SIPP (Safe Inhalation Pipe Provision): A study on providing safe inhalation pipes to people who use crack cocaine in England to reduce health risks and encourage their participation in services

Plain English summary of protocol

Background and study aims
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. 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.

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 rural and urban locations in Avon & Somerset and Nottinghamshire. We will work with three drug treatment services and three 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.

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. Every time someone receives 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 aim is to evaluate a safe crack inhalation intervention distributed to people who use crack via drug treatment services and peer networks in order to reduce crack-related health harms and inform legislative review. 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.

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 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.

Who can participate?
People aged 18 years or older who have used crack in the last 28 days.

What does the study involve?
Safe inhalation crack cocaine pipes will be distributed for a period of six months through drug treatment services and peer networks of people who use crack. The impact of this distribution will be evaluated by a mixed-methods evaluation using qualitative and quantitative methods.

The quantitative evaluation will involve a pre- and post-intervention survey which will measure changes in outcomes at baseline and follow-up among participants. We will examine evidence of a dose-response relationship between intensity of exposure to SIPP and primary (crack pipe sharing in the past 28 days) and secondary outcome measures (drug treatment service engagement; reduced injecting; acute injuries; use of homemade pipes; use of ash, respiratory risk markers).

Survey participants will be recruited via drug treatment services and through peer networks of people who use crack cocaine. Participants will complete a 20-30 minute structured closed questionnaire that will be administered by drug treatment service staff or peer researchers, with consent-taking built into the survey platform.

The qualitative evaluation will involve a combination of 32 interviews with PWUC (lasting up to 60 minutes), and 8 focus groups (lasting up to 120 minutes) comprised of PWUC, service provider staff, and other relevant stakeholders such as the police. This qualitative work will be complemented by observations conducted during fieldwork visits. The qualitative workpackage will assess SIPP acceptability, fidelity, and contextual mechanisms of impact, and will focus on understanding implementation experience and impact on practice from the perspective of people who use crack and drug treatment service staff, and the process of implementation in context.

What are the possible benefits and risks of participating?
Long term potential benefits of this study include sustained harm-reduction support from drug treatment services throughout the United Kingdom. This includes the provision of safe inhalation equipment which international evidence suggests reduces some of the risks associated with crack cocaine use (reduced viral transmission; reduced respiratory damage), and sustained engagement with drug treatment services among a highly marginalised population providing an opportunity to address broader health and social harms associated with crack use.

We recognise that discussing drug use, drug treatment care, and the possible experience of stigma due to crack use can be difficult. We also recognise that there is a risk of pre-existing stigma and prejudice, which can be a barrier to research engagement with PWUC and staff. Interviews with people who use crack will concentrate on their experiences of the health consequences of smoking crack; care seeking practices (self-care/medical care/drug treatment services); barriers and facilitators to engagement with drug treatment services; barriers and facilitators to safe crack pipes; crack use (smoking techniques/practices, e.g. home-made pipe use; crack use management); perceptions of the SIPP intervention; what 'safe' crack smoking might look like for each participant. Being asked to discuss some of these topics may cause embarrassment or distress for participants.

Where is the study run from?
London School of Hygiene & Tropical Medicine (UK)

When is the study starting and how long is it expected to run for?
June 2022 to December 2025

Who is funding the study?
National Institute for Health and Care Research (NIHR) (UK).

Who is the main contact?
Aubrey.Ko@lshtm.ac.uk

Contact information

Study information

Eligibility

Locations

Countries of recruitment

• United Kingdom
• England

Study participating centres

Results and Publications

Study outputs

Editorial Notes

27/05/2025: The overall end date was changed from 31/05/2025 to 31/12/2025.
28/02/2025: The overall study end date was changed from 28/02/2025 to 31/05/2025 and the Total final enrolment number was added.
10/06/2024: The study website was added.
24/01/2024: Publication reference added.
03/04/2023: Internal review.
09/03/2023: Trial's existence confirmed by the National Institute for Health and Care Research (NIHR) (UK).