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Socializing in an Open Drug Scene : The relationship Between Access to Private Space and Drug-Related… DeBeck, Kora; Wood, Evan; Qi, Jiezhi; Fu, Eric; McArthur, Doug; Montaner, Julio; Kerr, Thomas Jan 1, 2012

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Socializing in an Open Drug Scene: The relationship BetweenAccess to Private Space and Drug-Related Street DisorderKora DeBeck1, Evan Wood1,2, Jiezhi Qi1, Eric Fu1, Doug McArthur3, Julio Montaner1,2, andThomas Kerr1,21 British Columbia Centre for Excellence in HIV/AIDS2 Division of AIDS, Department of Medicine, University of British Columbia3 School of Public Policy, Simon Fraser UniversityAbstractBackground—Limited attention has been given to the potential role that the structure of housingavailable to people who are entrenched in street-based drug scenes may play in influencing theamount of time injection drug users (IDU) spend on public streets. We sought to examine therelationship between time spent socializing in Vancouver's drug scene and access to private space.Methods—Using multivariate logistic regression we evaluated factors associated with socializing(three+ hours each day) in Vancouver's open drug scene among a prospective cohort of IDU. Wealso assessed attitudes towards relocating socializing activities if greater access to private indoorspace was provided.Results—Among our sample of 1114 IDU, 43% fit our criteria for socializing in the open drugscene. In multivariate analysis, having limited access to private space was independentlyassociated with socializing (adjusted odds ratio: 1.80, 95% confidence interval: 1.28 – 2.55). Infurther analysis, 65% of ‘socializers’ reported positive attitudes towards relocating socializing ifthey had greater access to private space.Conclusion—These findings suggest that providing IDU with greater access to private indoorspace may reduce one component of drug-related street disorder. Low-threshold supportivehousing based on the ‘housing first’ model that include safeguards to manage behaviors associatedwith illicit drug use appear to offer important opportunities to create the types of private spacesthat could support a reduction in street disorder.Keywordsinjection drug use; street disorder; drug scenes; supportive housing; prospective cohort study1. IntroductionDrug-related street disorder, including public drug use and intoxication and loitering inpublic areas, negatively impacts neighborhood businesses and surrounding communities and© 2011 Elsevier Ireland Ltd. All rights reserved.Send correspondence to: Thomas Kerr BC Centre for Excellence in HIV/AIDS 608-1081 Burrard Street, Vancouver, B.C.CANADA V6Z 1Y6 Tel: (604) 806-9116 uhri-tk@cfenet.ubc.ca.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptDrug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.Published in final edited form as:Drug Alcohol Depend. 2012 January 1; 120(1-3): 28–34. doi:10.1016/j.drugalcdep.2011.06.015.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptcan detract from the enjoyment of public spaces (Cusick and Kimber, 2007; Johnson et al.,1990; Skogan, 1990). Drug-related street disorder is a burden for law enforcement agenciesand recent evidence suggests that exposure to street-based drug scenes poses risks toindividual drug users (DeBeck, 2011; Messner et al., 2007; Zimmer, 1990). Policy responsesto address street disorder in open drug scenes have, to date, largely relied on lawenforcement measures to deter disorderly behavior in public settings (Aitken et al., 2002;Fagan and Davies, 2000; Zimmer, 1990).In some areas with concentrated drug and street disorder problems, police agencies haveinitiated crackdown campaigns, which involve targeting policing efforts on drug-relatedstreet disorder (Aitken et al., 2002; Fagan and Davies, 2000; Zimmer, 1990). Increasedpolice presence and patrol and arresting individuals for disorderly behaviors are some keyfeatures of crackdown campaigns (Aitken et al., 2002). In Canada, some provinces have alsointroduced legislation specific to street disorder. For instance, legislation in severalCanadian provinces (i.e., the ‘Safe Streets Act’ in Ontario and British Columbia) provideslaw enforcement officers with additional tools to limit soliciting in public locations (Collinsand Blomley, 2003; Hermer and Mosher, 2002). Although law enforcement measures havebeen found to reduce the visual presence of street disorder (Koper, 1995; Sherman, 1990;Weisburd and Green, 1995), these effects are typically short-lived and are often associatedwith unintended negative consequences (Wood et al., 2004). These include displacingdisorderly behavior to surrounding areas and separating illicit drug users from health andsocial services (Clear, 2007; Cooper et al., 2005; Dixon, 2002; Hermer and Mosher, 2002;Kerr et al., 2005; Rhodes et al., 2003a; Roberts, 1998; Small et al., 2006; Wood et al., 2003).Given the apparent limitations of law enforcement based approaches, there is a need toidentify novel interventions with potential to address street disorder.To guide our analyses of drug-related street disorder we drew on Rhodes’ ‘RiskEnvironment Framework’ (Rhodes, 2002; Rhodes et al., 2003b). Rhodes suggests thatsocial, structural and environmental conditions constitute a ‘risk environment’ that mediatesindividual behavior (Rhodes, 2002; Rhodes et al., 2003b). In turn, individual behaviorshould be viewed in the context or environment in which it occurs. From this perspective,responding to risky and undesirable practices associated with illicit drug use involvesaltering the ‘risk environment’ by addressing relevant social, structural and environmentalfactors. Examples of key structural factors include economic conditions (e.g., employmentopportunities), laws (e.g., prohibition of drugs), local policing practices, and social policiessuch as access to low-threshold and supportive housing (Rhodes, 2009).To date, policy-makers and researchers have given limited consideration to the potential rolethat the structure of the housing available to people who are entrenched in drug scenes mayplay in influencing the amount of time individuals spend on public streets. Restrictions onsocializing in residential spaces, either through space constraints or regulations that imposebarriers to having guests in private venues may inadvertently contribute to street disorder.Therefore, we sought to examine the relationship between time spent socializing inVancouver's open drug scene and access to private space among local injection drug users(IDU). We hypothesized that spending time socializing in the open drug scene would beassociated with having limited access to private space. We also sought to characterize druguse patterns and risk factors associated with socializing in Vancouver's open drug scene, aswell as assess whether IDU would prefer access to private indoor space.DeBeck et al. Page 2Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript2. Methods2.1 DataData for this study was obtained from the Vancouver Injection Drug Users Study (VIDUS),an open prospective cohort that began enrolling IDU through street outreach and self-referral in May 1996. This study has been described in detail previously (Wood et al., 2003;Wood et al., 2004). In brief, to be eligible, participants must reside in the Greater VancouverRegional District, have injected illicit drugs in the previous month, and provide writteninformed consent. At enrollment and on a bi-annual basis, participants complete aninterviewer-administered questionnaire and visit with study nurses who take a blood samplefor serologic testing. At each study visit, participants are provided with a stipend ($20 CDN)for their time. The study has received ethical approval from St. Paul's Hospital and theUniversity of British Columbia's Research Ethics Board. The present analyses are restrictedto those participants seen for study follow-up during the period of June 2008 to June 2009 asmeasures for key variables of interest are available only for this period. If individuals wereseen for multiple study follow-up visits during this study period only data from their firstvisit was used.2.2 Socializing in Vancouver's open drug scene and access to private spaceIn our first analysis, the outcome of interest was spending time socializing in Vancouver'sopen drug market scene. To measure ‘socializing’ we asked respondents to estimate theaverage number of hours they spend on the street each day, and then we asked them tospecify how many of those hours on average were spent socializing. Because we wereinterested in socializing in an open drug scene as an indicator of drug-related street disorderwe wanted to ensure that we were identifying individuals who spent significant amounts oftime in this environment. We therefore used two criteria to define ‘socializing:’ firstly, weidentified the median number of hours participants reported socializing on the street in anaverage day, which was three hours, and used a median split to create our dependentvariable; secondly, we included only individuals who either resided in or frequently visited(at least two times per week) Vancouver's drug use epicenter, which is a well defined anddescribed area of the city known as the Downtown Eastside (DTES) (Wood et al., 2004).This helped to ensure that we were identifying individuals who were likely contributing tostreet disorder in Vancouver's open drug market scene (and not simply spending timeoutdoors in non-drug market scenes and venues).The primary explanatory variable of interest for this first analysis was having ‘limitedprivate space for socializing.’ Individuals who answered “no” to the question: “Do you havea private indoor space for socializing with friends and acquaintances?” were included in thiscategory. Because we wanted to include an objective marker in our measure of access toprivate space for socializing, we also considered the number of guests individuals wereallowed to have in their residence at one time, including all reports of being allowed lessthan three guests at one time in the ‘limited private space’ category -even if respondentsinitially reported “yes” to having private space for socializing. Similarly, if other significantbarriers to having guests in their residence were reported, these individuals were alsoincluded in the category of having ‘limited private space for socializing.’ Significant barriersincluded ‘guest fees’ (typically $5-10 per guest), time restrictions on visitors, restrictions onthe appearance of guests (e.g., visitors must be well groomed, can not appear intoxicated)and the requirement that guests must show picture identification. Participants reporting“yes” to having access to private space and reported none of the above restrictions to havingguests were included in the comparison group.DeBeck et al. Page 3Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptTo determine whether there was a significant relationship between socializing in an opendrug scene and having limited access to private space we a priori selected a range ofsecondary explanatory variables that we hypothesized might be associated with bothsocializing in an open drug scene and having access to private space. Variables that wereunlikely to be associated with both of these outcomes were not considered in this model.Secondary explanatory factors that were considered included the following socio-demographic factors: age (per year older); gender (female vs. male); Aboriginal ancestry(yes vs. no); high school education (yes vs. no), regular employment (yes vs. no), evertesting positive for HIV (which in our setting might influence the types of housing optionsavailable) (yes vs. no), and living in Vancouver's drug use epicenter, the Downtown Eastside(DTES) (yes vs. no). Individual-level risk and protective factors that were consideredincluded: sex trade involvement, defined as exchanging sex for money, shelter, drugs orother commodities (yes vs. no); participation in drug dealing (yes vs. no); participation inany addiction treatment program (yes vs. no); daily cocaine injection (yes vs. no); dailyheroin injection (yes vs. no); daily crack cocaine smoking (yes vs. no); and binge drug use(yes vs. no). Binge drug use was based on the question: “In the past six months, did you goon runs or binges (that is, when you injected drugs, or used non-injection drugs, more thanusual)”? The terms “runs” and “binges” are generally well understood by local IDU andindicate engaging in higher intensity drug use for a period of time typically ranging from afew days to a few weeks (Miller et al., 2006). Structural-level factors included having beenincarcerated (yes vs. no). Unless otherwise stated, socio-demographic, individual andstructural level factors refer to the previous six-month period. To account for a potentialseasonal influence on the amount of time individuals spend on the street socializing, we alsoincluded a categorical variable representing the month that participants completed our studyquestionnaire. This ensured that our multivariate analysis was adjusted for seasonal variationin responses.2.3 Socializing in Vancouver's open drug scene and risk factorsIn our second analysis we sought to identify drug use patterns and risks associated withsocializing in Vancouver's open drug scene. Our outcome of interest remained ‘socializingin Vancouver's open drug scene.’ Basic socio-demographic variables of interest included:age (per year older); and gender (female vs. male). We also considered the same individual-level risk factors considered in the first analysis, which were: sex work, drug dealing,addiction treatment, daily cocaine injection, daily heroin injection, daily crack cocainesmoking, and binge drug use. In addition, we considered the following new risk factors:non-fatal overdose (yes vs. no); syringe sharing, defined as borrowing or lending syringesalready used by someone else to inject drugs (yes vs. no); having multiple sex partners (yesvs. no); encounters with police in the last month, defined as being questioned, searched orstopped by police (yes vs. no); and being a victim of violence defined as being physicallyassaulted (yes vs. no). We also sought to assess the relationship between socializing andhousing status. To do this we created a categorical variable for housing with ‘stable housing’as the reference. Categories for housing status were mutually exclusive and based on whereparticipants were residing at the time of the interview. The categories considered included:stable housing, defined as living in a house or apartment; single room occupancy (SRO),defined as a single room in a hotel; shelter, defined as sleeping in temporary shelters forhomeless individuals (which are typically only open at night); no fixed address, defined ashaving no stable residence, including sleeping on the street as well as staying with friends oracquaintances on a short term basis, i.e., ‘couch surfing’; and ‘other’ which included livingin an addiction treatment centre or recovery house, jail or prison, and all other situations thatdid not fit into the above categories. This analysis also included a categorical variablerepresenting the month that participants completed our study questionnaire to adjust for anyseasonal variation in responses.DeBeck et al. Page 4Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript2.4 Factors associated with positive attitudes towards relocating to private indoorlocationsIn our final analysis, we sought to assess and identify factors associated with having apositive attitude towards relocating socializing activities to indoor private locations if suchspaces were made available. This analysis was restricted to participants who reportedsocializing in an open drug scene and who have limited access to private indoor space. Tomeasure attitudes towards relocating we asked participants “Would you spend less timesocializing on the street if you had a private indoor space (or more private indoor space) forsocializing with friends and acquaintances?” The geographic location of where privateindoor space might be located was not specified and no additional description of the type ofprivate space was given. Variables of interest for this analysis included all variablesconsidered in either the first or second analyses with the exception of high school education,‘limited access to private space’ and DTES residency. The latter two variables wereexcluded because they were so closely linked to the inclusion criteria for this analysis. Oneadditional factor that we considered was the level of socializing, which was defined as acontinuous variable based on the number of hours participants reported socializing in theopen drug scene. Unless otherwise stated, all drug use and behavioral variables refer to theprevious six-month period. As in analyses one and two, a categorical variable representingthe month that participants completed our study questionnaire was also included in themultivariate analysis to adjust for any seasonal variation in responses.2.5 Statistical AnalysesIn analysis one, to assess the relationship between socializing and access to private space, asa first step we conducted univariate analyses for our primary and secondary outcomes ofinterest stratified by socializing in an open drug scene. We used Pearson's chi-square test fordichotomous variables and the Mann-Whitney test for continuous variables. To fit ourmultivariate model, we used a modified version of a backwards selection process previouslydescribed by Maldonado and Greenland (1993) and Rothman and Greenland (1998). Webegan with all outcomes of interest in a full model. To ensure that socio-economic statuswas appropriately considered, the following socio-demographic factors remained in themultivariate model: age, gender, Aboriginal ancestry, high school education, and recentemployment. Since ‘limited access to private space’ was our primary variable of interest, italso remained in the multivariate model. For all other factors we used backward selectionand removed all variables that were associated with the dependent variable at p >0.05. Thefinal model, referred to as ‘Model 1’, included the above-mentioned socio-demographicfactors, ‘limited access to private space,’ and all remaining secondary explanatory variables.For analyses two and three, we used logistic regression to determine factors associated withour outcomes of interest, which were socializing in Vancouver's open drug scene (analysistwo, Model 2) and attitudes towards relocating to private indoor spaces (analysis three,Model 3). In univariate analyses, categorical explanatory variables were analyzed usingPearson's chi-square test and continuous variables were analyzed using the Mann-Whitneytest. Fisher's exact test was used when one or more of the cell counts was less than or equalto five. To evaluate factors independently associated with our outcomes of interest, we usedAkaike information criterion (AIC) with the best subset selection procedure. This provided acomputationally efficient method to screen all possible combinations of candidate variablesand identify the model with the best overall fit as indicated by the lowest AIC value(Shtatland et al., 2002). All statistical analyses were performed using SAS software version9.1 (SAS, Cary, NC). All p-values are two sided.DeBeck et al. Page 5Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript3. ResultsDuring the study period, a total of 1,114 participants completed follow-up visits, including393 (35%) women and 396 (36%) persons who identified as being of Aboriginal ancestry.The median age of all participants was 44 years (interquartile range [IQR] = 38-50), and thecurrent housing statuses of study participants are displayed in Figure 1. Among our sampleof 1,114 participants, the median number of hours spent socializing in the open drug scenewas 3 (IQR= 1-8) and 475 individuals (43%) fit the criteria for socializing in the open drugscene. The characteristics of the study sample stratified by socializing in the open drug sceneare presented in Table 1.The univariate analyses of associations between socializing in the open drug scene andsocio-demographic, individual, and structural level factors are presented in Table 2. Havinglimited access to private space for socializing was significantly associated with socializingin the open drug scene (Odds Ratio [OR] = 2.85, 95% Confidence Interval [CI]: 2.11-3.86).The results of the final multivariate logistic regressions for Model 1 and Model 2 are alsoshown in Table 2.In Model 1 the primary explanatory variable, ‘limited access to private space,’ remainedindependently associated with socializing in the open drug scene (Adjusted Odds Ratio[AOR] =1.80, 95% CI: 1.28-2.55) after adjusting for key socio-demographic factors, as wellas Downtown Eastside (DTES) residency, drug dealing, engagement in any addictiontreatment, daily crack cocaine smoking, and binge drug use.In Model 2, after adjusting for drug dealing, multiple sex partners and having encounterswith police, factors positively associated with socializing included daily crack smoking,binge drug use, Aboriginal ancestry, and the following housing statuses: living in a singleroom occupancy hotel, shelter, and having no fixed address. Engagement with addictiontreatment and syringe sharing were negatively associated with socializing.In the third analysis, 254 (65%) of the 390 participants that reported having limited access toprivate space and socializing in the open drug scene also reported positive attitudes towardsrelocating socializing if they were provided with more access to private indoor space. Thecharacteristics of these individuals stratified by positive attitudes toward relocating toprivate indoor spaces are presented in Table 3. The univariate and multivariate analyses ofassociations between positive attitudes towards relocating and variables of interest are alsopresented in Table 3. In the multivariate analysis, Model 3, when compared to participantswith stable housing, the no fixed address category was over eight times more likely to havepositive attitudes towards relocating socializing. Individuals living in single room occupancyhotels (SROs) and shelters were two and six times more likely to have positive attitudesrespectively. Aside from current housing status, daily heroin injection was the only otherfactor that was significantly associated with positive attitudes towards relocating (AOR=1.89, 95% CI: 1.05-3.38).4. DiscussionIn the present study we found that, among local injection drug users, having limited privatespace was significantly associated with spending an average of three or more hours per daysocializing in the open drug scene. This association persisted after adjustment for a range ofpotential confounding factors. In our second analysis, we found current housing status wasstrongly associated with socializing in the open drug scene. Specifically, those with no fixedaddress were most likely to report socializing in the open drug scene, followed byindividuals living in a shelter, and individuals living in a single room occupancy hotel.Binge drug use and daily crack cocaine use were also positively associated with socializingDeBeck et al. Page 6Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptin the open drug scene, while syringe sharing and engagement with addiction treatment werenegatively associated with socializing in this environment. The majority (65%) of those whohad limited access to private space and spent significant time socializing in the open drugscene reported positive attitudes towards relocating socializing away from the open drugscene if they were provided with access to more private spaces. Not surprisingly, whencompared to IDU who lived in stable housing, study participants who lived in single roomoccupancy hotels (SROs), shelters and had no fixed address were significantly more likelyto socialize in the open drug scene and were significantly more likely to have positiveattitudes towards relocating. It is notable that no risk behaviors were negatively associatedwith reporting positive attitudes towards relocating. This suggests that policy initiatives thatinvolve increasing access to private space could be expected to have an impact even amonghigh-risk and high intensity drug users.These findings are consistent with existing data highlighting that open drug scenes andcongregations of drug users often exist in locations where rates of homelessness andunstable housing are a problem among drug using populations (Broadhead et al., 2002;Shlay and Rossi, 1992; Skogan, 1990). Although the links between homelessness and streetdisorder have been previously described (Broadhead et al., 2002; DeBeck et al., 2009;Navarro and Leonard, 2004), to our knowledge, our study is the first to highlight that a lackof access to private space is likely playing a role in generating street disorder in open drugscenes.A central implication of these findings is that providing street-involved drug users with areaswhere they can socialize in comfort and privacy may offer the potential to reduce acomponent of drug-related street disorder. The benefits of relocating street-involvedindividuals to indoor locations by providing housing or creating alternative venues forsocializing appears particularly valuable given the burden that drug-related street disorderposes for law enforcement agencies and surrounding communities, as well as potentialharms that exposure to drug scenes poses to drug users themselves (DeBeck et al., 2009;Zimmer, 1990; DeBeck et al., 2011).Although it can be challenging to provide housing for some chaotic drug using individuals,there is a growing body of literature which suggests that approaches such as the “housingfirst” model, which provide drug using individuals with independent stable housingregardless of their drug use practices, are more successful than abstinence-based supportivehousing in retaining and stabilizing active drug users (Greenwood et al., 2005; Larimer etal., 2009; Tsemberis et al., 2004). Our study suggests that if these housing models canaccommodate active drug users and provide housing with social spaces for this population,they could play an important role in the reduction of street disorder. It is important torecognize, however, that there are potential unintended harms that might result fromrelocating active drug users into private indoor locations, particularly if these locations areunsupervised and do not have safeguards to manage behaviors that might be associated withactive drug use, such as drug overdose events or illicit drug dealing which is often linkedwith violence given the unregulated nature of the illicit drug market (Erickson, 2001).To address risks associated with active drug use, there may be a role for supervised drugconsumption facilities integrated into supportive housing models. Indeed, the integration ofa ‘harm reduction’ supervised injecting room in one supportive housing facility for peoplewith HIV/AIDS in Vancouver has been shown to be successful in reducing risky drug usepractices on the premises (Krusi et al., 2009). Furthermore, in our study setting, a number ofnon-profit housing societies have been able to successfully provide supportive housing forindividuals who actively use drugs and have been able to manage behaviors associated withillicit drug use (Atira Women's Resource Society, 2010; Gurstein and Small, 2005). WithinDeBeck et al. Page 7Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptthese models, special consideration is given to ensure that residents’ health and physicalsecurity needs are met. In particular, measures are taken to accommodate and address therisks associated with drug use, including drug use which normally would take place inoutdoor locations within the open drug scene (Gurstein and Small, 2005).Although there is now a wide literature suggesting that low-threshold housing options in linewith a housing first model successfully support and retain individuals with high intensityaddiction and, as our study indicates, have potential to reduce street disorder, low-thresholdhousing currently makes up only a small proportion of existing housing units in our studysetting (Eby and Misura, 2006; Housing Centre Community Services Group, 2007). Ourdata add to existing evidence highlighting the need to increase the supply of low-thresholdsupportive housing that includes safeguards to manage behaviors associated with activeillicit drug use including drug overdose events and drug dealing and accompanying risks forviolence (Martinez and Burt, 2006; Salit et al., 1998).There are a number of limitations in this study. Firstly, Vancouver's housing situation andopen drug scene have unique features that may limit the generalizability of these findings.However, drug-related street disorder and lack of supportive housing for drug usingpopulations are issues in many other urban settings and therefore the findings of this studymay be relevant to other areas. Secondly, while our definition of the variable ‘limited privatespace for socializing’ included individuals who had no access to private space, it alsoincluded individuals who had access to private space, but who were restricted to having lessthan three guests visit at one time. Despite the restriction, it should be noted that theseindividuals could socialize in their own private space. Thirdly, a number of our measureswere based upon self-report data and are therefore vulnerable to recall bias and sociallydesirable responding. In this study, issues with recall could have resulted in an over- orunderestimation of the number of hours spent on the street socializing, suggesting that ifrecall issues were present they would have biased our result towards the null. If sociallydesirable responding was an issue, we suspect this response bias would have led to anunderreporting of the number of hours spent on the street, which in turn may have led to anunderestimation of the association between access to private space and socializing in theopen drug scene. Finally, our third analysis relied on participants’ attitudes and does notrepresent actual behavior change. There are likely multiple factors that contribute tosocializing in public spaces and providing private space may not change this behavior.In summary, our data indicate that a lack of access to private space among people who usedrugs may contribute to street disorder in open drug scenes. Study findings further suggestthat increasing access to private spaces that accommodate socializing among active drugusers and include safeguards to manage behaviors associated with active illicit drug use haspotential to reduce one component of street disorder. Low-threshold supportive housingapproaches based on the housing first model appear to offer important opportunities to meetthese objectives.ReferencesAitken C, Moore D, Higgs P, Kelsall J, Kerger M. The impact of a police crackdown on a street drugscene: evidence from the street. Int. J. Drug Policy. 2002; 13:189–198.Atira Women's Resource Society. 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Page 12Table 1Characteristics of study sample stratified by socializing in Vancouver's open drug scene (n=1114)Socializes in open drug sceneaCharacteristic Yes n= 475, n (%) No n= 639, n (%)Socio-Demographic Factors    Age (Median, IQR)b        Per year older 44 (37-49) 45 (38-50)        Female Gender 172 (36) 221 (35)        Aboriginal Ancestry 196 (4l) 200 (31)        High School Education 214 (45) 326 (51)        Employment c 86 (l8) 157 (25)        HIV Positive 152 (32) 214 (33)    DTES Residencyc,d 415 (87) 357 (56)        Current Housing Status        Stable Housing 78 (16) 270 (42)        Room in Hotel (SRO) 225 (47) 245 (38)        Shelter 19 (4) 20 (3)        No Fixed Address 144 (30) 75 (12)        Othere 9 (2) 29 (5)Individual-Level Risk and Protective Factors        Sex Trade c 68 (14) 53 (8)        Drug Dealing c 184 (39) 134 (21)        Any Addiction Treatment c 243 (51) 391 (61)        Daily Cocaine Injection c 53 (11) 45 (7)        Daily Heroin Injection c 120 (25) 97 (15)        Daily Crack Smoking c 260 (55) 187 (29)        Binge Drug Use c 233 (49) 198 (31)        Overdose (non-fatal) c 26 (5) 18 (3)        Syringe Sharing c 14 (3) 35 (5)        Multiple Sex Partners c 90 (19) 82 (13)Structural-Level Factors        Limited Private Space c 405 (85) 428 (67)        Recent Incarceration c 72 (15) 64 (10)        Police Encounters f 148 (31) 116 (18)        Victim of Violence c 99 (21) 101 (16)Note:Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 13aSocializing in the open drug scene was defined as living in or frequenting Vancouver's drug use epicenter and spending on average three or morehours on the street each day socializingbIQR=Inter Quartile RangecDenotes activities or situations occurring in the previous 6 monthsd‘DTES’ = ‘Downtown Eastside’, Vancouver's drug use epicentere‘Other’ includes the categories: ‘treatment recovery’, ‘jail (prison)’, and ‘other’fDenotes activities or situations occurring in the previous month.Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 14Table 2Univariate and Multivariate analyses of factors associated with socializinga in Vancouver's open drug scene among injection drug users (n=1114)CharacteristicUnivariate Analyses of Factors Associated withSocializingModel 1. Confounding Model for Socializing andAccess to Private SpaceModel 2. Explanatory Model Considering RiskFactors for SocializingORb  (95% CI)p-valueAORc  (95% CI)p-valueAORc  (95% CI)p-valueSocio-Demographic Factors    Age per year older0.99 (0.98 – 1.00)0.1831.00 (0.99 – 1.02)0.846--        Female Gender1.07 (0.84 – 1.38)0.5750.79 (0.58 – 1.07)0.122--        Aboriginal Ancestry1.54 (1.20 – 1.98)<0.0011.56 (1.16 – 2.10)0.0031.62 (1.22 – 2.14)0.001        High School Education0.79 (0.62 – 1.00)0.0490.88 (0.67 – 1.15)0.344        Employment d0.68 (0.51 – 0.91)0.0100.93 (0.66 – 1.31)0.672        HIV Positive d0.93 (0.73 – 1.20)0.601--        DTES Residency d, e5.46 (4.00 – 7.47)< 0.0013.74 (2.66 – 5.26)<0.001        Current Housing Status        Stable Housing- Reference-- Reference-        Room in Hotel (SRO)3.18 (2.33 – 4.34)<0.0012.41 (1.73 – 3.35)<0.001        Shelter3.29 (1.67 – 6.47)<0.0012.97 (1.41 – 6.25)0.004        No Fixed Address6.65 (4.56 – 9.68)<0.0014.15 (2.72 – 6.33)<0.001        Otherf1.07 (0.49 – 2.37)0.8591.02 (0.44 – 2.35)0.969Individual-Level Risk and Protective Factors        Sex Trade d1.85 (1.26 – 2.70)0.001----        Drug Dealing d2.38 (1.83 – 3.11)<0.0011.51 (1.10 – 2.08)0.0121.34 (0.97 – 1.87)0.079        Addiction Treatment d0.66 (0.52 – 0.84)<0.0010.63 (0.48 – 0.83)0.0010.67 (0.51 – 0.88)0.004        Daily Cocaine Injection d1.66 (1.09 – 2.51)0.017----        Daily Heroin Injection d1.89 (1.40 – 2.55)< 0.001----        Daily Crack Smoking d2.92 (2.28 – 3.75)< 0.0011.60 (1.18 – 2.16)0.0031.66 (1.23 – 2.24)0.001        Binge Drug Use d2.14 (1.68 – 2.74)< 0.0011.59 (1.19 – 2.12)0.0021.73 (1.30 – 2.30)<0.001Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 15CharacteristicUnivariate Analyses of Factors Associated withSocializingModel 1. Confounding Model for Socializing andAccess to Private SpaceModel 2. Explanatory Model Considering RiskFactors for SocializingORb  (95% CI)p-valueAORc  (95% CI)p-valueAORc  (95% CI)p-value        Overdose (non-fatal) d2.00 (1.08 – 3.69)0.024--        Syringe Sharing d0.52 (0.28 – 0.99)0.0420.30 (0.15 – 0.60)<0.001        Multiple Sex Partners d1.59 (1.15 – 2.20)0.0051.33 (0.92 – 1.92)0.133Structural-Level Factors        Limited Private Space d2.85 (2.11 – 3.86)<0.0011.80 (1.28 – 2.55)<0.001        Recent Incarceration d1.61 (1.12 – 2.30)0.010--        Police Encounters g2.04 (1.54 – 2.70)< 0.0011.28 (0.92 – 1.78)0.140        Victim of Violence d1.40 (1.03 – 1.91)0.030--Note:*Models adjusted for the month that the interview was conducted.a Socializing in the open drug scene was defined as living in or frequenting Vancouver's drug use epicenter and spending on average three or more hours on the street each day socializingb OR = Odds Ratio, CI = Confidence Intervalc AOR = Adjusted Odds Ratiod Denotes activities or situations occurring in the previous 6 monthse ‘DTES’ = ‘Downtown Eastside’, Vancouver's drug use epicenterf ‘Other’ includes the categories: ‘treatment recovery’, ‘jail (prison)’, and ‘other’g Denotes activities or situations occurring in the previous month.Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 16Table 3Univariate and multivariate analyses of factors associated with positive attitudes towards relocating socializinga away from the open drug scene to privatespaces among injection drug users in Vancouver (n=390)Positive attitudes towards relocating socializing activities to private indoor spacesCharacteristicYes n= 254, n (%)No n= 136, n (%)ORb  (95% CI)p-valueAORb  (95% CI)p-valueSocio-Demographic Factors    Age Per year older43(36-48)c46(40-50)c0.97 (0.95 – 1.00)0.017        Female Gender95 (37)51 (37)1.00 (0.65 – 1.53)0.985        Aboriginal Ancestry104 (41)54 (40)1.05 (0.69 – 1.61)0.812        Employment d44 (17)18 (13)1.37 (0.76 – 2.49)0.293        HIV Positive77 (30)49 (36)0.77 (0.50 – 1.20)0.250        Current Housing Status        Stable Housing14 (6)26 (19)- Reference-- Reference-        Room in Hotel (SRO)106 (42)84 (62)2.34 (1.15 – 4.77)0.0192.39 (1.17 – 4.90)0.017        Shelter13 (5)4 (3)6.04 (1.65 – 22.05)0.0076.35 (1.72 – 23.44)0.006        No Fixed Address115 (45)21 (15)10.17 (4.57 – 22.61)<0.0018.36 (3.71 – 18.85)<0.001        Othere6 (2)1 (1)11.14 (1.22 – 102.00)0.03310.87 (1.17 – 100.77)0.036Individual-Level Risk and Protective Factors    Hours Socializing Per additional hourd,f8(4-12)c6(4-12)c1.04 (1.00 – 1.09)0.029        Sex Trade d44 (17)18 (13)1.37 (0.76 – 2.49)0.293        Drug Dealing d109 (43)47 (35)1.42 (0.93 – 2.19)0.109        Addiction Treatment d122 (48)72 (53)0.82 (0.54 – 1.25)0.355        Daily Cocaine Injection d23 (9)20 (15)0.58 (0.30 – 1.09)0.090        Daily Heroin Injection d84 (33)21 (15)2.71 (1.59 – 4.61)<0.0011.89 (1.05 – 3.38)0.033        Daily Crack Smoking d156 (61)71 (52)1.46 (0.96 – 2.22)0.079        Binge Drug Use d130 (51)64 (47)1.18 (0.78 – 1.79)0.438        Overdose (non-fatal) d16 (6)6 (4)1.46 (0.56 – 3.81)0.441Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 17Positive attitudes towards relocating socializing activities to private indoor spacesCharacteristicYes n= 254, n (%)No n= 136, n (%)ORb  (95% CI)p-valueAORb  (95% CI)p-value        Syringe Sharing d*7 (3)3 (2)1.26 (0.32 – 4.94)1.000        Multiple Sex Partners d50 (20)24 (18)1.14 (0.67 – 1.96)0.625Structural-Level Factors        Recent Incarceration d48 (19)16 (12)1.75 (0.95 – 3.21)0.070        Encounters with Police g96 (38)33 (24)1.90 (1.19 – 3.03)0.007        Victim of Violence d62 (24)19 (14)2.00 (1.13 – 3.49)0.0151.72 (0.94 – 3.14)0.078Note:**Model adjusted for the month that the interview was conducted.a Socializing in the open drug scene was defined as living in or frequenting Vancouver's drug use epicenter (the Downtown Eastside, DTES) and spending on average three or more hours on the street eachday socializingb OR = Odds Ratio, CI = Confidence Interval, AOR = Adjusted Odds Ratioc Median value and Interquartile ranged Denotes activities or situations occurring in the previous 6 monthse ‘Other’ includes the categories: ‘treatment recovery’, ‘jail (prison)’, and ‘other’f ‘Hours Socializing’ was defined as a continuous variable and measured per additional hourg Denotes activities or situations occurring in the previous month.* p-value and 95% CI reported from Fisher's Exact Test as 25% of cells had expected counts less than 5.Drug Alcohol Depend. Author manuscript; available in PMC 2013 January 1.

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