Article

The Impact of a Police Presence on Access to Needle Exchange Programs

October 2003
JAIDS Journal of Acquired Immune Deficiency Syndromes 34(1):116-8

DOI:10.1097/00126334-200309010-00019

Source
PubMed

Authors:

Will Small

Simon Fraser University

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Impacts of Intensified Police Activity on Injection Drug Users: Evidence From an Ethnographic Investigation

Article

Mar 2006
INT J DRUG POLICY

In an effort to dismantle the open drug market and improve public order, a large-scale police initiative named the Citywide Enforcement Team (CET), began in Vancouver's Downtown Eastside (DTES) on 7th April 2003. This research sought to assess the CET's impact upon drug consumption activities as well as access to sterile syringes and health services among injection drug users (IDUs). Ethnographic research methods including participant observation and semi-structured interviews were employed. Interviews were conducted with 30 individuals recruited from an ongoing cohort study of IDUs and nine individuals who provide health services to drug users. In addition, an ongoing participant-observation program investigating public drug use in the DTES yielded data during the period of the CET, as well as seven months prior to its commencement. With regard to drug use patterns, intensified police presence prompted 'rushed' injections, injecting in riskier environments, discouraged safer injection practices, and increased unsafe disposal of syringes. Service providers indicated that the CET negatively impacted contact between health services and IDUs, as outreach was compromised due to the displacement of IDUs. Police activities also negatively influenced IDUs' access to syringes and their willingness to carry syringes, and syringe confiscation was reported. The intensification of police activities led to less drug related activity in the area where the drug market was traditionally concentrated, but widespread displacement of drug use activities to other locations also occurred. The adverse impact of concentrated police activities upon urban drug problems and the implications for both public order and public health should be recognized. (c) 2005 Elsevier B.V. All rights reserved.

The Public Health and Social Impacts of Drug Market Enforcement: A Review of the Evidence

Article

Aug 2005
INT J DRUG POLICY

The primary response to the harms associated with illicit injection drug use in most settings has involved intensifying law enforcement in an effort to limit the supply and use of drugs. Policing approaches have been increasingly applied within illicit drug markets since the 1980s despite limited scientific confirmation of their efficacy. On the contrary, a growing body of research indicates that these approaches have substantial potential to produce harmful health and social impacts, including disrupting the provision of health care to injection drug users (IDU), increasing risk behaviour associated with infectious disease transmission and overdose, and exposing previously unaffected communities to the harms associated illicit with drug use. There are, however, alternatives to traditional targeted enforcement approaches that may have substantially less potential for negative health and social consequences and greater potential for net community benefit. Some of these approaches involve modifying policing practices, fostering partnerships between policing and public health agencies, and developing systems to monitor policing practices. Other alternatives involve the provision of harm reduction services, such as safer injecting facilities, that help to minimize drug-related harms, and addiction treatment services which ultimately help to reduce the demand for illicit drugs.

Area restrictions, risk, harm, and health care access among people who use drugs in Vancouver, Canada: A spatially oriented qualitative study

Article

Aug 2015

Displacement of Canada's largest public illicit drug market in response to a police crackdown

Article

May 2004

Evan Wood

Background: Law enforcement is often used in an effort to reduce the social, community and health-related harms of illicit drug use by injection drug users (IDUs). There are, however, few data on the benefits of such enforcement or on the potential harms. A large-scale police “crackdown” to control illicit drug use in Vancouver's Downtown Eastside provided us with an opportunity to evaluate the effect. Methods: As part of our ongoing prospective cohort study of IDUs in Vancouver, we examined data collected from 244 IDUs in the 3 months before the police crackdown and from 142 IDUs in the 3 months after the start of the crackdown, on Apr. 7, 2003. All study subjects were active drug users. We also examined external data on needle exchanges and syringe disposal. Results: The 2 groups of IDUs were statistically similar: they were mainly young (mean age 39 years) and male (63%), and they had injected illicit drugs for 13 years on average. Ethnic background and the proportion homeless were also similar. There were no statistically significant reported differences (all p > 0.1) in the street price of heroin, cocaine or “crack” in the 2 periods. In the 3-month periods before and after the crackdown, respectively, the rates of daily heroin injection were 27.9% and 26.8%, daily cocaine injection 28.7% and 27.5%, and daily crack use 59.4% and 60.6% (all p > 0.1). The proportions of study subjects receiving methadone treatment, 41.0% and 44.4% (p = 0.516), did not differ. However, the proportions reporting a change in where drugs were used, 22.5% and 33.8% (p < 0.05), and the proportions reporting a change in the neighbourhood of use because of police presence, 18.1% and 26.8% (p < 0.05), increased significantly. Needle-exchange data confirmed that the community levels of drug use were unchanged. Disposal statistics demonstrated that the monthly average number of used syringes found on the streets outside the traditional area of drug use increased from 784 in the 3 months before Apr. 1 to 1253 in the subsequent 3 months (p = 0.002) and the monthly average number of used syringes found in public boxes for the safe disposal of syringes decreased from 865 to 502 (p = 0.018). Interpretation: The effort to control illicit drug use did not alter the price of drugs or the frequency of use, nor did it encourage enrolment in methadone treatment programs. Several measures indicated displacement of injection drug use from the area of the crackdown into adjacent areas of the city, which has implications for both recruitment of new initiates into injection drug use and HIV prevention efforts.

Law Enforcement Strategies to Disrupt Illicit Drug Markets 1-2 Review of the Literature

Article

Full-text available

Nov 2021

Yvon Dandurand

This report reviews the research literature on illicit drug markets and law enforcement attempts to disrupt them. Attempts by law enforcement to disrupt illicit drug markets take many forms, including attempts to control or reduce the illicit supply or distribution of drugs, interfere with the activities of drug market participants, or arrest and convict some of these participants. Each type of illicit drug market disruption is triggered differently, requires different types of resources and strategies, and involves a different level of law enforcement intervention. The market disruption strategies reviewed in this report are not very promising. In fact, these interventions tend to have a very limited effect on drug markets or on the availability of illicit drugs. None of them seems to have a lasting impact on illicit drug markets and very few of them seem to have an impact on organized crime groups and networks that exploit and profit from these markets. In brief, illicit drug markets invariably prove themselves resilient and flexible, and they either promptly adapt to change and reconfigure or displace themselves. Furthermore, law enforcement disruption strategies often risk having a detrimental impact on affected communities, whether from a public health, quality of life, violence prevention, or police-community relation perspective.

Attitudes of Police Officers Towards Syringe Access, Occupational Needle-Sticks, and Drug Use: A Qualitative Study of One City Police Department in the United States

Article

Full-text available

Mar 2006
INT J DRUG POLICY

Removal of legal barriers to syringe access has been identified as an important part of a comprehensive approach to reducing HIV transmission among injecting drug users (IDUs). Legal barriers include both law on the books and law on the streets, i.e., the actual practices of law enforcement officers. Changes in syringe and drug control policy can be ineffective in reducing such barriers if police continue to treat syringe possession as a crime or evidence of criminal activity. Despite the integral role of police officers in health policy implementation, little is known of their knowledge of, attitudes toward, and enforcement response to harm-minimization schemes. We conducted qualitative interviews with 14 police officers in an urban police department following decriminalization of syringe purchase and possession. Significant findings include: respondents were generally misinformed about the law legalizing syringe purchase and possession; accurate knowledge of the law did not significantly change self-reported law enforcement behavior; while anxious about accidental needle sticks and acquiring communicable diseases from IDUs, police officers were not trained or equipped to deal with this occupational risk; respondents were frustrated by systemic failures and structural barriers that perpetuate the cycle of substance abuse and crime, but blamed users for poor life choices. These data suggest a need for more extensive study of police attitudes and behaviors towards drug use and drug users. They also suggest changes in police training and management aimed at addressing concerns and misconceptions of the personnel, and ensuring that the legal harm reduction programs are not compromised by negative police interactions with IDUs.

Elevated rates of antiretroviral treatment discontinuation among HIV-infected injection drug users: Implications for drug policy and public health

Article

Apr 2004
INT J DRUG POLICY

The benefits of highly active antiretroviral therapy (HAART) for the treatment of HIV disease are well documented, although concerns regarding access to and adherence to HAART among injection drug users (IDU) are of growing concern. We evaluated all antiretroviral naı̈ve HIV-infected men and women who initiated HAART between 1 August 1996 and 31 July 2000, and who were followed until 31 March 2002 in a province-wide HIV treatment programme that delivers antiretroviral therapy and AIDS care free of charge. We evaluated time to the first HAART discontinuation greater than 3 months using Kaplan–Meier methods and Cox proportional hazards regression. Overall, 1422 patients initiated HAART among whom 359 (25.3%) were IDU. At 12 months after the initiation of HAART, 30.3% of non-IDU versus 42.5% of IDU had discontinued HAART (P

Feasibility study on drug consumption rooms in Belgium

Technical Report

Full-text available

Feb 2018

People who use illicit drugs (PWUD) experience a wide range of drug-related harms. The goal of harm reduction is to reduce these adverse effects of drug use, without necessarily reducing drug use itself. By providing a safe and hygienic environment to consume pre-obtained drugs under the supervision of trained staff, drug consumption rooms (DCRs) aim to reduce both individual-level and public-level harms associated with illicit drug use. A substantial body of evidence has accumulated over the past three decades to support the effectiveness of DCRs in achieving their primary health and public order objectives, and therefore supports their role within a continuum of services for PWUD. Despite the abundance of scientific evidence supporting DCRs, there continues to be social and structural barriers to the implementation of this public health intervention in communities across the globe. Yet, the debate about implementing new DCRs remains high on the political agenda in a number of countries worldwide. To date, Belgium does not offer a DCR to its drug using population. Against this background, the Belgian Science Policy Office (BELSPO) commissioned a first-ever study to assess the feasibility of DCRs in Belgium. The objective of the current feasibility study was to identify (legal) preconditions, design and operational considerations that would allow a DCR to be added within a continuum of policy initiatives for PWUD in five Belgian cities: Ghent, Antwerp, Brussels, Charleroi and Liège. The aims were threefold: (1) provide an up-to-date overview of the effectiveness, models, and barriers of DCRs worldwide, with particular attention to DCRs in Belgium’s four neighbouring countries; (2) conduct an in-depth analysis of the legal framework within a DCR could operate in Belgium; and (3) conduct a feasibility study with local stakeholders and PWUD from each of the five cities. Based on our findings, we formulate 18 recommendations specifically tailored to the Belgian context: essential preconditions (including legal options); main considerations when implementing a DCR; the implementation process; and monitoring and evaluation.

Policing space in the overdose crisis: A rapid ethnographic study of the impact of law enforcement practices on the effectiveness of overdose prevention sites

Article

Full-text available

Sep 2019
INT J DRUG POLICY

North America is in the midst of an overdose crisis. In some of the hardest hit areas of Canada, local responses have included the implementation of low-threshold drug consumption facilities, termed Overdose Prevention Sites (OPS). In Vancouver, Canada the crisis and response occur in an urban terrain that is simultaneously impacted by a housing crisis in which formerly ‘undesirable’ areas are rapidly gentrifying, leading to demands to more closely police areas at the epicenter of the overdose crisis. We examined the intersection of street-level policing and gentrification and how these practices re/made space in and around OPS in Vancouver's Downtown Eastside neighborhood. Between December 2016 and October 2017, qualitative interviews were conducted with 72 people who use drugs (PWUD) and over 200 h of ethnographic fieldwork were undertaken at OPS and surrounding areas. Data were analyzed thematically and interpreted by drawing on structural vulnerability and elements of social geography. While OPS were established within existing social-spatial practices of PWUD, gentrification strategies and associated police tactics created barriers to OPS services. Participants highlighted how fear of arrest and police engagement necessitated responding to overdoses alone, rather than engaging emergency services. Routine policing near OPS and the enforcement of area restrictions and warrant searches, often deterred participants from accessing particular sites. Further documented was an increase in the number of police present in the neighborhood the week of, and the week proceeding, the disbursement of income assistance cheques. Our findings demonstrate how some law enforcement practices, driven in part by ongoing gentrification efforts and buttressed by multiple forms of criminalization present in the lives of PWUD, limited access to needed overdose-related services. Moving away from place-based policing practices, including those driven by gentrification, will be necessary so as to not undermine the effectiveness of life-saving public health interventions amid an overdose crisis.

Factors associated with take-home naloxone kit usage in British Columbia: an analysis of administrative data

Article

Full-text available

Mar 2022
SUBST ABUSE TREAT PR

Background The British Columbia (BC) Take-Home Naloxone (THN) program provides naloxone to people at risk of experiencing or witnessing an opioid overdose for use in reversing suspected overdose events. This study seeks to examine trends and correlates of individuals obtaining a THN kit in BC between 2017 and 2020. Methods Records of THN kits distributed between 2017 and 2020 were the primary source of data for this analysis. Frequency tables were used to describe characteristics of people obtaining kits from THN sites. Correlates of individuals obtaining a THN kit to replace a previous kit reported as used to reverse an overdose were assessed with multivariate logistic regression. Results Between January 1, 2017, and December 31, 2020, 240,606 THN kits were reported distributed by registered sites to members of the public, with 90,011 records indicating that a kit was obtained to replace a previous kit that had been used to reverse an overdose. There was a significant trend in increasing kits reported used by year ( p < 0.01). The kit recipient’s risk of overdose was a significant predictor of having reported using a THN kit, and the strength of the association was dependent on gender (Male: Adjusted odds ratio (AOR) 5.37 [95% confidence interval (CI) 5.08 – 5.67]; Female: AOR 8.35 [95% CI 7.90 – 8.82]; Trans and gender expansive: AOR 3.68 [95% CI 2.82 – 4.79]). Conclusions Between 2017 and 2020, THN kits were used to reverse tens of thousands of overdose events in BC, with people at risk of overdose (i.e. people who use drugs [PWUD]) having greater odds of using a kit to reverse an overdose than those not at risk. Thus, PWUD are responsible for reversing the vast majority of overdoses. THN kits are being distributed to the people who use them most. However, additional strategies in conjunction with community-based naloxone distribution programs are needed to address the rising number of illicit drug toxicity deaths.

Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city

Article

Full-text available

Mar 2022

Julie Holeksa

Background The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access. Methods Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy. Results Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission. Conclusion Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.

Assessing Syringe Exchange Program Access among Persons Who Inject Drugs (PWID) in the District of Columbia

Article

Full-text available

Jan 2016
J URBAN HEALTH

Prior research has explored spatial access to syringe exchange programs (SEPs) among persons who inject drugs (PWID), but these studies have been based on limited data from short periods of time. No research has explored changes in spatial access to SEPs among PWID longitudinally. The purpose of this research is to examine spatial access to SEPs among PWID who accessed services at a SEP in Washington, District of Columbia (DC), from 1996 to 2010. The geometric point distance estimation technique was used to calculate the mean walking distance PWID traveled from the centroid point of their zip code of home residence to the mobile exchange site where they accessed SEP services. Analysis of variance (ANOVA) was used to examine differences in walking distance measures by year. The results of this research suggest that the distance DC PWID traveled to access SEP services remained relatively constant (approximately 2.75 mi) from 2003 to 2008, but increased to just over 4 mi in 2010. This research provides support for expanding SEP operations such that PWID have increased access to their services. Increasing SEP accessibility may help resolve unmet needs among injectors.

Protecting Urban Health and Safety: Balancing Care and Harm in the Era of Mass Incarceration

Article

Full-text available

Dec 2015

This paper explores theoretical, spatial, and mediatized pathways through which policing poses harms to the health of marginalized communities in the urban USA, including analysis of two recent and widely publicized incidents of officer-involved killings in Ferguson, Missouri and Staten Island, New York. We examine the influence of the "broken windows" model in both policing and public health, revealing alternate institutional strategies for responding to urban disorder in the interests of the health and safety of the city. Drawing on ecosocial theory and medical anthropology, we consider the roles of the segregated built environment and historical experience in the embodiment of structural vulnerability with respect to police violence. We examine the recent shootings of Eric Garner and Michael Brown as the most visible, most circulated symbols of this complex and contradictory terrain, focusing on the pathways through which theories of causality authorize violent and/or caring intervention by the state. We show how police killings reveal an underlying and racialized association between disorder and deviance that becomes institutionalized and embodied through spatial and symbolic pathways. If public health workers and advocates are to play a role in responding to the call of the Black Lives Matter movement, it is important to understand the interpretations and translations of urban social life that circulate on the streets, in the media, in public policy, and in institutional practice.

The spatial–temporal relationship of policing in areas with high drug activity

Article

Full-text available

Nov 2015
DRUG ALCOHOL DEPEN

Impacts sociaux et pour la santé publique de la répression du marché des drogues : une synthèse des données

Article

Reçue le 27 mai 2004 ; version révisée reçue le 27 avril 2005 ; validée le 28 avril 2005 Résumé La première réponse aux risques liés à l'injection illicite de drogues dans la plupart des situations implique une répression renforcée, dans un effort de limiter l'offre et la demande de drogues. Depuis les années 1980, les approches politiques sont de plus en plus appliquées sur le marché des drogues illicites, malgré une confirmation scientifique limitée de leur efficacité. A contrario, un corpus grandissant de recherches indique que ces approches ont le potentiel non négligeable de produire des impacts sociaux et sanitaires néfastes, y compris l'interruption de la fourniture de soins aux utilisateurs de drogues injectables (UDI), ce qui augmente les comportements à risques associés à la transmission de maladies infectieuses et aux overdoses et exposent des communautés auparavant non affectées aux risques liés à l'usage de drogues illicites. Il existe toutefois d'autres solutions aux approches répressives ciblées traditionnelles qui peuvent potentiellement générer bien moins de conséquences négatives pour la santé et la société et plus d'avantages nets pour la communauté. Certaines de ces approches nécessitent de modifier les pratiques de politique, d'encourager les partenariats entre police et agences de santé publique et de développer des systèmes de surveillance des pratiques policières. D'autres possibilités impliquent la fourniture de services de réduction des risques, comme les centres d'injection sécurisée qui aident à minimiser les risques liés à la drogue, et les services de traitement de l'addiction qui finissent par contribuer à la réduction de la demande en drogues illégales. © 2005 Elsevier B.V. Tous droits réservés.

Police bribery and access to methadone maintenance therapy within the context of drug policy reform in Tijuana, Mexico

Article

Full-text available

Jan 2015
DRUG ALCOHOL DEPEN

Legal space for syringe exchange programs in hot spots of injection drug use-related crime

Article

Full-text available

Apr 2016

Background Copious evidence indicates that syringe exchange programs (SEPs) are effective structural interventions for HIV prevention among persons who inject drugs (PWID). The efficacy of SEPs in supporting the public health needs of PWID populations is partially dependent on their accessibility and consistent utilization among injectors. Research has shown that SEP access is an important predictor of PWID retention at SEPs, yet policies exist that may limit the geographic areas where SEP operations may legally occur. Since 2000 in the District of Columbia (DC), SEP operations have been subject to the 1000 Foot Rule (§48–1121), a policy that prohibits the distribution of “any needle or syringe for the hypodermic injection of any illegal drug in any area of the District of Columbia which is within 1000 feet of a public or private elementary or secondary school (including a public charter school).” The 1000 Foot Rule may impede SEP services in areas that are in urgent need for harm reduction services, such as locations where injections are happening in “real time” or where drugs are purchased or exchanged. We examined the effects of the 1000 Foot Rule on SEP operational space in injection drug use (IDU)-related crime (i.e., heroin possession or distribution) hot spots from 2000 to 2010. Methods Data from the DC Metropolitan Police Department were used to identify IDU-related crime hot spots. School operation data were matched to a dataset that described the approximate physical property boundaries of land parcels. A 1000-ft buffer was applied to all school property boundaries. The overlap between the IDU-related crime hot spots and the school buffer zones was calculated by academic year. Results When overlaying the land space associated with IDU-related crime hot spots on the maps of school boundaries per the 1000-ft buffer zone stipulation, we found that the majority of land space in these locations was ineligible for legal SEP operations. More specifically, the ineligible space in the identified hot spots in each academic year ranged from 51.93 to 88.29 % of the total hot spot area. Conclusions The removal of the 1000 Foot Rule could significantly improve the public health of PWID via increased access to harm reduction services. Buffer zone policies that restrict SEP operational space negatively affect the provision of harm reduction services to PWID.

Measuring the public health impact of police activities on illicit drug users

Article

Jun 2005
INT J DRUG POLICY

The Cedar Project: Impacts of policing among young Aboriginal who use injection and non-injection drug users in British Columbia, Canada

Article

Full-text available

May 2013

Background: Policing has profound health implications for people who use illicit drugs. Among Aboriginal communities, distrust of police is common, due partly to legacies of colonial policing. In response to the paucity of research among Aboriginal people who use drugs, this paper aims to: (1) Describe the policing experiences of young Aboriginal people who use drugs; (2) Identify policing activities associated with unsafe injection practices; and (3) Elucidate barriers to positive police relations. Methods: The Cedar Project is a cohort study involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. This mixed-methods study (N=372) used period prevalence from 2007 to 2010 to describe policing experiences, mixed effects regression models to identify correlates of policing activities, and thematic qualitative analysis to assess attitudes to police relations. Results: Many participants were stopped by police (73%), experienced physical force by police (28%), had drug equipment confiscated (31%), and changed location of drug use because of police (43%). Participants who reported dealing drugs (40%) were significantly more likely to experience police engagement. Among participants in Prince George, 4% reported to have had non-consensual sex with members of the criminal justice system. Policing activity was significantly associated with syringe sharing, rushed injection, and reused syringe. Due to personal experience, practical concerns, and intergenerational legacies of unfair policing practices, most participants did not want a positive relationship with police (57%). Desire for a positive relationship with police was directly associated with being helped by police, and inversely associated with being stopped by police and experiencing physical force by police. Conclusion: Policing activities may be impacting the well-being of Aboriginal people who use drugs. Due to focused prosecution of street-level drug dealing, some police may favor enforcement over harm reduction. Positive police engagement and less aggressive policing may enhance perceptions of police among young Aboriginal people who use drugs.

Injection drug users' involvement in drug dealing in the downtown eastside of Vancouver: Social organization and systemic violence

Article

May 2013

Racial/Ethnic Disparities in HIV infection among people who inject drugs: An international systematic review and meta-analysis

Article

Jul 2012
ADDICTION

Aims: The Ethnic Minority Meta-Analysis (EMMA) aims to assess racial/ethnic disparities in HIV infection among people who inject drugs (PWID) across various countries. This is the first report of the data. Methods: Standard systematic review/meta-analysis methods were utilized, including searching for, screening and coding published and unpublished reports and meta-analytical statistics. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for reporting methods. Disparities were measured with the odds ratio (OR) for HIV prevalence among ethnic minority PWID compared to ethnic majority PWID; an OR >1.0 indicated higher prevalence among ethnic minorities. Results: Racial/ethnic disparities in HIV prevalence among PWID were examined in 131 prevalence reports, with 214 racial/ethnic minority to majority comparisons, comprising 106 715 PWID. Overall, the pooled OR indicates an increased likelihood of higher HIV prevalence among racial/ethnic minority compared to racial/ethnic majority PWID [OR = 2.09, 95% confidence interval (CI): 1.92-2.28]. Among 214 comparisons, 106 produced a statistically significant higher OR for minorities; in 102 comparisons the OR was not significantly different from 1.0; six comparisons produced a statistically significant higher OR for majority group members. Disparities were particularly large in the United States, pooled OR = 2.22 (95% CI: 2.03-2.44). There was substantial variation in ORs-I(2) = 75.3%: interquartile range = 1.38-3.56-and an approximate Gaussian distribution of the log ORs. Conclusions: Among people who inject drugs, ethnic minorities are approximately twice as likely to be HIV seropositive than ethnic majorities. The great heterogeneity and Gaussian distribution suggest multiple causal factors and a need to tailor interventions to local conditions.

Public Health and International Drug Policy

Article

Mar 2016
LANCET

Spatial Patterns of Arrests, Police Assault, and Addiction Treatment Center Locations in Tijuana, Mexico

Article

Full-text available

Feb 2016
ADDICTION

Aims: In the context of a public health-oriented drug policy reform in Mexico, we assessed the spatial distribution of police encounters among people who inject drugs (PWID) in Tijuana; determined the association between these encounters and the location of addiction treatment centers; and explored the association between police encounters and treatment access. Design: Geographically weighted regression (GWR) and logistic regression analysis using prospective spatial data from a community-recruited cohort of PWID in Tijuana and official geographic arrest data from the Tijuana Municipal Police Department. Setting: Tijuana, Mexico. Participants: 608 participants (median age 37; 28.4% female) in the prospective Proyecto El Cuete cohort study recruited between January and December 2011. Measurements: We compared the mean distance of police encounters and a randomly distributed set of events to treatment centers. GWR was undertaken to model the spatial relationship between police interactions and treatment centers. Logistic regression analysis was used to investigate factors associated with reporting police interactions. Findings: During the study period, 27.5% of police encounters occurred within 500 meters of treatment centers. The GWR model suggested spatial correlation between encounters and treatment centers (Global R(2) = 0.53). Reporting a need for addiction treatment was associated with reporting arrest and police assault (Adjusted Odds Ratio = 2.74, 95% Confidence Interval [CI]: 1.25 - 6.02, p = 0.012). Conclusions: A geospatial analysis suggests that in Mexico, people who inject drugs are at greater risk of being a victim of police violence if they consider themselves in need of addiction treatment, and their interactions with police appear to be more frequent around treatment centres.

Beyond equipment distribution in Needle and Syringe Programmes: An exploratory analysis of blood-borne virus risk and other measures of client need

Article

Full-text available

May 2016

Background Despite high levels of equipment distribution through Needle and Syringe Programmes (NSPs) in Australia, the levels of reuse of equipment among people who inject drugs remain concerning. This paper used an exploratory analysis to examine the needs of NSP client that could be addressed by NSPs to enhance service impact and blood-borne virus risk practices. Methods People who inject drugs were recruited from six NSP sites in Sydney, Australia, to undertake a self-completed survey. Results Using the responses of 236 NSP client participants, three factors were identified in an exploratory factor analysis: recent risky injection (Eigenvalue 3.63, 20.2 % of variance); disadvantage and disability (Eigenvalue 2.26, 12.5 % of variance); and drug use milieu (Eigenvalue 1.50, 8.4 % of variance). To understand the distribution of these factors, the standardised factor scores were dichotomised to explore those participants with ‘above average’ vulnerability on each factor. A small group of NSP clients reported a cluster of vulnerability measures. Most participants (55.5 %) reported vulnerability on none or only one factor, indicating that 45.5 % could be considered as having double (35.6 %) or triple (8.9 %) vulnerability. Conclusions These results challenge NSPs to understand the heterogeneity among their client group and develop programmes that respond to their clients’ range of needs beyond those immediately associated with blood-borne virus (BBV) risk. This paper contributes to the growing evidence base regarding the need for BBV prevention efforts to examine strategies beyond equipment distribution.

Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey of municipal police in Tijuana, Mexico

Article

Full-text available

Sep 2018
BMC Int Health Hum Right

Background: Mexican law permits syringe purchase and possession without prescription. Nonetheless, people who inject drugs (PWID) frequently report arrest for syringe possession. Extrajudicial arrests not only violate human rights, but also significantly increase the risk of blood-borne infection transmission and other health harms among PWID and police personnel. To better understand how police practices contribute to the PWID risk environment, prior research has primarily examined drug user perspectives and experiences. This study focuses on municipal police officers (MPOs) in Tijuana, Mexico to identify factors associated with self-reported arrests for syringe possession. Methods: Participants were active police officers aged ≥18 years, who completed a self-administered questionnaire on knowledge, attitudes and behaviors related to occupational safety, drug laws, and harm reduction strategies. Univariable and multivariable logistic regression was used to identify correlates of recent syringe possession arrest. Results: Among 1044 MPOs, nearly half (47.9%) reported always/sometimes making arrests for syringe possession (previous 6mo). Factors independently associated with more frequent arrest included being male (Adjusted Odds Ratio [AOR] = 1.62; 95% Confidence Interval [95% CI] =1.04-2.52; working in a district along Tijuana River Canal (where PWID congregate) (AOR = 2.85; 95%CI = 2.16-3.77); having recently experienced a physical altercation with PWID (AOR = 2.83; 95% CI = 2.15-3.74); and having recently referred PWID to social and health services (AOR = 1.97; 95% CI = 1.48-2.61). Conversely, odds were significantly lower among officers reporting knowing that syringe possession is legal (AOR = 0.61; 95% CI = 0.46-0.82). Conclusions: Police and related criminal justice stakeholders (e.g., municipal judges, prosecutors) play a key role in shaping PWID risk environment. Findings highlight the urgent need for structural interventions to reduce extra-judicial syringe possession arrests. Police training, increasing gender and other forms of diversity, and policy reforms at various governmental and institutional levels are necessary to reduce police occupational risks, improve knowledge of drug laws, and facilitate harm reduction strategies that promote human rights and community health.

Preferences and acceptability of law enforcement initiated referrals for people who inject drugs: A mixed methods analysis

Article

Full-text available

Oct 2020
SUBST ABUSE TREAT PR

Background Law enforcement officers (LEOs) come into frequent contact with people who inject drugs (PWID). Through service referrals, LEOs may facilitate PWID engagement in harm reduction, substance use treatment, and other health and supportive services. Little is known about PWID and LEO attitudes and concerns about service referrals, however. The objective of this mixed-methods study was to examine the alignment of service referral preferences and acceptability among PWID and LEOs in Tijuana, Mexico. Methods We assessed service referral preferences and perceived likelihood of participation in health and social services, integrating data from structured questionnaires with 280 PWID and 306 LEOs, contextualized by semi-structured interviews and focus groups with 15 PWID and 17 LEOs enrolled in two parallel longitudinal cohorts in Tijuana, Mexico. Results Among potential service referral options, both PWID (78%) and LEOs (88%) most frequently cited assistance with drug- and alcohol-use disorders. Over half of PWID and LEOs supported including harm reduction services such as syringe service programs, overdose prevention, and HIV testing. The majority of PWID supported LEO referrals to programs that addressed basic structural needs (e.g. personal care [62%], food assistance [61%], housing assistance [58%]). However, the proportion of LEOs (30–45%) who endorsed these service referrals was significantly lower ( p < 0.01). Regarding referral acceptability, 71% of PWID reported they would be very likely or somewhat likely to make use of a referral compared to 94% of LEOs reporting that they thought PWID would always or sometimes utilize them. These results were echoed in the qualitative analysis, although practical barriers to referrals emerged, whereby PWID were less optimistic that they would utilize referrals compared to LEOs. Conclusions We identified strong support for LEO service referrals among both LEO and PWID respondents, with the highest preference for substance use treatment. LEO referral programs offer opportunities to deflect PWID contact with carceral systems while facilitating access to health and social services. However, appropriate investments and political will are needed to develop an evidence-based (integrated) service infrastructure.

“…I can use any syringe I find”: contextual determinants of HIV risk in public injecting settings in Nigeria

Article

Full-text available

Sep 2020

Purpose The purpose of this study is to explore the contextual determinants of HIV risk among people who inject drugs (PWID) in public settings in Nigeria. Design/methodology/approach In-depth, individual interviews were conducted with 29 street-based PWID recruited through snowball sampling in Uyo, Nigeria. Interviews were tape-recorded, transcribed, coded and analysed hematically. Findings Homelessness and withdrawal pains encouraged consumption of drugs in public spaces (e.g. bunks, public parks). Conversely, the benefits of participation in street drug-use scenes, including reciprocity norms that guarantee free drugs during withdrawal and protection during overdose, fostered a preference for public injecting. Although participants recognized the need to inject with sterile syringes, scarcity of syringes compelled them to improvise with old syringes or share syringes, increasing risk for HIV transmission. HIV risk was exacerbated by unlawful and discriminatory policing practices, which deterred possession of syringes and encouraged risky behaviours such as rushing injection and sharing of equipment. Practical implications Contextual factors are key determinants of HIV risk for street-based PWID. Implementation of needle and syringe programmes as well as reforming legal frameworks and policing practices to support harm reduction are needed responses. Originality/value This is one of very few qualitative studies that explore risk factors for HIV transmission among PWID in West Africa. The focus on scarcity of sterile syringes and HIV risk is unique and has important policy implications.

Individual-level needle and syringe coverage in Melbourne, Australia: a longitudinal, descriptive analysis

Article

Full-text available

Aug 2016
BMC HEALTH SERV RES

Background Coverage is used as one indicator of needle and syringe program (NSP) effectiveness. At the individual level, coverage is typically defined as an estimate of the proportion of a person who injects drugs’ (PWID) injecting episodes that utilise a sterile syringe. In this paper, we explore levels of individual syringe coverage and its changes over time. Methods Data were extracted from 1889 interviews involving 502 participants drawn from the Melbourne drug user cohort study (MIX).We asked questions relating to participants syringe acquisition, distribution and injecting frequency within the two weeks before interview. We created a dichotomous coverage variable that classified participants as sufficiently (≥100 %) covered if all their injecting episodes utilised at least one sterile syringe, and insufficiently (<100 %) covered if not. We categorised participants as “consistently covered” if they were sufficiently covered across interviews; as “consistently uncovered” if they were insufficiently covered across interviews; and “inconsistently covered” if they oscillated between coverage states.Chi-square statistics tested proportions of insufficient coverage across sub-groups using broad demographic, drug use and service utilisation domains. Logistic regression tested predictors of insufficient coverage and inconsistently covered categorisation. ResultsAcross the sample, levels of insufficient coverage were substantial (between 22–36 % at each interview wave). The majority (50 %) were consistently covered across interviews, though many (45 %) were inconsistently covered.We found strong statistical associations between insufficient coverage and current hepatitis C virus (HCV) infection (RNA+). Current prescription of opioid substitution therapy (OST) and using NSPs as the main source of syringe acquisition were protective against insufficient coverage. Conclusion Insufficient coverage across the sample was substantial and mainly driven by those who oscillated between states of coverage, suggesting the presence of temporal factors. We recommend a general expansion of NSP services and OST prescription to encourage increases in syringe coverage.

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011-2018

Article

Nov 2019

Background: People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID. Methods: Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age. Results: Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective. Conclusion: In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.

Sharing the costs of structural interventions: What can models tell us?

Article

Full-text available

Mar 2020
INT J DRUG POLICY

Background The global HIV response needs to both integrate with the broader health system and tackle the structural drivers of HIV. Cross-sectoral financing arrangements in which different sectors agree to co-finance structural interventions – have been put forward as promising frameworks to address these concerns. However, co-financing arrangements remain rare for HIV, and there is no consensus on how to distribute costs. Methods We use case studies to investigate how structural interventions can be incorporated within three quantitative decision-making frameworks. First, we consider cost-benefit analyses (CBA) using an opioid substitution therapy (OST) program in Armenia; second, we construct a theoretical example to illustrate the lessons game theory can shed on the co-financing arrangements implied by CBA; and third we consider allocative efficiency analyses using needle-syringe programs (NSPs) in Belarus. Results A cross-sectoral cost-benefit analysis of OST in Armenia demonstrates that the share of that should be funded by the HIV sector depends on the willingness to pay (WTP) to avert an HIV-related DALY, the long-term cost-benefit ratio, and the HIV risk reduction from OST. For reasonable parameter values, the HIV sector's share ranges between 0–48%. However, the Shapley value––a game-theoretic solution to cost attribution that ensures each sector gains as much or more as they would from acting independently––implies that the HIV sector's share may be higher. In Belarus, we find that the HIV sector should be willing to co-finance structural interventions that would increase the maximal attainable coverage of NSPs, with the contribution again depending on the WTP to avert an HIV-related DALY. Conclusion Many interventions known to have cross-sectoral benefits have historically been funded from HIV budgets, but this may change in the future. The question of how to distribute the costs of structural interventions is critical, and frameworks that decision-makers use to inform resource allocations will need to take this into account.

Public Health and Drug Policing in Malaysia: Using Empirical Evidence for Advocacy

Article

Full-text available

Nov 2016

Fifa Rahman

Introduction: Malaysia adopted harm reduction (HR) as official policy in 2006 and subsequently implemented needle-and-syringe exchange programs (NSEP) and methadone maintenance therapies (MMT). Today these programs continue, somewhat in conflict with criminalisation of drug use (incarceration, corporal punishment, and police surveillance post-release from incarceration). Seven years from date of Malaysia’s HR policy inception, with funding from the Dutch government under the Community Action on Harm Reduction and the European Union funded Asia Action on Harm Reduction (Asia Action) projects, the Malaysian AIDS Council (MAC) and the Centre of Excellence for Research in AIDS (CERiA) carried out qualitative research with police officers and people who use drugs (PWUD) to determine attitudes towards harm reduction and drug use, and to elicit perspectives on better approaches in drug law enforcement. Methodology: We conducted qualitative research with 20 drug user participants and 11 police officers based in police stations in various states in Malaysia (Kuala Lumpur, Pahang, and Kelantan). Based among others at the Malaysian AIDS Council, the lead author has been undertaking evidence-based advocacy and has been maintaining an advocacy log containing key events including meetings with key officials, tweets, emails and text messages that contributed to improving police awareness about harm reduction and drug evidence-based drug policy. Results: In this article we summarize our approach to evidence-informed advocacy work. Our results show that police lack understanding on the efficacy and operation of harm reduction programs. They also expressed incredulity at the possibility of a drug free ASEAN region. Drug user interviews pointed to a host of police practices that constitute barriers to treatment, including abuse, corruptive practices, and failure to inform of rights. These results will also inform subsequent quantitative surveys to generate further evidence on drug law enforcement and public health implications in Malaysia. Discussion: Based on the results of the qualitative research and mileage gained in advocacy, larger scale interventions involving high-level police officials may be necessary to change practices, which oppose public health evidence but are structural or are ingrained in police culture. Negative practices have the potential to seep (and in some cases, are already seeping) into other agencies in drug policy and drug control. A consolidated written drug policy would assist in mitigating these issues.

Do police crackdowns disrupt drug cryptomarkets? A longitudinal analysis of the effects of Operation Onymous

Article

Full-text available

Feb 2017
CRIME LAW SOCIAL CH

In recent years, there has been a proliferation of online illicit markets where participants can purchase and sell a wide range of goods and services such as drugs, hacking services, and stolen financial information. Second-generation markets, known as cryptomarkets, provide a pseudo-anonymous platform from which to operate and have attracted the attention of researchers, regulators, and law enforcement. This paper focuses on the impact of police crackdowns on cryptomarkets, and more particularly on the impact of Operation Onymous, a large-scale police operation in November 2014 that targeted many cryptomarkets. Our results demonstrate that cryptomarket participants adapt to police operations and that the impact of Operation Onymous was limited in time and scope. Of particular interest is the finding that prices did not increase following Operation Onymous, even though many dealers retired shortly after it occurred.

Implementation dilemmas of the Needle Syringe Exchange Programme (NSEP): Between the law and prevention

Article

Full-text available

Nov 2016

HIV/AIDS is a potentially serious threat to national development. In 2006, the Needle and Syringe Exchange Programme (NSEP) was formally introduced to prevent further spread of HIV/AIDS. However, this programme places many of its clients in a dilemma because they want to access NSEP services but are afraid of being arrested by the police since drug use in is a criminal offense in Malaysia.

The Urban Environment, Drug Use, and Health

Chapter

Full-text available

Jan 2005

Drug use continues to be a major concern in urban centers and significantly affects the health of cities at the beginning of the new millennium. Drug users still face considerable challenges to their health and well-being. The extent to which the urban environment affects the occurrence of drug use and its consequences is an area of growing research. Early investigations suggest that specific features of the urban environment are related to not only the occurrence of drug use, but also its course and consequences. Many questions remain unanswered with respect to the impact of the urban social and physical environment, along with larger societal structures, on illicit drug use. Because of the large number of drug users in urban areas, cities provide a unique opportunity for public health practitioners, urban planners, and policy makers to develop and test creative programs and interventions to improve the health outcomes for this population.

Jail and Overdose: Assessing the Community Impact of Incarceration on Overdose

Article

Full-text available

Jul 2021

Background and aims Incarceration produces a specific public health threat for drug overdose, and correctional settings do not offer medication for opioid use disorder. This study examined the overall impact of jail incarceration on overdose, the specific hazard for those booked on a syringe-related charge, and the proportion of all overdose decedents in the community who were in the jail prior to death. Design A cohort study of fatal overdose outcomes among a sample of individuals booked into and released from jail between January 1, 2017, and December 31, 2019. Setting Marion County, Indiana, United States of America Participants All individuals released from one county jail between January 1, 2017, to December 31, 2017 and decedents who died within the county from an accidental fatal overdose between January 2017 and December 2019. Measurements Using information on all jail booking events, including charge type, over a 5-year period (January 2015 through December 2019), we looked at the hazard of accidental fatal overdose post-release, controlling for age, sex, and race. Findings Of all overdose deaths in the county, 21% (n = 237) had been in the county jail within 2 years prior to their death. Each prior booking increased the hazard of mortality by approximately 20% [hazard ratio (HR) = 1.21, 95% confidence interval (CI) = 1.15, 1.28], while presence of syringe charge at most recent booking prior to release more than tripled the hazard of mortality [HR = 3.55, 95% CI = 2.55, 4.93]. Conclusions In Marion County, Indiana, USA, there appears to be an association between increased risk of fatal drug overdose and both syringe-related arrests and repeat jail bookings.

The perspectives of people who use drugs regarding short term involuntary substance use care for severe substance use disorders

Article

May 2021
INT J DRUG POLICY

Background In the Canadian Province of British Columbia (BC), the BC Mental Health Act permits involuntary care for treating mental disorders. However, the Act has also been applied to provide involuntary care to individuals with a primary substance use disorder, in the absence of specific guidelines and legislation, and with insufficient understanding of perspectives of people who use drugs (PWUD) regarding this approach. Methods As part of a larger mixed-methods research project providing an overview of involuntary care for severe substance use disorders in BC, three focus groups were convened with: PWUD, families and caregivers, and Indigenous community stakeholders. This analysis examines perspectives from the focus group of PWUD, consisting of nine participants from local and regional drug user and advocacy organizations regarding involuntary care. A qualitative descriptive approach and thematic analysis were conducted, using a coding framework developed deductively and inductively, and participant perspectives were interpreted drawing on problematization theory. Results Participants did not endorse the use of involuntary care, instead emphasizing significant changes were needed to address shortcomings of the wider voluntary care system. When asked to conceptualize what an acceptable involuntary care scenario might look like (under hypothetical and ideal conditions), participants recommended it should include: individual control and autonomy, peer advocacy in decision-making, and elimination of police and criminal justice system involvement from treatment encounters. Participants saw involuntary care to be an inappropriate approach given the shortcomings of the current system, noting also problems inherent in its use to manage severe SUDs and imminent harm, and prioritized alternate approaches to offsetting risks. Conclusion Improving voluntary care for substance use, along with addressing the social determinants of health that put individuals at risk of problematic substance use and harm, were prioritized in participant perspectives. Participant comments regarding the use of involuntary care bring forward alternate solutions in the context of the opioid overdose crisis, and a reconceptualization of the ‘problem’ of managing severe substance use disorders.

Toward a Critical Criminology of HIV Criminalization

Article

Full-text available

Mar 2021
Crit Criminol

Andrew Novak

Persons living with human immunodeficiency virus (HIV) (hereinafter, “PLHIV”) face barriers at each stage of the criminal justice process, including prosecution for non-disclosure of HIV status. Justice institutions reinforce the stigma of HIV, which has perverse consequences for HIV prevention and treatment services. This article takes a critical criminological approach to “HIV criminalization,” using the frames of queer criminology and epidemiological criminology to analyze both the punishment of “deviant” sex and the public health consequences of HIV stigma. Finally, this article offers a comprehensive consideration of the criminal justice barriers that PLHIV face in light of current criminological research, providing both mainstream and critical criminologists new insights into the social construction of deviance, legitimacy of institutions, definition of victims, and purposes of punishment.

Recent incarceration and use of a supervised injection facility in Vancouver, Canada

Article

Sep 2009
ADDICT RES THEORY

There are concerns that Vancouver's supervised injection facility (SIF) for injection drug users (IDU) is an amplifier of drug-related crime. Therefore, we sought to evaluate the possible association between SIF use and recent incarceration among IDU. We examined incarceration experiences among participants in the Scientific Evaluation of Supervised Injecting (SEOSI) prospective cohort. The relationship between recent incarceration and frequent SIF use was assessed using generalised estimating equations (GEE). Nine-hundred two individuals were included in this analysis, of whom 255 (28.27%) were female. The rate of incarceration remained stable throughout follow-up with between one-quarter and one-third reported incarceration in the previous 6 months at each study visit. In a multivariate GEE analysis, frequent SIF use was not associated with recent incarceration (AOR: 0.99, p = 0.916). Although incarceration is a common experience among local IDU, our analysis does not provide evidence to support claims that, use of the SIF is increasing involvement in drug-related crime in the community. Our findings also indicate that incarceration continues to be associated with high-risk behaviours.

Knowledge of a Drug-Related Good Samaritan Law Among People Who Use Drugs, Vancouver, Canada

Article

Mar 2021

Background Across the United States and Canada drug-related Good Samaritan laws (GSLs) have been enacted to encourage observers of acute drug overdose events to contact emergency medical services (EMS) without fear of legal repercussions. However, little is known about the working knowledge of GSLs among people who use illicit drugs (PWUD). We sought to evaluate the prevalence and factors associated with accurate knowledge of a GSL among PWUD in Vancouver, Canada, 1 year after the GSL was enacted. Method We used data from participants in three community-recruited prospective cohort studies of PWUD interviewed between June and November 2018. Multivariable logistic regression was used to identify factors associated with accurate knowledge of the GSL. Results Among 1,258 participants, including 760 males (60%), 358 (28%) had accurate knowledge of the GSL. In multivariable analyses, participants who reported ever having a negative police encounter (defined as being stopped, searched, or detained by the police) were less likely to have accurate knowledge of the GSL (adjusted odds ratio [AOR] = 0.70; 95% CI [0.54, 0.90]), while those involved in drug dealing were more likely to have accurate knowledge of the GSL (AOR = 1.50; 95% CI [1.06, 2.06]). Discussion Despite having been enacted for a full year, approximately three quarters of participants did not have accurate GSL knowledge, warranting urgent educational efforts among PWUD. Additional research is needed to understand whether GSLs can mitigate the fears of legal repercussions among those engaged in drug dealing and with past negative experiences with the police.

Policing Drug Markets

Chapter

Jan 2021

Jack Spicer

Having critically outlined the specific drug supply context of County Lines, this chapter considers theoretically the policing of illicit drug markets. An often highly contentious area of law enforcement, for the past half century, policing has remained the principle way that drug markets and the various actors involved in them are responded to officially by the state. Among other things, the role of the police as the visible representation of the ‘war on drugs’ stresses the importance of understanding and analysing how their work in this area is actually undertaken. If illegal drug markets and the way they operate can be considered as inextricably allied with the policy of prohibition, it is arguably only right that attention is trained acutely on those on the opposing side who, as Young (The drugtakers: The social meaning of drug use. London: MacGibbon & Kee, 1971, p. 28) put it, “man the barricades which society sets up between itself and the deviant”.

Illicit Drug Use and Harms, and Related Interventions and Policy in Canada: A Narrative Review of Select Key Indicators and Developments since 2000

Article

Sep 2015

Background: By the year 2000, Canada faced high levels of illicit drug use and related harms. Simultaneously, a fundamental tension had raisen between continuing a mainly repression-based versus shifting to a more health-oriented drug policy approach. Despite a wealth of new data and numerous individual studies that have emerged since then, no comprehensive review of key indicators and developments of illicit drug use/harm epidemiology, interventions and law/policy exist; this paper seeks to fill this gap. Methods: We searched and reviewed journal publications, as well as key reports, government publications, surveys, etc. reporting on data and information since 2000. Relevant data were selected and extracted for review inclusion, and subsequently grouped and narratively summarized in major topical sub-theme categories. Results: Cannabis use has remained the principal form of illicit drug use; prescription opioid misuse has arisen as a new and extensive phenomenon. While new drug-related blood-borne-virus transmissions declined, overdose deaths increased in recent years. Acceptance and proliferation of - mainly local/community-based - health measures (e.g., needle exchange, crack paraphernalia or naloxone distribution) aiming at high-risk drug users has evolved, though reach and access limitations have persisted; Vancouver's 'supervised injection site' has attracted continued attention yet remains un-replicated elsewhere in Canada. While opioid maintenance treatment utilization increased, access to treatment for key (e.g., infectious disease, psychiatric) co-morbidities among drug users remained limited. Law enforcement continued to principally focus on cannabis and specifically cannabis users. 'Drug treatment courts' were introduced but have shown limited effectiveness; several attempts cannabis control law reform have failed, except for the recent establishment of 'medical cannabis' access provisions. Conclusions: While recent federal governments introduced several law and policy measures reinforcing a repression approach to illicit drug use, lower-level jurisdictions (e.g., provincial/municipal levels) and non-governmental organizations increasingly promoted social- and health-oriented intervention frameworks and interventions, therefore creating an increasingly bifurcated - and inherently contradictory - drug policy landscape and reality in Canada.

Police Encounters Among Needle Exchange Clients in Baltimore: Drug Law Enforcement as a Structural Determinant of Health

Article

Full-text available

Jul 2015
AM J PUBLIC HEALTH

We piloted a monitoring mechanism to document police encounters around programs targeting people who inject drugs (PWID), and assessed their demographic predictors at 2 Baltimore, Maryland, needle exchange program (NEP) sites. In a brief survey, 308 clients quantified, characterized, and sited recent police encounters. Multivariate linear regression determined encounter predictors, and we used geocoordinate maps to illustrate clusters. Within the past 6 months, clients reported a median of 3 stops near NEP sites (interquartile range [IQR] = 0-7.5) and a median of 1 arrest in any location (IQR = 0-2). Three respondents reported police referral to the NEP. Being younger (P = .009), being male (P = .033), and making frequent NEP visits (P = .02) were associated with reported police stops. Among clients reporting arrest or citation for syringe possession, Whites were significantly less likely than non-Whites to report being en route to or from an NEP (P < .001). Reported encounters were clustered around NEPs. Systematic surveillance of structural determinants of health for PWID proved feasible when integrated into service activities. Improved monitoring is critical to informing interventions to align policing with public health, especially among groups subject to disproportionate levels of drug law enforcement. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e8. doi:10.2105/AJPH.2015.302681).

Police drug crackdowns and hospitalisation rates for illicit-injection-related infections in New York City

Article

Jun 2005
INT J DRUG POLICY

Using longitudinal data, this analysis tests the hypothesis that eight police drug crackdowns implemented in 27 New York City police precincts between 1995 and 1999 were associated with subsequent increases in monthly precinct-specific hospitalisation rates for illicit-injection-related abscesses, cellulitis, and endocarditis. Crackdowns are sustained police initiatives designed to reduce the possession and sale of illicit drugs through heightened surveillance and arrests of drug users and street-level dealers. We linked hospitalisation data (48,986 illicit-injection-related abscess or cellulitis cases and 5452 illicit-injection-related endocarditis cases) and arrest and United States Census data to police precincts to calculate hospitalisation and arrest rates. Analyses indicate that drug-related arrest rates climbed 39% in the crackdowns’ first year compared with the previous year. Contrary to our hypothesis, we found evidence of a stasis or decline in hospitalisation rates in the crackdowns’ first year, based on multivariate Poisson regression models that included sensitivity analyses that accounted for the increased incarceration of injectors after each crackdown's onset. We discuss several possible explanations for these findings and conclude that future research is warranted regarding the relationship between police strategies and drug users’ health that incorporates inmate health data and both individual-level and precinct-level data.

What do you do when you hit rock bottom? Responding to drugs in the City of Vancouver

Article

Mar 2006
INT J DRUG POLICY

The emergence of innovative cannabis distribution projects in the downtown eastside of Vancouver, Canada

Article

May 2020
INT J DRUG POLICY

The ongoing overdose crisis in the United States and Canada has highlighted the urgent need for innovative interventions to reduce drug-related harms. This, in turn, has led to increased interest in the potential of cannabis as a harm reduction strategy. While Canada has recently legalized cannabis, meaningful barriers to accessing legal cannabis remain for people who use drugs (PWUD) from marginalized communities. In the Downtown Eastside of Vancouver, Canada, innovative, grassroots cannabis distribution programs that dispense cannabis and cannabis products from unregulated sources to PWUD for free have recently emerged. In this study, we draw upon 23 in-depth qualitative interviews and ethnographic fieldwork with PWUD who access these programs. We found that these distribution programs play an important function in bridging access to cannabis for PWUD in a structurally disadvantaged neighborhood and do so by implementing few restrictions on who can access, providing a variety of cannabis products that would otherwise be inaccessible, and distributing cannabis at no cost. In addition, many people reported the program spaces provided an avenue to socialize and connect. Most of our participants reported that legal cannabis was inaccessible both through the legal medical and non-medical systems. Considering Canadian governments have made important regulatory changes in regards to cannabis, understanding emerging patterns and the structural barriers to accessing legal cannabis will be critical to maximizing the potential uses of cannabis as a harm reduction tool and ensuring equitable access to structurally disadvantaged populations. Examining the impact of cannabis use on PWUD and ensuring these groups have access to cannabis is an important component in determining whether cannabis deregulation reduces drug-related harms.

Examining the Spatial Distribution of Law Enforcement Encounters among People Who Inject Drugs after Implementation of Mexico’s Drug Policy Reform

Article

Full-text available

Oct 2014

In 2009, Mexico decriminalized the possession of small amounts of illicit drugs for personal use in order to refocus law enforcement resources on drug dealers and traffickers. This study examines the spatial distribution of law enforcement encounters reported by people who inject drugs (PWID) in Tijuana, Mexico to identify concentrated areas of policing activity after implementation of the new drug policy. Mapping the physical location of law enforcement encounters provided by PWID (n = 461) recruited through targeted sampling, we identified hotspots of extra-judicial encounters (e.g., physical/sexual abuse, syringe confiscation, and money extortion by law enforcement) and routine authorized encounters (e.g., being arrested or stopped but not arrested) using point density maps and the Getis-Ord Gi* statistic calculated at the neighborhood-level. Approximately half of the participants encountered law enforcement more than once in a calendar year and nearly one third of these encounters did not result in arrest but involved harassment or abuse by law enforcement. Statistically significant hotspots of law enforcement encounters were identified in a limited number of neighborhoods located in areas with known drug markets. At the local-level, law enforcement activities continue to target drug users despite a national drug policy that emphasizes drug treatment diversion rather than punitive enforcement. There is a need for law enforcement training and improved monitoring of policing tactics to better align policing with public health goals.

Longitudinal analysis of change in individual-level needle and syringe coverage amongst a cohort of people who inject drugs in Melbourne, Australia

Article

Apr 2017

Background: Needle and syringe program (NSP) coverage is often calculated at the individual level. This method relates sterile needle and syringe acquisition to injecting frequency, resulting in a percentage of injecting episodes that utilise a sterile syringe. Most previous research using this method was restricted by their cross-sectional design, calling for longitudinal exploration of coverage. Methods: We used the data of 518 participants from an ongoing cohort of people who inject drugs in Melbourne, Australia. We calculated individual-level syringe coverage for the two weeks prior to each interview, then dichotomised the outcome as either "sufficient" (≥100% of injecting episodes covered by at least one reported sterile syringe) or "insufficient" (<100%). Time-variant predictors of change in recent coverage (from sufficient to insufficient coverage) were estimated longitudinally using logistic regression with fixed effects for each participant. Results: Transitioning to methamphetamine injection (AOR:2.16, p=0.004) and a newly positive HCV RNA test result (AOR:4.93, p=0.001) were both associated with increased odds of change to insufficient coverage, whilst change to utilising NSPs as the primary source of syringe acquisition (AOR: 0.41, p=0.003) and opioid substitution therapy (OST) enrolment (AOR:0.51, p=0.013) were protective against a change to insufficient coverage. Conclusions: We statistically tested the transitions between time-variant exposure sub-groups and transitions in individual-level syringe coverage. Our results give important insights into means of improving coverage at the individual level, suggesting that methamphetamine injectors should be targeted, whilst both OST prescription and NSP should be expanded.

A Meta-Narrative Literature Synthesis and Framework to Guide Future Evaluation of Legal Empowerment Interventions

Article

Full-text available

Dec 2018
Health Hum Right Int J

Legal empowerment is increasingly recognized as a key approach for addressing socio-structural determinants of health and promoting the well-being and human rights of vulnerable populations. Legal empowerment seeks to increase people’s capacity to understand and use the law. However, limited consensus remains on the effectiveness of legal empowerment interventions in optimizing health outcomes. Leveraging a meta-narrative approach, we synthesized literature describing how legal empowerment interventions have been operationalized and empirically studied with respect to health determinants. The studies included here document diverse legal empowerment approaches and highlight how interventions changed the context surrounding the health of vulnerable populations. The absence of robust conceptualization, operationalization, and measurement of the risk contexts in which legal empowerment approaches operate limits the clarity with which interventions’ impact on health can be ascertained. Despite this, legal empowerment is a promising approach to address the health of marginalized populations. To foster support between the fields of legal empowerment and health, we explore the limitations in study design and measurement of the existing evidence base; such scrutiny could strengthen the rigor of future research. This paper provides a guide to the socio-structural levels across which legal empowerment interventions impact health outcomes in order to inform future interventions.

Evaluation of a drug user-led safer injecting education campaign

Article

Jan 2011

Cody Terry Callon

Older Adults

Chapter

Full-text available

Jan 2005

Social determinants predict needle-sharing behaviour among injection drug users in Vancouver, Canada

Article

Full-text available

Oct 1997

Despite the fact that needle exchange was introduced in Vancouver as early as 1988, needle sharing remains common. An analysis was conducted to identify determinants of borrowing used needles among subjects participating in a case-control study. IDUs had a documented HIV seroconversion after 1 January, 1994 (n = 89), or repeatedly tested HIV-seronegative after this date (n = 192). Interviewer-administered questionnaires focused on drug use, sexual behaviours, source of needles and depression. Subjects were asked if they had "ever been forced to have sex" as a child, youth or adult. Logistic regression identified determinants of borrowing needles. After controlling for HIV serostatus, factors independently associated with borrowing were injecting > 4 times/day, polydrug use, and ever experiencing non-consensual sex (AOR = 3.4, 95% CI: 1.8, 6.5). Depression was associated with borrowing, although not independently so. Homosexual activity was independently associated with borrowing among males, whereas living with a sexual partner was an independent predictor for females. Access or barriers to clean needle use were not associated with borrowing. Social determinants, particularly a history of sexual abuse, are among the most significant predictors of needle borrowing among Vancouver's IDUs. Early identification of these factors should be a component of HIV prevention programmes.

Impact of supply-side policies for control of illicit drugs in the face of the AIDS and overdose epidemics: Investigation of a massive heroin seizure

Article

Full-text available

Jan 2003

More than 93% of the nearly $500 million spent annually on Canada's drug strategy goes toward efforts to reduce the illicit drug supply. However, little is known about the effectiveness of this strategy. On Sept. 2, 2000, Canadian police seized approximately 100 kg of heroin in one of the nation's largest-ever seizures of this drug. An ongoing prospective cohort study of injection drug users afforded an opportunity to evaluate the impact of this seizure. The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users that began in 1996. The present study relied primarily on data acquired from participants who were seen during the 30-day periods immediately before and after the seizure. We compared drug use and behavioural characteristics, heroin and cocaine prices, and participants' reports of whether law enforcement had affected their source of drugs or the types of drugs available on the street, as well as overdoses, in these 2 periods. The 138 participants seen before the seizure were similar to the 123 participants seen after the seizure with respect to age, sex, ethnic background, education, HIV serostatus, neighbourhood residence, instability of housing, employment status, use of methadone maintenance therapy and all other measured potential confounders (all p > 0.10). We found no difference in the extent to which participants in the 2 groups reported daily use of heroin, frequency of nonfatal overdoses, or whether law enforcement had affected their source of drugs or the types of drugs available on the street (all p > 0.10). Although we detected no difference in the price of cocaine, the median reported price of heroin went down after the seizure (p = 0.034), which suggests that other shipments compensated for the seizure. External evaluations of deaths from overdoses and heroin purity indicated that the seizure had no impact, nor was any impact seen when the periods of analysis were extended. The massive heroin seizure appeared to have no measurable public health benefit. Closer scrutiny of enforcement efforts is warranted to ensure that resources are delivered to the most efficient and cost-effective public health programs.

An External Evaluation of a Peer-Run "Unsanctioned" Syringe Exchange Program

Article

Full-text available

Oct 2003

In Vancouver, British Columbia, Canada, difficulty accessing syringes at night has been shown to be strongly associated with human immunodeficiency virus (HIV) risk behavior among the city's injection drug users (IDUs). On September 1, 2001, the Vancouver Area Network of Drug Users (VANDU) initiated an unsanctioned all-night needle-exchange program on a street corner in the heart of the neighborhood where many of the city's IDUs are concentrated. An external evaluation of the population reached by the VANDU exchange was performed through the Vancouver Injection Drug User's Study, a prospective cohort study of IDUs begun in 1996. Persons accessing syringes through the exchange were compared to those active injectors who acquired their syringes from other sources, including the city's fixed site exchange, which closes at 8:00 PM. Overall, 587 active IDUs were seen during the period September 2001 to June 2002; of these individuals, 165 (28.1%) reported using the VANDU exchange. In multivariate analyses, participants who used the VANDU table were more likely to frequently inject cocaine (adjusted odds ratio [AOR]=1.56; 95% confidence interval [CI]=1.00-2.44), inject in public (AOR=2.71; 95% CI=1.62-4.53), and require help injecting (OR=2.13; 95% CI=1.33-3.42). Interestingly, use of the table was also independently associated with safer syringe disposal (AOR=2.69; 95% CI=1.38-5.21). Results indicate that the unsanctioned exchange appears to have reached those IDUs at highest risk of HIV infection. Although the cross-sectional nature of the study design warrants caution, we also found that use of the nighttime exchange was strongly associated with higher rates of safe syringe disposal. The data suggest that drug user organizations can play a major role in reducing harm among their peers by reaching the highest risk drug users with harm reduction services. The findings also suggest that other forms of syringe-exchange programs should consider the benefits of offering fixed site nighttime service.

Collateral Damage in the War on Drugs: HIV Risk Behaviors among Injection Drug Users

Article

Feb 1999
INT J DRUG POLICY

Objective: To determine whether two key War on Drugs policies, the criminalization of syringes and the disqualification of drug users from the Supplemental Security Income (SSI) program, are associated with injection-related human immunodeficiency virus (HIV) risk behaviors among injection drug users (IDUs). Methods: IDUs were interviewed regarding HIV risk behaviors, drug use, and criminal activities in six San Francisco Bay Area communities in 1996 and followed through 1997 (n=1257). Multivariate analysis was conducted to examine the association between concern about arrest while carrying drug paraphernalia and injection-related risk behaviors. Regarding SSI, respondents were interviewed before (1996) and after (1997) drug and alcohol addicts were disqualified from SSI (n=88). Bivariate analysis was conducted comparing IDUs who lost SSI benefits with those who retained benefits. Results: Among our study sample, 32% of IDUs reported being concerned about possible arrest while carrying drug paraphernalia. In multivariate analysis, concerned IDUs were over one-and-a-half times more likely to share syringes than IDUs not concerned (adjusted odds ratio=1.74; 95% confidence interval =1.24, 2.44). Regarding SSI, 60% (53/88) of baseline SSI recipients had lost benefits by their follow-up interview. IDUs who lost benefits were more likely to participate in illegal activities (48 vs. 27%; P

Needle exchange and difficulty with needle access during an ongoing HIV epidemic

Article

Jun 2002
INT J DRUG POLICY

During the mid to late 1990s, Vancouver, Canada experienced a rapid injection drug use-related HIV epidemic, despite the presence of a well-established, high-volume, needle exchange program (NEP). The NEP presently exchanges needles through several fixed sites, the largest of which operates in the city's Downtown Eastside where injection drug users (IDU) are concentrated, and through mobile exchange vans which exchange needles throughout neighboring areas. The program's inability to prevent the epidemic has led to persistent questions about the efficacy of needle exchange as a public health intervention. We recently sought possible explanations for persistent needle sharing through an evaluation of the Vancouver Injection Drug Users Study (VIDUS), an ongoing cohort study of IDU that began in 1996. In these analyses, the strongest predictor of needle sharing was difficulty accessing needles; those who reported difficulty accessing needles were 3.5 times more likely to report sharing than those who did not have difficulty with access. In the present study, we sought to identify reasons why IDU continued to have difficulty accessing needles despite the efforts of the NEP. Overall, 761 active injectors were interviewed during the period June 2000–May 2001. Of these 172 (22.6%) reported having difficulty accessing sterile needles. In a multivariate analysis, frequent cocaine injection and bingeing were associated with difficulty accessing needles, whereas residing in the Downtown Eastside was negatively associated with difficulty. When we evaluated IDU's reasons for difficulty with access, the most common reasons given were the operating hours of the NEP, difficulty meeting the needle exchange van, being away from the area where needles are exchanged, and being refused sterile needles at pharmacies. These findings suggest that programmatic deficiencies related to the operation of the needle exchange and refusal of pharmacists to sell needles may be primary factors related to difficulty accessing needles.

Social Determinants Predict Needle-Sharing Behaviour among Injection Drug Users in Vancouver

Article

Oct 1997
ADDICTION

Despite the fact that needle exchange was introduced in Vancouver as early as 1988, needle sharing remains common. An analysis was conducted to identify determinants of borrowing used needles among subjects participating in a case-control study. IDUs had a documented HIV seroconversion after 1 January, 1994 (h = 89), or repeatedly tested HIV-seronegative after this date (h = 192). Interviewer-administered questionnaires focused on drug use, sexual behaviours, source of needles and depression. Subjects were asked if they had “ever been forced to have sex” as a child, youth or adult. Logistic regression identified determinants of borrowing needles. After controlling for HIV serostatus, factors independently associated with borrowing were injecting > 4 times/day, poly drug use, and ever experiencing non-consensual sex (AOR = 3.4, 95% CI: 1.8, 6.5). Depression was associated with borrowing, although not independently so. Homosexual activity was independently associated with borrowing among males, whereas living with a sexual partner was an independent predictor for females. Access or barriers to clean needle use were not associated with borrowing. Social determinants, particularly a history of sexual abuse, are among the most significant predictors of needle borrowing among Vancouver's IDUs. Early identification of these factors should be a component of HIV prevention programmes.

Needle exchange decreases the prevalence of HIV-1 proviral DNA in returned syringes in New Haven, Connecticut

Article

Sep 1993
AM J MED

To report on the deployment of the syringe tracking and testing system in the New Haven needle exchange program, which is the first federally funded evaluation of a needle exchange program conducted in the United States. A legal needle exchange for intravenous drug users began in New Haven, Connecticut, in November 1990. All syringes distributed by the program received unique tracking codes. Syringes were tracked and HIV-1 proviral DNA prevalence in returned syringes was assessed using polymerase chain reaction and Southern blotting. At the outset of the program, the prevalence of HIV-1 proviral DNA in syringes exceeded two thirds. Prevalence decreased rapidly to less than 45% during the first 3 months of the program and remained at this level for the following 10 months. During the periods of decreasing prevalence and subsequent steady state, no changes in the demographics of program participants or in the drug use habits of newly enrolling clients that could account for the decrease in HIV-1 prevalence in needles were detected. In addition, the program referred almost 20% of its clients to drug treatment programs. The needle exchange program in New Haven has decreased the percentage of syringes testing positive for HIV-1 proviral DNA among needle exchange clients while simultaneously serving as an entry point for drug treatment.

HIV incidence among injecting drug users in New York City syringe-exchange programs

Article

Nov 1996

There have been no studies showing that participation in programmes which provide legal access to drug-injection equipment leads to individual-level protection against incident HIV infection. We have compared HIV incidence among injecting drug users participating in syringe-exchange programmes in New York City with that among non-participants. We used meta-analytic techniques to combine HIV incidence data from injecting drug users in three studies: the Syringe Exchange Evaluation (n = 280), in which multiple interviews and saliva samples were collected from participants at exchange sites; the Vaccine Preparedness initiative cohort (n = 133 continuing exchanges and 188 non-exchangers, in which participants were interviewed and tested for HIV every 3 months; and very-high-seroprevalence cities in the National AIDS Demonstration Research (NADR) programme (n = 1029), in which street-recruited individuals were interviewed and tested for HIV every 6 months. In practice, participants in the NADR study had not used syringe exchanges. HIV incidence among continuing exchange-users in the Syringe Exchange Evaluation was 1.58 per 100 person-years at risk (95% CI 0.54, 4.65) and among continuing exchange-users in the Vaccine Preparedness Initiative it was 1.38 per 100 person-years at risk (0.23, 4.57). Incidence among non-users of the exchange in the Vaccine Preparedness Initiative was 5.26 per 100 person-years at risk (2.41, 11.49), and in the NADR cities, 6.23 per 100 person-years at risk (4.4, 8.6). In a pooled-data, multivariate proportional-hazards analysis, not using the exchanges was associated with a hazard ratio of 3.35 (95% CI 1.29, 8.65) for incident HIV infection compared with using the exchanges. We observed an individual-level protective effect against HIV infection associated with participation in a syringe-exchange programme. Sterile injection equipment should be legally provided to reduce the risk of HIV infection in persons who inject illicit drugs.

An opportunity lost: HIV infections associated with lack of a National needle-exchange programme in the USA

Article

Apr 1997

Our aim was to estimate the number of HIV infections that could have been prevented had needle-exchange programmes been implemented during the early stages of the AIDS epidemic in the USA. We also estimated the cost to the US health-care system to treat these preventable HIV infections. The formula we used to calculate the annual number of preventable HIV infections accounted for the effectiveness and level of use of needle-exchange programmes, as well as sexual transmission to injection drug users (IDUs) and secondary transmission to their sexual partners and children. Data for the model were obtained from epidemiological and mathematical studies in peer-reviewed published research, government reports, and consultations with experts. Using data from Australia as a model, we calculated the number of HIV infections that could have been prevented by a national needle-exchange programme in the USA between 1987 and 1995. Cost calculations were based on the current US government estimate of the discounted lifetime cost of treating an HIV infection (US $55640). Our conservative calculation of the number of HIV infections that could have been prevented ranged from 4394 (15% incidence reduction due to needle exchanges) to 9666 (33% incidence reduction). The cost to the US health-care system of treating these preventable HIV infections is between US $244 million and US $538 million, respectively. If current US policies are not changed, we estimate that an additional 5150-11329 preventable HIV infections could occur by the year 2000. The failure of the federal government in the USA to implement a national needle-exchange programme, despite six government-funded reports in support of needle exchanges, may have led to HIV infection among thousands of IDUs, their sexual partners, and their children. Revoking the US government ban on funding for needle-exchange programmes and accelerating the growth of such programmes in the USA are urgent public-health priorities.

Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco

Article

Jan 1998

Drug paraphernalia and prescription laws make syringe exchange programs (SEPs) illegal in most states in the U.S. Nonetheless, SEPs have been started in 25 states and the District of Columbia as of September 1995. In some states like California and New Jersey, SEPs have operated despite police arrest of volunteers and clients. We examine the impact of police action and threat on SEPs by comparing an underground syringe exchange site (SES) in West Oakland to a tolerated SES in the Fillmore neighborhood of San Francisco. The following data sources are utilized: demographic and service utilization data from Alameda County Exchange (ACE) in West Oakland and Prevention Point Needle and Syringe Exchange (PPNSE) in the Fillmore, San Francisco; demographic and syringe exchange utilization information collected from street-recruited samples of injection drug users (IDUs) in West Oakland and the Fillmore; and participant observation of SES in these two communities. We found that police action and the threat of police action in West Oakland decreased utilization of SEP by IDUs, limited the number and diversity of volunteers at SES, and inhibited the operation and expansion of SEP.

The effect of syringe exchange use on high-risk injection drug users: A cohort study

Article

Apr 2000

To determine whether syringe exchange program use is associated with cessation of syringe sharing among high-risk injection drug users. Between 1992 and 1996, street-recruited injection drug users were interviewed and received HIV testing and counseling semi-annually, as part of a dynamic cohort study. We examined a cohort of 340 high-risk injection drug users for whom two observations, 6-months apart, were available and who reported syringe sharing at the first interview. Multivariate logistic regression analysis was performed to determine the relationship between syringe exchange program use and cessation of syringe sharing, while controlling for confounding factors. At follow-up interview, 60% (204 of 340) reported quitting syringe sharing. High-risk injection drug users who began using the syringe exchange program were more likely to quit sharing syringes [adjusted odds ratio (AOR), 2.68; 95% confidence interval (CI), 1.35-5.33], as were those who continued using the syringe exchange program (AOR,1.98; 95% CI, 1.05-3.75) in comparison with non-syringe exchange program users, while controlling for confounding factors. The initiation and continuation of syringe exchange program use among high-risk injection drug users is independently associated with cessation of syringe sharing. Syringe exchange program use can be an important component in reducing the spread of blood-borne infectious diseases among high-risk injection drug users.

Syringe laws and pharmacy regulations are structural on HIV prevention in the US

Article

Jul 2000

To review the legal and regulatory barriers that restrict pharmacy sales of syringes to injection drug users (IDUs) and to discuss how reducing these barriers can facilitate access to sterile syringes for IDUs and improve HIV prevention. IDUs' access to sterile syringes from community pharmacies in the United States is limited by state laws and regulations governing syringe sales. Restricted availability of sterile syringes from pharmacies is a structural barrier that greatly impedes HIV prevention for IDUs, who often share and reuse syringes because they cannot obtain and possess sterile syringes. These high-risk behaviors contribute to the transmission of HIV and other blood-borne pathogens among IDUs, their sexual partners, and their children. STATE EXPERIENCES: In Connecticut, because of high HIV prevalence among IDUs, restrictive syringe laws were changed. After the legal changes in Connecticut, both pharmacy sales of syringes in areas of high drug use and purchases of syringes in pharmacies (reported by IDUs) increased, while syringe sharing (reported by IDUs) decreased. Maine and Minnesota have made similar changes in laws. Increasing access to sterile syringes through pharmacies requires the repeal or modification of legal barriers. Pharmacy sale of syringes to IDUs is an inexpensive HIV prevention intervention with the potential to substantially reduce HIV transmission. Further studies are needed to document how changes to legal barriers can influence HIV prevention for IDUs.

Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users

Article

Aug 2001

Unsafe injection practices in a cohort of injection drug users in Vancouver: Could safer injecting rooms help?

Article

Sep 2001

In several European countries safer injecting rooms have reduced the public disorder and health-related problems of injection drug use. We explored factors associated with needle-sharing practices that could potentially be alleviated by the availability of safer injecting rooms in Canada. The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users (IDUs) that began in 1996. The analyses reported here were restricted to the 776 participants who reported actively injecting drugs in the 6 months before the most recent follow-up visit, during the period January 1999 to October 2000. Needle sharing was defined as either borrowing or lending a used needle in the 6-month period before the interview. Overall, 214 (27.6%) of the participants reported sharing needles during the 6 months before follow-up; 106 (13.7%) injected drugs in public, and 581 (74.9%) reported injecting alone at least once. Variables independently associated with needle sharing in a multivariate analysis included difficulty getting sterile needles (adjusted odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8-4.1), requiring help to inject drugs (adjusted OR 2.0, 95% CI 1.4-2.8), needle reuse (adjusted OR 1.8, 95% CI 1.3-2.6), frequent cocaine injection (adjusted OR 1.6, 95% CI 1.1-2.3) and frequent heroin injection (adjusted OR 1.5, 95% CI 1.04-2.1). Conversely, HIV-positive participants were less likely to share needles (adjusted OR 0.5, 95% CI 0.4-0.8), although 20.2% of the HIV-positive IDUs still reported sharing needles. Despite the availability of a large needle-exchange program and targeted law enforcement efforts in Vancouver, needle sharing remains an alarmingly common practice in our cohort. We identified a number of risk behaviours--difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdose)--that may be alleviated by the establishment of supervised safer injecting rooms.

Factors associated with persistent high-risk needle sharing in the presence of an established needle exchange programme

Article

May 2002

Vancouver has experienced an explosive HIV epidemic despite the presence of a needle exchange programme (NEP). We sought possible explanations for high-risk syringe sharing among Vancouver injection drug users over the period January 1999 to October 2000. Overall, 14% of participants reported high-risk sharing. Although acquiring needles exclusively from the NEP was independently associated with less sharing, we identified several risk factors for persistent sharing, including difficulty accessing sterile needles, bingeing, and frequent cocaine injection.

Intensive injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic

Article

May 2003

The explosive and ongoing injecting drug use-related HIV-1 epidemic in Vancouver continues to receive international attention. This study was conducted to determine how patterns of cocaine use influence the risk of HIV infection. The Vancouver Injection Drug Users Study is an open prospective cohort of injecting drug users that began in May 1996. At enrollment and at semi-annual follow-up visits an interviewer administers a detailed semi-structured questionnaire. Cox proportional hazards models were used to determine behavioral and drug use patterns reported in the 6 months prior to HIV seroconversion. One-hundred and nine incident HIV infections have been observed during a mean follow-up of 31 months, from 940 HIV-seronegative participants. During the 6 months prior to seroconversion, predictors of HIV infection were injecting cocaine use [adjusted hazards ratio (AHR), 3.72], incarceration (AHR, 2.74), unstable housing (AHR, 2.36), methadone maintenance treatment (AHR, 1.98), and Aboriginal ethnicity (AHR, 1.78). Injecting cocaine use was predictive of HIV infection in a dose-dependent fashion. Compared with infrequent cocaine users, participants who averaged more than three injections per day were seven times more likely to contract HIV. In addition, the time to HIV infection was accelerated among regular cocaine injectors independent of concurrent heroin use. Injecting cocaine use was a strong, dose-dependent predictor of HIV seroconversion in this poly-drug using population. Injection cocaine users remain particularly vulnerable to HIV infection and treatment options for cocaine dependency remain woefully inadequate.

Jan 2003
887

Tyndall

The Impact of a Police Presence on Access to Needle Exchange Programs

No full-text available

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