SFU Crack Study

Drugs: education, prevention and policy,
August 2010; 17(4): 333–353
Social, health and drug use characteristics of primary

crack users in three mid-sized communities in British
Drugs Edu Prev Pol Downloaded from informahealthcare.com by Simon Fraser University on 07/03/10
Columbia, Canada
BENEDIKT FISCHER1,2,3, KATHERINE RUDZINSKI2,

ANDREW IVSINS4, OWEN GALLUPE3, JAYADEEP PATRA2,
& MEL KRAJDEN5,6
1
Faculty of Health Sciences, Centre for Applied Research in Addictions & Mental Health,
Simon Fraser University, Vancouver, BC, Canada, 2Centre for Addiction and Mental
Health, University of Toronto, Toronto, ON, Canada, 3School of Criminology, Simon
For personal use only.
Fraser University, Vancouver, BC, Canada, 4Department of Sociology, University of

Victoria, Victoria, BC, Canada, 5BC Centre for Disease Control, Vancouver, BC, Canada,
and 6Department of Pathology and Laboratory Medicine, University of British Columbia,
Vancouver, BC, Canada
Abstract
Aims: Despite the increased prevalence of crack use, research on street drug use in
Canada currently focusses mainly on injection drug use and/or use in large urban centres.
This study’s objective was to assess the distinct socio-demographic characteristics, drug-
use patterns, health profiles and risk behaviours as well as intervention needs of primary
crack users in three mid-sized communities in British Columbia, Canada.
Methods: Study participants were recruited with the help of local service agencies and
peer recruiters, and assessed between July and November 2008 based on a protocol
involving quantitative, qualitative and biological measures.
Findings: The majority of the samples: reported unstable housing/homelessness; relied
on social benefit payments for income generation; were under current criminal justice
supervision; were poly-drug users, using other drugs like alcohol, cannabis or opioids;
reported physical and mental health problems; were hepatitis C virus positive; had
numerous crack-use episodes per day; frequently shared crack-use paraphernalia; and
obtained crack pipe paraphernalia from makeshift items.
Conclusions: This study documents crack use as a prevalent street drug use activity
associated with extensive social and health risks and harms, which currently are not
sufficiently addressed by the existing interventions in the study sites. Concerted attention
Correspondence: Benedikt Fischer, CARMHA/Faculty of Health Sciences, Simon Fraser

University, 2400-515 West Hastings St., Vancouver, BC V6B 5K3, Canada. Tel: 778-782-5148.
Fax: 778-782-7768. E-mail: bfischer@sfu.ca
ISSN 0968–7637 print/ISSN 1465–3370 online ß 2010 Informa UK Ltd.

DOI: 10.3109/09687630903357700
334 B. Fischer et al.
to, and delivery of, targeted prevention and treatment interventions for the public health
problem of crack use in Canada is urgently required.
Background
Over the past decade or so, evidence has suggested that crack use is a highly – and
in many places increasingly – prevalent drug use phenomenon among street drug
users in Canada (CCENDU, 2003a; Fischer et al., 2006b; Health Canada,
2006). For example, in the most recent (2006) I-Track study assessing samples
of injection drug users (IDUs) in multiple cities across Canada, 65.2% of
participants had also used crack in the past 6 months, compared to 52.2% in
the previous assessment (2004) (Health Canada, 2004, 2006). In the OPICAN
study, a multi-site cohort study of illicit opioid and other drug users in cities
across Canada, 54.6% of participants reported current crack use (Fischer et al.,
2005a). In the Vancouver injection drug user study (VIDUS), a cohort of
1600 IDUs assessed for over a decade, lifetime prevalence of crack use had
increased substantially from 7.4% in 1996 to 42.6% in 2005 (Werb et al., 2008).
In numerous cities across Canada, crack has been reported to be the most
commonly used and available street drug (Boyd, Johnson, & Moffat, 2008;
CCENDU, 2003b; Chase Project Team, 2005; Khandor & Mason, 2008).
As evidenced by studies conducted in Canada and abroad, crack users tend
to be characterized by disproportionate levels of health and social problems.
Crack users feature a distinct ‘social profile’, with many characterized by
extreme poverty, homelessness and illegal income generation (Corneil et al.,
2006; DeBeck et al., 2007; Fischer et al., 2005b). A number of Canadian studies
with regular crack users have found that the respective majorities of participants
were homeless or lived in unstable housing conditions (Fischer et al., 2006b;
Leonard et al., 2008; Shannon et al., 2008). Several studies conducted in
North America and elsewhere have shown that regular crack users indicate
a disproportionately higher involvement in drug-related acquisition crime
(e.g. theft, burglary, robbery) as well as arrests and imprisonment even when
compared to other illegal drug users (Bennett, Holloway, & Farrington, 2008;
Cross, Johnson, Davis, & Liberty, 2001). The Canadian OPICAN study found
that crack users reported significantly higher levels of crime and criminal justice
involvement than non-crack users; specifically they reported more property crime,
arrests and imprisonment than non-crack users (Fischer et al., 2005b; Manzoni,
Brochu, Fischer, & Rehm, 2006). In the US, it has been shown that over time
cities with higher rates or crack-use experiences substantially higher rates of
property and other crime than comparison cities (Baumer, Lauritsen, Rosenfeld,
& Wright, 1998).
Crack users have also been found to be at a substantially higher risk for
a multitude of health problems, including a large variety of infectious diseases.
In several studies of inner-city, street-based drug user populations, crack use
has emerged as a significant predictor for both human immunodeficiency
Characteristics of primary crack users in Canada 335
virus (HIV) and hepatitis C virus (HCV) infection status (McMahon & Tortu,
2003; Ouellet et al., 2000; Roy et al., 2001; Wallace, Porter, Weiner, & Steinberg,
1997). For example, a multi-site US study found that the prevalence of HIV
infection among crack users (15.7%) was 2.4 times that of non-users (5.2%);
among a sample of not-in-treatment drug users, HIV prevalence was more
than twice (males; 17.8%) or three times (females; 23.6%) as high compared
to non-crack users (Edlin et al., 1994; Metsch et al., 1999). A number of studies
have also demonstrated that crack users present highly elevated rates of sexually
transmitted infections (STIs), including syphilis, gonorrhea, chlamydia and
herpes simplex 2 (DeHovitz et al., 1994; Maranda, Han, & Rainone, 2004; Ross,
Hwang, Zack, Bull, & Williams, 2002). In one study of inner-city youth who were
either regular smokers of crack cocaine or non-smokers of crack cocaine, the
prevalence of STIs among female (74.5%) and male (65.6%) crack users was
almost double than that of non-crack users (43.6% and 33.1%, respectively)
(Metsch et al., 1999). In addition, several studies have found that crack use
is independently associated with an elevated risk of tuberculosis (Howard, Klein,
Schoenbaum, & Gourevitch, 2002; Leonhardt, Gentile, Gilbert, & Aiken, 1994;
McElroy et al., 2003).
A large part of the elevated prevalence of HIV, HCV and STIs among crack
users is explained by the fact that crack users have been shown to frequently
engage in a multitude of high-risk behaviours facilitating the transmission of these
diseases, including: sex work for income generation and/or high-risk sexual
activities (e.g. unprotected/oral/anal sex, multiple sex partners), sex for drugs
exchanges, risky injection practices, drug bingeing (Booth, Kwiatkowski, &
Chitwood, 2000; Lejuez, Bornovalova, Daughters, & Curtin, 2005; Logan &
Leukefeld, 2000; Maranda et al., 2004). Crack users have been shown to have
chronic oral sores or wounds (related to risky oral crack-use practices, e.g. the
use of unsafe crack-use paraphernalia and high-frequency patterns of use),
compromised immune-system functioning and nutritional deficiencies, further
facilitating the transmission of infectious disease in the context of the aforemen-
tioned risk behaviours (Faruque et al., 1996; Garrity, Leukefeld, Carlson, &
Falck, 2007; National Institute on Drug Abuse, 2005; Porter & Bonilla, 1993).
In recent years, a number of studies have also shown that samples of crack
users without an injection drug use history reported highly elevated prevalence
rates of HCV up to 17% (Scheinmann et al., 2007). These high HCV infection
rates among non-injection crack users have given rise to the hypothesis that
HCV transmission among crack users might occur through the sharing of
HCV-contaminated oral crack-use paraphernalia (Faruque et al., 1996; Roy
et al., 2004; Tortu, McMahon, Pouget, & Hamid, 2004). One recent
study suggested that on the basis of virological detection of HCV on crack
paraphernalia that such transmission between crack users might be plausible
(Fischer et al., 2008b). Besides physical health problems, crack users also feature
disproportionately elevated levels of mental health problems, for example, anti-
social personality disorders, paranoia and depression. Falck, Wang, Siegal,
& Carlson (2004) found that in a group of not-in-treatment crack cocaine users,
the most common non-dependence disorders were anti-social personality

disorder (ASPD 24%), depression (17.8%), and posttraumatic stress disorder
(PTSD 11.8%).
While crack use is substantially prevalent across Canada, and clearly results in
substantial health and social problems, most currently available interventions for
street drug users target injection or opioid users, and very few are specifically
available to the crack user population (Boyd et al., 2008; Fischer & Coghlan,
2007; Shannon et al., 2008). On the treatment side, even though several dozens
of medications have been investigated in recent decades for the treatment of
cocaine/crack dependence, the field currently lacks an effective pharmacological

treatment regimen (e.g. as analogous to opioid maintenance treatment for opioid
dependence) (Castells et al., 2007; Gorelick, Gardner, & Xi, 2004; Grabowski,
Shearer, Merrill, & Negus, 2004). In recent years, a few select municipal
jurisdictions across Canada initiated so-called ‘safer crack-use kit’ distribution as
a prevention measure – similar to the concept of needle exchange services
for injectors – for crack users, i.e. initiated the dissemination of safer hardware for
crack paraphernalia in order to reduce the need for unsafe paraphernalia use and
sharing (Haydon & Fischer, 2005; Malchy, Bungay, & Johnson, 2008). Even
though such programmes have demonstrated effectiveness in reducing risky
crack-use patterns, several of the Canadian municipalities where such pro-

grammes were available have suspended these programmes in the wake of severe
political opposition (James, 2007; O’Byrne & Holmes, 2008; Symington, 2007).
In several European countries, several of the so-called ‘supervised consumption
facilities’ for street drug users include ‘safer inhalation’ rooms offered to the
risk population crack users; however, proposals to establish such facilities
in Canadian cities (e.g. Vancouver, Victoria) have been ignored or rejected
to date (EMCDDA, 2007; Fischer & Allard, 2007; James, 2007).
Relatively little primary research is conducted on the risk population of crack
users in Canada, and most existing studies furthermore focus on crack-user
populations in large urban centres (Haydon & Fischer, 2005; Shannon et al.,
2008). The objective of this study was to assess the distinct socio-demographic
characteristics, drug use patterns, health profiles and risk behaviours as well as
intervention needs of primary crack users in three mid-sized communities
(Nanaimo, Campbell River and Prince George) in British Columbia (BC),
Canada. The primary purpose of this effort was to characterize this particular risk
population in non-urban settings as well as provide the evidence-base for the
development of targeted and improved interventions (e.g. prevention, treatment)
for the target population in these particular settings.
Methods
Study assessments in the three study sites were conducted between July and
November 2008. Study participants were recruited from existing local crack-user
populations utilizing the assistance of central local social and health service
agencies and peer recruiters. The study relied on a ‘snowball’ recruitment

approach, that is, handout cards with pertinent study information were
disseminated in local drug use populations and invited potential participants to
contact the study. The fieldwork, that is, participant screening and assessment,
was conducted by two trained field researchers. A field study office was setup on
the premises of one of the central social/health services agencies catering to the
study population in each of the study sites. Upon contacting the study (in-person
at the study location), potential participants were screened for eligibility following
a pre-set screening protocol. Eligible participants had to (1) be at least 16 years
of age, (2) be regular crack cocaine smokers (‘regular’ defined as ‘having used
crack on at least half of the past 30 days’), (3) be willing to participate in the study
protocol and (4) not be intoxicated at the time of the assessment. If the applicant
was found to be eligible for the study, the assessment was either conducted
immediately thereafter or an appointment was scheduled for a time within the
next 48 h. Prior to the study assessment, participants provided informed verbal
consent. The study protocol was conducted anonymously (i.e. no personal
information was collected) and included (1) a face-to-face interview based on
a standardized questionnaire including closed and some open-ended questions,
and (2) a self-administered saliva sample for HIV and HCV antibody testing,
using the OraSureÕ oral specimen collection device. The study questionnaire
was based on assessment instruments and items developed, validated and
implemented in previous studies targeting similar large-scale study populations –
that is, high-risk street-entrenched crack and other drug users – and enriched by
several quantitative and qualitative items of particular interest (Fischer et al.,
2005a, 2006b, 2008b). The face-to-face interviews were conducted in a secure
interview space, ensuring privacy and confidentiality. Each assessment lasted
approximately 60 min. Upon study completion, participants’ received a $20
honorarium.
After completion of data collection, the data were entered into a standardized
data entry shell. The quantitative data were analysed by appropriate descriptive
statistics and stratified by location, using SPSS (SPSS Inc., 2007). This was done
for individual cities and combined across all sites. Differences across study sites
were tested for significance using chi-square tests with accompanying adjusted
standardized residuals for categorical variables and ANOVAs for continuous
variables. The qualitative data were manually reviewed, coded and analysed
according to emerging themes and issues. A content analysis of the qualitative
data was first conducted to identify the major themes with respect to the topic
areas covered by the open-ended questions. Main themes were hand-coded,
reviewed and adjusted, by the two experienced interviewers/research analysts who
originally conducted the interviews. The most salient themes were then organized
into matrices in order to facilitate a richer understanding of the data, and on this
basis informed data presentation and discussion (in this specific article,
qualitative data collected is used primarily to contextualize quantitative data
obtained). Laboratory testing for HIV and HCV antibody status was conducted
at the BC Centre for Disease Control, Vancouver. Previous validation of the
OraSureÕ device confirmed high sensitivity for both the HIV (96.4%) and HCV
(94.6%) antibody testing methods (Buxton et al., 2009; Judd et al., 2003).
This study was approved by applicable institutional research ethics boards.
Results
The study included n ¼ 148 participants in total (Nanaimo n ¼ 70, Campbell
River n ¼ 37, Prince George n ¼ 41).
Socio-demographics, income generation and crime

Two-thirds (63.5%) of the samples were male; respondents ranged in age from
20 to 50 years and above (Table I). The majority of participants lived in either
unstable/temporary (26.4%) housing or were homeless (33.1%). For income
generation, most participants (85.8%) reported that they drew income from social
or income-assistance programmes (e.g. disability, welfare, pension, unemploy-
ment programs). Further main income sources were sex work, soliciting,
panhandling and binning activities (45.9%) and drug dealing (39.9%). Half of
the samples in the Campbell River and the Prince George sites (48.6% and
51.2%), and a quarter in the Nanaimo (24.3%) had been arrested in the past
year. Property offenses (36.4%) and drug-related offenses (29.1%) were cited
most commonly as reasons for arrest. Three quarters of the sample (73.5%)
were currently under some form of criminal justice supervision or restraint,
(e.g. probation, parole, bail orders).
Health risks and status

Half the sample (52.4%) described their physical health as ‘fair’ or ‘poor’, and
two-thirds (64.9%) stated that they experienced physical health problems in the
past 30 days (Table II). The majority (58.8%) had experienced mental/emotional
health problems in the past 30 days. In the majority of cases (74.1%), these
consisted of mood problems, (e.g. symptoms of depression or sadness (data not
shown)).
A third (37.8%) of participants had engaged in unprotected sex in the 30 days
prior to assessment. One in 10 (9.5%) of the samples tested positive for
HIV antibodies, and the majority (58.8%) tested positive for HCV antibodies.
One HIV-positive and 14 HCV-positive participant were not aware of their
HIV-positive or HCV-positive status, that is, they were tested positive but had
not tested positive before or did not think on the basis of other information they
had that they were HIV-positive or HCV-positive, respectively. About two-thirds
(63.6%) of participants who self-reported HIV positive status indicated that
they ever received treatment for HIV, whereas just over one in 10 (13.9%) of the
participants who self-reported HCV positive status indicated that they had ever
received treatment for HCV.
Table I. Socio-demographics, income generation and crime indicators, n(%).
Nanaimo Campbell River Prince George Total 2 exact

(n ¼ 70) (n ¼ 37) (n ¼ 41) (n ¼ 148) p-value
Sex
Male 53 (75.7)a 21 (56.8) 20 (48.8)a 94 (63.5) 0.011
Age (in years)
18–20 1 (1.4) 1 (2.7) 0 (0.0) 2 (1.4) 0.978
21–30 13 (18.6) 9 (24.3) 7 (17.1) 29 (19.6)
31–40 21 (30.0) 10 (27.0) 12 (29.3) 43 (29.1)
41–50 22 (31.4) 11 (29.7) 13 (31.7) 46 (31.1)
51þ 13 (18.6) 6 (16.2) 9 (22.0) 28 (18.9)
Housing statusb
Stable 24 (34.3) 18 (48.6) 18 (43.9) 60 (40.5) 0.259
Unstable/temporary 22 (31.4) 5 (13.5) 12 (29.3) 39 (26.4)
Homeless 24 (34.3) 14 (37.8) 11 (26.8) 49 (33.1)
Income sourcesb
Paid work 23 (32.9) 11 (29.7) 13 (31.7) 47 (31.8) 0.947
Social benefits 61 (87.1) 29 (78.4) 37 (90.2) 127(85.8) 0.295
Family/partner/friends 16 (22.9) 15 (40.5)a 9 (22.0) 40 (27.0) 0.100
Drug dealing 29 (41.4) 15 (40.5) 15 (36.6) 59 (39.9) 0.877
Sex work, soliciting, panhandling, binning 30 (42.9) 15 (40.5) 23 (56.1) 68 (45.9) 0.300
Criminal activity 13 (18.6) 9 (24.3) 15 (36.6) 37 (25.0) 0.106
Other 20 (28.6)a 11 (29.7) 0 (0.0)a 31 (20.9) 0.001
Respondents arrestedc 17 (24.3)a 18 (48.6) 21 (51.2)a 56 (37.8) 0.005
Reason for arrest (among those arrested)d
Drug possession/use 4 (23.5) 3 (16.7) 3 (15.0) 10 (18.2) 0.782
Drug dealing/production/trafficking 3 (17.6) 2 (11.1) 1 (5.0) 6 (10.9) 0.469
Property offence 5 (29.4) 6 (33.3) 9 (45.0) 20 (36.4) 0.585
Violent offence 3 (17.6) 3 (16.7) 2 (10.0) 8 (14.5) 0.768
Sex work/prostitution 0 (0.0) 0 (0.0) 4 (20.0)a 4 (7.3) 0.023
Parole/probation/treatment order/bail violation 3 (17.6) 2 (11.1) 2 (10.0) 7 (12.7) 0.761
Other 5 (29.4) 8 (44.4) 4 (20.0) 17 (30.9) 0.262
Under current judicial restrainte 49 (71.0) 26 (70.3) 33 (80.5) 108(73.5) 0.486
a
Minimum adjusted standardized residual greater than absolute 2.0, where p-value for overall 2 0.10.
b
In the past 30 days.
c
In the past year (in the past 30 days in Nanaimo only due to technical error in questionnaire).
d
Prince George site n ¼ 20 due to missing data.
e
Nanaimo site n ¼ 69 due to missing data.
Table II. Health risks and status, n(%).
Nanaimo Campbell River Prince George Total 2 exact

(n ¼ 70) (n ¼ 37) (n ¼ 41) (n ¼ 148) p-value
Physical health statusa,b

Excellent, very good, good 28 (41.2) 19 (52.8) 22 (53.7) 69 (47.6) 0.347
Fair, poor 40 (58.8) 17 (47.2) 19 (46.3) 76 (52.4)
Participants reporting physical health problemsa 53 (75.7)c 20 (54.1) 23 (56.1) 96 (64.9) 0.032
Participants reporting mental/emotional health problemsa 40 (57.1) 25 (67.6) 22 (53.7) 87 (58.8) 0.427
Had unprotected sexa 22 (31.4) 21 (56.8)c 13 (31.7) 56 (37.8) 0.023
HIV positive when last testedd 6 (8.7) 0 (0.0) 5 (12.2) 11 (7.5) 0.108
Not tested HIV positive but think they are HIV positived 1 (1.4) 0 (0.0) 1 (2.4) 2 (1.4) 0.647
HIV antibody positive (laboratory) 6 (8.6) 3 (8.1) 5 (12.2) 14 (9.5) 0.778
Ever received HIV treatment(among HIV þ cases) 3 (50.0) 0 (0.0) 4 (80.0) 7 (63.6) 0.303
HCV positive when last testede 35 (50.7) 11 (30.6)c 26 (65.0)c 72 (49.7) 0.011
Not tested HCV positive but think they are HCV positivee 1 (1.4) 0 (0.0) 0 (0.0) 1 (0.7) 0.574
HCV antibody positive (laboratory) 41 (58.6) 17 (45.9) 29 (70.7) 87 (58.8) 0.085
Ever received HCV treatment (among HCV þ cases)f 3 (8.6) 1 (9.1) 6 (23.1) 10 (13.9) 0.252
a
b
Nanaimo site n ¼ 68, Campbell River site n ¼ 36; total n ¼ 145 due to missing data.
c
d
Nanaimo site n ¼ 69; total n ¼ 147 due to missing data.
e
Nanaimo site n ¼ 69; Campbell River n ¼ 36; Prince George n ¼ 40; total n ¼ 145 due to missing data.
f
Campbell River site n ¼ 10; total n ¼ 71 due to missing data.
Drug use and related risks

Besides regular crack use, study participants reported the current use of a variety
of other psychoactive substances in the past 30 days (Table III). Almost three
quarters (70.3%) of the sample used alcohol, followed by cannabis (59.5%).
Prescription opioids (excluding heroin or methadone; 50.0%) and cocaine
(47.3%) were used by half the samples, although site differences existed. Heroin
(32.4%), benzodiazepine/barbiturate (25.7%) and amphetamine (18.9%) use
were reported by sample minorities. Users of heroin (72.9%), prescription
opioids (54.1%) and cocaine (50.0%) indicated that ‘injection’ was the primary
route of administration for the respective substance (data not shown).

Overall, two out of five study participants (43.9%) were current drug injectors,
(i.e. in the past 30 days). This proportion was highest in Prince George and
lowest in Nanaimo. Half of the total sub-sample of current injectors stated
that they averaged one to two injecting episodes per injection day. One in 10
(12.7%) of the participants who reported involvement in injection drug use
indicated that they had shared a needle or syringe with someone else in the past
30 days. Six study participants (4.1%) reported a drug-related overdose in the
past 30 days.
Crack use-related behaviours and risks

The median length of crack use in the sample was 10 years (mean: 10.9); the
median number of crack-use episodes per crack use day was 20 (mean: 29.6)
(Table IV). Four out of five participants (79.1%) reported that they had shared
crack-use paraphernalia (e.g. crack pipes) with others in the past 30 days, and
almost half (44.3%) of these had done so on more than 20 occasions in that time
period. The largest proportion of respondents (49.3%) assembled their crack-use
paraphernalia mainly from makeshift items (e.g. pop cans, glass bottles or
inhalers); one-third (34.5%) purchased hardware parts (e.g. water piping); others
obtained their crack-use paraphernalia from other users (29.7%), friends or
partners (20.9%) or their drug dealer (12.8%). Virtually all (97.6%) respondents
from the Prince George site indicated that they had obtained paraphernalia
from the local crack paraphernalia distribution programme. About one in five
participants (21.6%) of the total sample indicated that they had experienced oral
sores or wounds related to crack use in the past 30 days.
Discussion
Our study on regular crack users in three mid-sized BC communities revealed
key information on socio-demographic characteristics, drug use patterns, health
profiles and risk behaviours of this particular street drug-use population outside
of main urban areas in a Canadian context. Socio-demographically, the study
sample was mainly characterized by unstable housing, income generation
from social-assistance programmes or illegal activities and intensive criminal
justice involvement, confirming the intensive socio-economic marginalization
Table III. Drug use and related risks (in the past 30 days).
Prevalence of use, n (%)

Nanaimo Campbell River Prince George Total 2exact

(n ¼ 70) (n ¼ 37) (n ¼ 41) (n ¼ 148) p-value
Alcohol 44 (62.9) 29 (78.4) 31 (75.6) 104 (70.3) 0.168

Marijuana/hashish 46 (65.7) 23 (62.2) 19 (46.3) 88 (59.5) 0.124
Mushrooms/ecstasy 7 (10.0) 3 (8.1) 0 (0.0) 10 (6.8) 0.120
Speed/methamphetamines/crystal meth/acid 21 (30.0)a 0 (0.0)a 7 (17.1) 28 (18.9) 0.001
Cocaine 20 (28.6)a 27 (73.0)a 23 (56.1) 70 (47.3) 0.000
Crack 70 (100.0) 37 (100.0) 41 (100.0) 148 (100.0) NA
Benzodiazepines/barbiturates 17 (24.3) 9 (24.3) 12 (29.3) 38 (25.7) 0.825
Heroin 26 (37.1) 16 (43.2) 6 (14.6)a 48 (32.4) 0.014
Methadone (from street) 9 (12.9)a 1 (2.7) 1 (2.4) 11 (7.4) 0.058
Other opioidsb 32 (45.7) 19 (51.4) 23 (56.1) 74 (50.0) 0.562
Injected drugsc 23 (32.9)a 17 (45.9) 25 (61.0)a 65 (43.9) 0.015
Shared needle/syringe (among injectors)d 3 (13.6) 3 (18.8) 2 (8.0) 8 (12.7) 0.593
Experienced an overdose 0 (0.0)a 4 (10.8)a 2 (4.9) 6 (4.1) 0.025
Note: NA, not applicable.
a
b
Includes talwin and ritalin, T3s and T4s (any codeine), fentanyl, demerol, dilaudid, percocet or percodan, morphine, oxycontin.
c
As main route of administration of one or more drugs used.
d
Nanaimo site n ¼ 22; Campbell River site n ¼ 16; total n ¼ 63 due to missing data.
Table IV. Crack-use indicators, n(%).
Nanaimo Campbell River Prince George Total 2/ANOVA

(n ¼ 70) (n ¼ 37) (n ¼ 41) (n ¼ 148) exact p-value
Length of crack use (years)a

Mean 10.7 12.8 9.8 10.9 0.205c
Standard deviation 7.8 6.9 7.5 7.5
Median 10.0 13.5 7.0 10.0
Range 0.5–33.0 0.2–26.0 1.0–30.0 0.2–33.0
Number of episodes of crack use per use dayb, d
e
Mean 20.8 48.1 28.9 29.6 0.016c,
Standard deviation 16.8 51.5 34.7 34.7
Median 17.5 20.0 20.0 20.0
Range 3.0–80.0 4.0–150.0 2.0–150.0 2.0–150.0
Respondents who shared crack paraphernaliaf 57 (81.4) 31 (83.8) 29 (70.7) 117 (79.1) 0.293
Number of paraphernalia sharing episodes (among respondents who reported sharingf, g
1 to 5 times 11 (19.3)h 14 (48.3)h 8 (27.6) 33 (28.7) 0.042
6 to 20 times 19 (33.3) 3 (10.3)h 9 (31.0) 31 (27.0)
421 times 27 (47.4) 12 (41.4) 12 (41.4) 51 (44.3)
Sources of crack paraphernaliaf
Crack kit programme 0 (0.0)h 0 (0.0)h 40 (97.6)h 40 (27.0) 0.000
Drug dealer 16 (22.9)h 3 (8.1) 0 (0.0)h 19 (12.8) 0.001
Other drug user 34 (48.6)h 5 (13.5)h 5 (12.2)h 44 (29.7) 0.000
Friend/partner 17 (24.3) 8 (21.6) 6 (14.6) 31 (20.9) 0.480
Makeshift/found items 50 (71.4)h 19 (51.4) 4 (9.8)h 73 (49.3) 0.000
Purchased parts in a store 27 (38.6) 20 (54.1)h 4 (9.8)h 51 (34.5) 0.000
Presented with oral sores/woundsf 18 (25.7) 9 (24.3) 5 (12.2) 32 (21.6) 0.223
a
Campbell River site n ¼ 36; total n ¼ 147 due to missing data.
b
Nanaimo site n ¼ 58; Campbell River site n ¼ 29; total n ¼ 128 due to missing data.
c
p-values for ANOVA.
d
n ¼ 4 outliers (scores 200) coded to next highest value (score ¼ 150).
e
Homogeneity of variance assumption violated (Welch p-value reported).
f
g
Campbell River site n ¼ 29 due to missing data.
h
that has been reported for crack users elsewhere (Corneil et al., 2006; DeBeck
et al., 2007; Fischer et al., 2005b). While crack use in itself is known to be
associated with considerable health and social problems, some of the above-
identified variables (e.g. homelessness or incarceration) have been clearly
identified as important ‘determinants’ of negative health outcomes (e.g. morbid-
ity or mortality) in drug users, and subsequently help to put crack users at
crucially elevated risk for such problems (Haydon & Fischer, 2005; Hwang, 2001;
Palepu et al., 1999).
Our study furthermore observed a high prevalence of physical and mental
health problems among our samples of primary crack users, with the majority
of the samples reporting such problems concurrently. This finding, for one,
illustrates that crack users present highly complex target populations not only for
addiction treatment but for health care or interventions in general, as they tend to
be burdened by severe ‘multi-morbidities’ (e.g. substance use, mental, physical
health problems) (Falck et al., 2004; Taubes, Galanter, Dermatis, & Westreich,
1998; Watkins et al., 2004). In our sample, the primary physical problem
reported was ‘pain’ (data not shown). Also given the high rate of mental health
problems, for example, mood problems, in this population it appears possible that
a considerable share of the drug use observed in the population may occur
in response to these other prevalent health problems, for example, as a form of

‘self-medication’ (Grant et al., 2004; Khantzian, 1997). These constellations
of acute co-morbidities pose considerable challenges for interventions, in that
many of the present co-morbid health problems – for example, substance
misuse, physical and mental health issues – are intertwined and need to be
addressed concurrently for care interventions to have positive and sustainable
results (Kresina et al., 2004; Loftis, Matthews, & Hauser, 2006). Resources
and skills for effective co-morbidity interventions among street drug users are
extremely rare even in well-served jurisdictions in Canada, and are far outweighed
by the demand (Urbanoski, Rush, Wild, Bassani, & Castel, 2007).
Notable and of great concern are the high rates of HIV and HCV infection
in our study sample of primary crack users which are similar to rates observed
in primary injection populations (Fischer, Haydon, Rehm, Krajden, & Reimer,
2004; Tyndall et al., 2003). These high prevalence rates must likely be explained
with the fact that the majority of participants were concurrent injectors and/or
had an injection history. Equally concerning is the fact that a substantial number
of participants infected with HCV were not aware of their infection status, and
thus may actively engage in high-risk behaviour for HCV transmission in the
absence of such knowledge. These circumstances probably point to a lack of
readily accessible opportunities for infectious disease testing in the study
locations, which are important for both prevention and initiation of treatment
(Edlin et al., 2005). The data on participants who have received HIV and
HCV treatment suggest that while HIV treatment has been extended to a
substantial part of infected street drug users, treatment for HCV infection – which
is substantially more prevalent among street drug users than HIV infection –
is only rarely provided, even though it has been shown to be feasible and
effective in this population (Bruggmann et al., 2008; Dalgard, 2005; Wilkinson

et al., 2009). Again, these gaps in infectious disease testing and care may
be amplified by the particular challenges for health care delivery in our non-urban
study sites.
Our study clearly evidenced that primary crack use in the population assessed
occurs by and large in a wider context of poly-substance use, that is, in
conjunction with the use of a wide variety of (legal and illegal) other psychoactive
substances, including alcohol, cocaine, opioids and benzodiazepines, some of
which was primarily associated with active injection drug use. Such multi-faceted
poly-substance combinations have been observed in most street drug-user

populations in cities across Canada (Fischer et al., 2005a; Health Canada,
2006; Khandor & Mason, 2008; Malchy et al., 2008). It is notable that
prescription opioid use was more common in the study population than heroin
use, a trend among street drug users in North America evidenced by several
recent studies (Fischer et al., 2006a). These poly-substance use patterns present
substantial challenges for health and interventions. First, certain drug combina-
tions – for example, opioids combined with cocaine, alcohol or benzodiazepines –
are known to bring substantially elevated risks for (fatal or non-fatal) overdose
risks (Darke & Hall, 2003; Kaye & Drake, 2004; Kerr et al., 2007). Second,
the co-use of these different substances may point to common problems

of multiple substance dependences in the study population, rendering the
effective delivery of both preventive and treatment interventions more challen-
ging, as multiple substance use problems need to be addressed at the same
time (Dennison, 2005). For example, methadone maintenance treatment is an
effective treatment intervention for opioid dependence, yet has been observed
to increase or intensify crack-use patterns among patients as a way to cope
with methadone’s side-effects (Best et al., 2000; Fischer, Chin, Kuo, Kirst,
& Vlahov, 2002).
With respect to crack use specifically, our study sample represented overall
lengthy crack-use histories as well as indicated that active crack use consisted
of a high frequency of crack-use episodes (‘bingeing’) use per day. The vast
majority of study participants engaged in the regular sharing of crack-use
paraphernalia. This is a concern from a public health perspective given recent
evidence that such sharing may facilitate the transmission of HCV from one user
to another (Fischer et al., 2008b; Tortu et al., 2004). Qualitative data in this
present study suggested that crack paraphernalia sharing can occur for a variety of
reasons, including: not carrying own paraphernalia for fear of arrest, the need for
immediate use after drug purchase when no paraphernalia was available,
economic reasons (i.e. pooling crack between users or trying to amass crack
resin from other users in one’s own pipe), yet also as a form of a social ritual or
gesture among users. Similar population-specific reasons have been identified for
the sharing of needles or syringes among injectors, yet clearly need to be better
understood and translated into feasible and effective prevention measures for
crack users (Haydon & Fischer, 2005; Latkin et al., 1995; Pollini et al., 2008).
The majority of participants assembled their crack-use paraphernalia largely from
high-risk materials like scrap metal, metal piping or broken glass pieces – which
are prone to lead to oral cuts, wounds or burns and hence to facilitate the
transmission of infectious disease by way of crack paraphernalia sharing or risky
sex practices (e.g. unprotected oral sex) – and ‘brillo’ or steel wool for filters –
which are prone to damage lung tissue (Boyd et al., 2008; Faruque et al., 1996;
Porter & Bonilla, 1993; Porter, Bonilla, & Drucker, 1997). Qualitative data
indicated that users would overall much prefer to use glass stems as crack-use
devices for health reasons, yet that these materials were extremely hard to
obtain in those sites where crack paraphernalia distribution programmes were
not available.
As the data from the Prince George study site – where a safer crack-use
materials distribution programme had been in effect at the time of the study –
suggests, such an intervention can attain a high uptake in the target population.
Local participants testified that the availability of the crack kit programme
reduced the need to share their crack-use paraphernalia, gave them access to safer
materials and reduced the need to rely on dealers or others to obtain crack-use
paraphernalia, as well as noted that the kits were distributed with information
on prevention and health care. Evidence from a more formal evaluation of the
crack paraphernalia distribution programme in Ottawa found that such initiatives
may reduce risk behaviours among crack users (Leonard et al., 2008). Given that
safer crack-use paraphernalia distribution programmes are cheaply and easily
delivered (e.g. in the context of needle exchange programmes or community
health services), can be used as an outreach tool to connect with crack users and
essentially are an extension of the well-accepted public health measure of needle
exchange services for the high-risk population of crack users, such programmes
should be routinely offered as a public health intervention in communities where
crack-use populations exist (Haydon & Fischer, 2005; Leonard et al., 2008;
Malchy et al., 2008). Authorities in BC some time ago announced that the
distribution of safer crack-use materials would become part of regular public
health programming for high-risk drug users, yet these efforts are still awaiting
systematic implementation (Small & Drucker, 2008; The Canadian Press, 2007).
Safer inhalation facilities for crack users – akin to the facilities operated in
Europe – would also constitute a worthwhile intervention, yet given that Canada
is currently home to only one experimental supervised drug consumption
facility, the prospects of such interventions seem limited for the time being
(Fischer et al., 2008a; Hedrich, 2004; Shannon et al., 2006). Clearly, however,
there is a dire need for more available and effective treatment options for crack
users. While the scarcity of addiction treatment is a major challenge especially
in non-urban settings across Canada, this problem is amplified by the
virtual absence of effective treatment strategies specifically for crack use.
Numerous study participants stated that even going for detoxification would
make little sense for them, since there are so few available treatment options to
enter after detoxification, and most users end up in their previous drug use
environments and habits. On this basis, most participants saw any attempt to quit
crack use as a futile effort in the long run.
One critical and central issue to this study and its findings is that of high-risk
substance use and interventions in rural/non-urban settings. While the
epidemiology and determinants of substance use, mental health and infectious
have become substantive foci of study within the emerging field of ‘urban health’
and numerous large-scale studies specifically focus on these issues in Canada,
very little attention has been given to these issues in rural/non-urban areas
(Galea, Rudenstine, & Vlahov, 2005; Tyndall et al., 2003; Wood et al., 2003).
This is in light of the fact that prevalence and disease consequences of these
problems are often as high or higher in non-urban/rural areas, and commonly
distinct, especially when highly disadvantaged (e.g. poor, Aboriginal, etc.)

communities are concerned (Day, Conroy, Lowe, Page, & Dolan, 2006;
Kringlen, Torgersen, & Cramer, 2006; Newbold, 1998; Robertson, Sloboda,
Boyd, Beatty, & Kozel, 1997; Steel & Haverkos, 1992). In many non-urban/rural
communities, basic services and interventions of relevance for the study
population, for example, detoxification or treatment for substance use, special-
ized infectious disease testing and/or treatment, targeted prevention programmes
for high-risk substance use, specialized mental health and/or co-morbidity care,
are only sparsely or not at all available and individuals in these settings face
substantial barriers to access for appropriate services (Borders & Booth, 2007;
Metsch & McCoy, 1999; Newbold, 1998; Steel & Haverkos, 1992). While
there is a basic need to establish and make available such interventions, they will
typically need to rely on distinct delivery models, for example, community
health care frameworks, etc (Borders & Booth, 2007; Metsch & McCoy, 1999;
Robertson et al., 1997; Steel & Haverkos, 1992; Vicary, Doebler, Bridger,
Gurgevich, & Deike, 1996). For the specific care of our study population – that is,
primary crack users in non-urban communities in BC – extensive service
improvement and expansion needs virtually exist on all ends. It is hoped and
recommended that basic and rudimentary care needs identified in the study
population,for example, detoxification and substance use treatment, infectious
disease testing and care, basic co-morbidity care and targeted prevention
measures for high-risk crack use – can realistically be made more available by
including these incrementally into existing community health infrastructure in the
communities under study.
Our study has several limitations. Due to the illegal status of crack use as well as
the recruitment methods used, the study sample cannot be assumed to
representative of crack users in the study sites or elsewhere, and hence results
are not generalizable to other populations. The largest part of our study data was
based on self-report, which brings concerns of data validity, even though validity
has been shown to be good in other studies (Darke, 1998). The salivary testing
methods for HIV and HCV assess antibody status, which does not necessarily
reflect chronic infection and hence may result in some over-reporting
(Micallef, Kaldor, & Dore, 2006; Villano, Vlahov, Nelson, Cohn, & Thomas,
1999). Finally, the fact that lifetime injection was not assessed by our study is a
limitation regarding the interpretation of the HIV and HCV prevalence estimates.
Future research will aim to better understand the social and behavioural contexts
and the determinants of crack paraphernalia sharing as well as poly-substance

use in the study population. Furthermore, exploratory research will aim to assess
delivery options for improved health and substance use care for the target
population.
In conclusion, crack users in our study in multiple mid-sized BC communities
were characterized by multiple severe social, health and drug use risks and
problems, many of which have been illustrated for crack-use populations in larger
urban centres in Canada and elsewhere. Most of these risks and problems are
not adequately addressed by interventions, which in part may reflect the limited
availability of intervention resources for crack use as well as for addiction

problems in non-urban areas in Canada. Given the high prevalence of crack use
across Canadian jurisdictions, the comprehensive improvement of preventive
and treatment interventions services for crack users is urgently needed.
Acknowledgements
The authors thank the community agencies and individuals in the study sites
which helped in the implementation of this study. This study was in part financed
by contract funding from the British Columbia Ministry of Health and the
Vancouver Island Health Authority (VIHA), as well as an Interdisciplinary
Capacity Enhancement grant from the Canadian Institutes of Health Research.
Dr Fischer acknowledges salary support from a CIHR/PHAC Chair in Applied
Public Health and a MSFHR Senior Scholar Career Investigator Award.
Declaration of interest: The authors report no conflicts of interest. The authors

alone are responsible for the content and writing of the article.
Reference
Baumer, E., Lauritsen, J., Rosenfeld, R., & Wright, R. (1998). The influence of crack cocaine on
robbery, burglary and homicide rates: A cross-city longitudinal analysis. Journal of Research in
Crime and Delinquency, 35, 316–340.
Bennett, T., Holloway, K., & Farrington, D. (2008). The statistical association between drug
misuse and crime: A meta-analysis. Aggression and Violent Behavior, 13, 107–118.
Best, D., Harris, J., Gossop, M., Farrell, M., Finch, E., Noble, A., et al. (2000). Use of non-
prescribed methadone and other illicit drugs during methadone maintenance treatment.
Drug and Alcohol Review, 19, 9–16.
Booth, R. E., Kwiatkowski, C. F., & Chitwood, D. D. (2000). Sex related HIV risk behaviors:
Differential risks among injection drug users, crack smokers, and injection drug users who
smoke crack. Drug and Alcohol Dependence, 58, 219–226.
Borders, T., & Booth, B. (2007). Rural, suburban, and urban variations in alcohol consumption
in the United States: Findings from the National Epidemiologic Survey on Alcohol and Related
Conditions. Journal of Rural Health, 23, 314–321.
Boyd, S., Johnson, J., & Moffat, B. (2008). Opportunities to learn and barriers to change: Crack
cocaine use in the Downtown Eastside of Vancouver. Harm Reduction Journal, 5, 1–12.
Bruggmann, P., Falcato, L., Dober, S., Helbling, B., Keiser, O., Negro, F., et al. (2008).
Active intravenous drug use during chronic hepatitis C therapy does not reduce sustained
virological response rates in adherent patients. Journal of Viral Hepatitis, 15, 747–752.
Buxton, J., Rothon, D., Durigon, M., Lem, M., Tu, A., Remple, V., et al. (2009). Hepatitis C
and HIV prevalence using oral mucosal transudate, and reported drug use and sexual
behaviours of youth in custody in British Columbia. Canadian Journal of Public Health, 100,
121–124.
Castells, X., Casas, M., Vidal, X., Bosch, R., Roncero, C., Ramos-Quiroga, J., et al. (2007).
Efficay of central nervous system stimulant treatment for cocaine dependence: A system-
atic review and meta-analysis of randomized controlled clinical trials. Addiction, 102,
1871–1877.
CCENDU (2003a). 2002 National report: Drug trends and the Canadian Community Epidemiology
Network on Drug Use (CCENDU). Ottawa: Canadian centre on substance abuse.
CCENDU (2003b). Vancouver site report for the Canadian Community Epidemiology Network
On Drug Use (CCENDU). Ottawa: Canadian centre on substance abuse.
Chase Project Team (2005). Community Health and Safety Evaluation (CHASE) project: Final
report (Rep. No. http://chase.hivnet.ubc.ca/project/pubdocs/CHASE_Reports/CHASE_Final_
Report.pdf). Vancouver: Chase Project Team.
Corneil, T., Kuyper, L., Shoveller, J., Hogg, R., Li, K., Spittal, P., et al. (2006). Unstable housing,
associated risk behaviour, and increased risk for HIV infection among injection drug users.
Health & Place, 12, 79–85.
Cross, J., Johnson, B., Davis, W. R., & Liberty, H. J. (2001). Supporting the habit: Income
generation activities of frequent crack users compared with frequent users of other hard drugs.
Drug and Alcohol Dependence, 64, 191–201.

Dalgard, O. (2005). Follow-up studies of treatment for hepatitis C virus infection among injection
drug users. Clinical Infectious Diseases, 40(Suppl 5), 336–8.
Darke, S. (1998). Self-report among injecting drug users: A review. Drug and Alcohol Dependence,
51, 253–262.
Darke, S., & Hall, W. (2003). Heroin overdose: Research and evidence-based intervention. Journal
of Urban Health, 80, 189–200.
Day, C., Conroy, E., Lowe, J., Page, J., & Dolan, K. (2006). Patterns of drug use and associated
harms among rural injecting drug users: Comparisons with metropolitan injecting drug users.
Australian Journal of Rural Health, 14, 120–125.
DeBeck, K., Shannon, K., Wood, E., Li, K., Montaner, J., & Kerr, T. (2007). Income generating
activities of people who inject drugs. Drug and Alcohol Dependence, 91, 50–56.
DeHovitz, J., Kelly, P., Feldman, J., Sierra, M., Clarke, L., Bromberg, J., et al. (1994). Sexually
transmitted diseases, sexual behavior, and cocaine use in inner-city women. American Journal
of Epidemiology, 140, 1125–1134.
Dennison, S. (2005). Substance use disorders in individuals with co-occurring psychiatric
disorders. In J. Lowinson, P. Ruiz, R. Millman & J. Langrod (Eds.), Substance abuse a
comprehensive textbook (4th ed., pp. 904–912). Philadelphia: Lippincott Williams & Wilkins.
Edlin, B. R., Irwin, K. L., Faruque, S., McCoy, C. B., Word, C., Serrano, Y., et al. (1994).
Intersecting epidemics: Crack cocaine use and HIV infection among young inner-city young
adults. The New England Journal of Medicine, 331, 1422–1427.
Edlin, B. R., Kresina, T. F., Raymond, D. B., Carden, M. R., Gourevitch, M. N., Rich, J. D., et al.
(2005). Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug
users. Clinical Infectious Diseases, 40(Suppl. 5), S276–S285.
EMCDDA (2007). EMCDDA European Monitoring Centre for Drugs and Drug Addiction selected issue
2007 – Cocaine and crack cocaine: A growing public health concern. Luxembourg: Office for Official
Publications of the European Communities.
Falck, R. S., Wang, J., Siegal, H. A., & Carlson, R. G. (2004). The prevalence of psychiatric
disorder among a community sample of crack cocaine users: An exploratory study with practical
implications. The Journal of Nervous and Mental Disease, 192, 503–507.
Faruque, S., Edlin, B. R., McCoy, C. B., Word, C. O., Larsen, S. A., Schmid, D. S., et al. (1996).
Crack cocaine smoking and oral sores in three inner-city neighborhoods. Journal of Acquired
Immune Deficiency Syndromes and Human Retrovirology, 13, 87–92.
Fischer, B., & Allard, C. (2007). Feasibility study on ‘supervised drug consumption’ options in the City
of Victoria. Victoria: Centre for Addictions Research of BC (CAR-BC).
Fischer, B., Chin, A., Kuo, I., Kirst, M., & Vlahov, D. (2002). Canadian illicit opiate users’
views on methadone and other opiate prescription treatment: An exploratory qualitative study.
Substance Use and Misuse, 37, 495–522.
Fischer, B., & Coghlan, M. (2007). Crack in North American cities: The neglected ‘epidemic’.
Addiction, 102, 1340–1341.
Fischer, B., Haydon, E., Rehm, J., Krajden, M., & Reimer, J. (2004). Injection drug use and the
hepatitis C virus: Considerations for a targeted treatment approach – The case study of Canada.
Journal of Urban Health, 81, 428–447.
Fischer, B., Kendall, P., & Allard, C. (2008a). The case for a supervised drug consumption site trial
in Victoria, British Columbia. BC Medical Journal, 50, 130–131.
Fischer, B., Monga, N., & Manzoni, P. (2005b). Differences between co-users of cocaine and crack
among Canadian illicit opioid users. Sucht, 51, 217–224.
Fischer, B., Powis, J., Firestone Cruz, M., Rudzinski, K., & Rehm, J. (2008b). Hepatitis C virus
transmission among oral crack users: viral detection on crack paraphernalia. European Journal
of Gastroenterology & Hepatology, 20, 29–32.
Fischer, B., Rehm, J., Brissette, S., Brochu, S., Bruneau, J., el-Guebaly, N., et al. (2005a).
Illicit opioid use in Canada: Comparing social, health and drug use characteristics of untreated
users in five cities (OPICAN study). Journal of Urban Health, 82, 250–266.
Fischer, B., Rehm, J., Patra, J., & Firestone Cruz, M. (2006a). Changes in illicit opioid use profiles
across Canada. Canadian Medical Association Journal, 175, 1–3.
Fischer, B., Rehm, J., Patra, J., Kalousek, K., Haydon, E., Tyndall, M., et al. (2006b). Crack
across Canada: Comparing crack and non-crack users in a multi-city cohort of opioid and other
street drug users. Addiction, 101, 1760–1770.
Galea, S., Rudenstine, S., & Vlahov, D. (2005). Drug use, misuse, and the urban environment.
Drug and Alcohol Review, 24, 127–136.
Garrity, T. F., Leukefeld, C., Carlson, R. G., & Falck, R. S. (2007). Physical health, illicit drug
use, and demographic characteristics in rural stimulant users. The Journal of Rural Health, 23,
99–107.
Gorelick, D., Gardner, E., & Xi, Z. (2004). Agents in development for the management of cocaine
abuse. Drugs, 64, 1547–1573.
Grabowski, J., Shearer, J., Merrill, J., & Negus, S. S. (2004). Agonist-like replace-
ment pharmacotherapy for stimulant abuse and dependence. Addictive Behaviors, 29,
1439–1464.
Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Dufour, M. C., Compton, W., et al.
(2004). Prevalence and co-occurrence of substance use disorders and independent mood and
anxiety disorders: Results from the National Epidemiologic Survey on Alcohol and Related
Conditions. Archives of General Psychiatry, 61, 807–816.
Haydon, E., & Fischer, B. (2005). Crack use as a public health problem in Canada – call for an
evaluation of ‘safer crack use kits’. Canadian Journal of Public Health, 96, 185–188.
Health Canada (2004). I-Track: Enhanced surveillance of risk behaviours among injecting drug users
in Canada (pilot survey report). Ottawa: Surveillance and Risk Assessment Division, Centre
for Infectious Disease Prevention and Control, Population and Public Health Branch, Health
Canada.
Health Canada (2006). I-Track: Enhanced surveillance of risk behaviours among injecting drug users
in Canada – Phase I report. Ottawa: Surveillance and Risk Assessment Division, Centre for
Infectious Disease Prevention, Health Canada.
Hedrich, D. (2004). European report on drug consumption rooms. Lisbon: European Monitoring
Centre on Drugs and Drug Addiction (EMCDDA).
Howard, A., Klein, R., Schoenbaum, E., & Gourevitch, M. (2002). Crack cocaine use and other
risk factors for tuberculin positivity in drug users. Clinical Infectious Diseases, 35, 1183–1190.
Hwang, S. (2001). Homelessness and health. Canadian Medical Association Journal, 164, 229–232.
James, D. (2007). Harm reduction policy background paper. Alberta: Alberta Alcohol and Drug Abuse
Commission (AADAC).
Judd, A., Parry, J., Hickman, M., McDonald, T., Jordan, L., Lewis, K., et al. (2003). Evaluation
of a modified commercial assay in detecting antibody to hepatitis C virus in oral fluids and dried
blood spots. Journal of Medical Virology, 71, 49–55.
Kaye, S., & Drake, S. (2004). Non-fatal cocaine overdose among injecting and non-injecting
cocaine users in Sydney, Australia. Addiction, 99, 1315–1322.
Kerr, T., Fairbairn, N., Tyndall, M., Marsh, D., Li, K., Montaner, J., et al. (2007). Predictors
of non-fatal overdose among a cohort of polysubstance-using injection drug users. Drug &
Alcohol Dependence, 87, 39–45.
Khandor, E., & Mason, K. (2008). The street health report 2007, Research bulletin #3: Homelessness &
crack use (Rep. No. http://www.streethealth.ca/publications.htm). Toronto: Street Health.
Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsid-
eration and recent applications. Harvard Review of Psychiatry, 4, 231–224.
Kresina, T. F., Normand, J., Khalsa, J., Mitty, J., Flanigan, T., & Francis, H. (2004). Addressing
the need for treatment paradigms for drug-abusing patients with multiple morbidities. Clinical
Infectious Diseases, 38, S398–S401.
Kringlen, E., Torgersen, S., & Cramer, V. (2006). Mental illness in a rural area. Social Psychiatry
and Psychiatric Epidemiology, 41, 173–179.
Latkin, C., Mandell, W., Vlahov, D., Knowlton, A., Oziemkowska, M., & Celentano, D. (1995).
Self-reported reasons for needle sharing and not carrying bleach among injection drug users
in Baltimore, Maryland. Journal of Drug Issues, 25, 865–870.
Lejuez, C., Bornovalova, M., Daughters, S., & Curtin, J. (2005). Differences in impulsivity and
sexual risk behaviour among inner-city crack/cocaine users and heroin users. Drug & Alcohol
Dependence, 77, 169–175.
Leonard, L., DeRubeis, E., Pelude, L., Medd, E., Birkett, N., & Seto, J. (2008). ‘‘I inject less
as i have easier access to pipes’’ Injecting, and sharing of crack-smoking materials, decline
as safer crack-smoking resources are distributed. International Journal of Drug Policy, 19,
255–264.
Leonhardt, K., Gentile, F., Gilbert, B., & Aiken, M. (1994). A cluster of tuberculosis among
crack house contacts in San Mateo County, California. American Journal of Public Health, 84,
1834–1836.
Loftis, J. M., Matthews, A. M., & Hauser, P. (2006). Psychiatric and substance use disorders
in individuals with hepatitis C: Epidemiology and management. Drugs, 66, 155–74.
Logan, T. K., & Leukefeld, C. (2000). Sexual and drug use behaviors among female crack users:
A multi-site sample. Drug and Alcohol Dependence, 58, 237–245.
Malchy, L., Bungay, V., & Johnson, J. (2008). Documenting practices and perceptions of ‘safer’
crack use: A Canadian pilot study. International Journal of Drug Policy, 19, 339–341.
Manzoni, P., Brochu, S., Fischer, B., & Rehm, J. (2006). Determinants of property crime among
illicit opiate users outside of treatment across Canada. Deviant Behaviour, 27, 351–376.
Maranda, M., Han, C., & Rainone, G. (2004). Crack cocaine and sex. Journal of Psychoactive Drugs,
36, 315–322.
McElroy, P., Rothenberg, R., Varghese, R., Woodruff, R., Minns, G., Muth, S., et al. (2003).
A network-informed approach to investigating a tuberculosis outbreak: Implications for
enhancing contact investigations. International Journal of Tuberculosis and Lung Disease, 7,
S486–S493.
McMahon, J., & Tortu, S. (2003). A potential hidden source of hepatitis C infection among
noninjecting drug users. Journal of Psychoactive Drugs, 35, 455–460.
Metsch, L. R., & McCoy, C. B. (1999). Drug treatment experiences: Rural and urban comparisons.
Substance Use & Misuse, 34, 763–784.
Metsch, L., McCoy, H., McCoy, C., Miles, C., Edlin, B., & Pereyra, M. (1999). Use of health care
services by women who use crack cocaine. Women and Health, 30, 35–51.
Micallef, J., Kaldor, J., & Dore, J. (2006). Spontaneous viral clearance following acute
hepatitis C infection: A systematic review of longitudinal studies. Journal of Viral Hepatitis,
13, 34–41.
National Institute on Drug Abuse (NIDA) (2005). NIDA info facts: Crack and cocaine (Rep. No.
http://www.nida.nih.gov/Infofacts/cocaine.html). Rockville: NIDA.
Newbold, K. B. (1998). Problems in search of solutions: Health and Canadian aboriginals. Journal
of Community Health, 23, 59–74.
O’Byrne, P., & Holmes, D. (2008). Evaluating crack pipe distribution in Canada: A systems change
case study. Addiction Research and Theory, 16, 181–192.
Ouellet, L., Thorpe, L., Huo, D., Bailey, S., Jimenez, A., Johnson, W., et al. (2000). Prevalence
and incidence of HIV among out-of-treatment injecting drug users, Chicago 1994–1996.
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 25, 443–450.
Palepu, A., Strathdee, S. A., Hogg, R. S., Anis, A. H., Rae, S., Cornelisse, P. G. A., et al. (1999).
The social determinants of emergency department and hospital use by injection drug users
in Canada. Journal of Urban Health, 76, 409–418.
Pollini, R., Brouwer, K., Lozada, R., Ramos, R., Cruz, M., Magis-Rodriguez, C., et al. (2008).
Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US
border cities. Addiction, 103, 101–108.
Porter, J., & Bonilla, L. (1993). Crack users’ cracked lips: An additional HIV risk factor. American
Journal of Public Health, 83, 1490–1491.
Porter, J., Bonilla, L., & Drucker, E. (1997). Methods of smoking crack as a potential risk factor
for HIV infection: Crack smokers’ perceptions and behavior. Contemporary Drug Problems, 24,
219–347.
Robertson, E., Sloboda, Z., Boyd, G., Beatty, L., & Kozel, N. E. (1997). Rural substance abuse: State
of knowledge and issues [NIDA Research Monograph Series 168]. Rockville, MD: National
Institute on Drug Abuse.
Ross, M. W., Hwang, L. Y., Zack, C., Bull, L., & Williams, M. L. (2002). Sexual risk behaviours
and STIs in drug abuse treatment populations whose drug of choice is crack cocaine.
International Journal of STD and AIDS, 13, 769–774.
Roy, E., Haley, N., Leclerc, P., Boivin, J. F., Cedras, L., & Vincelette, J. (2001). Risk
factors for hepatitis C virus infection among street youths. Canadian Medical Association Journal,
165, 557–560.
Roy, K. M., Goldberg, D. J., Hutchinson, S., Cameron, S. O., Wilson, K., & MacDonald, L.
(2004). Hepatitis C virus among self declared non-injecting sexual partners of injecting drug
users. Journal of Medical Virology, 74, 62–66.
Scheinmann, R., Hagan, H., Lelutiu-Weinberger, C., Stern, R., Des, J., Flom, P. L., et al. (2007).
Non-injection drug use and Hepatitis C virus: A systematic review. Drug & Alcohol Dependence,
89, 1–12.
Shannon, K., Ishida, T., Morgan, R., Bear, A., Oleson, M., Kerr, T., et al. (2006). Potential
community and public health impacts of medically supervised safer smoking facilities for
crack cocaine users. Harm Reduction Journal, 3, 1–8.
Shannon, K., Rusch, M., Morgan, R., Oleson, M., Kerr, T., & Tyndall, M. W. (2008). HIV and
HCV prevalence and gender-specific risk profiles of crack cociane smokers and dual users
of injection drugs. Substance Use & Misuse, 43, 521–534.
Small, D., & Drucker, E. (2008). Return to Galileo? The inquisition of the International Narcotic
Control Board. Harm Reduction Journal, 5, available at http://www.harmreductionjournal.com/
contents/5/1/16.
SPSS Inc (2007). SPSS for Windows (Version 15.0) [Computer software]. Chicago: SPSS Inc.
Steel, E., & Haverkos, H. (1992). AIDS and drug abuse in rural America: Policy practice and
research briefs. The Journal of Rural Health, 8, 70–73.
Symington, A. (2007). Ottawa: Crack pipe program cancelled by city council. HIV/AIDS Policy
and Law Review, 12, 29–30.
Taubes, T., Galanter, M., Dermatis, H., & Westreich, L. (1998). Crack cocaine and schizophrenia
as risk factors for PPD reactivity in the dually diagnosed. Journal of Addictive Diseases, 17, 63–74.
The Canadian Press (2007, December 12). Crack pipe sharing increases Hep C spread: Study. Canada:
CTV News.
Tortu, S., McMahon, J., Pouget, E., & Hamid, R. (2004). Sharing of noninjection drug-use
implements as a risk factor for Hepatitis C. Substance Use and Misuse, 39, 211–224.
Tyndall, M., Currie, S., Spittal, P., Li, K., Wood, E., O’Shaughnessy, M., et al. (2003). Intensive
injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS, 17,
887–893.
Urbanoski, K., Rush, B., Wild, T., Bassani, D., & Castel, S. (2007). Use of mental health care
services by Canadians with co-occurring substance dependence and mental disorders.
Psychiatric Services, 58, 962–969.
Vicary, J., Doebler, M., Bridger, J., Gurgevich, E., & Deike, R. (1996). A community
systems approach to substance abuse prevention in a rural setting. The Journal of Primary
Prevention, 16, 303–318.
Villano, S., Vlahov, D., Nelson, K., Cohn, S., & Thomas, D. (1999). Persistence of viremia and
the importance of long-term follow-up after acute hepatitis C infection. Hepatology, 29,
908–914.
Wallace, J. I., Porter, J., Weiner, A., & Steinberg, A. (1997). Oral sex, crack smoking, and HIV
infection among female sex workers who do not inject drugs. American Journal of Public Health,
87, 470.
Watkins, K. E., Hunter, S. B., Wenzel, S. L., Tu, W., Paddock, S. M., Griffin, A., et al. (2004).
Prevalence and characteristics of clients with co-occurring disorders in outpatient substance
abuse treatment. The American Journal of Drug and Alcohol Abuse, 30, 749–764.
Werb, D., Kerr, T., DeBeck, K., Li, K., Montaner, J., & Wood, E. (2008). Modeling crack use
trends over 10 years in a Canadian setting. Cracked but not broken conference, April 18th–20th,
2008 Vancouver, Canada.
Wilkinson, M., Crawford, V., Tippet, A., Jolly, F., Turton, J., Sims, E., et al. (2009). Community-
based treatment for chronic hepatitis C in drug users: High rates of compliance with therapy
despite ongoing drug use. Alimentary Pharmacology and Therapeutics, 29, 29–37.
Wood, E., Spittal, P. M., Kerr, T., Small, W., Tyndall, M. W., O’Shaughnessy, M. V., et al.
(2003). Requiring help injecting as a risk factor for HIV infection in the Vancouver epidemic:
Implications for HIV prevention. Canadian Journal of Public Health, 94, 355–9.

SFU Crack Study

Încărcat de

Informații document

Descriere originală:

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

SFU Crack Study

Încărcat de

Drepturi de autor:

Formate disponibile

Drugs: education, prevention and policy,

August 2010; 17(4): 333–353

Social, health and drug use characteristics of primary

BENEDIKT FISCHER1,2,3, KATHERINE RUDZINSKI2,

Fraser University, Vancouver, BC, Canada, 4Department of Sociology, University of

Correspondence: Benedikt Fischer, CARMHA/Faculty of Health Sciences, Simon Fraser

ISSN 0968–7637 print/ISSN 1465–3370 online ß 2010 Informa UK Ltd.

the most common non-dependence disorders were anti-social personality

cocaine/crack dependence, the field currently lacks an effective pharmacological

crack-use patterns, several of the Canadian municipalities where such pro-

agencies and peer recruiters. The study relied on a ‘snowball’ recruitment

Socio-demographics, income generation and crime

Health risks and status

Table I. Socio-demographics, income generation and crime indicators, n(%).

Nanaimo Campbell River Prince George Total 2 exact

Table II. Health risks and status, n(%).

Nanaimo Campbell River Prince George Total 2 exact

Physical health statusa,b

Drug use and related risks

route of administration for the respective substance (data not shown).

Crack use-related behaviours and risks

Prevalence of use, n (%)

Nanaimo Campbell River Prince George Total 2exact

Alcohol 44 (62.9) 29 (78.4) 31 (75.6) 104 (70.3) 0.168

Table IV. Crack-use indicators, n(%).

Nanaimo Campbell River Prince George Total 2/ANOVA

Length of crack use (years)a

in response to these other prevalent health problems, for example, as a form of

effective in this population (Bruggmann et al., 2008; Dalgard, 2005; Wilkinson

poly-substance combinations have been observed in most street drug-user

the co-use of these different substances may point to common problems

distinct, especially when highly disadvantaged (e.g. poor, Aboriginal, etc.)

and the determinants of crack paraphernalia sharing as well as poly-substance

availability of intervention resources for crack use as well as for addiction

Declaration of interest: The authors report no conflicts of interest. The authors

Drug and Alcohol Dependence, 64, 191–201.

S-ar putea să vă placă și

Nanaimo Campbell River Prince George Total 2 exact

Nanaimo Campbell River Prince George Total 2 exact

Nanaimo Campbell River Prince George Total 2exact

Nanaimo Campbell River Prince George Total 2/ANOVA