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The SIPP (Safe Inhalation Pipe Provision) study

A novel intervention to reduce health harms and enhance service engagement among people who use crack cocaine in England.

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About

The SIPP study is a mixed-methods evaluation of a crack pipe and harm reduction provision intervention. This is first study of its kind in England, as provision of smoking equipment to people who use crack is currently prohibited under the Misuse of Drugs Act.

Our project aims to generate robust evidence to inform legislative review, improve crack cocaine harm reduction services, and reduce health inequity among a highly marginalised population in England.

This project is funded by NIHR [PHR NIHR133118]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the DHSC

Participatory research

The SIPP study is an academic-community collaboration. Our team includes people with lived experience of crack use, drug treatment service providers, social enterprise and policy experts as well as academics from a variety of disciplines.

We are providing the SIPP intervention through drug treatment services and peer networks with the support of local police forces. Capacitating local community members to help deliver the study is a crucial component of our participatory approach – working with people who are currently using crack to reach and improve outcomes for their communities.

SIPP Intervention

Partner drug treatment services and peer researchers will distribute safe inhalation crack kits and harm reduction information co-produced by people who use crack and the research team.

The SIPP intervention consists of:

  • A SIPP crack pipe kit
  • Peer to peer harm reduction information
  • An e-learning module for drug treatment and harm reduction providers

We will measure impact of the SIPP intervention through a before and after survey carried out at intervention sites, and also control sites where no intervention will be implemented. SIPP acceptability and impact on practice will be explored through qualitative interviews and observations.

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About
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UK drug treatment services are currently prohibited from providing safe inhalation equipment to people who use crack cocaine. Although services are able to supply injection equipment, the Misuse of Drugs Act currently limits the specific support which drug treatments services are able to offer people who smoke crack cocaine. 

SIPP has been designed in collaboration with people who use crack and drug treatment services with the aim of informing legislative review to enable the provision of safe inhalation equipment to people who use crack cocaine as a harm reduction intervention.

Partner drug treatments services and peer researchers will distribute safe inhalation crack kits and co-produced harm reduction information for six months. Pre-and post-intervention surveys and a qualitative process evaluation will measure the impact and effectiveness of SIPP and provide a robust evidence base to inform legislative review.

The project is led by Professor Magdalena Harris and is supported by researchers from The London School of Hygiene & Tropical Medicine, Liverpool John Moores University, University of Bristol, Bristol Drugs Project, Nottingham Health Shop, POW, Cranstoun, Change Grow Live, The Hepatitis C Trust, Exchange Supplies, and Release.

Study rationale

Over 180,000 people use crack cocaine in England. Crack which can be smoked or injected, can cause serious health harms. People who use crack  are vulnerable to infectious diseases, acute injuries and long-term respiratory problems.

Engagement with this marginalised population is a challenge as UK drug treatment services have little to offer people who use crack. There is currently no pharmacotherapy for crack, and although services for people who use drugs can provide the equipment needed for safe injecting, the supply of equipment to reduce risk when smoking crack is prohibited by law.

“Just this helpless feeling of feeling like I didn't have anywhere to turn. Like even when I was involved in the services, they could manage my heroin use, but they couldn't manage my crack cocaine use because there wasn't a substitute in place for it to manage use, whereas, I imagine, there probably could be, it was just seen as, no, there's no availability for it, it's only mental, deal with it.

Many people make the pipes or suspension devices they use to smoke crack from unsafe materials such as cola cans, glass bottles, wire wool, or cigarette ash (increasing respiratory harm), share their pipes (blood borne virus & COVID-19 transmission risk) or inject drugs rather than smoke them (high risk for HIV, hepatitis C, & bacterial infections).

Glass pipe with wire wool

“Sometimes you got little tiny bits of metal in your mouth, but generally, if you did it okay you didn't, but, I mean, inhaling sharp bits of metal probably isn't that healthy for you, either.”

Metal pipe with wire wool

“[…] it did have a very large impact on my sort of ability to breathe clearly. I'd get out of breath walking up the road, I'd wake up in the middle of the night coughing up phlegm, blood, specks of blood in it, and I thought I'd done myself some serious damage […]”

Glass pipe wire wool

Research from countries such as Canada where crack pipe provision is legal show that safe inhalation interventions increase engagement with services and reduce pipe sharing, drug injecting and related health harms.

In a pilot study of people who use crack cocaine in London, we found that over half of our 33 respondents had reported sharing pipes in the last 28 days, with over two thirds relying on homemade pipes. Whilst only 5 participants had previously accessed a drug treatment or harm reduction service in the past 28 days, 23 participants said that they would if pipes were available there. This stresses the need for urgent change, and qualitative responses from the pilot indicate there are clear unmet health and treatment needs:

“Drug workers don’t know about crack or what advice to give me. I want to reduce, but they only give me methadone or bupe.”

“There’s no one I can speak to. I want to stop.”

Opiate substitution therapy and the provision of sterile injecting equipment through drug treatment services and needle exchanges has been proven to be an effective way to save lives. These services help avert hepatitis and HIV transmission by discouraging needle sharing and they offer people who use drugs important links to ancillary health and social care services.

Crack pipes are a valuable commodity for people who use crack and in a context where there are no pharmaceutical treatments available for crack use, pipes offer an important way for drug treatment services to provide a point of engagement for people who use crack. Although psychological treatments for cocaine dependence are encouraged, there is currently limited motivation from people who use crack cocaine to engage with services, and any potential increase in engagement can help people assess risk and encourage pathways to health and social care support, and drug dependency treatment.

The intervention

SIPP (Safe Inhalation Pipe Provision) will promote the availability and accessibility of crack pipes to people who use crack in each intervention site. The intervention has been designed to be pragmatic and practical for drug treatment services to implement, and for busy and preoccupied people who use crack to access. SIPP will engage with people who use crack in a variety of contexts including drug treatment services, drug treatment outreach, and through everyday interactions with peers.

The intervention comprises of three components:

  • The SIPP Kit: a pack containing a straight stem glass pipe; steel gauze; plastic mouthpieces; and harm reduction information.
  • Provider Training: an online crack harm reduction training module developed for service providers.
  • Peer-to-peer Training: a face-to-face risk reduction intervention developed by people with lived experiences of using crack
Terpan crack kit

SIPP kits will be distributed for six months via drug treatment services and peer researchers with lived experience of crack cocaine use. During this period the research team will conduct qualitative interviews and focus groups to understand the acceptability of SIPP for people who use crack and drug treatment services, and to develop and understanding of how the context of an intervention site is likely to affect intervention outcomes.

The impact of the intervention will be evaluated by a before and after survey which will run for 10 weeks in each control site. Surveys will be administered on a tablet, by peers and service providers located in drug treatment networks and the community. We are specifically engaging with peer networks to recruit people who use crack that are not in touch with services. We will assess the impact of the intervention by measuring whether there is any change in our primary and secondary outcomes between pre-and post-intervention and between the intervention and control sites. Our primary outcome measure is: crack pipe sharing frequency. Our secondary outcomes are: use of homemade crack pipes, drug treatment service presentation; crack injection frequency; acute injuries resulting from unsafe pipe use; frequency of ash use as suspension advice; and respiratory risk markers.

 

Participatory research
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The SIPP project is an academic-community collaboration. The project impetus stems from weekly meetings held throughout 2020-21 to monitor and facilitate swift response to drug-related harms during the COVID-19 pandemic. The online platform facilitated attendance from a core group of people who use drugs, drug treatment providers, public health policy leads and police constables across the UK. The vulnerability of crack smokers to respiratory harm and COVID-19 transmission was an early concern.

The SIPP concept has been developed in consultation with people who use crack and community drug treatment providers, including the type of pipe to be provided and inclusion of a brief harm reduction component for delivery with each pipe. This will be developed by the peer networks and disseminated to drug treatment services.

The peer networks we are partnering with were instrumental in providing safe injecting equipment during the height of the COVID-19 pandemic when pharmacy and drug treatment service provision was limited. We are in a unique position to capitalise on and support the capacity of these networks to increase their harm reduction engagement. They have unique access to populations of people who use crack who don’t engage with drug treatment services and have worked with us throughout proposal development to inform recruitment strategy.

All peers involved with the project will receive training in research methods. Training content will be tailored to needs identified by peer network leads and orientated towards practical project implementation. Peer researchers will be remunerated in cash for their time and expenses, including for training participation.

Project outputs and dissemination plans will be developed with the peer networks, particularly the creation of a harm reduction resource for PWUC. This will be co-produced in dissemination workshops with people who use crack and finalised in collaboration with peer network leads. This project responds to community identified need and will only deliver meaningful findings and results with the collaboration, expertise and good will of local networks of people who use crack.

Outputs
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We will disseminate findings through community, policy, police and academic networks, including through initiatives led by people who use crack. Our advisory board includes service users and providers, police, international experts and policy makers who have input into the proposal, will oversee project delivery and aid translation of evidence into policy and practice. The team are committed to disseminating research findings to community groups and project participants, including through social media and articles for community publications and websites, as well as more traditional academic routes (peer review publications, academic conferences).

Specific outputs to impact practice will include:

  • Finalised ‘best practice’ SIPP kit, e-learning module and training package.
  • Crack harm reduction resource developed for and by people who use crack
  • Guidelines for providers and commissioners to improve engagement with and health outcomes for people who use crack.
  • Policy brief to inform and action legislative review

These outputs will be developed to directly benefit both people who use crack, drug treatment, and harm reduction service providers. Our aim is that SIPP promotes a culture change in which people who use crack feel services have something to offer them, feel more confident to access the care they need and better supported to protect their health. 

Publications

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. Harris, M., Scott, J., Hope, V., Busza, J., Sweeney, S., Preston, A., Southwell, M., Eastwood, N., Vuckovic, C., McGaff, C., Yoon, I., Wilkins, L., Ram, S., Lord, C., Bonnet, P., Furlong, P., Simpson, N., Slater, H. & Platt, L. Harm Reduction Journal volume 21, Article number: 19 (2024)

Presentations

Harris, M. et al., (2022). Safe Inhalation Pipe Provision (SIPP): A novel intervention to reduce health harms and enhance service engagement among people who use crack cocaine in England

International Network on Health and Hepatitis in Substance Users Conference, 19 -21 Oct 2022, Glasgow

Harris, M. (2022). Introducing iHOST and SIPP: Innovative research interventions to influence policy and improve care for people who use heroin and crack cocaine.

Evidence-Based Interventions Seminar Series, Department of Social Policy and Intervention, Oxford University. 15th November 2022.

Harris, M. (2022). Safe inhalation pipe provision (SIPP): Intervening to transform harm reduction provision for people who use crack cocaine in England.

Hit Hot Topics Conference, Sharing the love, 18 Nov 2022, Liverpool

Harris, M. (2021). Crack pipes: Reducing health harms and promoting engagement among the most marginalised​

European Harm Reduction Conference. Prague, 10-12 November 2021

Harris, M. (2022) Safe inhalation pipe provision (SIPP) & Improving Hospital Opioid Substitution Therapy (iHOST): two new interventions to improve access to care for people who use drugs.

RCGP & AP Managing Drug and Alcohol Problems in Primary Care Conference, 24-25 March 2022 London

Harris, M. et al., (2022). Introducing iHOST and SIPP: Innovative research interventions to influence policy and improve care for people who use heroin and crack cocaine.

Drug Science Symposium, 16th June 2022, London.

Harris, M. et al., (2022). Safe Inhalation Pipe Provision (SIPP): Introducing an intervention to reduce health harms and enhance service engagement among people who use crack cocaine in England

International Network on Health and Hepatitis in Substance Users Conference, 19 -21 Oct 2022, Glasgow

Harris, M. (2022). Community-led models for improving the health of people who use drugs – Successes, challenges and where to next? Invited Plenary presentation.

International Conference on Health and Hepatitis Care in Substance Users. 19-21 October 2022, Glasgow

Who we are
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Profiles List
Prof Magdalena Harris

Magdalena
Harris

Prof of Inclusion Health (Sociology)
Principal Investigator

Magdalena is a sociologist in inclusion health based at LSHTM. She leads a mixed-method programme of research on health interventions for people who use heroin and crack cocaine in the UK, including through NIHR projects. She has 18 years’ experience in qualitative and participatory research with people who use drugs, holds the 2020 Society for the Study of Addiction Award for Impact on Policy and Practice and in 2022 was awarded a Membership through Distinction of the Faculty of Public Health.

Lucy
Platt

Professor of Public Health Epidemiology

Lucy Platt is Professor of Public Health Epidemiology at LSHTM. Her research focuses on examining how social and health policies and interventions influence people who sell sex and/or inject drugs’ vulnerability to blood-borne viruses, sexually transmitted infections and other health harms.

Jenny Scott

Jenny Scott

Senior Lecturer

Jenny is a Senior Lecturer in Primary Care, and has expertise in intervention development in community pharmacies including online training development, previous clinical experience in hospital pharmacy and current clinical experience in a community drug treatment team.

Vivian Hope

Vivian Hope

Professor

Viv is currently Professor of Public Health at the Public Health Institute, Liverpool John Moore University. Prior to this he worked at Public Health England, and he has held academic posts at London School of Hygiene & Tropical Medicine, Imperial College London, and the University of Birmingham. He has over 25 years’ experience of research and public health practice focused on understanding the health issues associated with drug use and the responses to these. His research has focused on the harms associated with the injection of drugs, particularly infections, and preventing drug-related deaths. His research interests also include the use of human enhancement drugs, sexualised drug use, sexual health, and the well-being of LGBT+ communities.

Niamh Eastwood

Niamh Eastwood

Executive Director

Niamh is Executive Director of Release, the UK’s centre of expertise on drugs and drugs law. Niamh has co-authored a number of Release’s policy papers including “A Quite Revolution: Drug Decriminalisation across the Globe" and "The Colour of Injustice: "Race’, drugs and law enforcement in England and Wales”.  Niamh is an Associate Member of the Drug and Alcohol Research Centre, Middlesex University. She is also a committee member for DrugScience and has been a technical advisor to the Global Commission on Drug Policy. She is regularly asked to comment in the media on drug policy. Niamh started at Release as a legal advisor, supporting the legal rights of people who use drugs, especially those who have a history of drug dependency.

Ms Joanna Busza

Joanna
Busza

Associate Professor

Joanna is Director, Centre for Evaluation and Associate Professor in Sexual & Reproductive Health. Joanna has over 25 years’ international research experience in the fields of HIV, sexual and reproductive behaviour, and the social determinants of risk among vulnerable and hard-t-reach groups, particularly sex workers and mobile populations.

Cedomir Vuckovic

Research Fellow

Cedomir is Research Fellow at London School of Hygiene and Tropical Medicine. He is a qualitative researcher specialising in the study of everyday life and practice, cultural studies, and resistance.

Caitlynne McGaff

Caitlynne McGaff

Research Fellow

Caitlynne is a Research Fellow at the London School of Hygiene and Tropical Medicine specializing in quantitative analysis.  She has experience in HIV surveillance and global sexual and reproductive health research, particularly among adolescents.

Mr Sujit D Rathod

Sujit D
Rathod

Programme Content Director

Sujit is an epidemiologist and project statistician who has interest in policy-relevant research with marginalised populations in the UK and in low- and middle-income settings. In addition to SIPP, he supports the quantitative component of the Homeless Health Peer Advocate evaluation.

Dr Sedona Sweeney

Sedona
Sweeney

Assistant Professor

Sedona is a health economist, with a research focus on economic evaluation in low- and middle-income settings. Her particular interest is in the economic impact of substantial long-term health shocks, both at the provider level and within the household. Her research to date has been focused on measurement and understanding of the costs of chronic illness – including HIV, TB, chronic non-communicable diseases, and HCV.

Philippe Bonnet

Philippe Bonnet

Outreach and Pharmacy Testing Manager - West Midlands ODN - The Hepatitis C Trust

Philippe is originally from France and has been in the UK for over thirty years, mainly in his adopted and beloved Birmingham. He has worked with people who use drugs for nearly two decades, as a drug worker and trainer, following a decade and a half of injecting drugs. He is a strong harm reduction advocate who firmly believes in helping people, as opposed to chastising them. He is currently the Hepatitis C Trust Outreach and Pharmacy Testing Manager for the West Midlands Operation Delivery Network, as well as Chair of the National Needle Exchange Forum.

He was recently appointed Board Trustee for Addiction Professionals, where he hopes to bring policy changes for the substance misuse sector. Philippe has a wealth of experience in working with people who inject drugs, especially heroin and crack cocaine. He specialises in blood borne viruses, naloxone and safer use of drugs. He has won industry and Police awards for his work with crack users in inner city Birmingham. He has developed treatment pathways for crack users and trained health professionals on crack cocaine Harm Reduction.

Louise Wilkins

Louise Wilkins

Team Leader

Lou works for Nottinghamshire Healthcare Foundation Trust as the Team Leader for The Health Shop, which is a sexual health and drug harm reduction service and have been in the field for nearly twenty years.  She is passionate about health inequalities and strive to find creative ways to support people to improve their health in Nottingham city. Lou is proud to have worked on a number of specific harm reduction projects including reducing barriers for sexual health screening, smoking cessation for people who use drugs and Hepatitis C elimination for Nottingham Recovery Network. We have been trying to improve harm reduction services for people who smoke crack for a long time, so am really excited to be part of the SIPP project.

Andrew Preston

Andrew Preston

Founder Social Enterprise Exchange Supplies

Andrew has been working in harm reduction for over 30 years. Following a decade of clinical practice as a community drug worker delivering OST and needle exchange, in 2002 he founded Social Enterprise Exchange Supplies to develop equipment to improve harm reduction by better serving the needs of people who inject drugs, and provide employment and training to people who inject drugs. Exchange Supplies provide on-site peer delivered needle and syringe programme for their local community, and are the equipment suppliers to the SIPP study sites.

Holly Slater

Service Co-ordinator

Holly is the Service Co-ordinator at POW Nottingham. POW is a peer-funded charity set up in 1990 to support sex workers and those affected by sex work. POW supports sex workers from all backgrounds in Nottingham, including sex workers who are also substance users. She has worked at POW for 6 years in multiple roles including as a drop-in worker, outreach worker, progression worker and now as part of the management team. POW are not an exiting-focused charity, and harm minimisation is at the forefront of everything that we do to support sex workers.

Mat Southwell

Mat Southwell

Technical support consultant

Mat is Technical Support Consultant specialising in drugs / HIV in international development. I coordinated a team of peer writers to research and write the first draft of UNODC WHO UNAIDS HIV Prevention, treatment, care and support for people who use stimulant drugs technical guide. He is completing a 3-part webinar toolkit on stimulants and HIV support UNODC to promote the intervention in the Guide. In the UK Mat championed crack harm reduction developing new practice and peer support tools that he promoted through a t raining programme. Mat was the founder of the Crack Squad - peer educators promoting self-control and harm reduction. He created a training initiative between the Crack Squad and RCGP that led to the development of "Guidance for working with cocaine and crack users in primary care". Mat functions as a bridgebuilder helping to create a dynamic interaction between lived and learned experience. He works for the drug user rights movement and have developed peer training programmes and resources.

Peter Furlong

Peter Furlong

National Harm Reduction lead

Peter Furlong is the National Harm Reduction lead for Change Grow Live (CGL) and has been working in Drug services since the late 1990s. Starting as a volunteer Peter has worked across a range of frontline roles including outreach worker, needle and syringe exchange, drug worker, services manager and  NW Regional Development Manager. Peter developed a Peer to Peer harm reduction program in Merseyside in 2007 that won a national training award and was instrumental in pioneering the development of take-home naloxone in Sefton in 2010, one of the first services in the country to pilot its first provision as a core intervention. With a passion for research, Peter led on the introduction of nasal naloxone (nyxoid) for CGL services in 2019 and its evaluation report independently evaluated by the University of Manchester (2020). Peter currently works in the clinical directorate of CGL leading on Harm Reduction Strategy national for CGL.

Ian
Yoon

Research Fellow in Health Economics

Ian is a research fellow at the London School of Hygiene and Tropical Medicine, with an interest in economic evaluations of health and public health interventions. He is supporting the economic evaluation of the Safe Inhalation Pipe Provision project as well assessing novel tuberculosis diagnostic strategies in South Africa. His prior experience includes advising Malawi's Ministry of Health on strategic purchasing, resource mobilization, and public financial management during his tenure with the Clinton Health Access Initiative. Ian holds a Master's degree in International Health Policy (Health Economics) from the London School of Economics and a Bachelor's degree in Economics and International Relations from the University of St. Andrews. 

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Advisory board
  • Professor Catriona Matheson, University of Stirling
  • Professor Sharon Hutchinson, Glasgow Caledonian University/Public Health Scotland
  • Mr Steve Taylor, Office for Health Improvement and Disparities
  • Mr Ernst Wisse, Medicines du Monde
  • Mr Martin Powell, Transform Drug Policy Foundation
  • Professor Alex Stevens, University of Kent
  • Mr Jason Kew, Centre for Justice Innovation
  • Mr Jody Clark, West Midlands Police and Crime Commissioner
  • Ms Cheryl White, Self-employed Peer Advisor
  • Dr Martyn Hull, Turning Point