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Police and public health partnerships: Evidence from the evaluation of Vancouver's supervised injection… DeBeck, Kora; Wood, Evan; Zhang, Ruth; Tyndall, Mark; Montaner, Julio; Kerr, Thomas May 7, 2008

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ralSubstance Abuse Treatment, ssBioMed CentPrevention, and PolicyOpen AcceShort ReportPolice and public health partnerships: Evidence from the evaluation of Vancouver's supervised injection facilityKora DeBeck1, Evan Wood1,2, Ruth Zhang1, Mark Tyndall1,2, Julio Montaner1,2 and Thomas Kerr*1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada and 2Department of Medicine, University of British Columbia, Vancouver, CanadaEmail: Kora DeBeck - uhri@cfenet.ubc.ca; Evan Wood - ewood@cfenet.ubc.ca; Ruth Zhang - uhri@cfenet.ubc.ca; Mark Tyndall - mtyndall@cfenet.ubc.ca; Julio Montaner - jmontaner@cfenet.ubc.ca; Thomas Kerr* - uhri@cfenet.ubc.ca* Corresponding author    AbstractIn various settings, drug market policing strategies have been found to have unintended negativeeffects on health service use among injection drug users (IDU). This has prompted calls for moreeffective coordination of policing and public health efforts. In Vancouver, Canada, a supervisedinjection facility (SIF) was established in 2003. We sought to determine if local police impactedutilization of the SIF. We used generalized estimating equations (GEE) to prospectively identify theprevalence and correlates of being referred by local police to Vancouver's SIF among IDUparticipating in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort during the period ofDecember 2003 to November 2005. Among 1090 SIF clients enrolled in SEOSI, 182 (16.7%)individuals reported having ever been referred to the SIF by local police. At baseline, 22 (2.0%)participants reported that they first learned of the SIF via police. In multivariate analyses, factorspositively associated with being referred to the SIF by local police when injecting in public include:sex work (Adjusted Odds Ratio [AOR] = 1.80, 95%CI 1.28 – 2.53); daily cocaine injection (AOR =1.54, 95%CI 1.14 – 2.08); and unsafe syringe disposal (AOR = 1.46, 95%CI 1.00 – 2.11). Thesefindings indicate that local police are facilitating use of the SIF by IDU at high risk for various adversehealth outcomes. We further found that police may be helping to address public order concernsby referring IDU who are more likely to discard used syringes in public spaces. Our study suggeststhat the SIF provides an opportunity to coordinate policing and public health efforts and therebyresolve some of the existing tensions between public order and health initiatives.BackgroundIn various urban settings, street-level policing practicestargeting drug related public disorder, such as open drugdealing and drug consumption, have been shown to inter-crackdowns have been found to displace IDU away fromneedle exchange programs and other specialized HIV pre-vention and health promotion services, as well as exacer-bate risky injection practices among street injectorsPublished: 7 May 2008Substance Abuse Treatment, Prevention, and Policy 2008, 3:11 doi:10.1186/1747-597X-3-11Received: 27 March 2008Accepted: 7 May 2008This article is available from: http://www.substanceabusepolicy.com/content/3/1/11© 2008 DeBeck et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5(page number not for citation purposes)rupt health service use by injection drug users (IDU) [1,2].Specifically, pressures introduced by street level policeincluding rushing injections and injecting with usedsyringes [3-7]. This has prompted calls for more effectiveSubstance Abuse Treatment, Prevention, and Policy 2008, 3:11 http://www.substanceabusepolicy.com/content/3/1/11coordination of policing and public health initiatives [8-10].In Vancouver, Canada, local street level policing practiceshave similarly been found to complicate HIV preventioninitiatives in some instances [11-13]. However, the localVancouver Police Department supported the opening of apilot supervised injection facility (SIF) in Vancouver inSeptember 2003 and subsequently adopted the strategy ofactively encouraging individuals found injecting in publicto attend the local SIF [14]. Past evaluations of SIFs inother settings indicate that police support plays an impor-tant role in the successful operation of these facilities [15],however, we know of no studies which have specificallyexamined police referrals and their impact on facilitatingaccess to SIFs. Given the continued call for more effectivepolicing-public health partnerships [16,17] we sought todetermine if local police were facilitating the use of Van-couver's SIF.MethodsThe current analysis is based on longitudinal data derivedfrom the Scientific Evaluation of Supervised Injecting(SEOSI) cohort which is a representative sample of super-vised injection facility users. This study has been describedin detail previously [18,19]. Briefly, beginning December2003, randomly selected SIF clients were recruited intoSEOSI. At baseline and semi-annually participants pro-vide blood samples and complete an interviewer-admin-istered questionnaire. The questionnaire elicitsdemographic data as well as information about drug usepatterns, HIV risk behavior, access to health and socialservices, SIF use, and interactions with local police andcriminal justice systems. All participants provide writteninformed consent and are given a $20 honorarium at eachstudy visit. The study has received ethical approval fromSt. Paul's Hospital and the University of British Colum-bia's Research Ethics Board.To explore the role of local police in supporting use ofVancouver's SIF we assessed the proportion of participantswho reported first learning of the SIF via communicationwith police. In addition, we asked participants at baselineand at each study follow-up if local police had helpedthem find the SIF, or taken them there when they wereinjecting in public. To identify the population mostaffected by this policing strategy we conducted longitudi-nal analysis of factors associated with reporting havingbeen referred to the SIF by local police. For this weincluded all participants seen for baseline and follow-upinterviews during the period of December 2003 toDecember 2005. Given that policing practices are knownto exacerbate high-risk injecting among IDU who inject inonly as having been referred to the supervised injectionfacility by police when injecting in public in the last sixmonths. Other variables of interest included socio-demo-graphic information: age (per year older), gender (femalevs. male), Aboriginal ethnicity (yes vs. no) and homeless-ness, defined as having no fixed address for the last sixmonths (yes vs. no). Drug use variables considered referto behaviours in the past six months and included: fre-quent heroin injection (≥ daily vs. < daily), frequentcocaine injection (≥ daily vs. < daily), borrowing andlending used syringes (yes vs. no), and unsafe syringe dis-posal, defined as having dropped a syringe outdoors afterusing it (yes vs. no). Another characteristic considered wasinvolvement in sex work in the last six months (yes vs.no).Since analyses of factors potentially associated with hav-ing been referred to the SIF by police included serial meas-ures for each participant, we used generalized estimatingequations (GEE) for binary outcomes with logit link forthe analysis of correlated data to determine factors associ-ated with referrals to the SIF throughout the 24-monthfollow-up period. These methods provided standarderrors adjusted by multiple observations per person usingan exchangeable correlation structure. Therefore, datafrom every participant follow-up visit was considered inthis analysis. This approach has been used successfully inprevious analysis [20,21]. As a first step, we used univari-ate GEE analyses to determine factors associated with hav-ing been referred to the injection facility by police. Allvariables that were p < 0.05 in GEE univariate analyseswere then entered in a multivariate logistic GEE model.All statistical analyses were performed using SAS softwareversion 9.1 (SAS, Cary, NC). All p-values are two sided.ResultsA total of 1090 participants were recruited during thestudy period, including 317 (29.1%) women and 211(19.4%) persons of Aboriginal ancestry. The median ageof participants was 38.4 years (IQR = 32.7–44.3) at base-line. This sample contributed 3083 observations and themedian number of study visits was 3 (IQR = 2–4). A totalof 182 (16.7%) participants reported having been referredto the SIF by police at some point during the study period.At baseline, 22 (2.0%) participants reported that they firstlearned of the SIF via communication with local police.The univariate GEE analyses of factors associated withhaving been referred to the SIF by local police are pre-sented in Table 1. Factors found to be associated with hav-ing been referred to the SIF by local police in univariateanalyses included: older age (odds ratio [OR] = 0.98, 95%confidence interval [CI] 0.96–1.00); Aboriginal ethnicityPage 2 of 5(page number not for citation purposes)public spaces [3-6,11], the dependent variable for thepresent study was based on self-report and was defined(OR = 1.51, 95%CI 1.05–2.16); homelessness (OR = 1.49,95%CI 1.08–2.06); sex work (OR = 2.03, 95%CI 1.46–Substance Abuse Treatment, Prevention, and Policy 2008, 3:11 http://www.substanceabusepolicy.com/content/3/1/112.83); frequent heroin injection (OR = 1.53, 95%CI 1.14–2.06); frequent cocaine injection (OR = 1.66, 95%CI1.24–2.24); and unsafe syringe disposal (OR = 1.73,95%CI 1.20 – 2.50).In the multivariate GEE analysis, also shown in Table 1,factors that remained independently associated with hav-ing been referred to the SIF by local police included: sexwork (adjusted odds ratio [AOR] = 1.80, 95%CI 1.28 –2.53); frequent cocaine injection (AOR = 1.54, 95%CI1.14 – 2.08); and unsafe syringe disposal (AOR = 1.46,95%CI 1.00 – 2.11).DiscussionIn the present study, we found that approximately 17% ofparticipants reported having been referred to the SIF byVancouver police officers when injecting in public andthose engaged in sex work and frequent cocaine injectionwere more likely to be referred. Given the criminalizationof sex work in Canada, the association between sex workand police referrals may be a reflection of sex worker'shigher exposure to police. Other research in this settinghas documented that interactions between sex workersand police are frequent and at times violent. In addition,contact with police was found to displace sex workers toisolated industrial areas where their ability to protectthemselves from violence and HIV risk was severity com-promised [22]. However, by referring IDU engaged in sexrelated harms by reaching IDU at heightened risk foradverse health outcomes, including HIV infection andviolence [22,23]. Further, by referring IDU who engage inunsafe public syringe disposal to the SIF, police may alsobe helping to reduce the public order impacts of publicinjecting.Collectively, these contributions suggest that the Vancou-ver SIF is providing local police with a mechanism toaddress public injection drug use in a manner that pro-motes public safety and appears to resolve some of theexisting tensions between public health and public orderinitiatives. Given previously documented tensionsbetween police and other public health initiatives in thissetting [11-13], the ability of SIFs to promote public orderobjectives may help to explain why local police have beensupportive of this particular program. In fact, researchconducted for the Canadian Expert Advisory Committeeon Supervised Injection Site Research found that themajority of local Vancouver police officers interviewedsupport the Vancouver SIF as means of improving publicorder [24]. Despite clear support for the Vancouver SIF bylocal police officers, external national law enforcementbodies remain vocally opposed to the facility. Mostrecently the Canadian Police Association (CPA) issued apublic call for the Government of Canada to "shut downthe failed Supervised Injection Site experiment" and sug-gested that most police officers do not support the initia-Table 1: Univariate and multivariate GEEa analyses of factors associated with being referred to Vancouver's supervised injection facility by local police officersCharacteristicf ORb (95% CId) p-valuec AORb (95% CId) p-valueOlder Ageper year older 0.98 (0.96 – 1.00) 0.041 1.00 (0.98 – 1.02) 0.961GenderFemale vs. Male 0.73 (0.52 – 1.01) 0.059Aboriginal EthnicityYes vs. No 1.51 (1.05 – 2.16) 0.027 1.41 (0.99 – 2.03) 0.065Homelessness eYes vs. No 1.49 (1.08 – 2.06) 0.014 1.28 (0.92 – 1.78) 0.140Sex Work eYes vs. No 2.03 (1.46 – 2.83) <0.001 1.80 (1.28 – 2.53) <0.001Frequent Heroin Injection e≥ daily vs. < daily 1.53 (1.14 – 2.06) 0.005 1.32 (0.98 – 1.79) 0.070Frequent Cocaine Injection e≥ daily vs. < daily 1.66 (1.24 – 2.24) <0.001 1.54 (1.14 – 2.08) 0.005Syringe Sharing eYes vs. No 0.99 (0.68 – 1.44) 0.971Unsafe Syringe Disposal eYes vs. No 1.73 (1.20 – 2.50) 0.004 1.46 (1.00 – 2.11) 0.048Note: aGEE = Generalized Estimating Equation; bOR = Odds Ratio, AOR = Adjusted Odds Ratio; cValues based on Wald χ2 with 1 degree of freedom; dCI = Confidence Interval; eDenotes activities or situations referring to the previous 6 months; fFor full variable definitions see methods section.Page 3 of 5(page number not for citation purposes)work and frequent cocaine injection to a health focusedfacility, local police are likely helping to reduce health-tive [25,26]. These statements highlight a disconnectbetween the views of police officers working in directSubstance Abuse Treatment, Prevention, and Policy 2008, 3:11 http://www.substanceabusepolicy.com/content/3/1/11proximity to the SIF and those of external law enforce-ment organizations.In other settings with SIFs, police support appears to besimilarly connected with public order objectives andpolice typically partner with local services providers, resi-dents and business to ensure the successful operation ofSIFs [15]. Past evaluations of European SIFs highlight theimportance of obtaining police support for these initia-tives as policing practise in areas surrounding SIFs havebeen found to have considerable impact on the operationof, and public support for, these facilities. For example,police crackdowns on open drug scene and the potentialfor drug market activity to re-emerge in the vicinity of a SIFwere identified as forces that have undermined publicsupport for SIFs [15]. The importance of coordinatingefforts among police, service providers and other stake-holder is widely acknowledged, however, documentationof successful policing approaches around SIFs, such thecurrent example of police referring IDU injecting in publicto the Vancouver SIF, warrants further exploration.While the findings of the present study suggest that localpolice are promoting use of the Vancouver SIF it should benoted that in a prior study it was found that 5% of localIDU reported having been deterred from using the SIF dueto police presence around the facility [27]. Still, whilelocal police presence may limit access to the SIF for some,overall findings indicate that they are helping to facilitateaccess. Regardless, in order to promote optimal access tothe SIF, additional efforts, including further research,should be undertaken to determine how particular serv-ices barriers can be addressed.Despite these positive findings, the extent to which policeare able to address public drug use by directing injectorsto the local SIF is largely constrained by the limited seat-ing capacity and operating hours of the 12 seat pilot facil-ity [27]. In addition, the SIF does not accommodate crackcocaine smoking which is a central contributing factor tocurrent drug-related street disorder [28]. While the SIFshas been shown to effectively reduce rates of syringe shar-ing, increase entry to detoxification services and improvepublic order in the area [29-31], it is clear that one smallintervention cannot meaningfully address public drug usein Vancouver and its potential to eradicate the public drugscene should not be overstated.There are several potential limitations in the study to benoted. Primarily, this study relied on self-reported infor-mation concerning stigmatized behaviours, such as publicdrug use and syringe disposal and hence is susceptible tosocially desirable reporting [32]. In the present study thispolicing presence may encourage use of the SIF amongpeople not directly referred and this study does notaccount for this positive effect on public order. In turn,our findings are likely conservative and may perhapsunder-represent the impact that local police are having onuse of the facility.Our findings indicate that local police are facilitating useof the SIF by IDU at heightened risk for various adversehealth outcomes. These data further suggest that policemay be helping to address public order concerns by refer-ring IDU who are likely to discard used syringes in publicspaces. Therefore, the SIF appears to provide an opportu-nity to coordinate policing and public health efforts andthereby resolve some of the existing tensions betweenpublic order and health initiatives.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsThe specific contributions of each author are as follows:KD and TK were responsible for study design and pre-pared the first draft of the analysis; RZ conducted the sta-tistical analyses; EW, MT and JM contributed to the maincontent and provided critical comments on the final draft.All authors approved the final manuscript.FundingThe evaluation of the supervised injecting facility wasoriginally made possible through a financial contributionfrom Health Canada, although the views expressed hereindo not represent the official policies of Health Canada.The evaluation is currently supported by the CanadianInstitutes of Health Research and Vancouver CoastalHealth. TK is supported by the Michael Smith Foundationfor Health Research and the Canadian Institutes of HealthResearch. KD is supported by a Canadian Institutes ofHealth Research Doctoral Research Award and a MichaelSmith Foundation for Health Research Senior GraduateTrainee Award. Funding agencies had no role in studydesign, data collection, analysis or writing of the report,nor did they have a role in the decision to submit thepaper for publication.AcknowledgementsThe authors wish to thank the participants in SEOSI and the staff of Insite, the Portland Hotel Society, and Vancouver Coastal Health (Chris Buchner, David Marsh, and Heather Hay.) We also thank the current and past SEOSI staff. We would specifically like to thank Deborah Graham, Tricia Colling-ham, Caitlin Johnston, Steve Kain, and Calvin for their research and admin-istrative assistance.ReferencesPage 4 of 5(page number not for citation purposes)may have led to an under-reporting of unsafe syringe dis-posal and other stigmatized behaviours. In addition,1. Kerr T, Small W, Wood E: The public health and social impactsof drug market enforcement: A review of the evidence.  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