Krakow Abstract Qual

Practitioners’ experiences of working with dual users of heroin and crack in community drug services. A thematic analysis

Felicia Heidebrecht and Mary Bell Macleod


The high prevalence of crack use among individuals accessing pharmacological treatment for heroin dependency has already been documented more than a decade ago, and it is still on the rise in the UK. Quantitative research studies have shown so far that dual users have worse treatment outcomes in opiate substitution therapy (OST) programmes compared to heroin-only users. Nonetheless, practitioners in drug services might have developed successful strategies of working with this group of clients, and their experience could be a valuable resource to inform further research on patterns of heroin and crack use, and to help improving the general practice and treatment outcomes.
The aim of this qualitative study was to explore the experience of substance misuse practitioners working with heroin and crack users.

Participants: Seven practitioners all of different ethnicities, three of them currently in leading positions, with an average age of 40 years (27-49), and average work experience of 12 years (2-20)
Setting: Three community drug services in London, UK
Data collection: Audio-recorded face-to-face semi-structured interviews exploring participant’s views on the particularities of heroin and crack users, and their practice with this particular group of clients
Analysis: Thematic analysis (Braun & Clarke 2006)

Three themes were identified:
1. The heroin and crack user (reasons for drug use from worker’s and client’s perspective, distinct and dynamic patterns of heroin and crack use, behavioural characteristics of clients such as chaos, unpredictability, taking health risks, unwillingness to discuss crack use, short attention span);
2. Worker-client relationship (worker’s strengths, the power of language, boundaries, power sides in shaping the interaction);
3. Interventions with heroin and crack users (engagement by creative means, elements of established interventions such as motivational interviewing or CBT, identity reconstruction, exploration of the combined heroin and crack buzz, separating the two drugs).

The pharmacological treatment (OST) was discussed by participants as a supporting rather than a main intervention.

The findings of this study suggest that when working with dual users of heroin and crack:
– OST is only a tool, but a significant one which can serve many functions (engagement, harm reduction, creating space to talk about underlying issues, separating the crack use from heroin use);
– A flexible approach works better than structured interventions, and the focus needs to be more on both drugs
– Workers need to be skilled in engaging clients with a constantly-changing presentation, and in delivering combined interventions tailored to the momentary needs of the client.

These insights can inform further research and developments to improve practice in drug services.