Kermit The Frog Smoking Crack Side
People who smoke crack cocaine experience a wide variety of health-related issues. However, public health programming designed for this population is limited, particularly in comparison with programming for people who inject drugs. Canadian best practice recommendations encourage needle and syringe programs (NSPs) to provide education about safer crack cocaine smoking practices, distribute safer smoking equipment, and provide options for safer disposal of used equipment.
Kermit The Frog Smoking Crack Side
We conducted an online survey of NSP managers across Canada to estimate the proportions of NSPs that provide education and distribute safer smoking equipment to people who smoke crack cocaine. We also assessed change in pipe distribution practices between 2008 and 2015 in the province of Ontario.
Analysis of data from 80 programs showed that the majority (0.76) provided education to clients on reducing risks associated with sharing crack cocaine smoking equipment and about when to replace smoking equipment (0.78). The majority (0.64) also distributed safer crack cocaine smoking equipment and over half of these programs (0.55) had done so for less than 5 years. Among programs that distributed pipes, 0.92 distributed the recommended heat-resistant Pyrex and/or borosilicate glass pipes. Only 0.50 of our full sample reported that their program provides clients with containers for safer disposal of used smoking equipment. The most common reasons for not distributing safer smoking equipment were not enough funding (0.32) and lack of client demand (0.25). Ontario-specific sub-analyses showed a significant increase in the proportion of programs distributing pipes in Ontario from 0.15 (2008) to 0.71 (2015).
Our findings point to important efforts by Canadian NSPs to reduce harm among people who smoke crack cocaine through provision of education and equipment, but there are still limits that could be addressed. Our study can provide guidance for future cross-jurisdiction studies to describe relationships involving harm reduction programs and provision of safer crack cocaine smoking education and equipment.
As part of a national-in-scope evaluation of NSP practices and policies, the first of its kind that we are aware of in Canada, we conducted a survey of program managers to estimate the proportions of NSPs providing education and distributing safer smoking equipment to people who smoke crack cocaine. For the province of Ontario, we used previously collected survey data  to assess if there had been a change in the distribution of safer smoking equipment over time.
Participants were asked questions (in Yes/No, multiple choice, Likert scale, and open-ended formats) about their program characteristics, distribution of harm reduction materials, including safer crack cocaine smoking equipment, and other key topics identified in the best practice recommendations [27, 30]. The questionnaire was developed for an online platform, FluidSurveys, and was offered in English and French. Please see Additional file 1 that contains English online survey text that is relevant to the findings we report in this article. Before launching data collection, we pilot tested the online survey with five program managers from different provinces and modified some questions as per their feedback. The University of Toronto Research Ethics Board (REB) approved this study.
Data were downloaded, managed, and analyzed using SPSS (version 24). Specifically, we report frequency distributions and bivariate statistics to characterize the proportion of programs offering safer crack cocaine smoking education and equipment distribution by NSPs. In addition, using data from an earlier study that used the same online survey methods for Ontario , we compared the proportion of programs in that province that distributed pipes in 2008 versus 2015. Similar data were not available for the other provinces or territories.
A majority of participants (0.76) reported that their program provides education to clients on reducing risks associated with sharing crack cocaine smoking equipment. Further, 0.75 indicated that their program provides education on identifying risks, such as cuts and injuries, from the use of improvised smoking equipment (e.g., soda cans as makeshift pipes), and 0.72 reported that they provide education on how to use safer smoking equipment.
Over three quarters of participants (0.78) reported that their program staff advise clients about when to replace smoking equipment. In terms of specific instances when it is time to replace smoking equipment, 0.75 of managers reported that their program advises clients to replace pipes and/or mouthpieces if these items have been used by anyone else; 0.74 advise clients to replace their pipe if it is scratched, chipped, or cracked; 0.71 advise clients to replace mouthpieces that are burnt; and 0.70 advise clients to replace the screen if it shrinks and becomes loose in the pipe.
Our study indicates an ongoing need to investigate and address barriers to best practice uptake, as 35% of managers in our sample reported that their program does not distribute any safer crack cocaine smoking equipment. More work is needed to address other domains found to promote uptake of evidence-based recommendations, including nurturing champions of organizational change, organizational cultures that support innovation and leaderships that promote the use of evidence-based practice, and ensuring adequate funding streams for distribution and disposal of safer smoking equipment [33, 34]. Only two managers among those who said that their programs do not distribute pipes selected police opposition as an underlying reason. This finding seems consistent with results from our larger evaluation study which show that the majority of NSP managers we sampled reported mostly positive relationships with their local law enforcement . However, interpretation of this finding is difficult in light of other research that has reported policing practices to be a barrier to services designed for people who smoke crack cocaine (e.g., [19, 24]). Police support and opposition regarding harm reduction programs are dynamic, though, for example, in Canada there are signs that police perspectives on supervised injection facilities have changed in recent years, seemingly linked to the opioid overdose epidemic (cf. [36, 37]). How police may view services for people who smoke crack cocaine and how those views are changing or may change are worthy of in-depth investigation.
Lastly, although collection and safer disposal of used injection equipment is a core activity of NSPs, including providing clients with rigid, tamper-resistant, and clearly labeled sharps containers (see  for evidence-based best practice recommendations regarding disposal and handling of used drug-use equipment), we found that only half of all NSPs that we sampled provide clients with containers for safer disposal of used smoking equipment. We did not include more detailed or follow-up questions about this issue in the online survey, so we are unsure if this lack of safer disposal container provision represents a resource or cost issue and/or something else. We know from anecdotal reports from members of the cross-regional, multi-stakeholder best practice team that cost can be a barrier and some programs already struggle to cover the costs of injection equipment disposal. It is also possible that NSP staff do not regard pipes and other safer smoking equipment as sharps and/or biohazard material requiring the same level of safety procedures as used injection equipment. The removal from circulation and safer disposal of used injection equipment have long been considered key elements of NSP strategies to reduce needle reuse and accidental needle-stick injuries which, in turn, reduce opportunities for infectious disease transmission [38, 39]. More research is needed to determine if disposal is similarly as important for reducing certain risks associated with crack cocaine smoking.
In terms of study limitations, our findings may not be generalizable across all programs in Canada. One province with many NSPs and other harm reduction programs did not participate. It is also possible, though perhaps unlikely, that there are some programs that distribute safer smoking equipment and no injection equipment, and these would have been excluded from our survey. Although not an ideal sample, we otherwise captured data from programs from all other regions, including the Maritimes and the northern territories, and are thus able to provide a highly unique snapshot of Canadian practices. Our findings can provide some guidance for future, larger-sample investigations to describe and report on relationships involving harm reduction programs and safer crack cocaine smoking education and equipment.
Outside the classroom, Lip spends much of his time drinking beer, smoking weed, and eventually participating in car theft schemes with Jimmy. Lip has a strong bond with Ian and is the first one to discover that Ian is gay. During the first season of the show, while tutoring Karen Jackson in mathematics, Lip develops a sexual relationship with her, and soon falls in love with her despite his refusal to commit. In season 2, Karen reveals to be pregnant with what is believed to be Lip's baby. Despite some initial hesitance, Lip looks forward to being a father and is devastated when the child is not his.
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