Description of study samples
The ethnographic sample was composed of 64 individuals (18-60 years old). Most participants were male and they ranged in age from approximately 18 to 60. The majority was white, Canadian-born, and French speaking. Approximately a fifth were English-speaking Canadians and about a sixth were of Afro-Canadian or Caribbean Canadian decent. Almost everyone was homeless or survived in precarious housing status (illegal squats, rented rooms in cheap hotels or in slumlord apartments). Most participants were welfare recipients and also had income-generating strategies dependent on the informal street economy (petty theft, panhandling, sex work, etc.).
Most survey participants were male, white, Canadian-born and French-speaking, and their mean age was 38.6 years (see ). Only 37.2% reported their own house or apartment as their principal dwelling place during the previous month. Similarly to the ethnographic component, the sample was essentially comprised of cocaine smokers and/or injectors.
| Table 1Baseline socio-demographic characteristics and cocaine use pattern |
Crack smoking overtaking cocaine powder injection
During fieldwork, emaciated individuals smoking crack in glass pipes was a common sight in the downtown area and many more crack smoking episodes were observed compared to cocaine injections. This contrasts with the former visibility of public injection reported in the early and mid-1990s [
5,
30]. In fact, ethnographic data suggests that from the early 2000s, the crack scene superseded the traditional powder cocaine dominated scene in Montréal:
Kevin: Crack is much bigger than powder cocaine.
Nelson: Since when has crack become more popular than powder cocaine? Kevin: I would say around the early 2000s.
(January 2009)
It seems plausible that the growth of crack smoking is related to the increased accessibility of crack on the streets. Long-time users reported that, in the past, they had to “cook” cocaine powder into crack themselves when they wanted to smoke it as no ready-to-smoke crack was available in the downtown area:
Nelson: Was ready-to-smoke crack available 7 years ago?
Eric: When I started smoking crack, people cooked their rock. Me, I couldn’t cook crack. It was one of my friends that cooked it for me.
(January 2008)
One should not presume from this that powder cocaine is no longer available in Montréal. Rather, selling strategies for powder cocaine have changed over time which can also have contributed to the increase of crack smoking. While powder cocaine used to be sold directly by dealers on street corners, it is now sold via telephone order. Users who want to inject powder cocaine require a good knowledge of the field and a sense of organization to obtain their drug of choice; they must comply with certain rules of sale:
Denis: Powder cocaine isn’t sold on the streets no more. It is sold by telephone-order/delivery. Almost all of the powder cocaine dealers adopted this system because it is an “in and out” system … … So you see it’s a lot less on the streets.
(March 2008)
Based on ethnographic data, powder cocaine dealers use a “telephone-order/delivery” system to sell their drugs. They deal solely with trusted buyers which limits their outings and unnecessary public exposure, thus reducing the risk of being arrested by the police. This contrasts with crack that can be bought freely in the streets:
Denis: When people come up to me and want to buy some crack there’s no problem. If someone wants powder cocaine … wait a minute … I have to check through my little book and find the right code [telephone number], call, wait and meet up with the guy.
(March 2008)
Survey data confirms the importance of crack smoking. In total, 97.4% of survey participants had smoked crack during their lifetime and 85.5% had done so in the last month. Most were regular smokers, with 13.9% smoking one day per week, 33.5% 2 to 3 days per week, 16.0% 4 to 6 days per week and 21.8% every day. Only 14.8% smoked crack less than one day a week.
Choosing between smoking and injecting cocaine
According to the survey, 31.5% of participants smoked crack but did not inject powder cocaine while 13.2% injected powder but did not smoke crack. Crack smokers who did not inject can be divided into two groups of users: those who had never injected cocaine (44.3%) and injectors who had quit injecting cocaine (55.7%). In the first group, many users said they had never injected cocaine because of their fear of needles and of the negative heath effects of injection.
Lenny: Nowadays, more people… they do the crack, because they’re afraid of syringes … a lot of people die … they get AIDS … so a lot of people are afraid of this. But they’re not afraid to smoke a piece of crack.
(May 2009)
Participants who had stopped injecting cocaine, often used the “effect rationale” to explain their mode of consumption; they had stopped because the effect was too intense:
Raymond: Now, I just smoke crack. Before, I injected, but I stopped.
Nelson: Is the “high” the same?
Raymond: Oh no! When you inject, the high is much more intense.
Nelson: Why did you stop?
Raymond: I got sick of the craziness. It was too intense for me. It got me too agitated.
(December 2007)
On the other hand, some participants preferred injecting to smoking; they considered injection to have a better cost-effectiveness ratio. Moreover, for long-time cocaine injectors, smoking did not provide the same “high” as injecting.
For some users, pragmatic considerations are involved. For example, one female sex worker started injecting powder cocaine and smoking crack in 2001 around the same time she began working as a street sex worker. For her, the effect of crack smoking was too short-lived. She preferred injecting cocaine because the high lasted longer, which meant she had more time to work. In 2004, she started dancing in strip clubs and working for escort agencies. She stopped injecting since she felt that it had consequences that were incompatible with her new line of work.
Nelson: You stopped injecting when you were dancing in strip clubs and working for escort agencies?
Maïka: I had to. Dancing with blue arms doesn’t work that well!!! And when I had clients, working with long sleeves didn’t work that well either! The guys wanted me to take off my shirt. There were a few occasions where I didn’t want to take off my shirt because there were marks on my arms. When you’re doing “street” sex work it’s not that bad because the clients know some girls inject.
(May 2008)
In 2006, she returned to street sex work. Without quitting crack smoking, she started injecting again.
Combining crack smoking and cocaine powder injection
Even though surveillance and ethnographic data point to an increase in crack smoking, powder cocaine injection has not disappeared. According to survey data, 67.7% of the participants had injected cocaine in the previous month. Of these, 99.2% injected the powder form and 12.6% injected the crack form (which requires the user to reconvert the substance by acidifying it into a soluble, injectable form). In fact, approximately 54.5% of participants reported having both smoked and injected cocaine in the previous month. Of those who reported that their main mode was injection (46.3%), 70.4% had also smoked crack cocaine. Of those who reported mainly smoking crack (51.2%), 40.4% had also injected cocaine.
The ethnographic data allowed a better understanding of the contexts surrounding alternation between crack smoking and powder injection. As mentioned earlier, the accessibility of a specific drug form can play an important role in the choice of the mode of consumption. As powder cocaine is harder to find than crack, some individuals would not hesitate to buy crack if they could not find powder cocaine. Drug quality was also mentioned as a factor influencing users’ choices:
Nelson: I didn’t know you smoked a lot of crack. I thought you only injected powder cocaine …
Stéphane: I smoke crack if it’s good. The batch of rock that I got was so good that I didn’t feel the need to inject.
(July 2008)
Conversely, those who mainly smoked crack also injected powder cocaine on some occasions; their choice being mostly based on economic capital. While crack and powder cocaine may be the same price ($20 CDN for a quarter of a gram), there is a major difference in the quantities in which they are sold in. The minimum powder cocaine dose sold is a quarter gram. On the other hand, some crack street dealers will sell pieces for as little as $5 CDN. Since the ethnographic sample participants had limited economic capital, cocaine users could have been influenced by these “cheap” and small doses and buy crack instead of powder cocaine. However, the situation could change under certain circumstances. For instance, some participants were engaged in a popular income-generating strategy consisting of buying drugs for other users in exchange for compensation (payment in money or drugs). When a crack user bought powder cocaine for another user and got paid with a dose of powder cocaine, there was a good chance he would inject. Also, numerous cocaine users who primarily smoked crack would take advantage of a sudden influx of cash (e.g. welfare check at the beginning of the month) to buy large amounts of powder cocaine:
Lenny: If they have coke, they’ll smash [inject] it. Check day when they have money, yes, they’ll buy maybe 5 quarters and smash it. But generally speaking, if they have $20, they don’t go for the powder, they just buy the rock.
(May 2009)
Cocaine users who mainly smoked crack reported sometimes injecting it. Based on the survey, it is only 12.6% of participants who reported injecting it on certain occasions, for instance when the substance was of poor quality:
Ted put a rock in his stem and smoked it. Because the taste was so bad, he did not want to smoke it any more. He decided that he’d inject it…He took a sachet of vinegar, poked a little hole in it with the needle of his syringe, and poured a couple of drops in his cooker to dissolve the rock. Ted plunged his needle in the cup and drew all the liquid. He immediately injected it into a vein in his left forearm.
(Fieldnotes, March 2009)
Logistic contexts may also determine utilization of one mode over the other for participants using both modes. Crack smoking seems to be more convenient; it is easier and faster than cocaine injection and it requires less complicated manoeuvres. This advantage seems to influence homeless cocaine users and those involved in the street economy:
Lenny: Like 90% of the time, I smoke.
Nelson: Is there a reason?
Lenny: … it’s more practical. It’s easier to find the crack, and on the streets it’s much better ‘cause it’s quick, you pull a little piece of crack, put it on a pipe … If you want to do it in a needle, you have to go sit down, and find a cup and a syringe, and … mix it up, put it in the syringe, then you have to find a vein and inject it, so it takes time, right? And plus when I’m selling the drug, I don’t really want to leave, cause I’m going to lose the money … it doesn’t slow me down when I smoke crack, you know?
(May 2009)
Smoking crack and injecting prescription opioids
Ethnographic fieldwork revealed that prescription opioids (POs) were highly present on the streets of downtown Montréal. These opioids (especially Hydromorphone Hydrochloride in the form of tablets and controlled release capsules) may have become a cheap alternative to heroin as they are readily available and inexpensive. In fact, it seems that POs are to heroin what crack cocaine is to powder cocaine. Like crack, POs can be bought directly on the street. To buy heroin, one has to have contacts and be willing to walk a certain distance to meet up with a dealer (as with cocaine powder). The user who does not have a contact will have to pay a commission to a person who has one. Also, like crack, users can buy a dose for as little as $5 CDN. The lowest heroin dose costs $20 CDN for half a “point” (0.05 gram). In addition to being inexpensive and available, POs have the advantage of being uniform in terms of quality, allowing users to better manage and control their consumption. These three characteristics make POs more and more popular.
As shown in , more than half of participants had consumed opiates, including POs, during the month prior to interview. Interestingly, 42.4% of users whose main mode of cocaine consumption was smoking reported having consumed opiates, with one third having injected them. For participants who smoked cocaine without injecting it, the proportions were 30.3% and 16.4%. The majority of participants who consumed opiates (prescription or otherwise) injected it (88.2%), even those who primarily smoked their cocaine (76.2%).
Wishing to test the idea that injecting continues among drug users in downtown Montréal, and verify its possible relation to the PO phenomenon, the ethnographer had this exchange with a participant:
Nelson: Why do you think people continue to inject even if there’s crack?
Nick: I think it’s cause of the dilau. People get hooked up really easy on that shit and it’s just 5 bucks! I smoke crack and then smoke some more crack and then I say to myself “Hey, I’m a junkie. I got to shoot up!!!”
(February 2008)
Somewhat unexpected was the high PO injection frequency observed. Probably due to differences in pharmacological properties, the number of PO injections per day can be much higher than is usually seen among heroin users. The ethnographer observed that some PO users can inject between six and eight doses per day. Moreover, due to the texture of some POs (especially hydromorphone capsules), one dose can generate as many as three or four injections:
Marianne crushed the small balls of hydromorphe with the plunger of her syringe. She added water, heated the cooker and crushed the mix once again. She put a clean cotton ball in the cooker and drew her first dose in her syringe. With the same syringe, she drew a second dose and injected it into the same arm. Once again, she plunged her syringe into the cooker now containing practically nothing besides a pasty, dense substance. She drew a third dose and injected it.
(Fieldnotes, September 2008)
The most commonly observed drug combination was the crack–PO. Both drugs are attractive because they are readily available and can be bought for a few dollars. Also, the complementarity of the drugs’ pharmacological effects seems to play a role in the way users manage these effects. In fact, alternate use of both drugs has a stabilizing and/or counteractive effect. For individuals who smoke a lot of crack and consequently become agitated and/or paranoid, POs may act as a sedative. Conversely, crack can be used to counteract side effects of opiate consumption such as excessive “nodding” and lethargy. Moreover, according to some participants, the combined use of both drugs may serve to maximize the effect of one drug or the other. To feel the full potential of an “upper’ drug like crack, some individuals would first take a “downer” drug (in our case POs), and vice-versa:
Maika: You’re always looking for the biggest gap between your current state and the one you’ll have after you take the drug. So, if you’re at +2 after your first puff wears off and you shoot up a dilau, “bam” you drop down to level −5. If you smoke a rock of crack after that “Pow!” you jump to level +5. That’s big gap! That’s what people are looking for.
(August 2008)
