, while it can be injected, is usually smoked.  In the course of being smoked, the makeshift equipment, which is often used, can burn the user, inflicting burns, cuts, and blisters on the face, hands, and tongue.  As a result, blood can be transmitted to subsequent users of the equipment. 

The next step in this unfortunate series of events is that a user who has hepatitis C or HIV may pass the disease on to the new user of the equipment.  With hepatitis C, transmission through saliva and mucous on the equipment is also possible.  Unprotected sex with an infected user is another means of passing on the disease.

We are most unlikely to eliminate crack use through punitive measures.  However, if we can lessen its more dangerous consequences we may both provide better opportunities and outcomes for users and save the health care system huge amounts of money. 

While hepatitis C can sometimes be cured, the regimen is extremely demanding and not tolerated by everyone.  Lifetime costs for treating hepatitis C can reach $300,000. For HIV/AIDS, it exceeds $100,000.  It is not unusual for a person to have both conditions.

To reduce these dangerous outcomes of smoking crack, addictions specialists have adopted an approach called harm reduction.  The application of this principle to crack usage involves providing users with a kit which includes a pipe, one that minimizes the danger of suffering burns, cuts, and blisters, thus minimizing the danger of transfer of hepatitis C and HIV.  Making a sufficient number of pipes available also cuts down on sharing, minimizing the transfer of these conditions.  The kits also include condoms, to promote safe sex.  Hepatitis C and HIV are also transmitted by sexual activity. 

Dr. Lynne Leonard, Department of Epidemiology and Community Medicine at the University of Ottawa, headed up a study of Ottawa’s Safe Inhalation Program. Her research found that making the kits and the pipes available led to a significant decline in the use of the unsafe equipment. Furthermore, many people who smoke crack also inject illicit drugs, and the free distribution of the pipes led to a decrease in drug injections.  Injection drug use and the sharing of needles is itself a practice that can lead to hepatitis C and HIV.  It can also lead to a variety of other health problems, some quite serious.

Having kits and pipes available at such locations as community health centres puts users in contact with facilities that can provide a range of health and social services for them, and it opens opportunities to get help to reduce or eliminate drug use.

Danny Lang, an addictions worker with the Ottawa Community Mental Health Association, speaking at a conference in Ottawa, pointed out that treatment of substance abuse problems often requires an integrated approach.  A person working with the substance abuser needs to engage in outreach in order to establish and maintain contact and must address a wide variety of health and social issues.  Otherwise, even if abstinence is obtained, there is increased risk of relapse.  And abstinence is in any case less likely to occur without concomitant attention to other issues. 

As Lang put it, “It is necessary to meet the client where he is at,” both geographically (outreach) and emotionally.  It is also necessary to move at his pace.  One does not begin by raising the issue of crack.  Instead the worker might ask about health.  And the user needs to be involved in the decision-making.  In order for it be effective, the person needs to share in the ownership of the problem and in the solution.

There are problems associated with the distribution of crack pipes.  First, there is the legal issue.  The HIV-AIDS Legal Network has offered an opinion on activities such as needle exchange and distribution of crack pipes.  They argue that such activities are in mitigation and prevention of disease, and are hence legitimate under the law.

Another issue is the disposal of used equipment.  There is a problem of pipes and such being strewn about rather than being deposited in appropriate receptacles.  Consequently, a distribution program needs to address the issue by including a program to pick up the trash, with efforts to reduce the scattering of crack-related waste.

Then there is the difficulty of finding a place to light up.  There are no designated sites.

And unfortunately there are criminal and other unpleasant behaviors associated with crack use.  Users may smoke 15 and more times a day, as the high is very short-lived, and habit is expensive. 

Ottawa Police Sergeant Uday Jasmal gave an estimate of $50,000 a year as the cost of sustaining a crack habit.  The money is obtained through such means as theft, panhandling, and prostitution.  If a neighborhood is frequented by users, the reputation of the area is negatively affected. 

However, the issue of illegal behavior by users would exist without a pipe distribution program, and if the program works, the objectionable and illegal activities would be lessened. Unfortunately, some police, on finding someone with a pipe, will destroy the pipe. 

What about prevention? 

Serious mental illness can often lead to significant substance abuse, in perhaps as many as 60% of the cases.  As well, substance abuse may lead to mental illness.  Then one comes to the issue of determinants of health: equitable income distribution, adequate housing, social supports, good education, etc.  Homelessness, poverty, and so one may drive a person toward substance abuse and mental ill health more generally.  Dr. Vera Etches, Ottawa’s Assistant Medical Officer of Health, added good care in the early years of life as a determinant.  Addressing these determinants of health might go a long way toward reducing substance abuse.

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