Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study

Abstract

Background Heroin pipe distribution may encourage people who use heroin (PWUH) to transition from injecting to smoking heroin, reducing harms associated with injection drug use. A syringe services program (SSP) in Seattle, Washington, led by people who use drugs developed a heroin pipe distribution program. Methods We conducted a pretest–posttest quasi-experimental study to evaluate the impact of heroin pipe distribution on drug consumption behaviors among PWUH between March and December 2019. SSP clients were surveyed during three weeklong timepoints before and four weeklong timepoints after heroin pipe distribution. Primary outcomes were change in proportion of SSP clients who exclusively injected heroin, exclusively smoked heroin, and both injected and smoked heroin in the past seven days comparing the pre- and post-intervention periods. Results Across the seven observation timepoints, 694 unique respondents completed 957 surveys. Multiple responses from a single respondent in a given period were collapsed, resulting in 360 pre-intervention and 430 post-intervention records. Heroin use was reported in over half of pre-intervention (56%, 201/360) and post-intervention records (58%, 251/430). Compared to pre-intervention behaviors, the proportion of respondents who exclusively injected heroin was lower after the start of heroin pipe distribution (32%, 80/251 vs 43%, 86/201, p = 0.02), while the proportion of respondents who both injected and smoked heroin was higher (45%, 113/251 vs 36%, 72/201, p = 0.048). Just under half (44%, 110/251) of respondents who used heroin during the post-intervention period used a heroin pipe obtained from the SSP, of which 34% (37/110) reported heroin pipe distribution had reduced their heroin injection frequency. Self-reported hospitalization for a pulmonary cause was not associated with using a heroin pipe. Conclusions The proportion of SSP clients who exclusively injected heroin was lower after implementation of heroin pipe distribution. Randomized studies with longer follow-up are needed to investigate whether heroin pipe distribution reduces heroin injection and improves health outcomes associated with drug use. Limited intervention exposure, loss to follow-up, and pipe availability from other sources pose methodological challenges to evaluations of route transition interventions in community settings. This pilot highlights the potential for organizations led by people who use drugs to develop, implement, and evaluate novel public health programming.

High levels of interest in access to free safer smoking equipment to reduce injection frequency among people who inject drugs in Seattle, Washington

“…For smoking crack, the self-reported reduction in injection frequency in our evaluation is similar to observations from a safer smoking equipment pilot study in Canada ( Leonard et al., 2008 ). For heroin, our findings are similar to other studies that describe PWUD using safer smoking equipment when they otherwise would have injected ( Pizzey and Hunt, 2008 ; Stöver and Schäffer, 2014 ; Dunleavy et al., 2021 ; Fitzpatrick et al., 2022 ).…”

“…Evaluations of safer smoking equipment distribution in Canada and Europe have shown high uptake of safer smoking equipment for crack and heroin ( Shannon et al., 2006 ; Leonard et al., 2008 ; Pizzey and Hunt, 2008 ; Stöver and Schäffer, 2014 ; Prangnell et al., 2017 ; Dunleavy et al., 2021 ), and some evidence for decreased injection frequency among people who used the safer smoking equipment ( Leonard et al., 2008 ; Pizzey and Hunt, 2008 ; Stöver and Schäffer, 2014 ; Dunleavy et al., 2021 ). Locally, an SSP led by people who use drugs (PWUD) in Seattle distributed pipes for smoking heroin, and an evaluation of program participants before and after the pipes were introduced showed a decrease in the proportion of people who exclusively injected heroin ( Fitzpatrick et al., 2022 ). Over a third of the people who said they used one of the SSP-distributed heroin pipes reported they reduced their injection frequency because of this access ( Fitzpatrick et al., 2022 ).…”

“…Locally, an SSP led by people who use drugs (PWUD) in Seattle distributed pipes for smoking heroin, and an evaluation of program participants before and after the pipes were introduced showed a decrease in the proportion of people who exclusively injected heroin ( Fitzpatrick et al., 2022 ). Over a third of the people who said they used one of the SSP-distributed heroin pipes reported they reduced their injection frequency because of this access ( Fitzpatrick et al., 2022 ). To our knowledge, no studies have examined the effects of safer smoking equipment for methamphetamine on reducing injection frequency.…”

“…Despite the evidence from international studies showing high levels of interest in safer smoking equipment among PWUD ( Shannon et al., 2006 ; Leonard et al., 2008 ; Pizzey and Hunt, 2008 ; Stöver and Schäffer, 2014 ; Prangnell et al., 2017 ; Dunleavy et al., 2021 ), and promising early evidence in support of reducing injection frequency ( Leonard et al., 2008 ; Pizzey and Hunt, 2008 ; Stöver and Schäffer, 2014 ; Dunleavy et al., 2021 ; Fitzpatrick et al., 2022 ), similar strategies have had limited uptake in SSPs in the United States. The present evaluation used responses to questions from a survey conducted among PWID in Seattle about access to free safer smoking equipment for drug consumption, and whether access could or did reduce injection frequency.…”

Trends and correlates of abscess history among people who inject drugs in Massachusetts: A mixed methods exploration of experiences amidst a rapidly evolving drug supply

“…There is an increasing prevalence of methamphetamine in the Northeast ( Wakeman et al., 2021 ), which may promote abscess formation when injected ( Salamanca et al., 2015 ). Broader access to safer smoking materials for people who inject stimulants, opioids, and other drugs as a means to encourage transitions to smoking may also serve to reduce abscess experiences ( Fitzpatrick et al., 2022 ; Kral et al., 2021 ). Further, existing literature emphasizes syringe reuse as a common practice related to abscess formation ( Ropelewski et al., 2011 ; Smith et al., 2015 ).…”