Title: Safe inhalation pipe provision (SIPP): A mixed method evaluation of an intervention to reduce health harms and enhance service engagement among people who use crack cocaine in England
Funder: Department of Health and Social Care

Abstract: 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 (PWUC) are vulnerable to infectious diseases, acute injuries and long-term respiratory problems._x000D_ _x000D_ Engagement with this marginalised population is a challenge as UK drug treatment services have little to offer PWUC. Although services for people who use drugs can provide the equipment needed for safe injecting, supply of equipment to reduce risk when smoking crack is prohibited by law. This means most PWUC make the pipes they use to smoke crack from unsafe materials (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). Research, from countries such as Canada where crack pipe provision is legal, show that safe inhalation interventions increase PWUC engagement with services and reduce pipe sharing, drug injecting and related health harms._x000D_ _x000D_ The SIPP (Safe inhalation pipe provision) intervention has been developed with PWUC and with input from service providers. It consists of a kit with heat-resistant glass pipe, risk reduction information, and tailored training for service providers. The SIPP kit will be provided to PWUC for six months in three areas (Avon & Somerset, Nottingham & the West Midlands) reflecting different patterns of crack use and service provision. We will work with four drug treatment services and four peer-led networks to deliver SIPP. We have local police force support. We will train and support peers to conduct research with PWUC who don’t access services and to ensure our methods and materials are acceptable._x000D_ _x000D_ We will use quantitative and qualitative methods to understand the needs of the local community and evaluate SIPP. We will conduct a survey at two time points (before and after SIPP provision), recruiting through peer networks and treatment services, including at three comparison sites where there will be no intervention. Everytime someone recieves a SIPP kit they will complete a brief questionnaire so we can measure change over time in individual risk practices. We will conduct interviews with PWUC and SIPP providers to understand SIPP acceptability. Our main outcome will be an assessment of whether SIPP reduces pipe sharing. Outputs will include: optimised SIPP intervention; protocols for service implementation; crack risk reduction resources co-produced with PWUC; evidence for legislative review._x000D_ _x000D_ We are a multi-disciplinary team with expertise in working to improve health outcomes for marginalised populations. The proposal is the product of an academic, community and industry collaboration: team members include service users and providers. SIPP has potential to reduce health harms, including COVID transmission, and engage a hard to reach population with drug treatment services. Exchange Supplies, a well-regarded social enterprise, will co-develop and provide SIPP kits for free. We have permission from West Midlands, Nottinghamshire and Avon & Somerset police for drug services to participate without risk of prosecution. We will provide training to peers and providers in research methods and crack risk reduction. PWUC alongside other stakeholders (police, commissioners, treatment providers) will be involved throughout the project to ensure our methods are ethical and acceptable and that our findings and outputs are relevant.

Lay abstract: Research question: To what extent and how does safe inhalation pipe provision (SIPP) reduce health risks and enhance service engagement among people who use crack cocaine (PWUC)?_x000D_ _x000D_ Background: Drug treatment services have little to offer PWUC in England. No evidence-based pharmacotherapies are available and crack pipe provision is prohibited. Pipes used for crack smoking are often homemade and/or shared, exacerbating risk of infectious disease transmission and chronic respiratory conditions. Legislative review of crack pipe prohibition is needed but must be evidence informed. This study is supported by police force partners who view SIPP as a needed public health intervention to support drug treatment engagement among a high risk population. _x000D_ _x000D_ Objectives_x000D_ 1. Measure the effect and cost-effectiveness of SIPP on harms and risks associated with crack use (pipe sharing, presentation at drug services, using home-made pipes, cuts/burns, crack injecting)_x000D_ 2. Evaluate SIPP fidelity, reach and acceptability in diverse drug treatment and peer-network settings._x000D_ 3. Explore the barriers and facilitators to SIPP uptake and service engagement among PWUC._x000D_ 4. Explore the mechanisms through which SIPP facilitates changes in health risks and access to services, to inform implementation at scale. _x000D_ 5. Build peer-network research capacity and explore whether the quality and impact of their SIPP engagement with PWUC differs in comparison with SIPP engagement through drug treatment services._x000D_ 6. Co-develop a scalable SIPP toolkit and harm reduction resources to enhance PWUC engagement with drug treatment services and facilitate crack-related risk reduction practices._x000D_ 7. Translate evidence to policy and advocacy outputs, including to inform legislative review._x000D_ _x000D_ Methods: Quasi-experimental design comprising a pre-post comparison study with a non-equivalent control group and a nested qualitative study to identify impacts and predictors of SIPP use to inform intervention scale up and an assessment of its cost-effectiveness._x000D_ _x000D_ Timeline: Our 5 phase project will be delivered over 30 months. P1. Optimisation [M1-6]: Evidence review; peer training; co-production; P2 Baseline data generation [M7-9]: Cross sectional survey; stakeholder interviews; provider focus groups; P3 Implementation [M10-18]: SIPP delivery; PWUC interviews, observations; P4 Evaluation [M19-24]: Follow-up survey, interviews, focus groups; economic evaluation; P5 Dissemination [M25-30]: Scalable SIPP toolkit; harm reduction resources; policy and public health advocacy. _x000D_ _x000D_ Impact: Systematic evaluation of safe inhalation interventions for PWUC is urgently needed in order to produce definitive evidence of their health and other benefits, and to allow for evidence-based program and policy decisions in the interest of public health. Led by a team of multidisciplinary researchers, drug treatment providers and PWUC, this research will provide value for money by evidencing the impact of a low-cost intervention on health care outcomes and drug treatment engagement among PWUC. _x000D_ _x000D_ PPI: Formative work with PWUC, drug treatment providers, police and crime commissioners, police force, and the Hepatitis C Trust inform our proposal. This project is a community-academic partnership, addressing community-identified need and building peer researcher capacity, with meaningful peer and community stakeholder involvement throughout ensuring project accountability and output relevance.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH