Between a rock and a hard place - a practical strategy for crack/cocaine users
Dawn Kennedy - Respect Users Union
Co-author: Matthew Southwell - East London & City Drug Services

1. INTRODUCTION

As someone who had a long history of crack use my approach to developing work around harm reduction and crack was informed by two key factors. Firstly, there was a recognition that drug services were still struggling to provide meaningful services to crack users and that current responses tended to be abstinence orientated reinforced by the absence of a available crack or cocaine substitute. Secondly, my experience as a crack user was that there were users which tended to have a stronger instinctive :harm reduction foundation.

This paper arises from a development project funded by East London & City Drug Services which grew out of the Healthy Option Team's original campaign on chasing. Drawing from the Dutch experience, HOT's original chasing project looked at the role of chasing with both heroin and crack. However, this dual focus was questioned as being inappropriate within a UK setting where crack was most often piped or injected. Therefore, it was decided to split the work into two separate initiatives - one looking exclusively at heroin chasing and a more diverse crack development project.

2. PHILOSOPHY OF THE CRACK PROJECT

The project set out to challenge the dominant approach to crack in the UK which, based on USA imported mythology, saw crack users as difficult to work with, violent, chaotic, predominantly black and unwilling to access services. Crack is seen by many professionals as the exception which challenges the harm reduction rule.

The project recognises that people only change if their self esteem/self worth is high enough to motivate the desire to change. ' Most services wait until external circumstances make change a non negotiable state for ongoing survival. This approach condemns crack users to experience loss and despair before intervention can be accessed. Further, externally driven change often results in relapse once these triggers are removed. In challenging this approach, we sought to demonstrate that not only is harm reduction a legitimate strategy for crack users but also to argue that it is a basic human right.

The project aims to promote positive images of crack users as people in control, making rational, empowered and informed choices over their drug use. Such an approach recognises and builds upon the dynamic role of existing user/dealer self-help networks.

3. PROJECT PROCESS

The project applied a model of community development to identify and test harm reduction responses to crack. The model (see Appendix A) recognises that information is held both among professionals but equally legitimately within the drug using community. The project gathered professional and user strategies and tested these against existing knowledge, with specialists in relevant fields (i.e police, forensic laboratories) and within the target community itself. Recognising the key role of crack production in a harm assessment model, the project directly targeted those involved in production as a discrete population for information gathering and consultation. The desired outcome of the project is the development of a comprehensive harm reduction strategy that focuses on both production and consumption of crack developed in partnership between Respect Users Union and drugs professionals.

To date the information gathering and consultation phases of the project have been completed although the restricted funding for the project has limited the scope of this work. However, the project has benefitted from substantial collaboration from both crack users and producers, demonstrating a genuine commitment to identify and formalise best practice from within the using community. Also those with a indirect interest in this field (i.e police, forensic labs, poisons unit etc.) have positively helped to test theories as harm reduction strategies have evolved. These sources have also welcomed an engagement with those working with drug users which they have identified as often missing at a practice level. Drugs professionals have responded in a mixed fashion to this project. A minority have positively supported the work while the majority (particularly field workers) have been highly suspicious of its aims. Certainly there is substantial fears that established orthodoxies are being challenged. One has to question workers' desires to obstruct change and to question how the existing paucity of options serves those who specialise in this field.

What has become evident throughout the project is that crack specialists have a limited knowledge of the process of either crack production or the various routes of administration. Also as drug workers rarely have access to those involved in production, advice targets individual user's behaviour change. Having sought specialist advice it became clear that harm reduction begins with a production methodology and that expecting users to right the wrongs of production was unrealistic. The project development process therefore considered two key elements in developing a harm reduction response - production and routes of administration.

4. PRODUCTION

The most commonly used method of crack production in the UK is the microwave method. This method maximises the potential harm to users due to the retention of all products during the production process. This ensures that bi-products such as bi-carbonate of soda and cutting agents such as sugar or mannitol will form part of the final product. 2 This is obviously attractive to dealers and one of the difficulties faced in challenging this method of production is that it provides the highest financial. rewards with least effort.

A second method of production is that of cooking crack. This is the method that is most strongly recommended. Cocaine hydrochloride is mixed with a alkaloid (e.g baking powders - sodium bicarbonate) in a proportion of approximately 3 - 1 and then water is added. The alkaloid baking powder causes liberation of the cocaine base which starts to separate as it is insoluble in water. Heating accelerates the process until, when the water is nearly boiling the cocaine base melts and forms an oily yellowish liquid in the bottom of the vessel. 3 Complete separation of cocaine is achieved by cooling the vessel causing the cocaine base to solidify as a solid lump (or rock) of crack. The surplus water is then drained off leaving the rock at the bottom of the container. This production route ensures that impurities are drained off with the water in the final stages of production resulting in an 85% to 99 purity. The remainder of the rock is made up of water and other minor alkaloids of the coca plant, such as cinnamoylcocaine, which were present in the original cocaine hydrochloride base. a This clearly provides the most pure and clean drugs for the user but reduces the profits of the dealer.

Producing crack with ammonia is another alternative method. There are concerns about this method of production given the flammability of ammonia and the potential for fumes to be inhaled by those involved in production. s It is unlikely that substantial ammonia fumes will be inhaled by the end user. Also ammonia can produce a rock which is less solid in form and thus less attractive to dealers. However, it provides a high purity of crack.

In reviewing production methods it is clear that it is not what mix is used but a way in which the production is undertaken that has the greatest impact on the purity and cleanness of the final product. In the next phase of the project, techniques for driving up purity will be considered both through direct intervention with crack producers and through mobilising positive peer pressure from crack users.

5. ASSESSING RISKS IN RELATION OF ROUTES TO ADMINISTRATION

The two dominant modes of administration in the UK are crack piping and injecting. This section will consider the major causes of harm linked to these two major routes of administration and then go on to reflect on more minor methods of use.

5.1 Injecting Crack

Crack taking is usually a repetitive process with many doses being taken in one session. A key factor in crack related harm is the anaesthetic action of cocaine. After the first injection, the injecting site has been locally anaesthetized creating the potential for hidden damage to be caused as the session progresses. If injecting heroin is a "bloody business" then crack injecting is potentially an even bloodier business exposing users to far higher environmental contamination, significant opportunities for the spread of blood borne viruses and substantial primary health care risks. Many strategies generally identified for injectors, such as the Viral Protection Campaign developed jointly by the Healthy Options Team, Respect and the Australian IV League are relevant for crack injectors.
However, two elements are worthy of greater emphasis:
1.   the rotation of injecting sites during an injecting session;
2.   the use of butterfly lines.

The second option builds on work undertaken by a Clinical Nurse Specialist at the Healthy Options Team which identified that butterfly lines can minimise long term damage to veins, reduce abscesses, help access more difficult to reach veins and reduce injecting related damage. The intention within a crack setting is that injectors would be encouraged to insert a temporary butterfly line at the beginning of a session before the anaesthetic affect has taken place and for this butterfly line to be retained throughout the single using session, thus requiring only one injection to take place. 6 ' There are anecdotal reports from users to support this view. However, in practice there is a clear need to back this information with empirical studies and further infection control advice.

5.2 Piping Crack

Piping is still the most popular route of administration in the UK. Most people make their own home pipes. There are significant concerns that users will inhale fumes from plastic bottles, dirty containers or tin cans that are made into homemade pipes. This compounds the damage caused to lungs by crack itself. However, there is no need to re-invent the wheel as much work has been done on this issue in the USA and it is positive that there is the possibility to take something good from the USA in relation to crack! Following advice from the Harm Reduction Coalition in New York 8 and the Prevention Point in Philadephia ' glass pipes stand out as the most safe method of piping and the UK would benefit from distributing glass pipes and providing a repair service as has been practised by some agencies in the USA. This will be considered in the second phase of this project although the implications of the paraphernalia laws will need to be considered. By providing such a service, workers would have a meaningful engagement tool with crack pipers not ready or willing to cease their use, offering opportunities for broader harm reduction interventions.

5.3 Chasing Crack

Although I began this paper stating that chasing is not popular in the UK with crack users currently, having spoken to a few crack chasers their feeling is that by chasing they have achieved a degree of control over their crack use that had not been enjoyed previously. It is now my believe that crack chasing could be promoted as a route of administration that affords additional control over quantities of crack consumed. Also it may reduce chaotic behaviour for those who wish to continue regular active use.

5.4 Chipping

Chipping small amounts of crack into tobacco and rolling it up in cigarette papers for smoking, is reasonably common practice for crack users who may wish to smoke crack but need to maintain control. Most crack using dealers interviewed for this paper spoke of this method of using whilst they were selling crack or other drugs. This method of administration certainly is worthy further consideration and promotion by both users and professionals.

5.5 Up Your Bum

This route of using crack has recently been tried by a core group of ten users. They reported the effect as being comparable to IV using, without some of the risks associated with injecting drugs. While there are some concerns with this route of administration, over all there seems little reason why this method cannot be promoted among long term injecting drug users.

6. CONCLUSION

From the initial development work around this project it is clear that drug services in the UK have failed to meet the needs of crack users because:

a)   USA imported mythology leads workers to be fearful of crack users;

b)   drug workers do not fully understand the process and thus the risk associated with crack using;

c)   drug workers do not fully understand the culture among crack users and dealers;

d)   UK drugs work remains "professionally" orientated thus excluding workers from a body of significant expertise (i.e crack users and dealers).

Positively building on existing user based strategies and scientific information it is possible to identify two key arenas in which harm reduction strategies can be considered:

i)   targeting those involved in the production of crack;

ii)   targeting those engaged in crack using.

While the project to date has focused on routes of administration, this is clearly only the beginning of the development of a comprehensive harm reduction strategy. Future work should actively build on the positive self-help networks that already exist within the crack using community. The project has unsurprisingly identified the need for further work around sexual health issues but this has remained outside the focus of this presentation. A further matter is the increasing transitions between crack and other drugs which is often selfmedication to manage the "come down" which may lead to a secondary dependency. Most significantly the project highlighted a substantial lack of knowledge about the process and the resulting harm reduction strategies relating to crack use among drug workers. There is an urgent need for drug workers to receive further training in the UK to provide a more sensitive and appropriate response to crack users that openly embraces a harm reduction approach.

Finally, a theme that has continually arisen throughout this first phase of the crack development project is the substantial impact of USA imported images of crack users and myths about crack use. This mythology has substantially affected the beliefs and attitudes of workers and the response of drug services to crack users. What remains unclear is how far such USA imported images and myths contribute to the social learning of behaviour among UK crack users. At this stage in the project this can only be posed as a question but the correlation between professional expectation and user behaviour has already been demonstrated and the potential for such social learning to increase risk behaviour is obviously concerning.

REFERENCES:

1.   Miller, W. Rollnick, S. Motivational Interviewing - preparing people to change addictive behaviours. Guildford Press New York (1991).

2.   Reddnick, S. Personal correspondence - The Forensic Science Service - London (1997)

3.   Metcalfe, J. What is crack? - Paper ACPO Crime Committee (1989)

4.   see reference 2

5.   Tempowski, J. Personal correspondence - Medical Toxicology Unit National Poisons Information Service, Guys and St Thomas' Hospital (1997).

6.   Wooton, D. Development work undertaken by Clinical Nurse Specialist at Healthy Options Team (1996)

7.   Phillips, P. Practical advice from Clinical Nurse Specialist at Healthy Options Team (1997).

8.   Clear, A. Personal communication (1997)

9.   Pipers Take Care Leaflet Prevention Point Philidelphia (1995)