redefined how harm reduction is going to work for us,’ said Jim Duffy, founding director of Smoke Works in Boston, Massachusetts( DDN, June, page 14). Smoke Works had an opportunity to scale up pipe distribution, which was an answer to a lot of local problems –‘ lack of engagement, lack of options. We did something a little different. Rather than filling up backpacks and hitting the streets, which was our day job, we decided to move behind the front lines and work for those who are doing the work.’

Smoke Works was designed as a procurement stream rather than an outreach organisation, he explained.‘ The question was“ what if we could take the money being spent on harm reduction, and make it fund more harm reduction?”’ In 2020, when he was working at the AHOPE needle exchange – which is funded by the Boston Public Health Commission – a private grant came through to procure pipes. This also‘ gave us the oppor tunity to get out and meet more folks, and

find out what the effect would be,’ he said.‘ The results were published and they were clear – the impact was awesome.’

In the past there’ d been‘ all these folks hanging around outside’ who had no reason to come into a needle exchange, he said.‘ And I realised that was my story too. I didn’ t inject. I wasn’ t going to walk into an exchange, because I smoked. I thought,“ what does that place have for me?” Little did I know it had plenty – HIV testing, people, connection. In hindsight I’ m embarrassed to admit that we thought everybody wanted to inject, so we never offered anything more. We were surprised by that.’

‘ We’ re doing this from harm reduction up, not public health down – that’ s what’ s made the difference.’

JIM DUFFY

UNREACHABLE COMMUNITIES Around three months into pipe distribution at AHOPE the numbers started to come back.‘ Of those folks coming in solely for pipes, completely new to the programme, no previous engagement – 50 per cent walked out with naloxone. That’ s huge, and it helped us get into communities and neighbourhoods that were unreachable prior to that.’ Even when people said they didn’ t need naloxone, staff could respond with‘ but I bet you know someone who does,’ he said.‘ It helped us put naloxone into places that we could not saturate before.’

The big question was who does harm reduction serve, he said.‘ Opioid injectors. So who are we excluding? Folks who primarily use stimulants, and people who use more than one drug.’ Syringe access reduced the risk of HIV and hep C, but pipe distribution was also a risk mitigation tool.‘ For safer smoking, pipes replace – and this is my story – drilling a hole in a lightbulb.’ Statistics from the Centers for Disease Control and Prevention, the US national public health agency, showed that people were up to ten times

more likely to enter treatment if they engaged with a syringe exchange, he pointed out.‘ Why do we exclude stimulant users and people who don’ t inject from that?’

LOGICAL INTERVENTION Pipes were a very logical intervention, he stressed.‘ It’ s safer, it’ s more discreet, it’ s less time consuming. It reduces overdose risk because it actually means that you pause for a moment to breathe – injection practice doesn’ t offer that, especially when it takes ten, 15, 20 minutes to get a shot. If it took me that amount of time to pour a drink at the end of the day, I’ m pouring a stiff drink.’

At Smoke Works he and his colleagues began contacting other harm reduction organisations on social media and setting up buyer’ s clubs for