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CORK Bibliography: Crack Cocaine

71 citations. January 2006 to present

Prepared: March 2009

Abu-Kishk I; Rosenfeld-Yehoshua N. Massive pulmonary hemorrhage in an adolescent. Israel Medical Association Journal 10(8-9): 593-594, 2008. (5 refs.)

Alavi SM; Ahmadi F; Ghasemirad MR. Seroepidemiological study of hepatitis E virus in drug addicts in Ahvaz, southern Iran: 2005-2006. Hepatitis Monthly 8(4): 263-266, 2008. (22 refs.)

Background and Aims: Poor personal health in drug addicts predisposes them to Hepatitis E virus (HEV) infection. The objective of this study was to determine the prevalence of antibody to HEV (HEV- IgG) and evaluate epidemiological features of HEV infection among drug addicts. Methods: 224 drug addicts were included in this analytic descriptive study in Ahvaz, southern Iran, from 2005 to 2006. After a through physical examination and completing a questionnaire, 5 mL blood was obtained from each case and tested for anti-HEV-IgG by an enzyme linked immunosorbent assay (ELISA) method using commercial kit (Dia-prob). Data were analyzed in SPSS 11.5 using chi-square test. Results: Of 228 cases, 35 (13.5%) were HEV-IgG positive. The sero-prevalence of positive HEV-IgG in injecting, inhalant and oral drug abusers was 22.8%. 9.1%, and 6.2%, respectively (p<0.05). HEV-IgG was positive in heroin, crack, and opiate abusers with a rate of 20.2%, 10.9%. and 11.6%. respectively. The sero-prevalence of positive HEV-IgG in the prison and addiction treatment center was 15.8%, and 13.3%, respectively (p>0.05). Conclusions: Drug addiction is associated with an increased risk of exposure to HEV and resulted in the high prevalence of anti-HEV-IgG in addicts.

Alvarez GG; van der Jagt RHC. "Crack lung and heart" presenting after chemotherapy in a 65-year-old man with non-Hodgkin lymphoma. Current Oncology 15(1): 63-65, 2008. (11 refs.)

Crack cocaine can cause a variety of pulmonary and cardiac, complications. Pulmonary findings in a 65-year-old man with non-Hodgkin lymphoma who presented with shortness of breath not resolving with antibiotics are presented here. The usual manifestation of "crack lung" in an unusual clinical circumstance underlines the importance of a clinical history in such cases. The finding of "crack lung" preceded the diagnosis of probable "crack heart." No other similar published case reports could be identified in the literature.

Bamaby L; Gibson RC. Factors affecting completion of a 28-day inpatient substance abuse treatment programme at the University Hospital of the West Indies. West Indian Medical Journal 57(4): 364-368, 2008. (18 refs.)

This study investigated factors leading to premature discharge from the residential substance abuse treatment programme at the University Hospital of the West Indies (UHWI). Two hundred and twenty-four patients, mean age 36 # 9.75 and age range of 16-66 years were studied. The patients, 87.5% men, were admitted to the programme over the period July 1999 to June 2002. Sources of data, including a routine patient-monitoring form and patients' medical records, were reviewed. Data analysis, performed using the Statistical Package for Social Sciences (SPSS), included frequencies, cross-tabulations and analyses of variance (ANOVA). Crack cocaine was the drug of impact for 60% of patients, alcohol for 17% and marijuana for 8%. Treatment ended prematurely for 22.8% of persons whose reasons for leaving included signing out against medical advice or self-discharge (27.4%), absconding (19.6%), fighting (9.8%), drug use (5.9%) and other rule breaking, including sexual acting out (15.7%). Premature discharge was uninfluenced by gender age, marital status, schooling, employment status or geographical location. There were significantly more premature discharges in persons admitted primarily for crack dependence versus those admitted primarily for alcoholism (p < 0.05). There were also significantly more premature discharges in persons with 0-10 years of using their most problematic substance when compared with 21-30 years of use (p < 0. 05) but not when compared with 11-20 years or over 30 years of use (p > 0. 05). The influence of duration of substance use requires further elucidation.

Brewer TH; Zhao W; Metsch LR; Coltes A; Zenilman J. High-risk behaviors in women who use crack: Knowledge of HIV serostatus and risk behavior. Annals of Epidemiology 17(7): 533-539, 2007. (32 refs.)

PURPOSE: To determine whether crack cocaine-using women who are aware of their HIV serostatus have made modifications in risk behaviors, we compared known HIV-positive (HIV+) and HIV-negative (HIV-) users with respect to sexual risk behaviors, prevalence of sexually transmitted infections (STIs) and vaginitis, and correlates of unprotected sex. METHODS: We used a cross-sectional design with street outreach, recruitment, and interviews of sexually active crack cocaine using women. Women received testing for HIV, STIs, and vaginitis. RESULTS: Sixty-one HIV+ and 117 HIV- women were enrolled. HIV+ women were significantly more likely to be African-American. There were no significant differences in drug use, types of sexual partners, number of paying partners, attitudes regarding condoms, or STI diagnoses. HIV+ women were less likely to engage in unprotected sex compared with HIV- women (56% vs. 75%, adjusted odds ratio [AOR], 0.36; 95% confidence interval [CI], 0. 13-0.99). Among HIV+ women, unprotected sex was negatively associated with stronger beliefs regarding the protective value of condoms (AOR, 0.07; 95% CI, 0.01-0.67) and concurrent injection-drug use (AOR, 0.19; 95% CI, 0.04-0-99). CONCLUSIONS: Although the majority of crack using HIV+ crack using women in this sample continued to engage in high-risk sexual activities, they were less likely to do so than HIV- women. Interventions targeting this population are needed.

Brewer TH; Zhao W; Pereyra M; del Rio C; Loughlin A; Anderson-Mahoney P et al. Initiating HIV care: Attitudes and perceptions of HIV positive crack cocaine users. AIDS and Behavior 11(6): 897-904, 2007. (37 refs.)

There is limited data on the initiation and use of HIV care services by HIV-positive crack cocaine users. We analyzed data from a study of 286 recently infected HIV-positive persons recruited from 4 U.S. cities. Participants completed an Audio Computer Assisted Self Interview (A-CASI) regarding HIV care knowledge, attitudes, beliefs and practices related to the initiation of HIV care. In multiple logistic regression analysis, higher scores on an assessment of knowledge, attitudes and beliefs regarding HIV care, and Hispanic race were positively associated with initiating HIV primary care. Crack cocaine use in the past 30 days and male gender were negatively associated with initiating care. Injection drug use was not associated with initiation of care. Targeted interventions for crack cocaine users, including drug treatment, may be required to provide optimal HIV primary care use in this population.

Buchanan D; Tooze JA; Shaw S; Kinzly M; Heimer R; Singer M. Demographic, HIV risk behavior, and health status characteristics of "crack" cocaine injectors compared to other injection drug users in three New England cities. Drug and Alcohol Dependence 81(3): 221-229, 2006. (37 refs.)

Objectives: To compare demographic, HIV risk behaviors, and health status characteristics of injection drug users (IDUs) who have injected "crack" cocaine with IDUs who have not. Methods: Nine hundred and eighty-nine IDUs were recruited in New Haven, CT, Hartford, CT and Springfield, MA from January 2000 to May 2002. Participants were administered a modified version of the National Institute on Drug Abuse Risk Behavior Assessment Questionnaire. Results: Nine percent (n=89) of participants reported "ever" injecting crack cocaine and 4.2% (n = 42) reported injecting crack in the past 30 days. Lifetime and current crack injectors did not differ significantly on any demographic characteristics. Lifetime and current crack injectors did not differ on gender, age or marital status from IDUs who have never injected crack. Significant differences were found on race, education, employment and residence, with crack injectors more likely to be white, employed, better educated and living in New Haven than IDUs who have never injected crack. After adjusting for current (past 30 day) speedball and powder cocaine injection, crack injectors reported higher rates of risky drug use behaviors and female crack injectors reported higher rates of risky sexual behaviors. Crack injectors reported higher rates of abscesses, mental illness and Hepatitis C infection, but not Hepatitis B or HIV infection. Conclusions: The emergence of crack cocaine injection requires urgent attention, as this new drug use behavior is associated with elevated rates of high risk behaviors.

Cook JA; Burke-Miller JK; Cohen MH; Cook RL; Vlahov D; Wilson TE et al. Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women. AIDS 22(11): 1355-1363, 2008. (36 refs.)

Background: Longitudinal associations between patterns of crack cocaine use and progression of HIV-1 disease are poorly understood, especially among women. This study explores relationships between crack use and HIV-1 disease outcomes in a multicenter cohort of infected women. Methods: Subjects were 1686 HIV-seropositive women enrolled at six US research centers in the Women's Interagency HIV Study. Approximately 80% were non-white and 29% used crack during the study period. Cox survival and random regression analysis examined biannual observations made April 1996 through September 2004. Outcome measures included death due to AIDS-related causes, CD4 cell count, HIV-1 RNA level, and newly acquired AIDS-defining illnesses. Results: Persistent crack users were over three times as likely as non-users to die from AIDS-related causes, controlling for use of HAART self-reported at 95% or higher adherence, problem drinking, age, race, income, education, illness duration, study site, and baseline virologic and immunologic indicators. Persistent crack users and intermittent users in active and abstinent phases showed greater CD4 cell loss and higher HIV-1 RNA levels controlling for the same covariates. Persistent and intermittent crack users were more likely than non-users to develop new AIDS-defining illnesses controlling for identical confounds. These results persisted when controlling for heroin use, tobacco smoking, depressive symptoms, hepatitis C virus coinfection, and injection drug use. Conclusion: Use of crack cocaine independently predicts AIDS-related mortality, immunologic and virologic markers of HIV-1 disease progression, and development of AIDS-defining illnesses among women.

Daniulaityte R; Carlson RG; Siegal HA. "Heavy users," "controlled users," and "quitters": Understanding patterns of crack use among women in a midwestern city. Substance Use & Misuse 42(1): 129-152, 2007. (67 refs.)

Over the past two decades, the use of crack cocaine has become an enduring part of the social ecology of many cities across the United States. The purpose of this exploratory study is to describe patterns of crack use drawing on life history interviews conducted with 18 women in Dayton, Ohio, between 1998 and 2000. Ten of the women were African American, and eight were white. Age ranged between 23 and 47. The women were at very different stages of their crack-cocaine careers. We focus on understanding the social factors, life history, and everyday circumstances that participants related to their current patterns and levels of crack use. Implications for intervention are discussed.

Day M; Norman LR. An exploration of gender differences in the initiation of and attitudes toward crack cocaine use in the English-speaking Caribbean. Addiction Research & Theory 15(3): 285-297, 2007. (45 refs.)

The aim of this article is to examine the contextual factors associated with the initiation of and attitudes toward crack cocaine use from a sample of out-of-treatment male and female users from three islands in the English-speaking Caribbean. Data from 111 persons who reported using crack cocaine in the previous 30 days are analyzed. Females were more likely than males to have been initiated into crack cocaine use by a sex partner ( 63% vs. 22%, p = 0.007). Women were more likely to report a history of exchanging sex in relation to crack cocaine ( 93% vs. 66%, p < 0.0001). Most men and women reported no perception of danger associated with crack before initiation; however, at time of interview, almost everyone perceived it as very dangerous. These findings suggest the importance of developing drug education messages that are substance-specific. Given the dangers associated with crack cocaine use, special efforts must be made to prevent initiation of use.

de Azevedo RCS; Botega NJ; Guimaraes LAM. Crack users, sexual behavior and risk of HIV infection. Revista Brasileira de Psiquiatria 29(1): 26-30, 2007. (40 refs.)

Objective: To compare a sample of injecting cocaine users and crack users, assessing sexual behavior, risk for infection by HIV and its seroprevalence. Method: 109 injecting cocaine users and 132 crack users were assessed, using the World Health Organization questionnaire from the expanded "Cross-Site Study of Behaviors and HIV Seroprevalence among Injecting Drug Users" and HIV serology. Data were assessed by Multiple Correspondences Analysis. Results: Crack users showed less time of drug consumption when compared to the injecting cocaine users. Despite this fact, they had higher rates of risky sexual activity, differences in poli-consumption of drugs, and higher rates of involvement in illegal issues. HIV seroprevalence among crack users, although lower than for injecting cocaine users (7% vs. 33%) is high when compared to the general population at the same age. Conclusions: Sexual behavior of crack users in the studied sample may be considered a risk factor for HIV infection. Crack users have access to information on HIV/AIDS, but do not make use of it to change risk behaviors that may expose them to HIV infection and dissemination. HIV seroprevalence among crack users (7%) is concerning, which makes it necessary to create preventive strategies for HIV infection and dissemination that are specifically directed toward this population.

Dias AC; Ribeiro M; Dunn J; Sesso R; Laranjeira R. Follow-up study of crack cocaine users: Situation of the patients after 2, 5, and 12 years. Substance Abuse 29(3): 71-79, 2008

The purpose of this study was to follow-up 131 crack users and examine drug use, treatment experience, employment status, and mortality at 2, 5, and 12 years. Consecutive crack dependent patients were re-interviewed in 1995-1996, 1998-1999, and 2005-2006. Of those subjects not using cocaine at 2 years, 19 (63%) were still abstinent at 5 years. Almost half of the users were abstinent at the same period. The abstinent group was still the most prevalent at 12 years. Twenty-seven (20.6%) patients had died by the 12-year follow-up, with homicide being the most common cause (n = 16). After 2000, however, it declined sharply with only 2 deaths in 7 years. There was a progressive movement toward abstinence over the follow-up period, with the evidence that once abstinence had been achieved it was maintained. On the other hand, the mortality rate was extremely high and probably more related with socioeconomic factors instead of the drug use itself.

Dickson-Gomez J; Bodnar G; Gueverra A; Rodriguez K; Gaborit M. Childhood sexual abuse and HIV risk among crack-using commercial sex workers in San Salvador, El Salvador: A qualitative analysis. Medical Anthropology Quarterly 20(4): 545-574, 2006. (69 refs.)

This article explores the relationship between childhood sexual abuse (CSA) and later HIV risk. It draws on qualitative, in-depth interviews with 40 women who either used crack or engaged in commercial sex work in the greater metropolitan area of San Salvador, El Salvador, 28 of whom experienced CSA. Although the relationship between CSA and later HIV risk has been clearly demonstrated, the processes that lead women who have experienced CSA to experience HIV risk are unclear. The theoretical model presented here incorporates the psychological effects of CSA, particularly stigmatization, as well as its social consequences and the larger context of poverty in which these women live. The meanings women draw from past abuse experiences and their rationale for choices made help explain the association between CSA and later risk as mediated through sex work and crack addiction. Self-report data gathered in this study indicate that HIV prevalence may be considerably higher in this high-risk population than Salvadoran national rates.

Dickson-Gomez J; Bodnar G; Guevara A; Rodriguez K; Gaborit M. Crack use sites and HIV risk in El Salvador. Journal of Drug Issues 37(2): 445-473, 2007. (43 refs.)

"The Social Context of Crack Use and Related Sexual Risk in El Salvador" study was designed to increase knowledge of the locations where drugs are consumed in urban San Salvador, the social dynamics within such sites, and their implications for HIV risk and prevention efforts. In-depth interviews with crack smokers reveal several different types of sites where drugs are consumed and risky sex may occur including trances (generally houses where crack is sold and consumed), brothels, motels, drug users' own homes, abandoned buildings, the street, parks, or cantinas. These range from private sites, where site "gatekeepers" strictly control access, to public sites where access is more open. However, even in more public sites there is considerable social interaction, rules regarding site usage, and in some cases gatekeeper control of the site. Social dynamics already normative at drug use sites may support a site-based, peer-led intervention approach.

Draus PJ; Carlson RG. Change in the scenery: An ethnographic exploration of crack cocaine use in rural Ohio. Journal of Ethnicity in Substance Abuse 6(1): 81-107, 2007

Though still largely perceived as an "inner city" drug, crack cocaine has become increasingly available in many areas of the United States. However, little research has been conducted on the phenomenon of crack cocaine use outside of urban areas. This paper draws on qualitative interviews with 50 recent and former crack-cocaine users to explore patterns of use and distribution in three counties in rural Ohio. The findings show that variable patterns of crack use previously documented among urban crack users are evident in rural areas as well, though these are modified by the context of the rural small town. It is postulated that local social networks are the primary means by which these patterns are both transmitted and translated. Implications of these exploratory findings and possible directions for future research are discussed.

Edwards JM; Halpern CT; Wechsberg WM. Correlates of exchanging sex for drugs or money among women who use crack cocaine. AIDS Education and Prevention 18(5): 420-429, 2006. (27 refs.)

This study examined the correlates of trading sex for drugs or money among women who use crack cocaine. Using baseline data (n = 669) from a woman-focused HIV intervention study among African American women who use crack cocaine, we conducted logistic regression analysis to examine the odds of trading sex associated with distal and proximal factors. The results indicate that heavier crack use, homelessness, and unemployment are associated with trading sex. In addition, childhood abuse is associated with trading sex and this relationship is, in part, mediated by psychological distress. This suggests that distal factors may underlie the relationship between current variables and sex trading. These findings underscore the importance for public health interventions to address both distal and proximal factors that contribute to and/or co-occur with women's drug use which, in turn, may affect their HIV risk and overall well-being.

Falck RS; Wang J; Carlson RG. Among long-term crack smokers, who avoids and who succumbs to cocaine addiction? Drug and Alcohol Dependence 98(1/2): 24-29, 2008. (43 refs.)

Crack cocaine is a highly addictive drug. To learn more about crack addiction, long-term crack smokers who had never met the DSM-IV criteria for lifetime cocaine dependence were compared with those who had. The study sample consisted of crack users (n�=�172) from the Dayton, Ohio, area who were interviewed periodically over 8 years. Data were collected on a range of variables including age of crack initiation, frequency of recent use, and lifetime cocaine dependence. Cocaine dependence was common with 62.8% of the sample having experienced it. There were no statistically significant differences between dependent and non-dependent users for age of crack initiation or frequency of crack use. In terms of sociodemographics, only race/ethnicity was significant, with proportionally fewer African-Americans than whites meeting the criteria for cocaine dependence. Controlling for sociodemographics, partial correlation analysis showed positive, statistically significant relationships between lifetime cocaine dependence and anti-social personality disorder, attention deficit/hyperactivity disorder, and lifetime dependence on alcohol, cannabis, amphetamine, sedative-hypnotics, and opioids. These results highlight the importance addressing race/ethnicity and comorbid disorders when developing, implementing, and evaluating interventions targeting people who use crack cocaine. Additional research is needed to better understand the role of race/ethnicity in the development of cocaine dependence resulting from crack use.

Falck RS; Wang JC; Carlson RG. Crack cocaine trajectories among users in a midwestern American city. Addiction 102(9): 1421-1431, 2007. (62 refs.)

Aims: Although crack cocaine first appeared in cities in the United States in the mid-1980s, little is known about its use over long periods of time. This study identified crack cocaine user groups on the basis of long-term trajectories. Design: Following a natural history approach, data were collected periodically from 1996 to 2005. Group-based modeling assessed the probability of a crack smoker becoming abstinent during the observation period. Settings: A targeted sampling plan guided the recruitment of a community sample of crack cocaine users in Dayton, Ohio. Participants: Crack smokers (n = 430) 18 years or older whose urine tested positive for cocaine metabolites at the baseline interview. Measurements Interviewer-administered and audio computer self-administered, structured questionnaires were used to collect data on a range of variables, including frequency of crack use. Abstinence was defined as not having used crack for at least 6 consecutive months during the study. Findings: Three trajectory-based groups were identified: (1) No Change, characterized by a very low probability of abstinence; (2) Some Change, characterized by a low to moderate probability of abstinence; and (3) Dramatic Change, characterized by a high probability of abstinence. African Americans and men were significantly less likely to become abstinent. For the majority of the people (63.6%), crack use was uninterrupted by extended periods of abstinence during the study. Conclusion: Crack cocaine use that persists for a decade or longer may well be the norm for a large proportion of people who have experience with the drug.

Fischer B; Coghlan M. Crack use in North American cities: The neglected 'epidemic'. (editorial). Addiction 102(9): 1340-1341, 2007. (25 refs.)

Fischer B; Rehm J; Patra J; Kalousek K; Haydon E; Tyndall M et al. Crack across Canada: Comparing crack users and crack non-users in a Canadian multi-city cohort of illicit opioid users. Addiction 101(12): 1760-1770, 2006. (89 refs.)

Aims: To examine possible differences between crack users and crack non-users across Canada. Design: Cohort study of illicit opioid and other drug users in five cities across Canada. Setting: Vancouver, Edmonton, Toronto, Montreal and Quebec City, Canada. Participants Regular illicit opioid and other street drug users not in treatment at time of assessment. Measurements Participants (n = 677) were assessed at baseline (2002) by way of an interviewer-administered questionnaire, a psychiatric diagnostic instrument (Composite International Diagnostic Interview), and salivary antibody tests for infectious disease. Findings Approximately half the sample had used crack in the past 30 days, although prevalence rates differed strongly between study sites. When examined by discriminant analysis, crack users in the study population were more likely to have: no permanent housing, have illegal and sex work income, indicate physical health problems and hepatitis C virus (HCV) antibodies, use walk-in clinics, use heroin and to have been arrested and in detention (in past year). They were less likely to report depressive symptoms, and use Dilaudid (hydromorphone) and alcohol. Conclusion: These results illustrate crack users' pronounced social marginalization (as expressed by homelessness and high involvement in illegal activities) as well as extensive health problems compared to non-crack users in the Canadian context. The development of targeted interventions -- addressing the dynamics of social marginalization -- of this population is urgently needed.

Garrity TF; Leukefeld CG; Carlson RG; Falck RS; Wang JC; Booth BM. Physical health, illicit drug use, and demographic characteristics in rural stimulant users. Journal of Rural Health 23(2): 99-107, 2007. (30 refs.)

Context: There is growing concern about illicit rural stimulant use, especially regarding methamphetamine use and its health consequences. Purpose: The present study describes associations between aspects of stimulant use and illness experience in rural areas, with additional focus on the role of demographic characteristics in these associations. Methods: The research participants were 710 stimulant drug users who were recruited from rural areas of Arkansas, Kentucky, and Ohio using Heckathorn's respondent-driven sampling method. Health was measured by self-reports of perceived health and extent of current, recent, and lifelong health problems. Drug use was measured with self-reports of type and frequency of use. Findings: Several associations were found between drug use and illness, controlling for demographics. Stimulant use pattern related significantly with the sum of health problems in the previous 6 months and the sum of lifetime illness diagnoses, after adjustment for demographic factors. Extent of illicit drug use in the past month and self-perceived drug and alcohol problems were associated with several measures of health. Conclusions: In this sample of stimulant users, methamphetamine use was associated with fewer recent medical problems than crack cocaine, combined crack and powder cocaine use, and use of all 3 of these stimulants. These results, across the 3 sites, suggest that prevalent assumptions about the methamphetamine "plague" and its negative health consequences must be viewed cautiously and examined with additional research.

Golder S; Logan TK. Correlates and predictors of women's sex trading over time among a sample of out-of-treatment drugs abusers. AIDS and Behavior 11(4): 628-640, 2007. (73 refs.)

This research addressed two research questions: (a) controlling for crack use, what are the factors associated with women's engagement in ever having traded sex? and (b) controlling for crack use, what are the factors associated with women's engagement in sex trading in the past 90 days? The sample included 149 sexually active, crack using women selected from a subsample of participants in the Kentucky NIDA AIDS Cooperative Agreement. Bivariate analyses indicated that in addition to the pattern of crack use, 13 of the candidate variables were significantly related to sex trading, ever and 11 related to sex trading in the past 90 days. The multivariate models accounted for more than 40% of the variance in sex trading, ever and almost 59% of the variance in sex trading over the past 90 days. Suggestions for HIV /AIDS prevention and intervention among drug-involved women are discussed; implications for future research are suggested.

Gossop M; Manning V; Ridge G. Concurrent use of alcohol and cocaine: Differences in patterns of use and problems among users of crack cocaine and cocaine powder. Alcohol and Alcoholism 41(2): 121-125, 2006. (39 refs.)

Aim: To investigate differences in alcohol and drug consumption behaviours and related problems among users of cocaine powder versus crack cocaine. Methods: The sample of concurrent users of alcohol and cocaine (n = 102) was recruited from clinical and community (non-clinical) settings in London. Those recruited in the community were contacted by means of snowball sampling methods. Data were collected by means of face-to-face structured interviews. Results: Heavy drinking was common. There were differences in alcohol consumption between users of cocaine powder and crack cocaine. Cocaine powder users reported more frequent heavy drinking than crack users. Heavy drinking often involved drinking excessive amounts over prolonged periods. Crack cocaine users reported more serious problems associated with cocaine, other illicit drugs, psychological and physical health problems, and acquisitive crime. Conclusions: Frequent heavy drinking represents a serious risk to the health of many cocaine users. The differences in alcohol consumption patterns confirm the importance of distinguishing between use of cocaine powder and crack cocaine. Few of the sample had received treatment for cocaine or alcohol problems. Healthcare professionals working in primary care or accident and emergency settings may need to be trained to detect, assess, and respond to concurrent alcohol and cocaine problems.

Guindalini C; Vallada H; Breen G; Laranjeira R. Concurrent crack and powder cocaine users from Sao Paulo: Do they represent a different group? BMC Public Health 6(AR 10): ARTN 10, 2006. (27 refs.)

Background: Cocaine abuse is a serious and socially damaging illegal drug problem. Different routes of administration are associated with a specific progression of use, different degrees of abuse liability, propensity for dependence and treatment response. There have been relatively few studies comparing different cocaine users groups and no studies into the characterization of the group of individuals reporting concurrent use of powder cocaine and crack cocaine. Methods: Six hundred and ninety-nine cocaine users were assessed during the period August 1997 to October 1998 in one outpatient and six inpatient clinics located in the Sao Paulo, Brazil. Patients were interviewed using a structured questionnaire schedule in Portuguese, designed specifically for the Brazilian population. The statistical analyses were performed using either ANOVA or a chi-squared test and focusing on their preferred form of use/route of administration and other variables. Results: For 83% of the variables tested in this study, the Dual Users subgroup (using both powder and crack cocaine) demonstrated statistical differences from the single drug user subgroups. Those differences include the initiation of cocaine, the abuse of other illicit drugs, and rates of criminal history. Conclusion: These data suggest cocaine-dependent individuals who report use of both powder and crack cocaine are an at least partially, distinct subgroup. However, further studies will be necessary to confirm this and to determine if they also show a different treatment response.

Hartley RD; Maddan S; Spohn CC. Prosecutorial discretion: An examination of substantial assistance departures in federal crack-cocaine and powder-cocaine cases. Justice Quarterly 24(3): 382-407, 2007. (64 refs.)

Recently there has been a call for research that explores decision-making at stages prior to sentencing in the criminal justice process. Particularly research is needed under a determinate sentencing system where judicial dispositions are usually restricted by guidelines, which increases the importance of earlier decision-making stages. As an answer to this call, and in an attempt to build on currents studies on the effects of departures as an intervening mechanism, and a source of unwarranted disparity, this study explores federal sentencing data on offenders convicted of crack-cocaine and powder-cocaine offenses. Although decision-making of all criminal justice actors generally, and prosecutors specifically, has been the subject of much research, studies have yet to resolve the nature and outcome of their "autonomous" discretion. This autonomy becomes especially salient regarding prosecutorial decisions for substantial assistance departures. In deciding who receives a substantial assistance departure, the prosecutor has carte blanche power.

Henskens R; Garretsen H; Bongers I; Van Dijk A; Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: Compliance, outcome, and client satisfaction. Substance Use & Misuse 43(10): 1464-1475, 2008. (9 refs.)

In a randomized controlled trial the effectiveness of an outreach treatment program (OTP) was compared with standard addiction care services for hard-drug addicts in Rotterdam (The Netherlands). The study aimed at chronic, high-risk crack abusers who were insufficiently engaged in standard addiction treatment services. Data were collected from February 2000 to December 2001. A total of 124 subjects participated in the study at baseline. Follow-up data were available for 94 subjects. Outcome measures included treatment compliance, outcome, and satisfaction. Data were collected by means of monthly registrations, EuropAsi interviews and an evaluation form. There was a high compliance with OTP in the treatment group; the average length-of-stay was 6 months, with visits three times a week. Although both groups were well represented in standard care, participation was mainly based on methadone maintenance. Subjects treated in OTP showed significant improvements in physical health, general living conditions, and psychiatric status, but no change in employment, substance abuse, and legal status. The control group remained almost unchanged. Clients of OTP reported feeling very satisfied with their treatment. On-the-spot incentives and a positive relationship with the care provider were directly associated with treatment retention. An outreach treatment program, as conducted in this study, is associated with high compliance, general improvement, and treatment satisfaction. Characteristics of this treatment modality are (1) assertive outreach, (2) a mixed program with incentives, and (3) a strong focus on individual-bound therapy. Further research is needed with larger groups and similar conditions at baseline assessment.

Hsue PY; McManus D; Selby V; Ren XS; Pillutla P; Younes N et al. Cardiac arrest in patients who smoke crack cocaine. American Journal of Cardiology 99(6): 822-824, 2007. (15 refs.)

The aim of the study is to determine the clinical features and outcomes of cocaine users admitted to the hospital after cardiac arrest and compare them with nonusers. Cocaine is associated with cardiovascular complications, including ventricular arrhythmias; however, resuscitated cardiac arrest in relation to cocaine use is not a well-defined clinical entity. We reviewed available hospital charts at San Francisco General Hospital with the International Classification of Diseases, Ninth Revision diagnosis of cardiac arrest and cocaine use from 1994 to 2006. Clinical features and outcomes of cocaine users were compared with those of randomly selected control patients and age-matched controls with resuscitated cardiac arrest without cocaine use. We identified 22 patients with resuscitated cardiac arrest in the setting of cocaine use. Their average age was 42 +/- 10 years, > 20 years younger than nonusers (68 +/- 16 years, p < 0.01). After cardiac arrest, 12 of 22 patients (55%) who used cocaine had complete neurologic recovery in contrast to only 3 of 20 unmatched controls (15%, p < 0.01) and 7 of 41 age-matched controls (17%, p < 0.01). Only 10 of 22 cocaine users (46%) died compared with 15 of 20 unmatched controls (75%, p = 0.05) and 32 of 41 age-matched controls (78%, p < 0.01). In a combined analysis of all patients, cocaine use was the only significant predictor of neurologic recovery (p < 0.01) and survival (p < 0.01). In conclusion, cocaine use is associated with cardiac arrest. In patients with cardiac arrest, cocaine users are younger than nonusers and more likely to survive with neurologic recovery, even compared with age-matched controls with cardiac arrest.

Ilse J; Prinzleve M; Zurhold H; Haasen C; Cocaine EU-Team. Cocaine and crack use and dependence in Europe: Experts view on an increasing public health problem. Addiction Research & Theory 14(5): 437-452, 2006. (53 refs.)

Background: The spread of cocaine and crack use in Europe poses a challenge to the European health-care systems. The assessment of the extent of the problem as well as the support needs of the users require involving all relevant parties in research and future planning. Method: Within the framework of a European multi-center and multi-modal research project, experts of nine European cities were interviewed according to a standardised structural interview protocol. Results: Cocaine use is considered to be on the increase in Europe. The prevalence rates vary substantially between countries and the problem emerges in different target groups in distinct patterns of use. Although cocaine and crack specific risks can be diagnosed, health risks follow basically the general risks of illicit drug use. Proposals for future planning include the broadening of the existing services and the implementation of evidence-based approaches to the problem. Conclusion: In dealing with the cocaine problem in Europe, a comprehensive public health approach is appropriate. An overall strategy should include preventive, harm reductive as well as rehabilitative measures. Consequently, cross-national guidelines should be established and their implementation as well as evaluation should be monitored.

Kliewer W; Murrelle L. Risk and protective factors for adolescent substance use: Findings from a study in selected Central American countries. Journal of Adolescent Health 40(5): 448-455, 2007. (25 refs.)

Purpose: To identify the prevalence of substance use and problems with use, and risk and protective factors at different levels of the adolescent's ecology associated with substance use among adolescents in selected Central American countries. Methods: Results of a survey of 17,215 students from Panama, Costa Rica, and Guatemala conducted in 2000-2001 served as the basis for the analyses. Lifetime use of alcohol, tobacco, marijuana, and five other drugs (inhalants, tranquilizers, cocaine, crack, and ecstasy), and problems with drugs and alcohol were the outcome variables. Risk factors included dysregulation, family problems with drugs/alcohol, negative family interactions, school disengagement, peer deviance, and exposure to community violence. Protective factors included a personal belief in God, positive family interactions, parent religiosity, and positive student-teacher interaction. Both hierarchical linear regression and logistic regression analyses were used to model main and interaction effects of risk and protective factors. Results: There was a linear association between number of risk and protective factors and substance use, however, risk factors were more strongly associated with substance use than were protective factors. There were significant risk-by-protective-factor interactions for alcohol and marijuana use, and for problems with drugs and alcohol. Risk interacted most consistently with a personal belief in God, but also with parent religiosity and with student-teacher communication. Conclusions: It is important to consider risk and protective factors at different levels of an adolescent's ecology. Prevention and intervention efforts should focus on interactions adolescents have in different microsystems (e.g., with parents, teachers, and peers).

Kouimtsidis C; Padhi A. A case of late-onset dependence on cocaine and crack. Addiction 102(4): 666-667, 2007. (4 refs.)

Aims: To raise awareness among the professional clinical and research community of the risk of cocaine misuse among elderly patients. Methods: Case report of a male patient, aged 72 years, who presented to a community substance misuse service with cocaine use disorder (hydrochloride and base form). Results The development of the disorder was marked by high levels of cocaine (and later crack cocaine use), repeated periods of abstinence followed by relapse in the past 4 years, with severe consequences to the patient and his family. Treatment involved a close collaboration between several specialist addictions and old-age psychiatry teams in National Health Service. Implications: Although dependence on cocaine among the elderly is considered very rare, clinical management can be challenging and is likely to require the involvement of several specialist and general health services.

Leonard L; DeRubeis E; Pelude L; Medd E; Birkett N; Seto J. "I inject less as I have easier access to pipes" - Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed. International Journal of Drug Policy 19(3): 255-264, 2008. (35 refs.)

Among injection drug users (IDUs) in Ottawa, the capital of Canada, prevalence rates of HIV (20.6 percent) and hepatitis C HCV (75.8 percent) are among the highest in Canada. Recent research evidence suggests the potential for HCV and HIV transmission through the multiperson use of crack-smoking implements. On the basis of this scientific evidence, in April 2005, Ottawa's needle exchange programme (NEP) commenced distributing glass stems, rubber mouthpieces, brass screens, chopsticks, lip balm and chewing gum to reduce the harms associated with smoking crack. This study aims to evaluate the impact of this initiative on a variety of HCV- and HIV-related risk practices. Active, street-recruited IDUs who also smoked crack consented to personal interviews and provided saliva samples for HCV and HIV testing at four time points: 6-months pre-implementation (N= 112), 1-month (N= 114), 6-months (N= 157) and 12-months (N = 167) post-implementation. Descriptive and univariate analyses were completed. Following implementation of the initiative, a significant decrease in injecting was observed. Pre-implementation, 96 percent of IDUs reported injecting in the month prior to the interview compared with 84 percent in the 1 month, and 78 percent in the 6- and 12-month post-implementation interviews (p <.01). Conversely, approximately one-quarter of participants at both the 6- and 12-month post-implementation evaluation points reported that they were smoking crack more frequently since the availability of clean equipment-25 and 29 percent, respectively. In addition to a shift to a less harmful method of drug ingestion, HCV- and HIV-related risks associated with this method were reduced. Among crack-smoking IDUs sharing pipes, the proportion sharing "every time" declined from:37 percent in the 6-month pre-implementation stage, to 31 percent in the 1-month, 12 percent in the 6-month and 13 percent in the 12-month post-implementation stages (p <.01). Since distributing safer crack-smoking materials by a NEP contributes to transition to safer methods of drug ingestion and significantly reduces disease-related risk practices, other NEPs should adopt this practice.

Malchy L; Bungay V; Johnson J. Documenting practices and perceptions of 'safer' crack use: A Canadian pilot study. International Journal of Drug Policy 19(4): 339-341, 2008. (19 refs.)

Background: People who smoke crack cocaine have a distinct social profile when compared to other drug user groups (e.g., injection drug users), may be at increased risk for particular health problems and experience unique social harms as a consequence of their crack use. In particular, they are exposed to dangers associated with unsafe crack pipe use and lack resources to enable safer consumption practices. The objectives of this pilot study were to determine the current practices of people who smoke crack in Vancouver and to discover common attitudes towards the modification of crack smoking practices in the direction of safer crack use. Methods: Members of a community coalition administered a short survey to street-entrenched crack cocaine users regarding their smoking equipment, their current crack smoking practices, the physical consequences of smoking crack and their attitudes towards safer crack use. Results: Most respondents engaged in 'unsafe' crack use practices and experienced harmful consequences associated with crack use. Those who shared their equipment were at higher risk for experiencing these harmful consequences. Conclusion: The information from this study suggests that strategies aimed at reducing the harms associated with crack use, as well as safer crack use education and programming, should be incorporated into substance misuse interventions, disease prevention and health promotion policy, and that further research about these issues is needed.

Manzoni P; Fischer B; Rehm J. Local drug-crime dynamics in a Canadian multi-site sample of untreated opioid users. Canadian Journal of Criminology and Criminal Justice 49(3): 341-373, 2007. (84 refs.)

This multi-site study analysed self-reported involvement in property crime, drug dealing, and sex work, across five Canadian cities, among a sample of 677 illicit opioid and other drug users outside of treatment. First, we assessed drug-use patterns and the extent of illegal income-generating behaviour for each city. We then analysed factors and city interactions contributing to engagement in the respective criminal activities, including drug-use patterns, socio-economic characteristics, and other illegal activities. With this approach we explored city-specific patterns of crime prediction; thus we identified local drug-crime associations. The study sample was recruited by outreach and snowball methods and was assessed by standardized study protocols. Findings revealed substantial differences among the cities regarding both the extent and frequency of illegal activities. In regard to local differences, multiple logistic regression models revealed that crack use was strongly associated with property crime in Toronto, while cocaine use was strongly related with sex work in Montreal and Quebec City. This evidence points to local dynamics of drug cultures that are related to specific criminal activities. Implications for further research and intervention efforts are discussed.

Maxwell JC; Cravioto P; Galvan F; Ramirez MC; Wallisch LS; Spence RT. Drug use and risk of HIV/AIDS on the Mexico-USA border: A comparison of treatment admissions in both countries. Drug and Alcohol Dependence 82(Supplement 1): s85-s93, 2006. (55 refs.)

This study analyzes trends in treatment admissions and summarizes HIV/AIDS risk factors along the US-Mexican border. Data are presented at the national level and at the state level for states along the border. Client data also are compared for treatment programs located in sister cities on the Texas-Mexico border. These data show that methamphetamine admissions are increasing nationally and methamphetamine use is a major problem in the western states on both sides of the border. Use of lee (smoked methamphetamine) has increased significantly. Use of crack (smoked cocaine) is a growing problem on the border, and injection is the primary route for using black tar heroin in this area. Each of these drugs is a risk factor, either from drug-influenced risky sexual behaviors or from sharing injection equipment. In addition, the availability of drugs on the border and patterns of risky behaviors among migrants mean that drug users on the border are at risk of HIV/AIDS, and this risk is expected to increase with the spreading methamphetamine epidemic and smoking of crack cocaine. Comparable data on HIV/AIDS are needed for further studies of the relationship of drug use and HIV/AIDS on the border.

Mistral W; Wilkinson S; Mastache C; Midgley S; Law F. Efficacy of naltrexone treatment with combined crack and opiate users: A descriptive study of a new treatment service in Bristol, UK. Drugs: Education, Prevention and Policy 15(1): 107-119, 2008. (34 refs.)

Naltrexone has been shown to be clinically effective in treating opioid dependence, although there are reports that it may be unsafe in treatment of unselected cases. Although there are no generally accepted pharmacological treatments for crack cocaine addiction alone, there is evidence that naltrexone can be useful in cases of concurrent cocaine and heroin use. In 2005 Bristol Specialist Drug Service initiated a naltrexone treatment programme targeted at pre-release offenders using both crack cocaine and heroin. Of 172 referrals, only 51 (30%) were inducted into treatment, and only 16% of these were retained at 3 months, and 4% at 9 months. There was evidence to support induction in prison, as 90% of those who were inducted there continued treatment on release. An integrated approach between criminal justice and community services is of primary importance in getting users into treatment. Interviews highlighted that the environment outside of prison can trigger relapse, and that community clinics need to separate clients on an abstinence programme from those who continue to use. Of clients interviewed, 52% reported that they use heroin to mitigate severe come down from crack, and it is suggested that naltrexone may be of use for these specialized combined users.

Monga N; Rehm J; Fischer B; Brissette S; Bruneau J; El-Guebaly N et al. Using latent class analysis (LCA) to analyze patterns of drug use in a population of illegal opioid users. Drug and Alcohol Dependence 88(1): 1-8, 2007. (62 refs.)

Background: The objective of this paper is to empirically determine a categorization of illegal opioid users in Canada in order to describe and analyze drug use patterns within this population. Methods: Drug use patterns of 679 eligible illegal opioid users outside treatment from the OPICAN study, a pan-Canadian cohort (recruited March to December, 2002) involving the cities of Toronto, Montreal, Vancouver, Edmonton and Quebec City, were empirically examined using latent class analysis. These latent classes were then further analyzed for associations using chi-square and t-test statistics. Findings: The opioid and other drug user sample surveyed were categorized into three latent classes. Class I (N=256) was characterized by the use of Tylenol 3 and benzodiazepines along with high levels of depression and self-reported pain. Class 2 (N=68) was described by the non-injection use of both heroin and crack while having a high level of homelessness. Class 3 (N=344) was shown to consist of injection drug users of heroin and cocaine exhibiting the highest levels of HIV and Hepatitis C infections amongst the classes. Conclusions: Using latent class analysis we found distinct patterns of drug use amongst illegal opioid users differing in terms of type of drugs co-used, social context, and co-morbid pathologies. These data may be useful as the empirical basis for the planning of specific prevention and treatment interventions.

Nelson BK. Adding fuel to the fire: United States v. Booker and the crack versus craack versus powder cocaine sentancing disparity. University of Richmond Law Review 40: 1161-1191, 2006. (256 refs.)

The sentencing structures for crack and powder cocaine have been dramatically different since the Anti-Drug Abuse Act of 1986 established a 100:1 ratio as the penalty differential between the two drugs, and set the same punishment for five grams of crack as for five hundred grams of powder cocaine. The ratio was followed in the Federal Sentencing Guidelines (the "Sentencing Guidelines") and has evoked considerable criticism over the past twenty years. Litigants have challenged the ratio in courts, judges have expressed their displeasure with the ratio, and the United States Sentencing Commission (the "Sentencing Commission" or the "Commission") has issued three reports to Congress disapproving of the ratio. Still, offenders have been consistently sentenced according to the once mandatory Sentencing Guidelines following the ratio. In January 2005, the Supreme Court handed down its decision in United States v. Booker, 5 effectively rendering the Sentencing Guidelines advisory instead of mandatory, as they once were. Although the 100:1 ratio lives on in the mandatory minimums, the Sentencing Guidelines would often provide for a sentence harsher than the mandatory minimum. Now, courts have the flexibility to depart from the Sentencing Guidelines when dealing with the crack/powder disparity. The courts may use a lower ratio, as the Sentencing Commission and numerous scholars and judges have suggested, provided that they still abide by the mandatory minimum set forth in 18 U.S.C. 3553(a). In order to understand fully where the Booker decision leaves us with respect to the crack/powder debate, it is necessary to understand the background of cocaine and the history leading up to Booker. To that end, Part II of this comment discusses the history and background of cocaine, including a brief history of drug use, a comparison of crack and powder cocaine, the formation of the 100:1 ratio, and responses to the ratio's formation since 1986. Part III analyzes the topic of sentencing without guidelines, sentencing after the imposition of the Sentencing Guidelines, and the erosion of the Guidelines leading up to Booker. Part IV then combines the two broad topics and analyze the impact that the Booker decision will likely have on the ongoing debate over the penalties for crack and powder cocaine. It will explain how the decision adds more momentum to the debate, and argue that it adds enough fuel to the fire to encourage changes to the current penalty structure.

Pallonen UE; Timpson SC; Williams ML; Ross MW. Stages of consistent condom use, partner intimacy, condom use attitude, and self-efficacy in African-American crack cocaine users. Archives of Sexual Behavior 38(1): 149-158, 2009. (49 refs.)

This study examined how condom use attitude, self-efficacy, and partner intimacy related to five stages of consistent condom use. Interview data were collected from sexually active, heterosexual, African-American crack cocaine smokers (N = 366). Dependent measures assessed both the participants' own responses and their perceptions about their last sex partner's own personal condom use attitude and participants' condom use self-efficacy expectations. Partner intimacy was assessed both as a continuous attitudinal and as a discrete relationship measure. Less than 10% were classified as consistent condom users. Two thirds of inconsistent users were in the Precontemplation (PC) stage. The contemplation (C) and preparation (P) stages were equal among the remainder of the inconsistent condom users. Higher partner intimacy reduced modestly readiness for consistent condom use. The stage but not the intimacy group was related to the condom use attitudes and self-efficacy measures. Last partners' perceived own negative attitudes were significantly related to the stages of consistent condom use and was especially low in the action (A) and maintenance (M) stages. Participants' own negative attitudes were unrelated to the stages. Of the self-efficacy measures, both participants' performance and situational condom use self-efficacies increased significantly after the PC stage and were highest in the P, A, and M stages. However, situational self-efficacy accounted for most of performance self-efficacy variance. In sum, consistent condom use was rare. A partner's attitudes and the participants' own situational self-efficacy expectations, rather than intimacy, determined the readiness to adopt consistent condom use.

Pechansky F; Kessler FHP; von Diemen L; Bumaguin DB; Surratt HL; Inciardi JA. Brazilian female crack users show elevated serum aluminum levels. Revista Brasileira de Psiquiatria 29(1): 39-42, 2007. (11 refs.)

Objective: There is no information in the literature on the impact of crack smoking using crushed aluminum cans as makeshift pipes, a common form of crack use in Brazil, Since aluminum intake is associated with neurological damage, we measured serum aluminum levels in crack smokers. The objective of this study was to ascertain the levels of aluminum in crack users who smoke on makeshift aluminum pipes. Method: 71 female crack smokers, their mean age being 28.0 (+/- 7.7), provided information about their drug use, and had blood samples tested for serum aluminum level. Results: 56 (79%) subjects smoked crack from crushed can pipes, while 15 (21%) smoked from other containers. Fifty-two (73.2%) out of the 71 subjects presented a serum aluminum level of 2 mu g/l and 13 (18.3%) had a serum aluminum level of 6 mu g/l cut-off point, which is above the reference value. When compared to non-drug users matched by their mean age and gender, they had similar median values and interquartile, ranges for serum aluminum level [3 (2-4.6) for crack smokers; 2.9 (1.6-41) for controls], but with different means and standard deviations (4.7 +/- 4.9 and 2.9 +/- 1.7, respectively). Discussion: Crack smokers have high serum aluminum level, but we are unsure of its complete association with aluminum cans. Further studies are needed. If such association is proven true in future research, further issues will be raised in dealing with this important disorder including proper planning and evaluation of public health policies in this area.

Pechansky F; Woody G; Inciardi J; Surratt H; Kessler F; Von Diemen L; Bumaguin DB. HIV seroprevalence among drug users: An analysis of selected variables based on 10 years of data collection in Porto Alegre, Brazil. Drug and Alcohol Dependence 82(Supplement 1): s109-s113, 2006. (22 refs.)

Data from five studies were pooled to describe associations between drug use and HIV The Risk Assessment Battery in Porto Alegre, Brazil, was used to collect data from 1449 subjects in 5 separate studies conducted between 1995 and 2004. The subjects were divided into categories based on their pattern of drug use: (1) injection drug users (IDUs), (2) crack smokers, (3) frequent drug users, and (4) infrequent cocaine/alcohol/marijuana users. The sample consisted primarily of young males with low education and income levels. Half of the subjects reported frequent condom use, and exchanges. involving drugs, sex, and money were infrequent (although more common in groups 1 and 2). The overall seroprevalence was 20.6%, and the prevalence was different across the four groups, showing a linear decrease from group 1 (57.1%) to group 4 (11.7%). The IDU and crack-smoking groups showed similarities in their risk levels when compared with the other two groups, and individuals in groups 1, 2, and 3 were more likely to report having had four or more sex partners. After controlling for all other risk factors, IDU, males having sex with males, and crack use were highly associated with HIV (OR 7.30, 95%CI: 5.10,10.40; OR 3.04, 95%CI: 1.89,4.80; OR 2.03, 95%CI: 1.40,2.92, respectively). The findings confirm that poverty, low education, and IDU remain risk factors for HIV in Porto Alegre, Brazil, and the study identifies crack smoking as a new risk factor.

Peters RJ; Williams M; Ross MW; Atkinson J; Yacoubian GS. Codeine cough syrup use among African-American crack cocaine users. Journal of Psychoactive Drugs 39(1): 97-102, 2007. (17 refs.)

While studies show evidence of a clear problem with the prevalence of crack cocaine and codeine cough syrup use separately, the relationship between these substances of abuse and concurrent polydrug use is unknown. In an attempt to ascertain beyond anecdotal evidence, the authors carried out a cross-sectional study among 482 African-American crack users to investigate the differences between those who were concurrently codeine cough syrup users and those who were not codeine cough syrup users in Houston, Texas. Logistic regression indicated that codeine use was significantly associated with lower participant age and lower education; codeine cough syrup users were significantly more likely than nonusers to not have a main sexual partner. In addition, codeine users had significantly higher odds of ever trading sex for money, marijuana use, and fry use. These findings are important in determining the "cultural novelties" relative to crack and codeine use among younger African Americans.

Peters RJ; Williams M; Ross MW; Atkinson J; McCurdy SA. The use of fry (embalming fluid and PCP-laced cigarettes or marijuana sticks) among crack cocaine smokers. Journal of Drug Education 38(3): 285-295, 2008. (18 refs.)

Statistics show that the prevalence of crack cocaine use and embalming fluid and phencyclidine (PCP)-laced cigarettes or marijuana sticks, commonly referred to on the street as "fry" or "wet" is a problem; however, the relationship between these substances of abuse and concurrent polydrug use is unknown. In the present study, a cross-sectional survey was conducted among 426 African-American crack users in Houston, Texas, to investigate the difference between those who concurrently reported lifetime (defined as at least one usage of fry in life) fry use and those who stated they never used fry. The data were analyzed using chi-square and logistic regression analyses. Fry users were significantly more likely than non-users to not have a casual sex partner (92% users vs. 84% non-users, p <= 0.05) and were more likely to have been diagnosed with gonorrhea in the past 12 months (9% users vs. 2% non-users, p <= 0.05). In addition fry users had significantly higher odds of currently trading sex for drugs (OR = 2.30, p <= 0.05), marijuana use (OR = 12.11, p <= 0.05), and codeine (syrup) use (OR = 8.10, p <= 0.05). These findings are important in determining the "cultural novelties" relative to crack and fry use among younger African Americans.

Reid SD. Poor educational attainment and sexually transmitted infections associated with positive HIV serostatus among female in-patient substance abusers in Trinidad and Tobago. Drug and Alcohol Dependence 82(Supplement 1): s81-s84, 2006. (22 refs.)

Female crack cocaine users are at high risk for HIV infection. Data from 121 female substance abusers admitted to an all-female rehabilitation center in Trinidad and Tobago between 1996 and 2002 were reviewed retrospectively to determine: human immunodeficiency virus (HIV) seroprevalence and associated risk factors. HIV seroprevalence was 19.8%, which is six times higher than in the general population. The univariate analysis identified the following factors associated with HIV infection: poor educational attainment, history of a sexually transmitted infection (STI), and use of crack cocaine. In the multivariate: analysis, only poor educational attainment and history of an STI were independently associated with HIV seroprevalence. Female substance abusers, especially female crack cocaine users, are at high risk of acquiring and transmitting the HIV virus. To reduce risk of HIV infection, rehabilitation programs should address risky sexual behaviors and screen for STIs, and they also should improve educational attainment, develop skills, and provide vocational training.

Restrepo CS; Carrillo JA; Martinez S; Ojeda P; Rivera AL; Hatta A. Pulmonary complications from cocaine and cocaine-based substances: Imaging manifestations. Radiographics 27(4): 941-U13, 2007. (75 refs.)

Cocaine is the illicit drug whose abuse most often results in cardiopulmonary symptoms and emergency treatment. Habitual smoking of alkaloidal cocaine ("freebase," "crack") has replaced nasal insufflation as the most common method of abuse. Smoking of cocaine exposes the lung directly to the volatilized drug as well as to the other combustion products of the smoked mixture, thereby increasing the risk of adverse pulmonary effects. A wide variety of pulmonary complications including interstitial pneumonitis, fibrosis, pulmonary hypertension, alveolar hemorrhage, asthma exacerbation, barotrauma, thermal airway injury, hilar lymphadenopathies, and bullous emphysema may be associated with the inhalation of crack cocaine or of associated substances such as talc, silica, and lactose. Cocaine abuse represents one of the most serious medical and social problems of our time. Radiologists should be familiar with the various pleuropulmonary complications associated with the abuse of illicit drugs in general and of cocaine in particular to ensure correct diagnosis and appropriate treatment planning in patients with respiratory manifestations associated with such abuse.

Rhodes T; Briggs D; Kimber J; Jones S; Holloway G. Crack-heroin speedball injection and its implications for vein care: Qualitative study. Addiction 102(11): 1782-1790, 2007. (49 refs.)

Background: We report on an exploratory qualitative study investigating drug injectors' narratives of vein damage and groin (femoral vein) injection associated with the injection of crack-heroin speedball. Methods: We undertook 44 in-depth qualitative interviews among injectors of crack-heroin speedball in Bristol and London, England, in 2006. Findings: The data suggest an emerging culture of crack-based speedball injection. Injectors' narratives link speedball injection with shifts towards groin injection articulated as an acceptable risk, and not merely as a last resort in the face of increased vein deterioration associated with speedball. Accounts of vein damage linked to speedball emphasize 'missed hits' related to the local anaesthetic action of crack, the excess use of citric in the preparation of speedball injections and 'flushing' when making a hit. We find that groin injection persists despite an awareness of health risks and medical complications. Conclusions We emphasize an urgent need for reviewing harm reduction in relation to vein care in the context of shifts to crack-based speedball injection, and the use of the femoral vein, among UK injectors. There is an additional need for interventions to promote safer groin and speedball injecting as well as to prevent transitions toward groin and crack injection.

Rhodes T; Stoneman A; Hope V; Hunt N; Martin A; Judd A. Groin injecting in the context of crack cocaine and homelessness: From 'risk boundary' to 'acceptable risk'? (editorial). International Journal of Drug Policy 17(3): 164-170, 2006. (37 refs.)

Drawing on data from recent surveys and pilot qualitative interviews among injecting drug users (IDUs) in England, we highlight the potential 'normalisation' of the use of the femoral vein (groin) as a site of injection. We estimate that 45% (428/952) of IDUs in English cities report groin injecting in the last 4 weeks, rising to over 50% in some areas. We also note transitions towards the injection of crack cocaine among poly drug injectors in some UK locations. We estimate that 40% (381/952) of IDUs in English cities report crack injection in the last 4 weeks, rising to over 70% in some cities. Findings from pilot qualitative interviews among homeless injectors in London are suggestive of groin injecting being situated as an 'acceptable risk'. We emphasise the need for research to explore the potential interplay between unstable housing, groin injecting and crack injecting. We call for renewed emphasis within harm reduction interventions advising injectors how to maximise the health and longevity of arm and other peripheral veins, and for greater preparedness to advise known groin injectors how to minimise health risks associated with groin injecting.

Ribeiro M; Dunn J; Sesso R; Dias AC; Laranjeira R. Causes of death among crack cocaine users. Revista Brasileira de Psiquitatria 28(3): 196-202, 2006. (91 refs.)

Objective: The study accompanied 131 crack-cocaine users over a 5-year period, and examined mortality patterns, as well as the causes of death among them. Method: All patients admitted to a detoxification unit in Sao Paulo between 1992 and 1994 were interviewed during two follow-up periods: 1995-1996 and 1998-1999. Results: After 5 years, 124 patients were localized (95%). By the study endpoint (1999), 23 patients (17.6%) had died. Homicide was the most prevalent cause of death (n = 13). Almost one third of the deaths were due to the HIV infection, especially among those with a history of intravenous drug use. Less than 10% died from overdose. Conclusions: The study suggests that the mortality risk among crack cocaine users is greater than that seen in the general population, being homicide and AIDS the most common causes of death among such individuals.

Ribeiro M; Dunn J; Sesso R; Lima MS; Laranjeira R. Crack cocaine: A five-year follow-up study of treated patients. European Addiction Research 13(1): 11-19, 2007. (29 refs.)

Objectives: To follow-up a group of 131 crack cocaine users and examine drug use, treatment experience, employment status, involvement in crime and mortality at 2 and 5 years. Methods: Consecutive crack-dependent patients who were admitted to a detoxification unit in Sao Paulo between 1992 and 1994 were re-interviewed on two occasions: 1995-1996 and 1998-1999. Results: 5 years after treatment information was obtained on 124 (95%) of the original cohort. 39.7% (n = 52) of the patients reported having been abstinent from cocaine for at least the last year, and 21.4% (n = 28) had used the drug. Of those subjects not using cocaine at 2 years, 19 (62%) were still abstinent at 5 years. Twenty-three (17.6%) patients had died by the 5-year follow-up with homicide, due to firearms or other weapons, being the commonest cause ( n = 13). The annual adjusted mortality rate for the sample was 24.92 deaths/1,000 individuals, the excess mortality rate was of 21.64 deaths/1,000 individuals, and the standardized mortality ratio was 7.60. A history of injecting drug use, unemployment at the time of the index admission and administrative discharge at the index admission were factors that contributed to the risk of dying over the next 5 years. Conclusions: There was a progressive movement towards abstinence over the follow-up period, and there was evidence that once abstinence had been achieved it was maintained. On the other hand, the mortality rate was extremely high and was higher among those who were still using crack at 2 years.

Richardson GA; Goldschmidt L; Larkby C. Effects of prenatal cocaine exposure on growth: A longitudinal analysis. Pediatrics 120(4): e1017-e1027, 2007. (58 refs.)

OBJECTIVE. There has been a limited amount of research on the long-term effects of prenatal cocaine exposure on growth of the infant, and there has been no use of longitudinal growth models. We investigated the effects of prenatal cocaine exposure on offspring growth from 1 through 10 years of age by using a repeated-measures growth-curve model. METHODS. Women were enrolled from a prenatal clinic and interviewed at the end of each trimester of pregnancy about their cocaine, crack, alcohol, marijuana, tobacco, and other drug use. Fifty percent of the women were white, and 50% were black. Follow-up assessments occurred at 1, 3, 7, and 10 years of age. RESULTS. Cross-sectional analyses showed that children exposed to cocaine during the first trimester (n = 99) were smaller on all growth parameters at 7 and 10 years, but not at 1 or 3 years, than the children who were not exposed to cocaine during the first trimester (n = 125). The longitudinal analyses indicated that the growth curves for the 2 groups diverged over time: children who were prenatally exposed to cocaine grew at a slower rate than children who were not exposed. These analyses controlled for other factors associated with child growth. CONCLUSIONS. To our knowledge, this is the first study of the long-term effects of prenatal cocaine exposure to conduct longitudinal growth-curve analyses using 4 time points in childhood. Children who were exposed to cocaine during the first trimester grew at a slower rate than those who were not exposed. These findings indicate that prenatal cocaine exposure has a lasting effect on child development.

Riehman KS; Wechsberg WM; Zule W; Lam WK; Levine B. Gender differences in the impact of social support on crack use among African Americans. Substance Use & Misuse 43(1): 85-104, 2008. (54 refs.)

This article examines the influence of social support on crack use in a sample of 435 African American out-of-treatment crack users recruited through street outreach in Raleigh, North Carolina, between 2000 and 2002. Multivariate regression models indicated that social support was not a strong influence on crack use. For women, no social support variables predicted crack use, whereas for men, having a non-using partner was negatively associated with crack use. Findings indicate that existing social support is not strongly linked to drug use among African Americans, but African American men may be positively influenced by non-using sexual partners. Limitations of the sample and data are discussed. Further research is needed on the influence of social support for African American drug-using populations.

Risser JMH; Timpson SC; McCurdy SA; Ross MW; Williams ML. Psychological correlates of trading sex for money among African American crack cocaine smokers. American Journal of Drug and Alcohol Abuse 32(4): 645-653, 2006. (14 refs.)

This article compares demographic characteristics, sexual practices, and psychosocial status among 193 African American female crack cocaine users who currently, previously, or never traded sex for money. Current traders were less likely to have a main sexual partner, more likely to have a casual sexual partner, and more likely to smoke larger quantities of crack. There was a significant trend towards current traders reporting lower self-esteem, greater depression and anxiety, poorer decision-making confidence, more hostility, less social conformity, greater risk taking behaviors, and more problems growing up, compared to previous and never traders. These differences suggest that interventions should address self-esteem, risk-taking practices, depression and anxiety as well as other psychosocial factors.

Ross MW; Risser J; Peters RJ; Johnson RJ. Cocaine use and syphilis trends: Findings from the arrestee drug abuse monitoring (ADAM) program and syphilis epidemiology in Houston. American Journal on Addictions 15(6): 473-477, 2006. (26 refs.)

There has been speculation that trends in syphilis have been fueled by crack cocaine use. This study examined the data on syphilis notifications and arrestee drug abuse monitoring ( ADAM) to ascertain the relationships between syphilis and cocaine use trends in three racial/ethnic groups. Syphilis notifications and data from the ADAM project were compared in Houston/Harris County, Texas, from 1991-1998 using a linear regression equation. Data indicated significant relationships between the data for cocaine use and syphilis in African Americans but not Hispanics or non-Hispanic whites. For African Americans, 58% of the variance between cocaine use and syphilis was explained. When data limited to jail syphilis notifications and ADAM cocaine in African Americans were examined, the association was stronger for males than for females. For African Americans, cocaine (probably crack cocaine) use trends were significantly associated with syphilis trends in this population. These data suggest that control of crack cocaine may have an impact on syphilis rates and that there may be close relationships between some STDs and drug abuse.

Ross MW; Timpson SC; Williams ML; Bowen A. The impact of HIV-related interventions on HIV risk behavior in a community sample of African American crack cocaine users. AIDS Care 19(5): 608-616, 2007. (54 refs.)

While there are reports of the impact of specific interventions designed to reduce HIV drug and sexual risk behaviors, there are few reports of the impact of HIV interventions in a community-based sample. We report on baseline data from a sample of African American crack smokers who were about to participate in an intervention designed to reduce HIV-related risk behaviors. The majority were male ( 80%), single ( 70%) and homeless ( 52%). Data indicated that 29% of the sample had been in a previous HIV intervention in the past 12 months, the majority in a correctional setting or CBO program. There were few systematic demographic differences between the two groups. Those who had been in an intervention reported using male and female condoms significantly more frequently on all measures of condom use, had positive condom use outcome expectations for male condoms and higher affective and situational condom-related self-efficacy beliefs. These data suggest that, at a community level, the spectrum of HIV risk-reduction programs does produce a significant improvement in condom use and related cognitions, although there is a need to cover a greater proportion of the population. Previous exposure to interventions must be a critical covariate in assessing the impact of future interventions.

Sanchez ZVDM; Nappo SA. From the first drug to crack: The sequence of drugs taken in a group of users in the city of Sao Paulo. Substance Use & Misuse 42(1): 177-188, 2007. (14 refs.)

To identify a progression in drug use and influencing factors among crack users, a qualitative methodology was used for a more in-depth investigation, taking into consideration the view that the interviewee has of the problem. A long duration and a semi-structured interview was used; a purposeful sampling was outlined and a criterion sampling was achieved. Thirty-one crack users or ex-users were interviewed in order to reach theoretical saturation. Two distinct phases of drug use were detected. The first, with licit drugs, where alcohol and tobacco were the most frequent, the relatives and friends were the ones who encouraged use, and the need for self-assurance was the reason most often reported. The early start and the "heavy use" of one or both drugs were determinant for the beginning of a progression towards illicit drugs. Marijuana was the first drug of the second phase. A stronger attitude for the search of a drug as a source of pleasure replaced the reason previously stated. The study reveals that the progression in drug use seems to be associated more with external decisions (e.g., peer pressure, dealing influence, etc.) than to the preference of the user. Two different progressions were identified: among the younger (<30): tobacco and/or alcohol, marijuana, snorted cocaine, and crack, and among the older (>30): tobacco and/or alcohol, marijuana, intravenous medication, snorted cocaine, intravenous cocaine, and crack. This pilot study's findings are limited in generalizability to its sample. Further research is needed.

Sawyer KM; Wechsberg WM; Myers BJ. Cultural similarities and differences between a sample of Black/African and colored women in South Africa: Convergence of risk related to substance use, sexual behavior, and violence. Women & Health 43(2): 73-92, 2006. (29 refs.)

South Africa is one of the six southern African countries where the HIV levels for childbearing women are 20% or higher. We conducted two focus groups aimed at developing an understanding of the intersections of substance abuse, sexual behavior, and violence affecting the lives of women of color in Cape Town, South Africa. Both Colored and Black/African participants reported using cannabis, methaqualone, and alcohol, although they differed on other drugs used. Black/African women also used heroin, and crack cocaine, whereas Colored women used methamphetamines. For participants in both groups, relationships with men affected sexual and substance use risk behaviors. Although the Black/African women did not trust men to use condoms, the Colored women in the study believed that almost all men use condoms. Both groups of women reported high rates of violence, with Colored participants reporting more gang violence and woman-on-woman violence compared with Black/African participants. The paper discusses these issues, as well as the implications for adapting a culturally specific, brief woman-focused HIV prevention intervention for the South African context.

Scheinmann R; Hagan H; Lelutiu-Weinberger C; Stern R; Des Jarlais DC; Flom PL et al. Non-injection drug use and hepatitis C virus: A systematic review. (review). Drug and Alcohol Dependence 89(1): 1-12, 2007. (47 refs.)

This systematic review examined the evidence on the prevalence of the Hepatitis C Virus (HCV) in non-injecting drug users (NIDUs) who sniff, smoke or snort drugs such as heroin, cocaine, crack or methamphetamine. The search included studies published from January 1989 to January 2006. Twenty-eight eligible studies were identified and the prevalence of HCV in these NIDU populations ranged from 2.3 to 35.3%. There was substantial variation in study focus and in the quality of the NIDU data presented in the studies. The results of our systematic review suggested that there are important gaps in the research of HCV in NIDUs. We identified a problem of study focus; much of the research did not aim to study HCV in users of non-injection drugs. Instead, NIDUs were typically included as a secondary research concern, with a principal focus on the problem of transmission of HCV in IDU populations. Despite methodological issues, HCV prevalence in this population is much higher than in a non-drug using population, even though some IDUs might have inadvertently been included in the NIDU samples. These studies point to a real problem of HCV in NIDU populations, but the causal pathway to infection remains unclear.

Schonnesson LN; Atkinson J; Williams ML; Bowen A; Ross MW; Timpson SC. A cluster analysis of drug use and sexual HIV risks and their correlates in a sample of African-American crack cocaine smokers with HIV infection. Drug and Alcohol Dependence 97(1-2): 44-53, 2008. (48 refs.)

The purpose of this cross-sectional study was to classify a sample of HIV-seropositive African-American crack cocaine smokers into homogenous HIV drub use and sexual risk groups using a two step multivariate cluster analysis. Two hundred and fifty-eight crack cocaine smokers participated in the study. Cluster analysis revealed three distinct HIV risk groups. The highest risk group, the largest one, was characterized by frequent, daily crack use, multiple sex partners, trading sex, and inconsistent condom use. The consistent condom use group, the smallest group, was characterized by consistent condom use. The inconsistent condom use group, the second largest group, was distinguished by inconsistent condom use. Comparisons of the three HIV risk groups revealed that the highest risk group had a higher proportion of illegal sources of income, higher proportion of binged crack use, frequent, daily, alcohol use, same gender sex partners, and scored higher on depressive symptoms. Members of the consistent condom use group were more likely to have been HIV diagnosed for a shorter time, to have HIV serodiscordant casual sex partners, higher psychological motivation for condom use. and a lower frequency of vaginal sex. Members of the inconsistent condom use group were more likely to have a main sex partner, to be married. to be on public assistance, to know the HIV serostatus of their casual partner, and less likely to conceal their HIV serostatus. An alarming finding was that a large number of participants inconsistently used condoms with HIV serodiscordant sex partners. Interventions aiming to prevent the secondary spread of HIV infection in African-American crack cocaine smokers should take this variability in account and focus on the differences.

Sena AC; Muth SQ; Heffelfinger JD; O'Dowd JO; Foust E; Leone P. Factors and the sociosexual network associated with a syphilis outbreak in rural North Carolina. Sexually Transmitted Diseases 34(5): 280-287, 2007. (44 refs.)

Objective: An investigation was conducted to determine factors associated with a syphilis outbreak in a rural North Carolina county. Study Design: A retrospective chart review was performed on 61 primary (PS), secondary (SS), and early latent (ELS) syphilis case patients reported in Columbus County between January 2001 and February 2002. Sociosexual network analysis was conducted using electronic contact tracing information. Results: We identified 20 PS, 25 SS, and 16 ELS case patients who were predominantly black. Seventy-two percent had reported >= 1 sexual partner with early syphilis, 51 % used crack cocaine and/or had sex with a crack-using partner, and 31 % exchanged sex for drugs or money. The sexual network exhibited predominantly linear connections between case patients and sexual partners. Adding social connections to the network further demonstrated dense cyclic interactions characteristic of core groups. Conclusions: The syphilis outbreak in this rural community was associated with crack cocaine and exchange of sex for drugs in a densely interconnected sociosexual network.

Shannon K; Bright V; Gibson K; Tyndall MW; Maka Project Partnership. Sexual and drug-related vulnerabilities for HIV infection among women engaged in survival sex work in Vancouver, Canada. Canadian Journal of Public Health 95(6): 465-469, 2007. (37 refs.)

Background: Women engaged in survival sex work face multiple sexual and drug-related harms that directly enhance their vulnerability to HIV infection. Although research on injection-drug-using women has explored predictors of sex work and HIV infection, little information currently exists on the complex vulnerabilities to HIV transmission faced by survival sex workers in this setting. This analysis aimed to determine HIV prevalence among women engaged in survival sex work, and explore sexual and drug-related vulnerabilities associated with baseline infection. Methods: Descriptive and univariate analysis were used to explore associations with baseline HIV infection. Variables found to be associated with baseline infection at the univariate level (p < 0.05) were entered into a fixed logistic regression model, adjusted for age. Results: Of a total of 198 women, baseline HIV prevalence was 26%. In multivariate logistic regression, baseline HIV infection was associated with early age of sex work initiation (< 18 years) (aOR=1.8, 95% CI: 1.3-2.2), Aboriginal ethnicity (aOR=2.1, 95% CI: 1.4-3.8), daily cocaine injection (aOR=2.2, 95% CI: 1.3-3.5), intensive, daily crack smoking (aOR=2.7, 95% CI: 2.1-3.9), and unprotected sex with an intimate partner (aOR=2.8, 95% CI: 1.9-3.6). Interpretation: Innovative and evidence-based strategies are urgently needed that address the sexual and drug-related vulnerabilities to HIV infection among survival sex workers and in particular, interventions targeting the precursors to early initiation into sex work.

Shannon K; Ishida T; Morgan R; Bear A; Oleson M; Kerr T; Tyndall MW. Potential community and public health impacts of medically supervised safer smoking facilities for crack cocaine users. Harm Reduction Journal 3: article 1, 2006. (38 refs.)

There is growing evidence of the public health and community harms associated with crack cocaine smoking, particularly the risk of blood-borne transmission through non-parenteral routes. In response, community advocates and policy makers in Vancouver, Canada are calling for an exemption from Health Canada to pilot a medically supervised safer smoking facility (SSF) for non-injection drug users (NIDU). Current reluctance on the part of health authorities is likely due to the lack of existing evidence surrounding the extent of related harm and potential uptake of such a facility among NIDUs in this setting. In November 2004, a feasibility study was conducted among 437 crack cocaine smokers. Univariate analyses were conducted to determine associations with willingness to use a SSF and logistic regression was used to adjust for potentially confounding variables (p<0.05). Variables found to be independently associated with willingness to use a SSF included recent injection drug use (OR=1.72, 95% CI: 1.09-2.70), having equipment confiscated or broken by police (OR=1.96, 95% CI: 1.24-2.85), crack bingeing (OR=2.16, 95% CI: 1.39-3.12), smoking crack in public places (OR=2.48, 95% CI: 1.65-3.27), borrowing crack pipes (OR=2.50, 95% CI: 1.86-3.40), and burns/ inhaled brillo due to rushing smoke in public places (OR=4.37, 95% CI: 2.71-8.64). The results suggest a strong potential for a SSF to reduce the health related harms and address concerns of public order and open drug use among crack cocaine smokers should a facility be implemented in this setting.

Shannon K; Rusch M; Morgan R; Oleson M; Kerr T; Tyndall MW. HIV and HCV prevalence and gender-specific risk profiles of crack cocaine smokers and dual users of injection drugs. Substance Use & Misuse 43(3/4): 521-534, 2008. (39 refs.)

The present analysis compares HIV and HCV prevalence and associated gender-specific risk patterns of dual users (i.e., crack smokers who inject drugs) and never injectors. Two logistic models, one restricted to female and the other to male crack smokers, were constructed to identify gender-specific risk factors associated with dual use (p 0.05). Of 437 crack smokers, 246 (56%) were dual users while 191 (44%) were never injectors. In a fitted logistic regression model, dual use among female crack smokers was associated with HCV infection (adjusted OR = 4.65, 95% CI: 1.92-9.70), exchanging sex for money, drugs, or shelter while using crack (aOR = 4.47, 95% CI: 1.56-12.80), having a casual partner who injects (aOR = 4.13, 95% CI: 1.05-16.26), having equipment broken or confiscated by police without being arrested (aOR = 3.66, 95% CI: 1.43-9.34), and HIV infection (aOR = 2.07, 95% CI: 1.18-5.96). Among male crack smokers, dual use was associated with HCV infection (aOR = 5.34, 95% CI: 2.10-13.18), exchanging sex for money, drugs, or shelter (aOR = 3.25, 95% CI: 1.59-6.65), crack use history 5 years (aOR = 2.16, 95% CI: 1.29-3.63), and smoking in a group of unknown people (such as crack houses, alleys; aOR = 1.70, 95% CI: 1.10-2.81). These findings highlight the need for evidence-based prevention and harm reduction initiatives that directly targeting crack cocaine smokers, with particular attention given to female dual users of injection drugs.

Siegal HA; Falck RS; Wang JC; Carlson RG; Massimino KP. Emergency department utilization by crack-cocaine smokers in Dayton, Ohio. American Journal of Drug and Alcohol Abuse 32(1): 55-68, 2006. (42 refs.)

The objective of this study was to determine the frequency, principal diagnoses, and correlates of emergency department (ED) visits made by persons with a history of crack-cocaine use (n = 333) over a 3-year period. Data were collected from participant self-reports and hospital records. During the study a total of 643 ED visits were made by 211 people, ranging from 53.5 to 76.7/100 persons/year. Injury and poisoning accounted for the largest single category of ED visits (29.5%). Men had lower odds of visiting the ED (OR=0.79, 95% CI = 0.62-0.99), as did participants with higher levels of education (OR= 0.83, 95%CI=0.73-0.94). Number of times in drug abuse treatment (OR=1.04, 95%CI=1.01-1.09), having a chronic disease (OR=1.46, 95%Cl=1.06-1.99), and higher Addiction Severity Index composite medical scores (OR=1.62, 95%CI=1.15-2.29) increased the odds of an ED visit. Factors in addition to drug use are likely to affect ED utilization rates among crack-cocaine smokers.

Stephens T; Mcgee W; Braithwaite RL. Age-based correlates of substance misuse among convicted felons in Georgia. American Journal of Drug and Alcohol Abuse 33(6): 885-892, 2007. (26 refs.)

Objective: This study sought to identify variables that independently correlate with age and substance use among a sample of 187 convicted felons in Georgia. Results: Results of regression analysis indicated that younger inmates were 2 times more likely than older inmates to report the occurrence of alcohol use (RR 2.07; 95% CI.37, 11.6) and three times more likely than older inmates to report some history of marijuana use ( RR 3.07; 95% CI 1.52, 6.11). In addition, younger inmates were half as likely or less to report using sedatives ( RR.53, 95% CI.22, 1.29), tranquilizers (RR.49, 95% CI.22, 1.29), crack or cocaine (RR.33, 95% CI.18,.62), heroin (RR.48, 95% CI.16, 1.25), and to having ever received treatment for a drug problem (RR.46, 95% CI.23,.90). Conclusion: In conclusion, age-based factors correlate with participant's history of substance use. Ascertainment of these variables among inmate populations has the potential to improve treatment decisions both during and after incarceration.

Strom KJ; MacDonald JM. The influence of social and economic disadvantage on racial patterns in youth homicide over time. Homicide Studies 11(1): 50-69, 2007. (83 refs.)

Explanations for the increase in youth homicide in the mid-1980s and early 1990s focus predominantly on crack cocaine markets and related firearms effects. This study examines whether weakened social controls contributed to the escalation of youth homicide, independent of drug market effects. Specifically, the authors consider how city-level chances in social and economic disadvantage contributed to increases in race-specific youth homicide victimization. They find that structural factors played an important role in race- and age-specific youth homicide rates, independent of others factors, including drug arrests. City-level increases in social and economic disadvantage were positively associated with increases in Black teenage and young adult homicide rates and White teenage homicide rates. The implications of these findings for theories of homicide are discussed.

Swaminathan S; Schoenbaum EE; Klein RS; Howard AA; Lo YT; Gourevitch MN. Two-step tuberculin skin testing in drug users. Journal of Addictive Diseases 26(2): 71-79, 2007. (37 refs.)

To assess the utility of booster testing and to identify factors associated with a positive booster test, two-step tuberculin testing was performed in drug users recruited from methadone treatment. Participants also received a standardized interview on demographics and testing for HIV and CD4+ lymphocyte count. Of 619 enrollees completing the protocol, 174 (28%) had a positive PPD and 24 of the remaining 445 (5%) had a positive booster test. On multivariate analysis, boosting was associated with older age (adjusted odds ratio [ORadj] 2.38/decade, 95% confidence interval [CI] 1.34-4.22), history of using crack cocaine (ORadj 2.61, 95% CI 1.10-6.18) and a history of working as a home health aide (ORadj 4.23, 95% CI 1.39-12.86). Two-step tuberculin skin testing increased the proportion of participants with latent tuberculosis infection from 22% to 25%. Given the effectiveness of chemoprophylaxis, booster testing should be considered when drug users are screened for tuberculosis infection.

van der Poel A; Barendregt C; van de Mheen D. Drug users' participation in addiction care: Different groups do different things. Journal of Psychoactive Drugs 38(2): 123-132, 2006. (30 refs.)

This study allocated 201 (nearly) daily users of heroin and/or crack into four groups, depending on their addiction care participation. Earlier studies have compared treatment groups and nontreatment groups. In this study the treatment group is divided into three categories: ( 1) drug users in contact with only treatment agencies-i.e., methadone maintenance, clinical and ambulant drug treatment; (2) drugs users in contact with only care agencies-i.e., day and night shelters and drug consumption rooms, which have no explicit aims to change patterns of drug use; and (3) drug users in contact with both treatment and care agencies. This allocation intro three different groups fits the notion of harm reduction, one of the policy aims in the Netherlands. The fourth group consists of drug users in contact with neither treatment nor care agencies. The results show that it is useful to distinguish these four categories, instead of two. The four groups are different from each other with respect to some of their characteristics (e.g. debt situation, prostitution, homelessness) and their drug use (e.g. drug use in public, use of crack, and use of other drugs). A much clearer distinction can be made between the "care" group and the "treatment and care" group. Treatment and care agencies can thus better match their services to their clients or patients.

Van der Poel A; Van de Mheen D. Young people using crack and the process of marginalization. Drugs: Education, Prevention and Policy 13(1): 45-59, 2006. (26 refs.)

Thirty current and former crack users aged 16-24 years participated in a qualitative study about their crack use and related behaviours. The study investigates the process of marginalization (social relations, sources of income and health situation) before and after the start of crack use. Results show that because many crack users were raised in a problematic home situation and have little education, they were already in a marginal position before they started using crack. However, the use of crack accelerated the process of marginalization, because they experienced a shrinking social network that developed around other users, and because they performed illegal activities to buy crack. As result, many users spent time in prison. Regarding health, they experienced respiratory problems, deteriorating physical fitness, paranoia and heart palpitations. Furthermore, homelessness and crack use are intertwined.

Wechsberg WM; Zule WA; Riehman KS; Luseno WK; Lam WKK. African-American crack abusers and drug treatment initiation: barriers and effects of a pretreatment intervention. Substance Abuse Treatment, Prevention, and Policy 2: article 10, 2007. (44 refs.)

Background: Individual and sociocultural factors may pose significant barriers for drug abusers seeking treatment, particularly for African-American crack cocaine abusers. However, there is evidence that pretreatment interventions may reduce treatment initiation barriers. This study examined the effects of a pretreatment intervention designed to enhance treatment motivation, decrease crack use, and prepare crack abusers for treatment entry. Methods: Using street outreach, 443 African-American crack users were recruited in North Carolina and randomly assigned to either the pretreatment intervention or control group. Results: At 3-month follow-up, both groups significantly reduced their crack use but the intervention group participants were more likely to have initiated treatment. Conclusion: The intervention helped motivate change but structural barriers to treatment remained keeping actual admissions low. Policy makers may be interested in these pretreatment sites as an alternative to treatment for short term outcomes.

Weeks MR; Li J; Dickson-Gomez J; Convey M; Martinez M; Radda K et al. Outcomes of a peer HIV prevention program with injection drug and crack users: The risk avoidance partnership. Substance Use & Misuse 44(2): 253-281, 2009. (30 refs.)

The Risk Avoidance Partnership (RAP) Project conducted in Hartford, Connecticut, tested a program to train active drug injectors and crack cocaine users as Peer Health Advocates (PHAs) to deliver a modular HIV, hepatitis, and STI prevention intervention to hard-to-reach drug users in their networks and others in the city. The intervention was designed to diffuse health promotion and risk-reduction interventions by supporting PHAs to model prevention practices and deliver risk- and harm-reduction materials and information. We compared change in behaviors and attitudes between baseline and 6-month follow-up of 112 primarily African-American and Latino PHAs, 223 of their drug-user network contact referrals, and 118 other study recruits (total n = 523). Results indicated significant HIV risk reduction among all study participants, associated with significant health advocacy action conducted by PHAs, and a relationship between exposure to the RAP peer-delivered intervention and risk reduction among all study groups. Findings suggest that active drug users' engagement in peer health advocacy can set in motion a feedback and diffusion process that supports both the continued work of the PHAs and the adoption of harm reduction and mimicking of health advocacy by their peers.

Young J; Beech D; Offodile R. Foreign body ingestion and management: "I swallowed a crack pipe". American Surgeon 73(11): 1144-1146, 2007. (10 refs.)

There is a wide variety of objects that find their way into the human gastrointestinal tract, either accidentally or deliberately. In this case a crack pipe was ingested in its entirety. Despite the seemingly rare and random nature that this scenario presents, this patient's care serves to reinforce what should be done to successfully manage a patient with an ingested foreign body, as well as the important issues related to crack cocaine abuse.

Zule WA; Morgan-Lopez AA; Lam WKK; Wechsberg WM; Luseno WK; Young SK. Perceived neighborhood safety and depressive symptoms among African American crack users. Substance Use & Misuse 43(3/4): 445-468, 2008. (63 refs.)

This study examined the association between perceived neighborhood safety and depressive symptoms among 443 out-of-treatment African American crack cocaine users interviewed between 2000 and 2002 in North Carolina and tested the regression of depression on perceived neighborhood safety and common predictors of depression. Perceived neighborhood safety was an important predictor of depressive symptoms in models that adjusted for other correlates of depression. The findings are limited by the cross-sectional nature of the data and the complex etiology and course of depression. Additional research is needed to clarify the relationship between perceived neighborhood safety and depression.