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Best practice portal:
Harm reduction interventions for smoking and inhaling drug use

This page refers to the current evidence on the effectiveness of the available harm reduction options for non-injecting routes of administration. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 12.2016     Next update: 04.2017

Harm reduction interventions for non-injecting routes of administration

Summary: There is no robust evidence supporting any specific intervention.

Beneficial

No interventions met the criteria for this category.

Likely to be beneficial

No interventions met the criteria for this category.

Trade-off between benefits and harms

No interventions met the criteria for this category.

Unknown effectiveness

Targeted (e.g., behavioural/community-based/outreach) measures to reduce HIV risk outcomes

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that, despite the fairly substantive body of largely controlled studies, there is:

  • mixed and short-term evidence, so not conclusive, on the effectiveness of targeted behavioural harm reduction measures, eg. peer-delivered intervention (‘EachOneTea-chOne’; EOTO), enhanced peer-delivered HIV education interventions, standard HIV prevention programs

‘Safer crack use paraphernalia distribution’ to reduce crack-related harms

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that there is:

  • mixed and short-term evidence, so not conclusive, on the effectiveness of the distribution of crack use paraphernalia on morbidity and mortality outcomes.

Evidence of ineffectiveness

No interventions met the criteria for this category.

References and definitions

List of references

Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

About smoking and inhaling drug use

Intranasal forms of drug consumption include inhaling the vapour of a heated substance (chasing), spraying dissolved drug into the nose, or snorting a drug in powder form. Smoking is another way of administering drugs, whereby the fumes of burning drugs are inhaled into the lungs.

Case definition (risks)

Infections

Infections in smokers and inhaling drug users occur in the lips due to sharing of equipment and poor hygiene, and as respiratory lesions due to smoking.

Respiratory problems

The most notable pulmonary complication of smoked cocaine is referred to as ‘crack lung’ and it is difficult to differentiate from several other associated and life-threatening diseases. The vasoconstrictor effect of smoked cocaine can also lead to pulmonary hypertension with chronic use.

People who smoke cannabis with or without tobacco also seem to be more susceptible to respiratory infections.

Aetiology

The speed with which a drug is absorbed and metabolised depends on the route of administration. Drugs taken intranasally enter the blood more rapidly through the mucous membranes of the nose. Smoking and injecting provide the fastest absorption, leading to a larger amount of drug getting into the brain more rapidly. For example, snorting heroin gives users a ‘high’ in 10–15 minutes, whereas users can feel the effect of heroin about seven seconds after smoking it or injecting it into a vein.

Prevalence

More than half of clients entering treatment for cocaine as the primary substance of use report sniffing as the main route of administration, and on- third report smoking or inhaling it. Among stimulants users, people who report sniffing it make up 21 % of all the patients entering treatment. Around 4 % of stimulant users report the main administration route as smoking or inhaling.

Interventions

Crack kits

Crack kit programmes offer kits that generally include a Pyrex tube, plastic tips, filters, condoms, lip balm, sterile compresses and chewing gum for salivation.

Personal vaporisers

Recent technological developments such as personal vaporisers, similar to electronic cigarettes for tobacco smokers, offer additional opportunities to reduce pulmonary and other bodily harm, as vaporisation and filtering can reduce the amount of combustion products inhaled while offering an acceptable alternative to crack pipes and perhaps even syringes.

Information, education and communication material and outreach activities

Projects exist that offer cocaine information in flyers, on the Internet and on the streets, including van-based outreach for cocaine to check lung capacity, blood pressure and heart rate .

Outcomes

  • reduction of morbidity
  • reduction of mortality
  • reduction of criminality
  • reduction of public nuisance
  • reduction of related medical problems

Primary outcomes

  • reduction of risky behaviours (self reported)
  • reduction of infections
  • reduction of related medical problems

References

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

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Page last updated: Friday, 16 December 2016