Page last updated October 30, 2023 by Doug McVay, Editor.

1. Clean Pipe Distribution and Reduced Health Concerns

"We observed that the increase in crack pipe distribution services coincided with a corresponding increase in the uptake of crack pipes obtained through health service points only. Further, rates of reporting health problems associated with crack smoking declined significantly after the crack pipe distribution program was implemented. In the multivariable analysis, compared to obtaining crack pipes through other non-health service sources only, obtaining pipes through health service points only was significantly and negatively associated with reporting health problems from smoking crack. These findings suggest that the recent expansion of crack pipe distributions in this setting has likely served to reduce health problems experienced by crack smokers, achieving the desired outcome of the program.

"While crack users are obtaining their safe crack smoking equipment from health service points, they may also be exposed to education around safer smoking techniques and practices, by being in direct contact with service providers in the community. This may also have the benefit of exposing drug users with no connections to health care to available providers in their area [27]. A previous study of an outreach-based crack smoking kit distribution service indicated that unsafe smoking practices such as using Brillo pads and sharing crack paraphernalia remained prevalent, even after the implementation of the service [10], suggesting the importance of placing such service in a continuum of broader health service system and ensuring the availability of smoking kits to reduce risky smoking behaviours."

Prangnell, A., Dong, H., Daly, P. et al. Declining rates of health problems associated with crack smoking during the expansion of crack pipe distribution in Vancouver, Canada. BMC Public Health 17, 163 (2017).

2. Provision of Safe Smoking Equipment Reduces Negative Health Consequences

"Our findings of a reduction of health problems, are consistent with harm reduction programs for people who inject drugs [19], including needle exchange programs and supervised injection sites, where they are effective in reducing overall negative health consequences. By providing users with high-quality smoking equipment and reducing the dependence on unsafe equipment, the unintended negative consequences, including exploding pipes, burns, and inhaling brillo fragments, are further reduced."

Prangnell, A., Dong, H., Daly, P. et al. Declining rates of health problems associated with crack smoking during the expansion of crack pipe distribution in Vancouver, Canada. BMC Public Health 17, 163 (2017).

3. Services at Supervised Consumption Sites

"Increasingly, SCS are incorporating services to address the risks associated with consuming adulterated drugs from the toxic drug supply. These services include incorporating drug checking services [60, 61] and the provision of pharmaceutical grade alternatives to street drugs (e.g., safe supply) [62, 63]; although these services are largely targeted to people who use opioids and often do not address the needs of people who use stimulants [64]. As these services are relatively recent developments, they were not discussed in the included articles and therefore the extent to which they are incorporated within SCS that allow non-injection routes of consumption remains unclear. However, the current emphasis on innovative solutions to the overdose crisis [65] highlights the need for SCS to be responsive to the needs of their participants. Furthermore, the current COVID-19 pandemic has also demonstrated the importance of flexibility in response to the evolving needs of SCS participants [66]. People who smoke illegal drugs may be particularly at risk for complications associated with respiratory illness [67]. Many people who use drugs have been impacted by sudden closures of their SCS due to their inability to meet public health directives [68, 69], while other SCS had to reduce their capacity to meet physical distancing requirements [70]. The operational characteristics of both injection and non-injection SCS should be flexible and continuously adapted to address local needs and context."

Speed, K. A., Gehring, N. D., Launier, K., O'Brien, D., Campbell, S., & Hyshka, E. (2020). To what extent do supervised drug consumption services incorporate non-injection routes of administration? A systematic scoping review documenting existing facilities. Harm reduction journal, 17(1), 72.

4. Supervised Inhalation Facilities

"Supervised inhalation rooms (SIR) have the potential to minimise the aforementioned barriers to care and harms associated with crack cocaine smoking [12,21]. Modelled after supervised injection facilities, SIRs are regulated environments in which people can smoke pre-obtained drugs with sterile equipment under the supervision of nurses or other trained staff [22]. These facilities aim to reduce high-risk drug use practices and blood-borne infections, increase contact between PWUD and health and social services, and improve public order through reductions in public drug use [23]. To date, SIRs have been implemented in seven countries: Canada, Germany, Luxembourg, Netherlands, Switzerland, Spain and France [24–26]. In contrast with the significant evidence of the health and community benefits of supervised injection sites, rigorous evaluation of the specific outcomes of SIRs is lacking [24,27]. However, it is plausible that many of the demonstrated health benefits associated with supervised injection sites could extend to SIRs, with available evidence suggesting that SIRs have potential to improve public order, connect PWUD with health and social services, and reduce drug-related harms [11,25]."

Cortina, S., Kennedy, M. C., Dong, H., Fairbairn, N., Hayashi, K., Milloy, M. J., & Kerr, T. (2018). Willingness to use an in-hospital supervised inhalation room among people who smoke crack cocaine in Vancouver, Canada. Drug and alcohol review, 37(5), 645–652.

5. Routes of Administration and Deaths from Toxic Drug Supply and Drug Overdose

"From January–June 2020 to July–December 2022, the number of overdose deaths with evidence of smoking doubled, and the percentage of deaths with evidence of smoking increased across all geographic regions. By late 2022, smoking was the predominant route of use among drug overdose deaths overall and in the Midwest and West regions. Increases were most pronounced when IMFs were detected, with or without stimulants. Increases in the number and percentage of deaths with evidence of smoking, and the corresponding decrease in those with evidence of injection, might be partially driven by 1) the transition from injecting heroin to smoking IMFs [Illicitly Manufactured Fentanyl] (3,4), 2) increases in deaths co-involving IMFs and stimulants that might be smoked†††† (1), and 3) increases in the use of counterfeit pills, which frequently contain IMFs and are often smoked (7). Motivations for transitioning from injection to smoking include fewer adverse health effects (e.g., fewer abscesses), reduced cost and stigma, sense of more control over drug quantity consumed per use (e.g., smoking small amounts during a period versus a single injection bolus), and a perception of reduced overdose risk among persons who use drugs (3,5,8). These motivations might also signify lower barriers for initiating drug use by smoking, or for transitioning from ingestion to smoking; compared with ingestion, smoking can intensify drug effects and increase overdose risk (9). Despite some risk reduction associated with smoking compared with injection (e.g., fewer bloodborne infections), smoking carries substantial overdose risk because of rapid drug absorption (5,9).

"Nearly 80% of overdose deaths with evidence of smoking had no evidence of injection; persons who use drugs by smoking but do not inject drugs might not use traditional syringe services programs where harm reduction messaging and supplies are often provided. In response, some jurisdictions have adapted harm reduction services to provide safer smoking supplies or established health hubs to expand reach to persons using drugs through noninjection routes.§§§§ In addition, harm reduction services (e.g., peer outreach and provision of fentanyl test strips for testing drug products and naloxone to reverse opioid overdoses), messaging specific to smoking drugs, and linkage to treatment for substance use disorders can be integrated into other health care delivery (e.g., emergency departments) and public safety (e.g., drug diversion) settings.

"The percentage and number of deaths with evidence of injection decreased across regions and drug categories. Observed decreases might reflect transitions to noninjection routes and response to public health efforts to reduce injection drug use because of its risk for overdose and infectious disease transmission (3,4,10). Despite these declines, more than 4,000 drug overdose deaths had evidence of injection during July–December 2022. Syringe services programs help to engage persons who use drugs in services (10); sustained efforts to provide sterile injection supplies, additional harm reduction tools, and linkage to treatment for substance use disorders, including medications for opioid use disorder, are important for further reduction in the number of overdose deaths from injection drug use. Lessons learned from implementing syringe services programs could be applied to other harm reduction and outreach models to reach more persons who use drugs by any route."

Tanz LJ, Gladden RM, Dinwiddie AT, et al. Routes of Drug Use Among Drug Overdose Deaths — United States, 2020–2022. MMWR Morb Mortal Wkly Rep 2024;73:124–130. DOI:

6. Methods of Heroin Use: Smoking Compared With Injecting

"People who use heroin (PWUH) have increased morbidity and mortality compared to the general population [1]. A syndemic of opioid overdose, human immunodeficiency virus (HIV), hepatitis C virus (HCV), skin and soft tissue infections (SSTI), and infective endocarditis accounts for many of the poor health outcomes among PWUH [2,3,4,5]. Heroin can be consumed in several ways, including injection and smoking [6]. High-risk injection behaviors, including syringe sharing and reuse of non-sterile injection equipment, are established routes of HIV and HCV transmission and increase risk of SSTI and infective endocarditis [7,8,9]. Opioid overdose is a common cause of mortality among PWUH, with higher overdose risk among those who inject [10,11,12].

"Because smoking heroin does not injure the skin or introduce non-sterile equipment into blood or tissue, this method of consumption does not entail the same risk of blood-borne infections or SSTI compared to injection. While similar pharmacological effects can be achieved by smoking or injecting heroin, peak plasma concentrations are 2–4 times lower when heroin is smoked, which may reduce risk of lethal opioid overdose [13, 14]. Programs that encourage PWUH to transition from injecting to smoking heroin may decrease injection frequency and thereby reduce harms associated with heroin use, including risks of infection and overdose [15]. Distribution of smoking equipment may also help PWUH avoid using pipes fashioned from cans or other poor-quality materials that easily crack or overheat, thereby reducing risk of developing burns or cuts on the lips that can serve as sites of infection [16,17,18]. Pipe distribution programs may also reduce pipe sharing, a risk behavior potentially associated with respiratory virus or HCV transmission [17,18,19,20]."

Fitzpatrick, T., McMahan, V.M., Frank, N.D. et al. Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study. Harm Reduct J 19, 103 (2022).

7. Methods of Heroin Use Before and After Distribution of Smoking Equipment

"In this pilot pretest–posttest quasi-experimental study, we saw a lower proportion of SSP clients exclusively inject heroin and a higher proportion of SSP clients consume heroin through both injection and smoking after the implementation of a heroin pipe distribution program. The proportion of SSP clients who reported syringe reuse was also lower following the heroin pipe distribution intervention. We did not observe any difference in self-reported health outcomes associated with drug use between the pre- and post-intervention periods; however, the short follow-up period and small sample size of this pilot study may have contributed to this null finding. Our results suggest heroin pipe distribution may be a novel RTI that can be added to existing SSPs to further reduce harms associated with heroin use. This study also highlights the potential for public health service innovations to be developed by marginalized communities and the importance of placing PWUD in leadership positions in efforts to optimize harm reduction programming.

"Despite the non-randomized design of this pilot study, several findings suggest heroin pipe distribution may have prompted changes in heroin consumption behaviors among PWUH. The proportion of SSP clients who exclusively injected heroin was lower by a quarter, while the proportion who both injected and smoked heroin was higher by over a quarter after heroin pipe distribution began. Twenty-four percent of respondents who used heroin reported heroin pipe distribution had reduced their heroin injection. Higher proportions of SSP clients who received heroin pipes exclusively smoked heroin or both smoked and injected heroin compared to SSP clients who did not receive a heroin pipe. We are unaware of any prior published research investigating heroin pipes as an RTI; however, pre–post-analyses examining foil distribution at SSPs in Europe found similar changes in drug consumption behaviors, with up to 85% of SSP clients having used foil to inhale rather than inject heroin on at least one occasion [23, 28]. Our non-randomized study design cannot control for confounding and prevents firm conclusions as to whether this observed shift from injection to smoking can be attributed to the intervention. Additionally, only 14% of respondents who used heroin completed surveys during both the pre- and post-intervention periods, and thus, outcomes may have been impacted by changes in the SSP client population across time periods. Further experimental research is needed to clarify the causal relationship between heroin pipe distribution and reductions in heroin injection. Study designs that are randomized by individual may be complicated by heroin pipe sharing across intervention and control groups. Cluster randomization may better control for contamination given extensive social networks and resource exchange among PWUD [29]."

Fitzpatrick, T., McMahan, V.M., Frank, N.D. et al. Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study. Harm Reduct J 19, 103 (2022).

8. Smoking Drugs and Harm Reduction

"Findings show that smoking drugs is a popular route of administration among people who use drugs and evidence from this review suggests that expanding access to safer smoking within harm reduction services is crucial to risk mitigation. Within the studies included in this review, most study participants, including people who smoke drugs, peers, and service providers, believed safer smoking services to be a necessary harm reduction intervention, especially when considered in relation to existing safer injection services [39, 40, 42,43,44, 51, 54, 56, 63, 64, 67, 68]. Further, across studies, people who use drugs reported a high willingness to utilize these services, and in places where services were offered, many studies reported high utilization of safer smoking services. Additionally, although efficacy data were limited, across studies, people who use drugs reported decreasing their injection drug use in favor of smoking, reducing the sharing of smoking equipment, and in some cases improved health outcomes (e.g., decreased burns and cuts). Despite the clear benefits of safer smoking practices, some people who use drugs and service providers reported ongoing barriers to accessing and delivering these services, respectively. Findings underscore the need for ongoing research and structural interventions to increase access to safer smoking programs and reduce drug use related morbidity and mortality.

"This is a burgeoning area of research, which we expect to grow and evolve as policies shift, more funding becomes available for the inclusion of safer smoking kits into harm reduction service offerings, and the benefits of these practices become more well known. In fact, since the time that this search was conducted, a new study was published in May 2023 that showed high interest in using safer smoking materials, with participants believing it would reduce their injection use of drugs. As additional studies are published, including those that are based on higher quality evidence, we anticipate a need to update this review in future years [70].

"Despite evidence that smoking has benefits over injecting [39, 40, 42,43,44, 51, 54, 56, 63, 64, 67, 68], across studies, people who use drugs report programs providing safer smoking materials are a minority among harm reduction organizations globally. Ongoing work is needed to incorporate safer smoking materials into the services provided by existing harm reduction organizations. The studies reviewed here provide evidence of the presence of peer workers who are part of these communities as people with lived experience and found peers to be integral in engaging people who use drugs and assisting them with changing their practices. Further outreach to educate people who use drugs about smoking as a harm reduction practice is necessary, including the nuanced benefits and risks associated with it."

Tapper, A., Ahern, C., Graveline-Long, Z. et al. The utilization and delivery of safer smoking practices and services: a narrative synthesis of the literature. Harm Reduct J 20, 160 (2023).

9. Harm Reduction Principles and Practices

"Historically, harm reduction principles are actualized when individuals and groups take sometimes illegal measures to protect their communities. Once systemic structures recognize the value in these practices, they might become decriminalized and widely supported by public health institutions. As an example, supervised consumption sites have been created; these are spaces where individuals can use drugs in a sterile and monitored space with access to supplies and care. Legalized in certain European nations, Canada, and Australia, supervised consumption sites in the U.S. operated quietly and against the law [8]. With increased evaluations published globally, and within the country on unsanctioned supervised consumption sites [9], we see increased receptiveness in academic circles. In the U.S., this illicit practice of providing safe spaces to consume drugs recently gained popular ground with Rhode Island becoming the first state to legalize supervised consumption sites [10], and OnPoint in New York City opening the first SCS in the U.S. [11]. Other recent innovations in public health lifted up by the advocacy of people who use drugs include drug checking and safer smoking initiatives."

Tapper, A., Ahern, C., Graveline-Long, Z. et al. The utilization and delivery of safer smoking practices and services: a narrative synthesis of the literature. Harm Reduct J 20, 160 (2023).