A new study published in Harm Reduction Journal highlights the health risks of this policy. Surveys with over 700 English people who smoke crack cocaine reveal that one-third have been hospitalized for respiratory illness, and the majority have recently experienced respiratory issues. Follow-up interviews indicate that people having to resort to homemade smoking devices contributes greatly to these startling figures.

“It was a bit of a risky study. How do you generate evidence about something that’s not within the law?”

The data come from the Safe Inhalation Pipe Project (SIPP), led by Dr. Magdalena Harris of the London School of Hygiene & Tropical Medicine. SIPP provided safer smoking kits in six locations across England to evaluate their impact on drug-user health.

“It was a bit of a risky study,” Harris told Filter. “How do you generate evidence about something that’s not within the law?”

Harris and her team overcame this “catch-22,” as she described it, by obtaining temporary police approval. They also received a generous donation of pipes from Exchange Supplies, since government research funding could not be used to fund the intervention.

While analysis of SIPP’s impact is still in progress, data from the baseline phase of the study document clear respiratory health issues among people who smoke crack in the UK.

“Looking at the baseline survey data from 733 people, 60 percent of them … had respiratory symptoms within the last 28 days,” Harris said. “In terms of hospitalization, 31 percent had been hospitalized for a respiratory condition ever. And diagnoses are really high—31 percent have been diagnosed with asthma, and 12 percent have been diagnosed with COPD.”

She also warned that even these high figures are likely underestimates, due to this population’s relatively limited access to medical care.

“We know that COPD is really underdiagnosed in this population,” Harris noted. “So if 12 percent have been diagnosed, I’m sure there’s a lot more undiagnosed, particularly given the high [prevalence of] symptoms.”

“People would often start out with tin cans.”

In addition to the survey questions about respiratory harms, Harris and her team also conducted 33 in-depth interviews with participants, asking them to share their strategies for making their own pipes in the absence of safer supplies.

“People would often start out with tin cans,” Harris said. Other common materials included miniature liquor bottles, asthma inhalers, umbrella handles, naloxone syringes and disposable vapes.

A tin can pipe, which Harris noted can be made “in less than a minute”

While these approaches were innovative, they also tended to be dangerous. Plastic containers, for instance, release toxic chemicals when heated or scraped for valuable residue, while certain glass containers cause severe burns and cuts.

“One of the biggest issues in terms of respiratory harm with homemade pipe use is unsafe suspension devices,” Harris said. When smoking out of tin cans, for example, people tend to place their crack on top of ash. “The issue there is that you’re inhaling a lot of ash, which is really bad for your lungs.”

“[People] talk about burns to their lips or their tongue. But … there’s also the impact of inhaling that hot vapor on their lungs or on their esophagus.”

Other popular suspension materials included stainless steel scrubber (also called “steel wool”), which quickly breaks apart into inhalable metal fragments, and small metal bolts, which reach scalding temperatures. Since stimulants like cocaine have numbing effects, the damage caused by these high temperatures is often greater than people are able to perceive.

“[People] talk about burns to their lips or their tongue,” Harris said. “But then what they’re probably not realizing is that there’s also the impact of inhaling that hot vapor on their lungs or on their esophagus.”

A repurposed metal cannabis pipe, which may cause severe burns

To mitigate use of these homemade alternatives, SIPP provided study participants with pipes made of heat-resistant glass and a more robust suspension material. However, not all participants preferred these safer, purpose-built pipes.

“We collated all of that participant information and took it back to Exchange Supplies and … developed a better pipe.”

“[T]he filter was too dense—it was a good, steel filter made specifically for using crack, but it was just too dense for people,” Harris said. “So what we were seeing is that often people might throw it away and go back to using stainless steel scrubber or whatnot.”

Many people were also unhappy with the size of the pipe and its carrying case, preferring a thinner, more discreet option.

“We collated all of that participant information about the pipes and took it back to Exchange Supplies and … developed a better pipe,” Harris said. “That was a really nice output of the study—something practical that reflects the participants [and] their preferences.”

The new pipe kit, redesigned based on SIPP participants’ feedback

While SIPP is based in the UK, the challenges it’s addressing are global. Many countries continue to crack down on pipe distribution, including the United States, where modest efforts to provide safer smoking supplies under the Biden Administration were met with political outcry.

Harris hopes that SIPP will provide an evidence-based perspective on how pipe distribution can impact the health of people who smoke stimulants. The final results—which will compare this baseline data to new surveys collected six months after the intervention—are still in progress, but preliminary evidence suggests positive effects.

“Our impact evaluation has shown reductions in crack pipe sharing, injecting of any drug, use of homemade pipes and use of ash as a suspension device,” Harris said. “This is a very positive outcome, with longer-term implications for reducing respiratory and injecting-related health harms.”

All photographs courtesy of Magdalena Harris

The post UK Stimulant Pipe Program Tracks the Risks of Homemade Options appeared first on Filter.

The Saskatchewan government began a program in November 2018 to distribute smoking kits including sterile pipes, in an effort to prevent HIV and hepatitis C transmissions from people sharing injecting equipment. The kits could be distributed by existing syringe service programs, providing an option for people injecting drugs to switch to smoking.

But in January, the province announced it would stop distributing sterile pipes. It now prohibits independent providers from handing them out if they receive provincial funding. “Providing crack pipes and instructions on how to use illicit drugs sends the wrong message. It’s giving individuals the impression that using illicit drugs is somehow safe or condoned,” Saskatchewan Mental Health and Addictions Minister Tim McLeod told CBC in January.

Saskatchewan also implemented a a “one-to-one” restriction on syringe provision. This means that only one sterile syringe can be given out for each used syringe returned—falling far short of the recommended needs-based provision to maximize protection for people who inject.

Harm reduction providers blasted the province’s new policy. The Saskatchewan Union of Nurses also criticized the approach, saying it was “gravely concerned.” The union noted that provision of sterile smoking equipment is an evidence-based practice to reduce harms, and called one-to-one syringe distribution “an outdated and ineffective practice” that “puts communities at elevated risk.”

“The ban on the supplies makes it more difficult for those using drugs to choose to smoke instead of the alternative of injecting.”

The new policy also bans use of public funds to distribute educational materials about smoking drugs, in what one harm reduction worker called a “book burning.”

Advocates are deeply concerned that grave public health situations in the province are now worsening. Saskatchewan already had Canada’s highest rate of new HIV diagnoses, according to 2022 federal figures—about four times the national rate. Regarding overdose deaths, local outlet CJME reports that an estimated 174 people had fatally overdosed in 2024 as of May—more than one person per day, and putting the province on course for another record high.

“The ban on the supplies makes it more difficult for those using drugs to choose to smoke instead of the alternative of injecting,” Miranda Deck, engagement manager at Prairie Harm Reduction in Saskatoon, told Filter, noting that making this switch can reduce risks. “The ban also makes it more difficult for organizations like ours to provide all the services to the roughly 300 people a month that we see who access our services. Instead of having a program like this funded as it had been since 2018, we are now in the position to pay out-of-pocket for these supplies, which adds a cost of $24,000 a year.”

“After the free pipes were implemented in 2018—a process that took five years—our organization saw a huge increase in people coming in to access services and connect with case managers and the harm reduction group’s support team,” she continued.

“Safe smoking supplies [also] gives people accessing our site the opportunity to use our smoking room,” she added, and “doing so [ensures] people are using new equipment … whichever drug they are choosing to use.”

Others who work with people using drugs are also concerned. Angela Chernoff, a shelter coordinator for Bruno’s Place in Yorkton, told Filter that since this policy change, she has anecdotally observed a rise in injecting and risky practices, like reusing and sharing syringes, among clients.

“We’ve had two clients through here that had very scary foot infections, that posed a health risk,” she said. “We know that once you start running out of places to use you go for the veins in your feet. That puts a burden on acute care, and a demand on the health system.” Chernoff is additionally worried about the impact on her area’s high HIV rates.

“We have run specific fundraising highlighting the Pipe Prohibition to help us cover the cost of the supplies that we do not receive funding for anymore.”

While pulling away from harm reduction, the provincial government is simultaneously investing in what it calls its Recovery-Oriented System of Care model. It plans to spend nearly CA$50 million to provide 500 new substance use treatment beds and a central intake system allowing self-referrals. The province describes this as a “holistic, flexible, and individualized approach,” including detox, inpatient treatment and supportive living. Though mostly abstinence-based, the plan does include more access to medications for opioid use disorder, including for people in, or recently released from, prisons and jails.

Chernoff is cautiously optimistic about some elements of this—she said that some facilities have opened or expanded, though there’s been no direct financial impact for her shelter yet. “The missing link in all this is we don’t have good continuation of care in this province,” she said. “So I’m going to go to medical detox for seven days, then I’m out and I’m waiting on a referral to a treatment center,” a period when people are often very vulnerable.

Beleaguered harm reduction providers like Prairie Harm Reduction are meanwhile having to find ways to adapt in order to meet acute needs for people who use drugs.

“We as an organization are continuing to provide the supplies that we have always provided at our safe consumption site,” Deck said. “We have increased our fundraising initiatives to help cover some of the cost that these changes have forced us to make, and have run specific fundraising highlighting the Pipe Prohibition to help us cover the cost of the supplies that we do not receive funding for anymore.”

Photograph by Jlcoving via Wikimedia Commons/Creative Commons 3.0

The post Saskatchewan’s “Pipe Prohibition” Sees Rise in Riskier Drug Use appeared first on Filter.

We decided to create this safe space because the Mouraria neighborhood in Lisbon has always been heavily marked by drug use in the streets. At the beginning of 2022, there were changes in the needs of the community of people who use drugs. They were incessantly looking for safe places to use drugs without being exposed to the gaze of neighbors, tourists and the police.

Consumption rooms have been allowed in Portuguese law since 2001, but the first consumption room only started operating in 2019. In Lisbon, there were only two formal consumption spaces and that was clearly insufficient for the needs of the community.

People need a place where there’s no judgment, where they can be accepted, have support and access to safe consumption material in a dignified space.

It has been a long process of constructing a space designed by the community of people who use drugs and by staff.

The GAT team (Grupo de Ativistas em Tratamentos/ Group of Activists in Treatment) decided to use some material, human resources and know-how from previous experiences to informally allow people to use a space to smoke and inject drugs. Taking this decision was a matter of survival because our community is struggling. We already had a previous experience from the mobile DCR (drug consumption room) in Lisbon.

Creating an unsanctioned drug consumption room has been a long process of constructing a space designed by the community of people who use drugs and by staff.

The DCR is led by peer mediators, nurses and harm reduction workers. There are two spaces: the injection area with eight seats; and the smoking area, which is an outdoor space which holds a maximum of 12 people at a time.

In each area there is usually a peer or harm reduction worker supervising the consumption and managing the space. Nurses supervise the injection, and are called in case of emergency or an overdose.

Both consumption areas are very different. The injection space is very intimate and people enjoy the quietness. The smoking area is for socializing and there is a lot of movement.

We’ve tried to create a space that doesn’t feel very medicalized. This is reflected in the leadership of peers and the importance of the participation of people who use drugs, who helped to design the space and service.

Relationships are based on trust, non-judgement and “horizontality” between professionals and members of the community.

When people enter the DCR, they indicate their registration number (if they have one, it’s not obligatory), and indicate which substance they are going to consume. Those who inject drugs are asked a few more questions for safety reasons.

There are more than 1,000 uses per month in the smoking space, and we’ve seen a significant increase in injection of drugs.

People can use the space for 20 to 30 minutes. These rules are a bit flexible according to the service flow.

Heroin and crack cocaine are the most ingested substances and there is a high rate of “speedball” use. There are more than 1,000 uses per month in the smoking space, and we’ve seen a significant increase in injection of drugs to around 350 per month.

Just next door to the DCR there is a drop-in center where there is access to peer counseling, social work services, safe sex and drug consumption material, psychiatry and general medicine consultations.

Considering that harm reduction is underfunded in Portugal, we believe that the formalizing of this drug consumption room is a reflection of the urgent need to provide a safe space to use drugs.

The post Inside a Busy Safe Consumption Site in Portugal appeared first on Filter.

CBC reported that Chief Coroner Lisa Lapointe described the urgent need for SCS as including “a safe place to smoke drugs.”

According to the BC Ministry of Mental Health and Addictions, 19 of the province’s 47 sanctioned SCS include inhalation spaces as of July 2023. Visit records for that month show that inhalation services were accessed more than 40,000 times.

An average of more than five deaths per day in August was attributed to BC’s unregulated drug supply. Though that rate represents a slight decrease overall, the rate of deaths associated with smoking drugs in BC has more than doubled since the province first declared the opioid-involved overdose crisis a public health emergency in 2016.

That was the most recent year that Coroners Service data showed injection as the most prevalent method of drug consumption; by 2017, data showed a shift to smoking, and the majority of BC harm reduction service participants surveyed continue to report smoking as their primary consumption method. Data from other provinces show the same pattern along the same timeframe. The BC Coroners Service report reasserted that medical safer supply. has not been associated with any increase in overdose deaths.

Two of Canada’s legal inhalation spaces currently operate under federal authority: Casey House Day Health Program Supervised Consumption Services in Ontario, and Prairie Harm Reduction in Saskatchewan. The majority are under provincial jurisdiction, and the regulations they’re subjected to vary accordingly.

In Ontario, for example, provincial authorities capped the number of SCS and banned inhalation in 2018, not long after Moss Park Overdose Prevention Site opened Toronto’s first safe smoking tent without authorization. Moss Park was relocated indoors to operate as a government-sanctioned site, minus the safe inhalation services.

One barrier to safe inhalation spaces is the additional layer of bureaucracy entailed in ventilation requirements. But another is that government-sanctioned SCS are limited to evidence-based interventions, and peer-reviewed research in Canada and the United States alike has historically been less interested in stimulant use than opioid use. Sanctioned SCS in Europe have accommodated smoking for decades, and dozens of SCS with safe inhalation spaces operate legally around the world.

The shift to smoking mirrors that taking place in the western US. 

Most drugs consumed at SCS across Canada are opioid-based. The shift to smoking mirrors that taking place in the western US. 

Since the onset of the COVID-19 pandemic, fentanyl pressed pills—AKA “the blues”—have rapidly overtaken less-potent substances like black tar heroin in the unregulated opioid supply. Deaths associated with fentanyl pressed pills more than doubled during the pandemic.

By December 2020, more than half of all overdose deaths reported in Western jurisdictions no longer showed evidence of injection use. In an effort to mitigate the heightened risk, more and more people using unregulated opioids were opting to smoke them.

Safe inhalation spaces are integrated into New York City’s two authorized SCS, as will be the case with the state-authorized SCS set to open in Rhode Island in early 2024. But those services are almost never referenced by legislators or media.

Stimulants are frequently injected and opioids frequently smoked, but smoking and stimulants have long been paired in the public consciousness. The stigma levied against stimulant users is a unique barrier to inhalation sites, one that persists even with the proper ventilation permits and sufficient academic evidence. Methamphetamine-involved deaths are being disastrously blown out of proportion in US overdose data—a body of evidence for safer smoking sites that isn’t accurate, but that still hasn’t generated much interest in them.

Top photograph of Insite Vancouver via Laura Thomas/Drug Policy Alliance/State of Massachusetts. Inset graphic via British Columbia Coroners Service.

The post Smoking, Not Injecting, Now Linked to Two-Thirds of BC Overdose Deaths appeared first on Filter.

In July 2021, Rhode Island enacted a two-year pilot program to evaluate SCS, also known as overdose prevention centers or in this case as “harm reduction centers.” It was the first state to authorize SCS, but has yet to open any.

In November 2021, New York City began operating what are currently the only two authorized SCS in the country, collectively called OnPoint NYC. Regulations for Rhode Island SCS didn’t take effect until February 2022, and since then the main barrier has been funding. But in late 2022 the state began accepting proposals for SCS to be funded with a portion of its opioid settlement payouts. On April 18, peer-led harm reduction nonprofit Project Weber/RENEW announced that it had been awarded a $2.6 million contract to open the center. 

All that remains is a vote in favor from the city of Providence, which will be held in early summer. Though approval is not guaranteed, Project Weber/RENEW Executive Director Colleen Daley Ndoye told Filter that the center has strong support from local stakeholders, the city council and the mayor.

Today we announced we will be opening the country’s first state-regulated overdose prevention center in 2024. This is the result of many years of hard work by so many on our staff and in the state. We’re ready to make history and save more lives. Read:https://t.co/Y0HXaCneK0 pic.twitter.com/wO84fomIpF

— Project Weber/RENEW (@WeberRenew) April 18, 2023

Project Weber/RENEW currently operates two local drop-in centers as well as street outreach. It’s planning to renovate the Providence building selected for the center in collaboration with CODAC Behavioral Healthcare, which has operated a methadone clinic there for decades. Though CODAC is moving to a new location in early fall, it will remain in a limited-service capacity to partner with Project Weber/RENEW and supervise the medical components of the center’s wraparound services. These include methadone and Suboxone access for participants who want them, but the center has no intention of pressuring anyone into treatment.

The clinic’s patients will be able to stay at the current location if they want, but Ndoye said that the “vast majority” are likely to move to the new one—which will make it easier for them to access the SCS without worrying their counselors will be nearby and see them with illicit drugs. Once CODAC moves out, Project Weber/RENEW moves in.

“The location is like a dream,” Ndoye said. “If you could create a location, you would create this location.”

The site has railroad tracks on one side and a five-lane highway on the other. Its next-door neighbors are a scrapyard and a used car dealership. At the same time, it’s near two bus stops and in the immediate vicinity of encampments and other overdose “hotspots” where people are at high risk due to using alone. Accessible to the people it’s intended for; out of the way of everyone else. 

“It’s really, really, really ideal, in terms of NIMBYs,” Ndoye said. “Nobody can say, ‘I’m a [concerned] neighbor,’ because they’re not a neighbor. There aren’t any neighbors … it’s the best of both worlds.”

Organizers are currently working out the blueprints to renovate the building, with the hope that once they have access they’ll be able to open within a few months. Those renovations include specifications for a new HVAC system—the building has to be properly ventilated.

“To only have this be open to people who are injecting would further exacerbate inequality.”

A 2021 cost-benefit analysis by the Rhode Island Department of Health acknowledged that smoking drugs at the future site would be allowed, but didn’t factor it in “due to the limited availability of outcome estimates … in the scientific literature.”

Safer smoking is often left out of discussions around SCS, and thus inhalation booths are left out of SCS themselves. Incremental as the progress around SCS has been, it still tends to leave stimulant users behind. But OnPoint NYC included safer smoking, and Dennis Bailer, who will be one of the Rhode Island center’s codirectors, pushed for inhalation booths as a central racial equity issue. Ultimately, smoking booths were codified as a requirement of the new center’s design.

“In Rhode Island we have a greater population of white people who are injecting drugs, and a greater population of people of color who are smoking,” Ndoye said. “And so to only have this be open to people who are injecting would further exacerbate inequality.”

Most of Project Weber/RENEW’s operations are being modeled off OnPoint NYC, which at publication time has averted 848 overdoses. Supplemental oxygen will be used to avert overdoses in the early stages, and injectable naloxone if the oxygen alone isn’t enough. The center is receiving 50,000 Narcan doses from the opioid settlement funds.

If the center opens on schedule, it will have about two years before the new end-date in March 2026.

Through Brown University’s School of Public Health, the center is also getting a forensic spectrometer to offer drug-checking via what’s commonly known as FTIR. This is a non-destructive technique that identifies all known substances in a given sample—not just fentanyl—and only takes a few minutes. Participants can learn which substances are in the bag they brought with them to use on the premises, and that knowledge often informs if or how they do so.

The original pilot was set to expire March 1, 2024. After an unsuccessful attempt in 2022 to extend the authorization and buy more time for SCS to get underway, a two-year extension was approved in March 2023. If the center opens on schedule, it will have about two years before the new end-date in March 2026. Though the contract is only for one year, opioid settlement funds would likely be what covers the second year, too.

In the meantime, organizers are focused on finalizing the blueprints so that they can begin renovations the moment the site is vacated.

“The building is—well, it’s pretty grim. One of the reasons that we are doing so much rehab is that we do want to make it a more welcoming and respectful space,” Ndoye said. “We certainly do not want to have this be a carceral-looking space. We [want to] make people feel like we care about them, because we do.”

Photograph by Photo Claude TRUONG-NGOC via Wikimedia Commons/Creative Commons 3.0

The post “A Dream Location”: RI Safe Injection, Inhalation Site Slated for Early 2024 appeared first on Filter.