Smoking heroin and other opioids can help people to avoid some of the harms associated with injecting, experts say. Meanwhile, new research suggests that handing out a pipe designed specifically as a harm reduction tool for heroin use could encourage people to inject less or switch entirely.
The research, published in the Harm Reduction Journal, was a team effort between the People’s Harm Reduction Alliance (PHRA), the Urban Survivors Union (USU), and researchers from the University of Washington in Seattle along with other institutions.
To study the impact of the pipe, which is sometimes known as the “hammer,” due to its appearance, the team surveyed people participating in a large PHRA-operated syringe service program in Seattle between March and December 2019. Dr. Tom Fitzpatrick, one of the authors and an infectious disease fellow at the University of Washington, and his colleagues collected responses to establish the number of people using and injecting heroin both before and after the pipes were handed out in a pilot program.
The number of people who exclusively injected heroin decreased—from 43 to 32 percent—after the pipes were distributed.
In all, the team gathered 360 surveys from the pre-implementation stage and 430 post-implementation. More than half of respondents in both periods used heroin: 56 percent pre-implementation and 58 percent post-implementation. But the research found that the number of people who exclusively injected heroin decreased—from 43 to 32 percent—after the pipes were distributed.
Meanwhile, the proportion of people who both smoked and injected heroin, suggesting that they may have injected less than before, rose from 36 percent to 45 percent. Just under 44 percent of the respondents who had used heroin after receiving the pipes actually used the pipes; of this group, 34 percent said that the pipes reduced their injection frequency.
“The proportion of SSP clients who exclusively injected heroin was lower after implementation of heroin pipe distribution …” the researchers wrote. “This pilot highlights the potential for organizations led by people who use drugs to develop, implement, and evaluate novel public health programming.”
Though the research describes the harm reduction products as heroin pipes, heroin certainly isn’t the only thing that passes through them, given the rise of fentanyl, other potent synthetic opioids and further adulterants in street supplies. It should also be noted that “smoking” here doesn’t mean combustion (which would destroy heroin and other opioids), but rather vaporization, which happens at lower temperatures.
An option for people who inject opioids to “give their veins a break.”
Shilo Jama, a Sacramento-based harm reductionist who previously co-founded and ran PHRA, was one of the coauthors on the study. Recalling how he designed the heroin pipe along with members of the Urban Survivors Union, he told Filter that he did so, in part, as an option for people who inject opioids to “give their veins a break.”
The input and effort of Urban Survivors Union was “vital and important,” and the work wouldn’t have been successful without it, he added. Filter reported in 2019 on the process of developing the pipe.
There previously hadn’t been a widely available pipe to meet the needs of people who use opioids. Back around 2015, Jama began trying to address this. He began looking into old-school opium den pipes, but they tended to be ornate and impractical. He then began looking at dab pipes, commonly used with cannabis concentrates. However, he ultimately decided that he needed to develop a different pipe that was both effective and cost-effective.
In all, Jama and his colleagues tested 10 different designs. The final result is made out of Pyrex because the pipes need to be heat-resistant. It allows people who inhale opioids to operate it in two ways. One is simply slowly heating the thick bottom until the drugs vaporize. The other is to put heroin in tar form on the end of a paperclip, heat the edge of the pipe with a lighter, then place the heroin near the hot glass and inhale. In all, it took two years to develop the pipe. It’s manufactured by a glassblower whom Jama did not wish to name.
The PHRA and Urban Survivors union began handing out the pipes around 2019, and Jama reached out to various researchers about investigating their harm reduction impact.
The “gold standard” for the test, researcher Tom Fitzpatrick told Filter, would have been a randomized trial including both people who wanted and did not want the pipe. However, that was not practical. For one thing, there was no way to account for people buying, selling or sharing the pipes. And offering a new service only at random to people who come into an SSP didn’t seem totally ethical.
“[The PHRA] didn’t want to deny people access to a service,” Fitzpatrick said. Because the research did not use a randomized sample, the authors call it a “quasi-experimental study.”
“There’s a need for more research to pin down what the benefits are and how beneficial they are.”
There are many theoretical medical benefits to smoking heroin over injecting it, Fitzpatrick said. It avoids the risk of injection-related skin and soft-tissue infections. The risk of overdose might also be lower, he said, simply because opioids are less bioavailable when they are smoked compared to when they are injected. Relatedly, Fitzpatrick said that smoking opioids can also result in a less intense high, helping people to navigate their lives.
Jama agreed that smoking could lower a person’s risk of overdose, particularly considering the presence of fentanyl in unknown amounts in most batches of opioids. It can help people better control their doses, as past research has indicated. With smoking, people can take smaller hits and adjust their high a bit more easily than with injecting, which hits harder and faster, he said.
However, we still have more to learn about the differences between inhalation and injection. “There’s a need for more research to pin down what the benefits are and how beneficial they are,” Jama said.
Photograph of the “hammer” courtesy of Shilo Jama