Among the impoverished drug addicts in Vancouver's Downtown Eastside, crack cocaine users face an extra hurdle to feed their addiction.
Heroin users can pick up clean needles from needle-exchange programs or the city's controversial safe-injection site - efforts that have at least partly curbed risky needle sharing. But crack pipes are more difficult to come by.
Some crack smokers can afford to buy small glass or Pyrex stems to use as pipes. Others fashion makeshift pipes from bottles, cans or even hollow car antennas. And in many cases, they just simply share, potentially putting themselves at risk of contracting disease.
That's about to change, as the local health authority prepares to launch a pilot project later this year to distribute clean, unused crack pipes to drug users.
It's part of the city's harm-reduction strategy that seeks to reduce the transmission of disease while ensuring health-care and social workers are able to interact with hard-to-reach drug addicts. Currently, the city distributes clean mouth pieces for crack pipes, but not the pipes themselves.
"We want to do it in a way that we can evaluate this, because there's a couple of questions I hope we can answer by doing this," says Dr. Patricia Daly, the medical health officer for Vancouver Coastal Health.
"And not just about demand and numbers, but can we use this as an engagement strategy like we do with our other harm-reduction initiatives. If you can deliver them [harm-reduction programs]in a way where you can get people into other services, that's very beneficial."
Unlike needle-exchange programs for injection drugs, programs to ensure users who smoke crack are using the drug safely are uneven across the country and, in some cases, non-existent. That's despite a growing body of evidence that smoking crack cocaine increases the risk of diseases such as HIV and hepatitis.
In a small handful of cities, including Calgary and Winnipeg, local health authorities pass out crack pipes. Others prefer to only hand out mouth pieces, which users can place on their own pipes to avoid exposing themselves to others' saliva and blood.
And in others still, the job of distributing either mouth pieces or pipes is left to local community groups.
That uneven approach is needlessly putting crack users at risk, say experts and advocacy groups, who argue crack-pipe distribution should be a standard tool in every provincial and municipal drug strategy.
"It's spotty across the country, some places have it, some don't," says Walter Cavalieri of the Canadian Harm Reduction Network, who suggests attitudes towards crack users is to blame.
"There is a huge stigma against people who use crack, more intense than the stigma for those who use heroin."
Mr. Cavalieri agrees that in addition to keeping drug users safe, the real benefit of harm-reduction programs is that they connect drug users with health-care workers. That interaction, he says, will help some users enter rehab, while ensuring those that don't are able to stay healthy.
"Will these services stop them from using drugs? For some people it will, but some won't," he says. "Some will continue to use drugs but use them safely, some will cut back, and some will die, but their lives and health will be greatly improved."
The calls for free crack pipes comes as advocates in Vancouver also push for a safe-inhalation site, where crack users could smoke the drug in the presence of health-care workers, who would respond to overdoses. Any decision on such a site will likely have to wait until the Supreme Court of Canada rules on the future of the city's safe-injection site, known as Insite.
The research on crack use is limited and the precise risk isn't yet clear, but the evidence that smoking crack - and, in particular, sharing pipes - puts users in danger is building.
Two years ago, a study out of B.C. found drug users who smoke crack cocaine were at an increased risk of contracting HIV.
Last month, figures released by faculty at the University of Victoria found about two-thirds of crack users in Vancouver and Victoria share pipes, which researchers warned was putting them at risk of HIV or hepatitis, even in cities that distribute mouth pieces.
Andrew Ivsins, a University of Victoria researcher who worked on the pipe-sharing data, says distributing mouth pieces without pipes doesn't eliminate the risk.
"They expect everybody to put this mouth piece on a pipe and when they're sharing a pipe, to remove it every time, which is not the easiest thing to do," says Mr. Ivsins.
"So people end up just not taking the mouth piece off and sharing it that way, or not putting a mouth piece on and just sharing the pipe. By not giving out the pipe, they're not really getting at the main problem."
But even when health officials want to set up programs for crack users, it's not always easy - harm-reduction services are often controversial. Neighbours complain, which can make politicians reluctant to back them.
Ottawa Public Health distributed crack pipes until 2007, when city council voted to end the program over complaints that it fostered addiction. A local community health centre has taken over pipe distribution.
In Nanaimo, B.C., health workers who were already distributing needles from a mobile van, began handing out mouth pieces several years ago, but local opposition forced them to stop in 2007.
It started up again last year, this time using a permanent location where users pick up their supplies. The program is paid for by the Vancouver Island Health Authority.
Nanaimo Mayor John Ruttan, who was elected in 2008, says there were complaints at first, but he says the city and the health region have worked to convince residents that the program can be done safely while saving the health-care system money.
"They [opponents]were concerned and alarmed, in some cases people saw that as the community supporting the proliferation of drugs," he says. "The reality is something different, of course."
Mr. Ruttan describes himself as "cautiously supportive." Cautious because he wants to ensure people living nearby where the crack kits are handed out feel safe and respected, but supportive because he's certain that harm-reduction works.
"I've seen a lot of data that demonstrates what it costs if a person does not receive treatment for their addictions. The problem only exacerbates," he says. "Give it a chance, and hopefully you'll find that it's a good program and worth supporting."