Why Does Vancouver Need a Crack Pipe Vending Machine?

A Canadian organization is turning heads after installing the first ever crack-pipe vending machines. As part of a larger harm reduction approach to safer crack use, the machines allow people who use crack to purchase a clean pipe for 25 cents, and help to reduce risk like HIV and hepatitis C. I sat down with Mark Townsend, director of the PHS Community Services Society, to discuss the vending machines, and the reasons behind them.

Why does Vancouver need crack pipe vending machines?

It’s part of a basic public health intervention, very similar to needle and syringe programs. People who smoke crack often get blisters or burns on their mouth, and sharing a pipe and mouthpiece means greater risk of HIV or hepatitis C, and possibly other infections like pneumonia. This vending machine makes clean pipes available those who need them.

But why vending machines?

Before we introduced the machines, a pipe cost anywhere between $1 and $10 on the street. This price was too high for many users, meaning people were more likely to share pipes or use unclean equipment. The machines increase the accessibility of affordable pipes at all hours of the day.

What do you say to critics who say that the machines promote drug use?

I would say that drug addiction is a tough issue in many countries. In Vancouver we are trying to find pragmatic ways of dealing with it. By helping to prevent new infections of HIV and hepatitis C, these machines save lives, but are also highly cost-effective. In Canada, an HIV infection costs taxpayers approximately $200,000 to $1.4 million, but at a mere 25 cents, a crack pipe saves us all money in the long run.

The vending machines are located in our Drug User Resource Center—a safe place for drug users to come in from the rain, have a meal, do their laundry, or participate in a creative arts or healing program. By providing people with clean needles and pipes, this center helps people who use drugs to stay safe, while also connecting them to other health services, including HIV and hepatitis C testing, counseling, and information about detox and drug treatment programs.

As with clean needle programs—that study after study have shown do not promote or increase drug use—the crack pipes are one way of reaching out to people and building trust so we can offer other services if and when they are ready.

Do you think this initiative will work?

Of course. We faced similar questions and debate with Insite, where research has proven that supervised injection not only reduces death and the spread of disease, but that people who use the facility are 30 percent more likely to go to detox and seek out drug treatment. We also offer those services right upstairs from Insite, at Onsite. So, crack pipe vending machines seem just like the kind of pragmatic approach we should embrace.

The machines themselves are not going to “solve” the complex problem of addiction, but they are one very effective piece of the puzzle. We are all familiar with the “tough love” messages for addicts, and we gave that argument up with heroin a long time ago. Now, needle and syringe programs are widely accepted as the best standard of care. But, we—advocates, the medical community, and governments—have not yet not fully embraced harm reduction for crack users. We need to.

Should other cities install crack pipe vending machines?

Communities need to come up with solutions that work for them. A vending machine is no substitute for human interaction. The vending machines work well in Vancouver because they are located within other programs. Whatever the local solutions are, they should include listening to what drug users say they need, and learning from what has worked elsewhere.

Many cities, including Vancouver, now have government-sponsored programs that distribute clean crack pipes. Yet as the debate about these vending machines demonstrates, the concept of harm reduction for stimulant drug use has just not taken hold the same way as its heroin counterpart.

Here are four cities that could use crack pipe distribution programs today to help reduce transmission of disease and to connect drug users with health services:

  • New York: In 2010, nearly two decades after syringe distribution programs first became legal in New York, drug user activists finally won a specific carve-out from the criminal law to allow people to carry syringes without fear of arrest; however, no such carve-out exists for crack-related equipment. Users carrying clean pipes could still be charged for possession of drug paraphernalia, or even for drug possession related to any residue in their pipes. Despite the scale of crack and cocaine use in NYC, to date, even very basic services for crack users—such as access to clean pipes—remain limited.
  • San Francisco: The City of San Francisco hands out 2.7 million clean needles a year to reduce HIV and hepatitis risk among injecting drug users. Earlier this year, the HIV Prevention and Planning Council made a formal recommendation to the city’s health department to start handing our crack pipes as part of a public health intervention. To date, this recommendation does not have the support of the Mayor, but some residents say they will do it on their own, citing the fact that needle exchange faced similar controversy when it got started.
  • Bogota: “El Bronx” occupies a few square city blocks, cordoned off by barriers and police vehicles. Approximately 2,000 drug users live there, and smoke basuco, a cheap, unrefined version of crack. A few years ago, Mayor Gustavo Pedro, set up an outreach bus that would provide primary health care, psychological support, and treatment referrals to residents of el Bronx. They are now considering expanding this initiative to include specific harm reduction interventions for stimulant smokers.
  • São Paulo: In January 2014, São Paulo Mayor Fernando Haddad launched “Operação Braços Abertos” (Operation Open Arms) to bring housing, healthcare, and income-generating activities to the troubled neighborhood known as “Cracolândia” (Crackland). Haddad’s initiative, which seeks to work with active users, is a bold new step for a city whose addiction policies have long been characterized by extreme repression. Yet more can be done to impact the transmission of HIV, hepatitis, and syphilis among the thousands of active smokers in Cracolândia. A local NGO distributes clean silicone mouthpieces. They work well, but with only two outreach workers, there is not enough clean equipment to go around.

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This is a welcomed initiative because of the range of communicable diseases that can spread through pipe sharing. However, the possibility of HIV transmission is blown out of proportion. Hep B and C, as well as TB and pneumonia are greater risks. Research shows that people who smoke crack are at greater risk of HIV infection but does not show that the route of infection is via the pipe.

To me, this is horrifying. To encourage and promote drug addiction is dangerous and irresponsible.

Hi Lady
Did you miss the section under the heading "What do you say to critics who say that the machines promote drug use?", particularly the last paragraph:
"As with clean needle programs—that study after study have shown do not promote or increase drug use—the crack pipes are one way of reaching out to people and building trust so we can offer other services if and when they are ready."

These machines do not promote drug use, they simple make it safer, and provide an opportunity for service providers to give help and assistance to users when they come to get one. Feeling comfortable and not judged is important for users to be able to seek help when they are ready for it.

Great initiative Vancouver!

NEVER USED CRACK. USED COCAINE AND HATED IT. MADE PEOPLE AWFUL. MEAN. GLAD THE US SEEMS TO BE LEGALIZING MARIJUANA. I WAS FORCED TO GO TO THE "JUST SAY NO BRUNCH". THE "WAR ON DRUGS" HAS JAILED GOD KNOWS HOW MANY YOUNG AFRICAN AMERICAN MEN WITH SMALL AMOUNTS IN THEIR POCKETS. WE WHITIES AREN'T STOPPED. I DON'T SMOKE POT ANY MORE. BUT IT SHOULD BE LEGAL ALL OVER THE COUNTRY. MY MOTHER WAS A BRILLIANT WOMAN BORN TOO SOON. SHE WROTE FOR THE FEDERAL WRITER'S PROJECT, ACTED IN FOLK PLAYS DURING THE WPA. THEN MARRIED AND HAD TWO BRATS, MY BROTHER AND ME. WE WERE ALL GOOD PEOPLE. BUT SHE GOT DEPRESSED AND TURNED TO DRUGS: ALCOHOL AND CIGARETTES. DIED AT 56. LEGALIZE AND REGULATE MARIJUANA AND COCAINE, HEROIN. TAKE THE MONEY FROM THE CRIMINALS. AND PAY IT TO HELP PEOPLE HAVE FOOD STAMPS.

WHY NOT? IT WAS MEANT TO BE PUBLIC. NOTHING WRONG ABOUT IT. LEGALIZE MARIJUANA. AMERICA IS AHEAD OF CANADA.

Here in Brazil we are very far from something like this. I support this initiative, since it's something integrated with other services that already exist in the region. But since it's not possible to have outreach workers on the streets to reach all crack users, with a machine like this the people who use drugs can get pipes whenever they want, helping prevent transmissions. I hope one day we can implement something like this here too!

The is a 'theoretical risk' or perhaps 'academic' is the better word, of spread of HIV or Hep C with old 'crack pipes' but there is no scientific research that I know linking the two. This concerns me because we have truly valid scientific research to show the risk of IV needles and unprotected sex for spread of HIV and Hep C. Crack pipe dispensers in contrast tend to make a joke of the real gains made by real science and public health efforts in the downtown east side. Crack pipe dispenser 'dilute' and 'distract' from the real threats in the community and real work being done to really save and restore lives in the DTES.

It doesn't take an academic paper or a rocket scientist to know that in the real world of Vancouver's DTES, or any other city with a similar context, a chipped, dirty, used or shared pipe is ultimately not as safe a choice as a clean and new one. The vending machine is small part of a larger continuum which includes detox and treatment programs that we operate in the DTES. Each plays its part in addressing the complexities of addiction, minimizing the risks to the user and the larger community and helping prevent the spread of illness/disease etc... It's all components working together that has led to significant improved health outcomes for the people in our community. The vending machine also acts as an admission point for a real debate on addressing addiction and the considerable challenges therein.

Here in San Francisco, crack use was identified as a driver of HIV transmission in the 2010 HIV prevention plan, but we haven't done anything about it. Crack pipe distribution is being discussed as a way to engage people who use crack, to start the conversation about HIV and hep C, and connect them to services they need. Something like this vending machine would be a great way to get people in the door and create the opening to talk about other issues.

"in San Francisco, crack use was identified as a driver of HIV transmission in the 2010 HIV prevention plan": can you please provide me with a reference to the evidence behind this? Thanks, David Hoffman, Perth, Western Australia

Great to see discussion about this important topic. While we don't want to exaggerate the risks associated with sharing crack pipes, it is important to recognize them. Smoking crack cocaine causes blisters, sores, and cuts on the lips and mouth. Hepatitis C---which is much more easily transmitted than HIV---has been found on crack pipes (see, for example, Fischer et al., European Journal of Gastroenterology & Hepatology. 2008, Vol 20 No 1).

Another Vancouver study (De Beck et al., CMAJ. 2009, Vol 181 No 9.) also found that even among people injecting drugs, crack smoking was independently associated with elevated risk of HIV, although research has not been able to pinpoint the exact sources of infection. However, the main point here is about harm reduction: providing drug users with a way to avoid infection is about dignity, safety, and increased opportunities to attract people into the services, and to demonstrate that those unable or unwilling to stop using drugs can still take positive steps to protect their health. These principles are well-established for needle and syringe programs, and yet (as this debate illustrates), the distribution of crack pipes remains a lightning rod for people who are opposed to harm reduction approaches.

David -- Here's a link to the relevant chapter of the 2010 San Francisco HIV Prevention Plan (pdf): http://www.sfhiv.org/wp-content/uploads/SFHIV_CH_2CommunityAssessment.pdf

Drivers are defined as "an underlying condition that is directly linked to a large number of new infections throughout San Francisco" and that is also prevalent in the most at risk groups. Crack/cocaine use was one of several drivers, and is discussed in detail starting on p. 116.

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