Crack-cocaine use practices, harms and respiratory problems: an analysis of gender differences using data from a cross-sectional survey in England

Background
The use of stimulants, such as crack-cocaine, is a global public health concern. Crack-cocaine use is increasing in the UK, but available data is focused on those who inject or also use opioids. To address this gap, characteristics of people using crack-cocaine in England, including respiratory problems among those who smoke, and variation in these by gender are described.

Methods
Adults self-reporting crack-cocaine use in the past 28 days, recruited by specialist services and peer networks in six sites during 2023, completed a self-report survey about demographic characteristics, drug use, crack use practices, health problems and service use. Bivariable analyses and logistic regression were used to explore gender-related differences in crack-cocaine use and crack-related respiratory problems.

Results
The participants’ (n = 731) median age was 42 years and 71% were men. Overall, 54% were stably housed, 71% had ever been imprisoned and 28% reported emergency department attendance in past 6 months. In the past 28 days, 99% had smoked crack-cocaine (44% shared pipes), with 30% injecting crack. Poly-sedative use was common including heroin (78%), pregabalin/gabapentin (41%), and benzodiazepines (28%), with 62% receiving opioid substitution therapy. Use of drugs normally smoked was common (90% tobacco, 62% cannabis and 25% spice). Women reported less polydrug use but more often vaped nicotine. Crack-related respiratory symptoms among those smoking crack were reported by 67% of women and 58% of men. In both men and women these symptoms were associated with increasing time since first crack-cocaine use and pregabalin/gabapentin use. In men they were also associated with food insecurity; smoking tobacco; temporary employment; and use in abandoned buildings or at friend’s place; reduced odds were associated with current heroin use and using with a close friend. Among women, having a respiratory symptom was also associated with sharing pipes.

Conclusions
Respiratory health problems are common among those smoking crack-cocaine, particularly among women. In combination with high poly-sedative use, this poses a mortality risk from respiratory depression. UK service provision is focused on prevention of opiate and injection-related risks. Services for people who use crack-cocaine and low-threshold respiratory care pathways require prioritisation to reduce avoidable morbidity and mortality.