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Drug-related street disorder : evidence for public policy responses DeBeck, Kora 2010

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ȱ ȱ ȱ ȱ DRUGȬRELATEDȱSTREETȱDISORDER:ȱEVIDENCEȱFORȱPUBLICȱPOLICYȱ RESPONSESȱ ȱ ȱ ȱ byȱ ȱ KORAȱDEBECKȱ BA,ȱMcGillȱUniversity,ȱCanada,ȱ2002ȱ MPP,ȱSimonȱFraserȱUniversity,ȱCanada,ȱ2007ȱ ȱ ȱ ȱ AȱTHESISȱSUBMITTEDȱINȱPARTIALȱFULFILMENTȱOFȱȱ THEȱREQUIREMENTSȱFORȱTHEȱDEGREEȱOFȱ ȱ ȱ DOCTORȱOFȱPHILOSOPHYȱ ȱ ȱ inȱ ȱ ȱ THEȱFACULTYȱOFȱGRADUATEȱSTUDIESȱ (InterdisciplinaryȱStudies)ȱ ȱ ȱ ȱ ȱ ȱ TheȱUniversityȱofȱBritishȱColumbiaȱ ȱ (Vancouver)ȱ ȱ Decemberȱ2010ȱ ȱ ©ȱKoraȱDeBeck,ȱ2010ȱ ȱ ii ABSTRACTȱ Background:ȱTheȱobjectivesȱofȱthisȱthesisȱwereȱtoȱdescribeȱtheȱ impactsȱofȱdrugȬrelatedȱ streetȱdisorderȱonȱstreetȬbasedȱinjectionȱdrugȱusersȱ(IDU)ȱinȱVancouver,ȱCanadaȱandȱtoȱ exploreȱ theȱpotentialȱ impactsȱ ofȱ threeȱpolicyȱ interventionsȱ (lowȬthresholdȱ supportiveȱ housing,ȱ lowȬthresholdȱ employment,ȱ andȱ supervisedȱ inhalationȱ facilities)ȱ onȱ theȱ reductionȱofȱstreetȱdisorder.ȱȱ Methods:ȱDataȱforȱtheseȱstudiesȱwereȱderivedȱfromȱtheȱVancouverȱInjectionȱDrugȱUsersȱ Studyȱ (VIDUS)ȱ whichȱ isȱ aȱ communityȱ recruitedȱ prospectiveȱ cohortȱ ofȱ IDU.ȱ Studyȱ participantsȱwereȱ invitedȱonȱbiȬannualȱbasesȱ toȱcompleteȱanȱ interviewerȬadministeredȱ questionnaire.ȱVariousȱmultivariateȱregressionȱtechniquesȱwereȱutilizedȱtoȱassessȱfactorsȱ associatedȱwithȱ exposureȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ socializingȱ inȱ Vancouver’’sȱ openȱ drugȱ scene,ȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activities,ȱ andȱ smokingȱ crackȱ cocaineȱ inȱpublicȱareas.ȱFurtherȱmultivariateȱanalysesȱwereȱ conductedȱ toȱassessȱ willingnessȱ toȱ reduceȱengagementȱ inȱbehavioursȱ thatȱcontributeȱ toȱdrugȬrelatedȱstreetȱ disorder.ȱȱ Results:ȱAtȱbaseline,ȱ21%ȱofȱtheȱstudyȱsampleȱreportedȱspendingȱoverȱ15ȱhourȱperȱdayȱ inȱVancouver’’sȱ openȱ drugȱ sceneȱ onȱ average.ȱDrugȱ sceneȱ exposureȱwasȱ foundȱ toȱ beȱ associatedȱ inȱ aȱ doseȬdependentȱ fashionȱwithȱ higherȱ intensityȱ drugȱ useȱ andȱmultipleȱ markersȱ ofȱ vulnerabilityȱ toȱ adverseȱ healthȱ outcomes.ȱ Inȱ furtherȱ analyses,ȱ 43%ȱ ofȱ participantsȱ reportedȱsocializingȱ inȱ theȱopenȱdrugȱsceneȱ forȱ3ȱorȱmoreȱhoursȱperȱday,ȱ andȱhavingȱlimitedȱaccessȱtoȱprivateȱspaceȱwasȱtheȱfactorȱmostȱstronglyȱassociatedȱwithȱ thisȱbehaviour.ȱAmongȱthisȱgroupȱ65%ȱreportedȱbeingȱwillingȱtoȱrelocateȱifȱgivenȱaccessȱ toȱ moreȱ privateȱ space.ȱ 47%ȱ ofȱ participantsȱ whoȱ engagedȱ inȱ disorderlyȱ incomeȱ generationȱactivitiesȱwereȱwillingȱtoȱforgoȱtheseȱincomeȱsourcesȱifȱgivenȱlowȬthresholdȱ employment,ȱandȱ71%ȱofȱcrackȱcocaineȱsmokersȱwhoȱreportedȱrecentlyȱusingȱinȱpublicȱ areasȱwereȱwillingȱtoȱvisitȱaȱsupervisedȱinhalationȱfacility.ȱ Conclusions:ȱTheseȱstudiesȱhighlightȱ theȱ importanceȱofȱviewingȱstreetȱdisorderȱ inȱ theȱ contextȱofȱcurrentȱpolitical,ȱeconomic,ȱandȱsocialȱconditionsȱandȱprovideȱaȱcompellingȱ bodyȱ ofȱ evidenceȱ indicatingȱ thatȱ structuralȱ andȱ environmentalȱ levelȱ interventions,ȱ specificallyȱ inȱ theȱareasȱofȱhousingȱ (i.e.,ȱprovisionȱofȱprivateȱ space),ȱemploymentȱandȱ supervisedȱdrugȱconsumptionȱfacilities,ȱareȱlikelyȱtoȱhaveȱaȱpositiveȱinfluenceȱonȱpublicȱ healthȱandȱreduceȱengagementȱinȱdrugȬrelatedȱstreetȱdisorder.ȱȱ ȱ iii PREFACEȱ Thisȱstatementȱisȱtoȱcertifyȱthatȱtheȱworkȱpresentedȱinȱthisȱthesisȱwasȱconceived,ȱ designed,ȱ written,ȱ andȱ disseminatedȱ byȱ Koraȱ DeBeckȱ (KD).ȱ Theȱ coȬauthorsȱ ofȱ theȱ manuscripts,ȱ includingȱDr.ȱ JulioȱMontanerȱ (JM),ȱDr.ȱDougȱMcArthurȱ (DM),ȱDr.ȱ Janeȱ Buxtonȱ (JB),ȱDr.ȱEvanȱWoodȱ (EW),ȱDr.ȱThomasȱKerrȱ (TK),ȱMs.ȱRuthȱZhangȱ (RZ),ȱMr.ȱ CalvinȱLaiȱ (CL),ȱandȱMs.ȱ JiezhiȱQiȱ (Qi)ȱmadeȱ contributionsȱonlyȱasȱ isȱ consistentȱwithȱ committee,ȱ collegial,ȱorȱ coȬauthorȱduties.ȱSpecificȱ contributionsȱ toȱeachȱ thesisȱ chapterȱ areȱasȱfollows:ȱChaptersȱ1ȱandȱ8:ȱ ȱWithȱguidanceȱandȱinputȱfromȱJM,ȱDM,ȱJB,ȱEWȱandȱ TK,ȱKDȱ conceivedȱandȱpreparedȱ theȱ initialȱdrafts;ȱ JM,ȱDM,ȱ JBȱandȱTKȱ reviewedȱandȱ providedȱfeedbackȱonȱChaptersȱ1ȱandȱ8.ȱChapterȱ2:ȱWithȱguidanceȱandȱinputȱfromȱTK,ȱ JM,ȱJB,ȱandȱDM,ȱKDȱwasȱresponsibleȱforȱundertakingȱtheȱliteratureȱreviewȱandȱpreparedȱ theȱfirstȱdraftȱofȱtheȱreview;ȱDMȱcontributedȱtoȱtheȱmainȱcontent;ȱandȱTK,ȱJM,ȱJB,ȱandȱ DMȱprovidedȱcriticalȱcommentsȱonȱtheȱfinalȱdraft.ȱChapterȱ3:ȱWithȱguidanceȱandȱinputȱ fromȱTK,ȱ JM,ȱ andȱEW,ȱKDȱwasȱ responsibleȱ forȱ studyȱdesignȱ andȱwroteȱ theȱ researchȱ protocol;ȱ RZȱ conductedȱ theȱ statisticalȱ analyses;ȱ KDȱ preparedȱ theȱ firstȱ draftȱ ofȱ theȱ analysis;ȱTK,ȱJB,ȱDM,ȱJM,ȱandȱEWȱcontributedȱtoȱtheȱmainȱcontentȱandȱprovidedȱcriticalȱ commentsȱonȱtheȱfinalȱdraft.ȱChapterȱ4:ȱWithȱguidanceȱandȱinputȱfromȱTK,ȱJM,ȱandȱEW,ȱ KDȱwasȱresponsibleȱforȱstudyȱdesignȱandȱwroteȱtheȱresearchȱprotocol;ȱCLȱconductedȱtheȱ statisticalȱanalyses;ȱKDȱpreparedȱtheȱfirstȱdraftȱofȱtheȱanalysis;ȱTK,ȱJB,ȱDM,ȱJM,ȱandȱEWȱ contributedȱ toȱ theȱmainȱ contentȱ andȱ providedȱ criticalȱ commentsȱ onȱ theȱ finalȱ draft.ȱ Chapterȱ5Ȭ7:ȱWithȱguidanceȱandȱ inputȱ fromȱTK,ȱ JM,ȱandȱEW,ȱKDȱwasȱresponsibleȱ forȱ ȱ iv studyȱdesignsȱandȱwroteȱ theȱ researchȱprotocols;ȱ JQȱconductedȱ theȱstatisticalȱanalyses;ȱ KDȱpreparedȱtheȱfirstȱdraftsȱofȱtheȱanalysis;ȱTK,ȱJB,ȱDM,ȱJM,ȱandȱEWȱcontributedȱtoȱtheȱ mainȱcontentȱandȱprovidedȱcriticalȱcommentsȱonȱtheȱfinalȱdrafts.ȱ Allȱmanuscriptsȱcontainedȱ inȱ thisȱ thesisȱwereȱpreparedȱandȱwrittenȱbyȱKDȱandȱ KDȱwasȱ responsibleȱ forȱ revisingȱ theȱmanuscriptsȱbasedȱonȱ theȱ suggestionsȱofȱ theȱ coȬ authors,ȱsubmittingȱmanuscriptsȱforȱpublicationȱandȱpreparingȱfinalȱrevisionsȱbasedȱonȱ theȱcommentsȱofȱtheȱjournalȱeditorsȱandȱexternalȱpeerȱreviewersȱ Allȱ researchȱ describedȱ inȱ thisȱ dissertationȱwasȱ approvedȱ byȱ theȱUniversityȱ ofȱ BritishȱColumbia/ProvidenceȱHealthȱCareȱResearchȱEthicsȱBoard;ȱ certificateȱnumbers:ȱ P05Ȭ0234,ȱH05Ȭ50234,ȱH01Ȭ50086,ȱP05Ȭ0233.ȱȱȱ ȱ v TABLEȱOFȱCONTENTSȱ ABSTRACT ..................................................................................................................................ii PREFACE .................................................................................................................................... iii TABLEȱOFȱCONTENTS............................................................................................................. v LISTȱOFȱTABLES ....................................................................................................................... ix LISTȱOFȱFIGURES..................................................................................................................... xi ACKNOWLEDGEMENTS......................................................................................................xii CHAPTERȱ1:ȱBackground,ȱRational,ȱObjectives,ȱandȱConceptualȱFramework.............. 1 1.1ȱBackground......................................................................................................................... 1 1.2ȱStudyȱJustification.............................................................................................................. 4 1.3ȱStudyȱObjectives................................................................................................................. 6 1.4ȱStudyȱDesign..................................................................................................................... 10 1.5ȱConceptualȱFramework................................................................................................... 11 1.6ȱSummary ........................................................................................................................... 14 CHAPTERȱ2:ȱDrugȬRelatedȱStreetȱDisorder:ȱAȱReviewȱofȱMeasuresȱandȱPolicyȱ Responses ................................................................................................................................... 18 2.1ȱIntroduction ...................................................................................................................... 18 2.2ȱReviewȱMethods............................................................................................................... 19 2.3ȱReviewȱFindings:ȱMeasuringȱDrugȬRelatedȱStreetȱDisorder..................................... 20 2.4ȱReviewȱFindings:ȱRespondingȱtoȱDrugȬRelatedȱStreetȱDisorder.............................. 25 2.4.1ȱLawȱEnforcementȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorder....... 25 2.4.1.1ȱPoliceȱCrackȬDownȱCampaigns ....................................................................... 25 ȱ vi 2.4.1.2ȱOrderȬMaintenanceȱPolicingȱBasedȱonȱtheȱBrokenȱWindowsȱTheory ....... 28 2.4.1.3ȱProblemȱOrientedȱPolicing ............................................................................... 33 2.4.1.4ȱHotȬSpotȱPolicing............................................................................................... 34 2.4.1.5ȱIncreasingȱPoliceȱPowersȱThroughȱLegislation ............................................. 35 2.4.1.6ȱSummaryȱofȱLawȱEnforcementȱBasedȱApproaches ...................................... 36 2.4.2ȱEnvironmentalȱDesignȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorder ................................................................................................................................... 36 2.4.3ȱEngagingȱInterventionsȱthatȱEnableȱBehaviourȱChange ..................................... 39 2.4.3.1ȱSupervisedȱInjectionȱFacilities.......................................................................... 39 2.4.3.2ȱAddictionȱTreatment ......................................................................................... 41 2.4.3.3ȱLowȬThresholdȱEmploymentȱPrograms......................................................... 42 2.5ȱConclusionsȱandȱNextȱSteps........................................................................................... 44 2.5.1ȱUnderexploredȱandȱInnovativeȱEngagingȱApproaches ...................................... 45 2.5.2ȱSummary .................................................................................................................... 46 CHAPTERȱ3:ȱAȱDoseȬDependentȱRelationshipȱBetweenȱExposureȱtoȱaȱStreetȬBasedȱ DrugȱSceneȱandȱHealthȬRelatedȱHarmsȱamongȱPeopleȱWhoȱUseȱInjectionȱDrugs ..... 50 3.1ȱIntroduction ...................................................................................................................... 50 3.2ȱMethods............................................................................................................................. 52 3.3ȱResults................................................................................................................................ 56 3.4ȱDiscussion ......................................................................................................................... 58 ȱ vii CHAPTERȱ4:ȱTheȱValidityȱofȱReportingȱWillingnessȱgoȱUseȱaȱSupervisedȱInjectingȱ FacilityȱonȱSubsequentȱProgramȱUseȱamongȱPeopleȱWhoȱUseȱInjectionȱDrugs.......... 68 4.1ȱIntroduction ...................................................................................................................... 68 4.2ȱMethods............................................................................................................................. 69 4.3ȱResults................................................................................................................................ 73 4.4ȱDiscussion ......................................................................................................................... 75 CHAPTERȱ5:ȱSocializingȱinȱanȱOpenȱDrugȱScene:ȱTheȱRelationshipȱBetweenȱAccessȱ toȱPrivateȱSpaceȱandȱStreetȱDisorder..................................................................................... 82 5.1ȱIntroduction ...................................................................................................................... 82 5.2ȱMethods............................................................................................................................. 84 5.3ȱResults................................................................................................................................ 90 5.4ȱDiscussion ......................................................................................................................... 92 CHAPTERȱ6:ȱOpportunitiesȱforȱReducingȱEngagementȱinȱDisorderlyȱIncomeȱ GenerationȱActivitiesȱamongȱPeopleȱWhoȱInjectȱIllicitȱDrugs ...................................... 102 6.1ȱIntroduction .................................................................................................................... 102 6.2ȱMethods........................................................................................................................... 104 6.3ȱResults.............................................................................................................................. 107 6.4ȱDiscussion ....................................................................................................................... 109 CHAPTERȱ7:ȱPublicȱCrackȱCocaineȱUseȱandȱWillingnessȱtoȱuseȱaȱSupervisedȱ InhalationȱFacility:ȱImplicationsȱforȱStreetȱDisorder....................................................... 122 7.1ȱIntroduction .................................................................................................................... 122 7.2ȱMethods........................................................................................................................... 124 7.3ȱResults.............................................................................................................................. 127 ȱ viii 7.4ȱDiscussion ....................................................................................................................... 128 CHAPTERȱ8:ȱConclusions ..................................................................................................... 136 8.1ȱSummaryȱofȱFindings .................................................................................................... 136 8.2ȱUniqueȱContributions.................................................................................................... 140 8.3ȱRecommendationsȱandȱImplications........................................................................... 142 8.3.1ȱMicroȱLevelȱRecommendationsȱandȱImplications.............................................. 143 8.3.2ȱMacroȱLevelȱRecommendationsȱandȱImplications............................................. 145 8.4ȱFutureȱResearch.............................................................................................................. 146 8.5ȱConclusions..................................................................................................................... 149 REFERENCES .......................................................................................................................... 151  ȱ ȱ ȱ ix LISTȱOFȱTABLESȱ Tableȱ2.1.ȱȱSummaryȱofȱmeasuresȱappropriateȱforȱdrugȬrelatedȱstreetȱdisorder.............. 24 Tableȱ2.2ȱȱ Descriptionȱofȱpolicyȱapproaches ......................................................................... 47 Tableȱ2.3ȱȱ Evidenceȱofȱimpactsȱofȱpolicyȱapproaches .......................................................... 48 Tableȱ3.1ȱȱ Baselineȱcharacteristicsȱofȱsampleȱstratifiedȱbyȱlevelȱofȱdrugȱsceneȱexposure64 Tableȱ3.2ȱȱ Univariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure ............. 65 Tableȱ3.3ȱȱ Multivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure .......... 66 Tableȱ4.1ȱȱ CharacteristicsȱofȱstudyȱpopulationȱstratifiedȱbyȱattendanceȱatȱVancouver’’sȱ supervisedȱinjectionȱfacility................................................................................... 79 Tableȱ4.2ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱattendingȱ Vancouver’’sȱsupervisedȱinjectionȱfacility ........................................................... 80 Tableȱ4.3ȱȱ GEEȱanalysisȱofȱfactorsȱassociatedȱwithȱnotȱusingȱtheȱsupervisedȱinjectionȱ facilityȱinȱtheȱlastȱsixȱmonthsȱamongȱthoseȱwhoȱinitiallyȱreportedȱbeingȱ willingȱtoȱuseȱtheȱfacility........................................................................................ 80 Tableȱ5.1ȱȱ UnivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱsocializingȱinȱVancouver’’sȱ openȱdrugȱsceneȱamongȱinjectionȱdrugȱusers..................................................... 97 Tableȱ5.2ȱȱ UnivariateȱanalysisȱofȱhousingȱstatusȱandȱsocializingȱinȱVancouver’’sȱopenȱ drugȱsceneȱamongȱinjectionȱdrugȱusers............................................................... 98 Tableȱ5.3ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱprimaryȱandȱsecondaryȱfactorsȱ associatedȱwithȱsocializingȱinȱVancouver’’sȱopenȱdrugȱsceneȱamongȱinjectionȱ drugȱusers ................................................................................................................ 98 Tableȱ5.4ȱȱ Univariateȱanalysesȱofȱinjectionȱdrugȱusersȱthatȱhaveȱlimitedȱaccessȱtoȱprivateȱ spaceȱandȱengageȱinȱsocializingȱinȱVancouver’’sȱopenȱdrugȱsceneȱstratifiedȱbyȱ willingnessȱtoȱrelocate............................................................................................ 99 Tableȱ5.5ȱȱ Univariateȱanalysisȱofȱhousingȱstatusȱandȱwillingnessȱtoȱrelocateȱamongȱ injectionȱdrugȱusers .............................................................................................. 100 Tableȱ5.6ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ willingnessȱtoȱrelocateȱsocializingȱactivityȱamongȱinjectionȱdrugȱusers ...... 100 ȱ x Tableȱ6.1ȱȱ Participationȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱ users ........................................................................................................................ 117 Tableȱ6.2ȱȱ Univariateȱanalysesȱofȱfactorsȱassociatedȱwithȱengagingȱinȱdisorderlyȱincomeȱ generationȱactivitiesȱamongȱinjectionȱdrugȱusers ............................................ 118 Tableȱ6.3ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ participationȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱ users ........................................................................................................................ 119 Tableȱ6.4ȱȱ Univariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱtoȱceaseȱengagingȱ inȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱusers....... 120 Tableȱ6.5ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ willingnessȱtoȱceaseȱengagingȱinȱdisorderlyȱincomeȱgenerationȱamongȱ injectionȱdrugȱusers .............................................................................................. 121 Tableȱ7.1ȱȱ Characteristicsȱofȱcrackȱcocaineȱsmokersȱstratifiedȱbyȱpublicȱdrugȱuse ....... 132 Tableȱ7.2ȱȱ Univariateȱandȱmultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱpublicȱdrugȱ useȱamongȱcrackȱcocaineȱsmokers...................................................................... 133 Tableȱ7.3ȱȱ Characteristicsȱofȱcrackȱcocaineȱsmokersȱwhoȱuseȱdrugsȱinȱpublicȱstratifiedȱ byȱwillingnessȱtoȱuseȱaȱsupervisedȱinhalationȱroom ....................................... 134 Tableȱ7.4ȱȱ Univariateȱandȱmultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱtoȱ useȱaȱsupervisedȱinhalationȱroomȱamongȱparticipantsȱthatȱsmokeȱcrackȱ cocaineȱandȱuseȱdrugsȱinȱpublicȱlocations......................................................... 135 ȱ ȱ ȱ xi LISTȱOFȱFIGURESȱ Figureȱ1.1.ȱTypesȱofȱdrugȬrelatedȱstreetȱdisorder.................................................................. 16 Figureȱ1.2.ȱProblemsȱassociatedȱwithȱdrugȬrelatedȱstreetȱdisorder .................................... 16 Figureȱ1.3.ȱSchematicȱofȱtheoreticalȱframework .................................................................... 17 Figureȱ3.1ȱFactorsȱassociatedȱwithȱdrugȱsceneȱexposure ..................................................... 67 Figureȱ4.1ȱStudyȱsample............................................................................................................ 81 Figureȱ5.1ȱHousingȱstatusȱamongȱinjectionȱdrugȱusers...................................................... 101 Figureȱ5.2ȱDistributionȱofȱinjectionȱdrugȱusersȱbyȱhousingȱstatusȱandȱaccessȱtoȱprivateȱ space........................................................................................................................ 101 ȱ ȱȱ ȱ xii ACKNOWLEDGEMENTSȱ Iȱwouldȱ likeȱ toȱ expressȱmyȱ sincereȱ gratitudeȱ toȱmyȱ thesisȱ supervisorȱDrȱ Julioȱ Montaner,ȱandȱmyȱcommitteeȱmembersȱDrsȱJaneȱBuxtonȱandȱDougȱMcArthurȱforȱtheirȱ generosity,ȱ encouragement,ȱ andȱ guidance.ȱ Iȱwouldȱ alsoȱ likeȱ toȱ thankȱmyȱ committeeȱ specialȱ advisorsȱDrsȱEvanȱWoodȱ andȱ ThomasȱKerrȱ forȱ theirȱ activeȱ involvementȱ andȱ constantȱ supportȱ throughoutȱ myȱ programȱ andȱ academicȱ training.ȱ Theȱ ongoingȱ mentorshipȱIȱhaveȱreceivedȱfromȱeachȱofȱtheseȱindividualsȱisȱinvaluableȱandȱIȱamȱveryȱ appreciativeȱ toȱ haveȱ hadȱ theȱ opportunityȱ toȱ beȱ guidedȱ byȱ suchȱ aȱ supportiveȱ andȱ experiencedȱ committee.ȱ Itȱ isȱ theirȱ energyȱ thatȱmadeȱ thisȱ projectȱ possibleȱ andȱ Iȱwillȱ foreverȱbeȱgratefulȱtoȱthem.ȱ NoneȱofȱthisȱworkȱwouldȱhaveȱbeenȱpossibleȱwithoutȱtheȱwillingnessȱofȱVIDUSȱ participantsȱ toȱ beȱ partȱ ofȱ theȱ studyȱ andȱ shareȱ theirȱ experiences.ȱ Iȱ extendȱ aȱ specialȱ acknowledgementȱandȱthanksȱtoȱallȱVIDUSȱparticipantsȱandȱhopeȱthisȱworkȱcanȱbeȱusedȱ toȱtheirȱbenefit.ȱȱIȱwouldȱalsoȱlikeȱtoȱthankȱallȱVIDUSȱfrontlineȱstaffȱforȱdoingȱtheȱhardȱ workȱofȱgatheringȱtheȱdataȱthatȱisȱtheȱbasisȱofȱthisȱproject.ȱȱȱ Iȱ wouldȱ likeȱ toȱ recognizeȱ aȱ largeȱ numberȱ ofȱ peopleȱ atȱ theȱ BCȱ Centreȱ forȱ Excellenceȱ inȱ HIV/AIDSȱ (CfE)ȱ andȱ theȱ Urbanȱ Healthȱ Researchȱ Initiativeȱ whoȱ haveȱ providedȱ invaluableȱ supportȱ toȱme.ȱ Inȱ particularȱ Iȱwouldȱ likeȱ toȱ thankȱ KellyȱHsu,ȱ DeborahȱGraham,ȱTriciaȱCollingham,ȱCarmenȱRock,ȱPeterȱVann,ȱCaitlinȱJohnston,ȱSteveȱ KainȱandȱIreneȱDay.ȱThanksȱtoȱBrentonȱWaltersȱforȱcopyȱeditingȱthisȱwork.ȱIȱhaveȱalsoȱ receivedȱ outstandingȱ statisticalȱ supportȱ andȱmentorshipȱ fromȱ JiezhiȱQi,ȱRuthȱZhang,ȱ andȱCalvinȱLaiȱ––ȱthankȱyou.ȱAnotherȱhugeȱsourceȱofȱinspirationȱandȱsupportȱhasȱcomeȱ fromȱ aȱ trulyȱ exceptionalȱ groupȱ ofȱ friendsȱ andȱ colleaguesȱ atȱ theȱ CfE.ȱ Thisȱ includesȱ BrandonȱMarshall,ȱMȬJȱMilloy,ȱWillȱ Small,ȱElisaȱLloydȬSmith,ȱKateȱ Shannon,ȱAngelaȱ Kaida,ȱ Vivianeȱ Diasȱ Lima,ȱ Arankaȱ Aanema,ȱ Andreaȱ Krüsi,ȱ Danȱ Werb,ȱ Lindseyȱ Richardson,ȱ Codyȱ Callon,ȱ Danyaȱ Fast,ȱ Kannaȱ Hayashiȱ andȱ Nadiaȱ Fairbairn.ȱ Iȱ lookȱ forwardȱtoȱcontinuingȱtoȱcollaborateȱwithȱandȱlearnȱfromȱyouȱall.ȱȱ Iȱwouldȱ likeȱ toȱ acknowledgeȱmyȱdoctoralȱ fundingȱ supportȱ fromȱ theȱCanadianȱ InstitutesȱofȱHealthȱResearch,ȱ theȱMichaelȱSmithȱFoundationȱ forȱHealthȱResearch,ȱ theȱ BCȱCentreȱforȱExcellenceȱinȱHIV/AIDSȱandȱtheȱUrbanȱHealthȱResearchȱInitiative.ȱȱ Lastly,ȱ Iȱwouldȱ likeȱ toȱ extendȱmyȱgratitudeȱ toȱmyȱpartner,ȱmyȱ familyȱandȱmyȱ friendsȱforȱtheirȱconstantȱsupportȱandȱendlessȱpatienceȱthroughoutȱmyȱPhDȱprogram.ȱȱ ȱ ȱ ȱ 1 CHAPTER 1: ȱ BACKGROUND,ȱRATIONAL,ȱOBJECTIVES,ȱANDȱ CONCEPTUALȱFRAMEWORKȱ 1.1 Backgroundȱ Theȱ everȬincreasingȱ expansionȱ andȱ revitalizationȱ ofȱ urbanȱ coresȱ isȱ generatingȱ uniqueȱpressuresȱforȱcityȱmanagersȱandȱpolicyȬmakers.ȱAsȱtheȱdensityȱofȱcitiesȱincreasesȱ andȱcitizensȱwithȱdiverseȱbackgroundsȱandȱinterestsȱareȱbroughtȱintoȱcloserȱproximity,ȱ tensionsȱrelatedȱtoȱtheȱuseȱofȱpublicȱspacesȱmayȱbecomeȱamplified.ȱȱ Oneȱcommonȱareaȱofȱcontentionȱ isȱ theȱpresenceȱofȱdrugȬrelatedȱstreetȱdisorder.ȱ DrugȬrelatedȱstreetȱdisorderȱcanȱbeȱdefinedȱasȱactivitiesȱandȱbehavioursȱassociatedȱwithȱ illegalȱ drugȱ useȱ thatȱ detractsȱ fromȱ otherȱ citizens’’ȱ enjoymentȱ ofȱ publicȱ spaces.ȱ Streetȱ disorderȱisȱoftenȱdefinedȱtoȱincludeȱmarkersȱofȱ‘‘physical’’ȱdisorder,ȱsuchȱasȱgraffiti,ȱlitterȱ andȱstructuralȱdecayȱinȱneighbourhoodsȱ(e.g.,ȱbrokenȱwindows),ȱasȱwellȱasȱmarkersȱofȱ ‘‘social’’ȱ disorder,ȱwhichȱ refersȱ toȱ activitiesȱ andȱ behavioursȱ thatȱ takeȱ placeȱ inȱ publicȱ spaces.1ȱ ȱ ȱ Inȱ theȱ contextȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ keyȱ activitiesȱ ofȱ relevanceȱ include:ȱpublicȱdrugȱuseȱ (consumingȱ illegalȱdrugsȱ inȱpublicȱspacesȱprimarilyȱ throughȱ injectionȱ andȱ smoking);ȱ drugȬrelatedȱ litterȱ (includingȱ discardingȱ needlesȱ andȱ crackȱ pipesȱ inȱpublicȱareas);ȱandȱpublicȱ intoxicationȱ(loiteringȱorȱsocializingȱ inȱpublicȱspacesȱ whileȱunderȱ theȱ influenceȱofȱdrugs).2Ȭ6ȱ ȱThereȱareȱalsoȱaȱnumberȱofȱ incomeȱgenerationȱ activitiesȱthatȱcontributeȱtoȱstreetȱdisorderȱwhich,ȱalthoughȱnotȱexclusivelyȱdrugȬrelated,ȱ ȱ 2 areȱlargelyȱdrivenȱbyȱillegalȱdrugȱuseȱandȱaddiction.2,ȱ7ȱTheseȱactivitiesȱinclude:ȱȱstreetȬ levelȱdrugȱtraffickingȱ(definedȱasȱsellingȱillegalȱdrugsȱinȱpublicȱspaces);ȱstreetȬbasedȱsexȱ workȱ(solicitingȱandȱcommunicatingȱforȱtheȱpurposesȱofȱsellingȱsexȱ inȱpublicȱsettings);ȱ panhandlingȱ (solicitingȱ moneyȱ orȱ otherȱ goodsȱ fromȱ passersȱ byȱ inȱ publicȱ areas);ȱ squeegeeȱ cleaningȱ (cleaningȱ theȱ windshieldsȱ ofȱ carsȱ atȱ stopȱ lightsȱ inȱ exchangeȱ forȱ donationsȱ fromȱ vehicleȱ drivers);ȱ ȱ andȱ lastly,ȱ engagementȱ inȱ ‘‘binning’’,ȱ recycling,ȱȱ salvagingȱ orȱ unsanctionedȱ streetȬvendingȱ (collectingȱ bottlesȱ andȱ otherȱ goodsȱ fromȱ allies,ȱdumpstersȱ andȱ otherȱpublicȱ areasȱ thatȱ areȱ returnedȱ forȱ refundȱ orȱ soldȱ onȱ theȱ streetȱforȱprofit)ȱ[seeȱFigureȱ1.1].2,ȱ8Ȭ10ȱ InȱVancouver,ȱCanada,ȱdrugȬrelatedȱstreetȱdisorderȱisȱparticularlyȱprevalentȱinȱanȱ areaȱofȱtheȱcityȱcalledȱtheȱDowntownȱEastsideȱ(DTES).ȱThisȱneighbourhoodȱcontainsȱaȱ highȱportionȱofȱ theȱcity’’sȱ lowȬcostȱhousingȱstockȱandȱ largeȱnumbersȱofȱcitizensȱ livingȱ withȱmentalȱhealthȱandȱaddictionȱissues.11,ȱ12ȱȱOverȱtheȱyearsȱtheȱDTESȱhasȱbecomeȱaȱhubȱ ofȱdrugȱmarketȱactivityȱandȱdrugȬrelatedȱstreetȱdisorderȱisȱcommonȱinȱtheȱarea.ȱȱInȱtheȱ earlyȱ1990sȱtheȱneighbourhoodȱwasȱfloodedȱwithȱhighȱpurityȱheroinȱandȱcocaineȱwhichȱ exacerbatedȱ streetȱdisorderȱproblemsȱ andȱ resultedȱ inȱ aȱpublicȱhealthȱdisasterȱ amongȱ peopleȱwhoȱinjectȱdrugsȱ(IDU).ȱAlongȱwithȱanȱexplosiveȱincreaseȱinȱoverdoseȱdeaths,13ȱ researchersȱdocumentedȱanȱHIVȱepidemicȱamongȱ localȱIDUȱthatȱrivaledȱHIVȱ infectionȱ ratesȱinȱBotswana,ȱAfrica.14,ȱ15ȱȱȱ ȱ 3 Manyȱpublicȱhealthȱ initiativesȱhaveȱbeenȱ implementedȱ toȱrespondȱ toȱ theȱhealthȱ andȱ streetȱ disorderȱ problemsȱ associatedȱ withȱ problematicȱ drugȱ use.ȱ Theseȱ haveȱ includedȱ scalingȱ upȱ addictionȱ treatmentȱ services,ȱ particularlyȱ methadoneȱ maintenance,16ȱ restructuringȱ theȱ neighbourhood’’sȱ needleȱ exchangeȱ programs,17Ȭ19ȱ andȱ establishingȱaȱpilotȱsupervisedȱinjectionȱfacilityȱinȱ2003.20,ȱ21ȱȱAsȱaȱresultȱofȱtheseȱefforts,ȱ progressȱhasȱbeenȱmadeȱ inȱ reducingȱoverdoseȱdeathsȱandȱHIVȱ infectionȱ ratesȱamongȱ peopleȱwhoȱinjectȱdrugs.22ȱȱHowever,ȱthereȱareȱstillȱsignificantȱgapsȱinȱhealthȱservicesȱforȱ peopleȱwhoȱuseȱdrugsȱandȱstreetȱdisorderȱremainsȱaȱprominentȱproblemȱinȱtheȱDTES.23Ȭ 25ȱȱȱ Inȱ addition,ȱ drugȱ useȱ trendsȱ inȱ theȱ neighbourhoodȱ haveȱ beenȱ changing.ȱ Specifically,ȱtheȱpopularityȱofȱcrackȱcocaineȱhasȱsignificantlyȱincreasedȱinȱtheȱDTES,26,ȱ27ȱ yetȱ itsȱ proliferationȱ hasȱ notȱ beenȱmetȱwithȱ anȱ adequateȱ publicȱ healthȱ response.28,ȱ 29ȱ Comparedȱtoȱotherȱdrugȱuserȱpopulations,ȱcrackȱcocaineȱusersȱareȱoftenȱdescribedȱasȱaȱ particularlyȱhighȱriskȱpopulation.ȱCrackȱcocaineȱusingȱpopulationsȱareȱfoundȱtoȱbeȱmoreȱ likelyȱ toȱ engageȱ inȱ riskyȱ behaviours30Ȭ32ȱ andȱ illegalȱ activities,7,ȱ 33ȱ toȱ experienceȱ homelessness29ȱandȱhealthȱproblems,29,ȱ34Ȭ37ȱyetȱareȱlessȱlikelyȱtoȱaccessȱhealthȱandȱsocialȱ services.38ȱ Indeed,ȱ recentȱ researchȱ indicatesȱ thatȱ afterȱ adjustingȱ forȱ establishedȱ riskȱ factors,ȱ frequentȱ crackȱ cocaineȱ smokingȱ remainsȱ independentlyȱ associatedȱwithȱHIVȱ incidenceȱ amongȱdrugȱusersȱ inȱVancouver.27ȱ ȱ Inȱ theȱDTESȱ theȱmajorityȱ ofȱ evidenceȬ basedȱpublicȱhealthȱresponsesȱtoȱproblematicȱdrugȱuseȱareȱnotȱtailoredȱforȱcrackȱcocaineȱ ȱ 4 usersȱandȱdoȱnotȱaddressȱtheirȱuniqueȱneeds.28,ȱ39ȱȱAsȱaȱresult,ȱhealthȱandȱstreetȱdisorderȱ problemsȱtendȱtoȱbeȱaccentuatedȱamongȱpeopleȱwhoȱuseȱcrackȱcocaine.ȱ 1.2 StudyȱJustificationȱ DrugȬrelatedȱstreetȱdisorderȱnegativelyȱimpactsȱcommunitiesȱandȱindividualsȱinȱ aȱnumberȱofȱways.ȱ Identifiedȱproblemsȱprimarilyȱ involveȱeconomic,ȱpublicȱsafetyȱandȱ publicȱhealthȱconcernsȱ[seeȱFigureȱ1.2].ȱWithȱrespectȱtoȱeconomicȱconsiderations,ȱstreetȱ disorderȱ isȱ citedȱ asȱ creatingȱ unpleasant,ȱ unwelcomingȱ environmentsȱ thatȱ discourageȱ retailȱactivityȱandȱdevelopment,ȱwhichȱinȱturnȱmayȱharmȱlocalȱbusinessesȱandȱerodeȱtheȱ economicȱvitalityȱ andȱgrowthȱ ofȱ areasȱ experiencingȱdrugȬrelatedȱ streetȱdisorder.8,ȱ 40Ȭ44ȱȱ Sinceȱstreetȱdisorderȱisȱtypicallyȱconcentratedȱinȱurbanȱcentres,ȱtheȱpresenceȱofȱdisorderȱ isȱfearedȱtoȱundermineȱurbanȱrenewalȱefforts,ȱwhichȱprovideȱimportantȱcommercialȱandȱ realȱestateȱinvestmentȱopportunitiesȱinȱmanyȱrapidlyȱexpandingȱurbanȱsettings.45ȱ Alongsideȱeconomicȱ issues,ȱpublicȱ safetyȱ isȱanotherȱcentralȱconcernȱwithȱdrugȬ relatedȱstreetȱdisorder.42ȱInȱparticular,ȱtheȱillegalȱdrugȱtradeȱcanȱbeȱviolent.46ȱȱBecauseȱofȱ theȱ illegalȱ statusȱ ofȱdrugs,ȱ individualsȱ engagedȱ inȱ theȱdrugȱ tradeȱ areȱunableȱ toȱ seekȱ assistanceȱ fromȱ lawȱ enforcementȱ andȱ legalȱ institutionsȱ toȱ settleȱ disputes.46ȱ ȱ Inȱ theȱ absenceȱofȱ traditionalȱdisputeȱ resolutionȱmechanismsȱandȱsafeguardsȱ itȱ isȱcommonȱ inȱ someȱareasȱ forȱstreetȬlevelȱdrugȱdealersȱ toȱcarryȱweaponsȱ (includingȱ firearms),ȱandȱ toȱ engageȱ inȱ territorialȱwarsȱorȱuseȱviolenceȱ toȱ resolveȱdisputes.41,ȱ 47ȱTheseȱ actionsȱoftenȱ bringȱ violenceȱ toȱ publicȱ spaces,ȱ andȱ engenderȱ aȱ senseȱ ofȱ dangerȱ amongȱ theȱ public.ȱȱ ȱ 5 Citizensȱmayȱalsoȱ fearȱbeingȱapproachedȱ inȱanȱaggressiveȱmannerȱbyȱpanhandlersȱorȱ squeegeeȱcleaners.43ȱTheȱerraticȱbehavioursȱassociatedȱwithȱtheȱuseȱofȱparticularȱdrugsȱ suchȱ asȱ crackȱ cocaineȱmayȱ equallyȱ intimidateȱ citizensȱ andȱmakeȱ themȱ feelȱ thatȱ theirȱ safetyȱisȱbeingȱthreatened.48,ȱ49ȱȱDiscardedȱinjectionȱequipmentȱisȱalsoȱperceivedȱtoȱposeȱaȱ threatȱ toȱ publicȱ safety.ȱAlthoughȱ incidentsȱ areȱ extremelyȱ rare,ȱ thereȱ isȱ concernȱ thatȱ individualsȱmayȱbecomeȱinfectedȱwithȱbloodȬborneȱdiseasesȱifȱaccidentallyȱprickedȱbyȱaȱ discardedȱ contaminatedȱ needle.5ȱ Inȱ addition,ȱ oneȱ theoryȱ rootedȱ inȱ criminologyȱ andȱ urbanȱsociologyȱknownȱasȱ ‘‘brokenȱwindows’’ȱsuggestsȱ thatȱstreetȱdisorderȱmayȱcreateȱ environmentsȱ thatȱ attractȱmoreȱ seriousȱ formsȱ ofȱ crimeȱ includingȱ robbery,ȱ theftȱ andȱ assaultȱandȱtherebyȱmayȱfurtherȱthreatenȱpublicȱsafety.40,ȱ50ȱ DrugȬrelatedȱstreetȱdisorderȱalsoȱhasȱimportantȱpublicȱhealthȱimplications.ȱAtȱtheȱ neighbourhoodȱlevel,ȱstudiesȱhaveȱlinkedȱneighbourhoodȱstreetȱdisorderȱtoȱpoorȱmentalȱ andȱphysicalȱhealthȱ outcomesȱ amongȱneighbourhoodȱ residents.51Ȭ55ȱ Inȱ addition,ȱ thoseȱ whoȱpartakeȱ inȱdrugȬrelatedȱ ‘‘disorderly’’ȱactivitiesȱareȱ typicallyȱvulnerableȱ individualsȱ facingȱmultipleȱnegativeȱhealthȱ issuesȱandȱengagingȱ inȱdrugȬrelatedȱdisorderȱcanȱposeȱ additionalȱhealthȱ risks.7,ȱ 56ȱ ȱ Inȱparticular,ȱ itȱ isȱwellȱdocumentedȱ thatȱasȱaȱ resultȱofȱ theȱ unregulatedȱnatureȱofȱdrugȱmarkets,ȱstreetȬbasedȱsexȱworkersȱareȱespeciallyȱvulnerableȱ toȱviolentȱencountersȱandȱ theirȱabilityȱ toȱnegotiateȱcondomȱuseȱcanȱbeȱconstrained.57Ȭ60ȱȱ Similarly,ȱ usingȱ injectionȱ drugsȱ inȱ publicȱ settingsȱ isȱ knownȱ toȱ increaseȱ vulnerabilityȱ amongȱinjectors.ȱPublicȱinjectingȱisȱassociatedȱwithȱrushingȱtheȱinjectionȱprocess,ȱwhichȱ ȱ 6 canȱincreaseȱriskȱforȱaȱrangeȱofȱnegativeȱoutcomesȱincludingȱdrugȱoverdose,ȱsoftȬtissueȱ damage,ȱandȱacquisitionȱofȱbloodȬborneȱdiseases.58,ȱ 61Ȭ65ȱ ȱAlthoughȱ theȱnegativeȱhealthȱ impactsȱ ofȱ engagingȱ inȱ streetȬbasedȱ sexȱworkȱ andȱpublicȱ injectionȱdrugȱuseȱ areȱwellȱ described,ȱ theȱhealthȱ implicationsȱofȱengagingȱ inȱotherȱdisorderlyȱactivitiesȱareȱnotȱasȱ widelyȱunderstood.ȱThereȱisȱsomeȱevidenceȱtoȱsuggestȱthatȱindividualsȱwhoȱengageȱinȱ panhandlingȱ andȱ relatedȱ incomeȱ generationȱ activitiesȱ canȱ beȱ theȱ recipientȱ ofȱ verbalȱ hostilityȱandȱphysicalȱviolence;2,ȱ 44,ȱ 66ȱhowever,ȱ theȱhealthȱ impactsȱofȱactivitiesȱ suchȱasȱ loiteringȱandȱsocializingȱremainȱlargelyȱunderstudied.ȱȱȱ Despiteȱ theȱattentionȱdrugȬrelatedȱ streetȱdisorderȱ isȱ receivingȱ fromȱ theȱgeneralȱ publicȱandȱpolicyȬmakers,ȱresponsesȱtoȱdateȱhaveȱbeenȱlargelyȱineffectiveȱinȱaddressingȱ theseȱbehavioursȱandȱresultingȱharms.ȱ Indeed,ȱ lawȱenforcementȱbasedȱresponsesȱhaveȱ beenȱshownȱtoȱoftenȱexacerbateȱtheȱharmsȱassociatedȱwithȱstreetȱdisorderȱinȱadditionȱtoȱ beingȱ unableȱ toȱ effectivelyȱ respondȱ toȱ theȱ activity.62,ȱ 67Ȭ69ȱ Therefore,ȱ alternativeȱ approachesȱ thatȱ haveȱ potentialȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorderȱ areȱ urgentlyȱ required.ȱȱ 1.3 StudyȱObjectivesȱ GivenȱtheȱproblemsȱassociatedȱwithȱdrugȬrelatedȱstreetȱdisorderȱandȱtheȱlackȱofȱ effectiveȱpolicyȱresponsesȱ toȱdate,ȱ theȱcentralȱaimsȱofȱ thisȱ thesisȱareȱ toȱ identifyȱ factorsȱ contributingȱto,ȱexploreȱtheȱ impactsȱof,ȱandȱassessȱpotentialȱpolicyȱresponsesȱto,ȱdrugȬ relatedȱstreetȱdisorder.ȱAnalysesȱwillȱinvolveȱdescribingȱtheȱhealthȱandȱsocialȱimpactsȱofȱ ȱ 7 exposureȱ toȱdrugȬrelatedȱstreetȱdisorder,ȱasȱwellȱasȱexploringȱ theȱpotentialȱ impactsȱofȱ threeȱpolicyȱ interventionsȱ toȱ reduceȱdrugȬrelatedȱ streetȱdisorder.ȱTheseȱ interventionsȱ wereȱselectedȱbasedȱonȱaȱreviewȱofȱcurrentȱliteratureȱ(seeȱChapterȱ2),ȱandȱfeasibilityȱforȱ evaluation.ȱ Itȱ isȱ hopedȱ thatȱ theȱ findingsȱ ofȱ thisȱworkȱwillȱ beȱ usedȱ toȱ informȱmoreȱ effectiveȱpolicyȱinterventionsȱinȱthisȱarea.ȱȱ SpecificȱObjectivesȱandȱResearchȱHypothesis:ȱ 1. Toȱ assessȱwhetherȱ exposureȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ inȱ theȱ formȱ ofȱ Vancouver’’sȱstreetȬbasedȱdrugȱscene,ȱposesȱpublicȱhealthȱrisks.ȱȱ Chapterȱ 3ȱ setsȱoutȱ toȱdescribeȱ factorsȱ associatedȱwithȱ exposureȱ toȱ streetȬbasedȱ drugsȱ scenesȱandȱdetermineȱ ifȱ thereȱ isȱ aȱdoseȱdependentȱ relationshipȱbetweenȱ exposureȱ andȱ markersȱ ofȱ vulnerabilityȱ andȱ higherȱ intensityȱ addiction.ȱ Itȱ isȱ hypothesizedȱ thatȱbeingȱexposedȱ toȱ theȱdrugȱ sceneȱ inȱVancouver’’sȱDowntownȱ Eastsideȱ willȱ beȱ associatedȱ withȱ markersȱ ofȱ vulnerabilityȱ andȱ thatȱ thisȱ relationshipȱwillȱ beȱ inȱ aȱ doseȱ dependentȱ fashion.ȱ Itȱ isȱ alsoȱ hypothesizedȱ thatȱ beingȱ exposedȱ toȱ theȱ drugȱ sceneȱ inȱ Vancouver’’sȱDowntownȱ Eastsideȱwillȱ beȱ associatedȱwithȱhigherȱintensityȱaddictionȱandȱthatȱthisȱrelationshipȱwillȱbeȱinȱaȱ doseȱdependentȱfashion.ȱ ȱ 8 2. Toȱassessȱwhetherȱwillingnessȱmeasuresȱmayȱbeȱeffectiveȱ toolsȱ forȱplanningȱ theȱdeliveryȱofȱpublicȱhealthȱprogramsȱforȱinjectionȱdrugȱuserȱpopulations.ȱȱ SinceȱChaptersȱ5Ȭ7ȱrelyȱonȱmeasuringȱstudyȱparticipants’’ȱwillingnessȱ toȱengageȱ withȱ variousȱ publicȱ healthȱ programsȱ andȱ services,ȱ itȱ isȱ criticalȱ toȱ determineȱ whetherȱtheseȱmeasuresȱhaveȱanyȱpredictiveȱvalidity.ȱToȱdetermineȱifȱwillingnessȱ measuresȱ areȱ reasonablyȱ validȱ tools,ȱ Chapterȱ 4ȱ comparesȱ priorȱmeasuresȱ forȱ willingnessȱ toȱ useȱ aȱ supervisedȱ injectionȱ facilityȱwithȱ laterȱ attendanceȱ atȱ theȱ facilityȱonceȱ itȱwasȱ established.ȱ Itȱ isȱhypothesizedȱ thatȱ reportedȱwillingnessȱ toȱ useȱaȱsupervisedȱinjectingȱfacility,ȱcollectedȱpriorȱtoȱtheȱopeningȱofȱVancouverȇsȱ supervisedȱ injectingȱ facility,ȱwillȱbeȱ significantlyȱandȱ independentlyȱassociatedȱ withȱusingȱtheȱprogramȱafterȱitȱwasȱestablished.ȱ 3. Toȱexamineȱ theȱ relationshipȱbetweenȱaccessȱ toȱprivateȱ spaceȱ andȱ timeȱ spentȱ socializingȱinȱanȱopenȱdrugȱscene.ȱȱ Toȱ investigateȱaȱpotentialȱpolicyȱ interventionȱ toȱaddressȱaȱ componentȱofȱdrugȬ relatedȱ streetȱ disorder,ȱ Chapterȱ 5ȱ usesȱ logisticȱ regressionȱ toȱ exploreȱ theȱ relationshipȱbetweenȱ timeȱspentȱonȱ theȱstreetȱsocializingȱandȱhousingȱstructureȱ (notȱhavingȱaȱprivateȱindoorȱplaceȱtoȱsocialize).ȱLogisticȱregressionȱisȱalsoȱusedȱtoȱ profileȱparticipantsȱthatȱreportȱaȱwillingnessȱtoȱrelocateȱtoȱprivateȱspacesȱifȱsuchȱ spacesȱwereȱmadeȱavailable.ȱItȱisȱhypothesizedȱthatȱspendingȱtimeȱsocializingȱinȱ theȱ openȱ drugȱ sceneȱwillȱ beȱ associatedȱwithȱ havingȱ limitedȱ accessȱ toȱ privateȱ ȱ 9 space.ȱ Itȱ isȱ alsoȱ hypothesizedȱ thatȱ ifȱ offeredȱ accessȱ toȱ privateȱ spaceȱ forȱ socializing,ȱ willingnessȱ toȱ relocateȱ toȱ privateȱ settingȱ willȱ beȱ associatedȱ withȱ markersȱofȱvulnerability.ȱ 4. Toȱassessȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱandȱexamineȱ theȱrelationshipȱbetweenȱprovidingȱ lowȬthresholdȱemploymentȱopportunitiesȱ andȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivities.ȱ Toȱ investigateȱanotherȱpotentialȱpolicyȱ interventionȱ toȱaddressȱaȱcomponentȱofȱ drugȬrelatedȱ streetȱ disorder,ȱ Chapterȱ 6ȱ assessesȱ engagementȱ inȱ disorderlyȱ incomeȱgenerationȱandȱtheȱpotentialȱimpactȱofȱofferingȱalternativeȱlowȬthresholdȱ employmentȱ opportunitiesȱ onȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activities.ȱ Itȱ isȱ hypothesizedȱ thatȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱwillȱ beȱ associatedȱwithȱmarkersȱ ofȱ vulnerabilityȱ andȱ highȱ intensityȱ addiction.ȱ Itȱ isȱ alsoȱ hypothesizedȱ thatȱ ifȱ offeredȱ lowȬthresholdȱ employmentȱ opportunities,ȱwillingnessȱ toȱgiveȱupȱdisorderlyȱ incomeȱgenerationȱbehavioursȱ willȱbeȱassociatedȱwithȱmarkersȱofȱvulnerability.ȱ 5. Toȱcharacterizeȱpublicȱcrackȱcocaineȱsmokingȱandȱassessȱwhetherȱaȱsupervisedȱ inhalationȱ facilityȱ hasȱ potentialȱ toȱ addressȱ streetȱ disorderȱ byȱ reducingȱ theȱ prevalenceȱofȱthisȱbehaviour.ȱȱ Lastly,ȱ toȱ investigateȱ theȱpotentialȱ forȱ supervisedȱ inhalationȱ facilitiesȱ toȱ reduceȱ publicȱcrackȱcocaineȱsmoking,ȱChapterȱ7ȱprofilesȱpublicȱcrackȱcocaineȱusersȱandȱ ȱ 10 assessȱwillingnessȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ amongȱ publicȱ crackȱ cocaineȱ smokers.ȱ Itȱ isȱ hypothesizedȱ thatȱpublicȱ crackȱ cocaineȱ smokingȱwillȱ beȱ commonȱ amongȱ localȱ crackȱ cocaineȱ usersȱ andȱ thisȱ practiceȱwillȱ beȱ associatedȱ withȱ markersȱ ofȱ vulnerabilityȱ andȱ higherȱ intensityȱ addiction.ȱ ȱ Itȱ isȱ alsoȱ hypothesizedȱthatȱtheȱmajorityȱofȱpublicȱcrackȱcocaineȱsmokersȱwillȱbeȱwillingȱtoȱ useȱaȱsupervisedȱinhalationȱfacility.ȱ 1.4 StudyȱDesignȱ TheȱproposedȱresearchȱwasȱundertakenȱusingȱdataȱfromȱtheȱVancouverȱInjectionȱ DrugȱUsersȱStudyȱ (VIDUS)ȱwhichȱ isȱaȱ longstandingȱprospectiveȱcommunityȱrecruitedȱ cohortȱthatȱbeganȱenrollingȱparticipantsȱinȱMayȱ1996.ȱToȱbeȱeligibleȱparticipantsȱhadȱtoȱ haveȱ injectedȱdrugsȱ inȱ theȱpreviousȱmonth,ȱ liveȱ inȱ theȱgreaterȱVancouverȱ region,ȱandȱ provideȱwrittenȱ informedȱ consent.ȱVIDUSȱ participantsȱ areȱ invitedȱ toȱ visitȱ theȱ studyȱ officeȱ locatedȱ inȱ theȱ Downtownȱ Eastsideȱ ofȱ Vancouverȱ onȱ aȱ biȬannualȱ basisȱ andȱ completeȱ anȱ extensiveȱ interviewerȬadministeredȱ questionnaire.ȱ Theȱ surveyȱ elicitsȱ informationȱpertainingȱ toȱ socioȬdemographicȱ characteristicsȱ includingȱhousingȱ status,ȱ incomeȱ generationȱ behaviours,ȱ sexualȱ behaviour,ȱ andȱ behaviouralȱ characteristicsȱ relatedȱ toȱ drugȱ useȱ andȱ injectionȱ practices.ȱ Respondentsȱ areȱ alsoȱ questionedȱ aboutȱ healthȱcareȱutilizationȱandȱuseȱofȱHIVȱpreventionȱandȱtreatmentȱservicesȱasȱwellȱasȱanyȱ significantȱcontactȱwithȱtheȱpoliceȱandȱtheȱcriminalȱjusticeȱsystem.ȱAlthoughȱmostȱofȱtheȱ measuresȱ onȱ theȱ questionnaireȱ remainȱ consistentȱ overȱ time,ȱ atȱ eachȱ sixȬmonthȱ studyȱ ȱ 11 followȬupȱ thereȱ isȱ anȱ opportunityȱ toȱ amendȱ theȱ VIDUSȱ questionnaireȱ toȱ addȱ newȱ questionsȱofȱinterest.ȱAtȱeachȱstudyȱvisitȱbloodȱsamplesȱareȱalsoȱprovidedȱforȱdiagnosticȱ testing.ȱVIDUSȱparticipantsȱreceiveȱaȱstipendȱinȱtheȱamountȱofȱ$20ȱCDNȱforȱtheirȱtimeȱatȱ theȱ conclusionȱ ofȱ eachȱ studyȱ visit.ȱ Theȱ studyȱ hasȱ receivedȱ ethicalȱ approvalȱ fromȱ ProvidenceȱHealthȱandȱtheȱUniversityȱofȱBritishȱColumbia’’sȱResearchȱEthicsȱBoardȱ(seeȱ AppendixȱI).ȱ Dataȱ forȱ theȱ analysesȱ inȱ Chaptersȱ 3ȱ andȱ 4ȱ wereȱ availableȱ fromȱ theȱ VIDUSȱ questionnairesȱadministeredȱbetweenȱDecemberȱ2005ȱandȱMarchȱ2009,ȱandȱDecemberȱ 2001ȱ toȱNovemberȱ2005ȱ respectively.ȱBeginningȱ inȱ Juneȱ2008ȱmeasuresȱ forȱ socializingȱ andȱaccessȱtoȱprivateȱspaceȱwereȱaddedȱtoȱtheȱVIDUSȱquestionnaireȱandȱprovidedȱdataȱ forȱ theȱanalysesȱ inȱChapterȱ5.ȱ InȱNovemberȱ2008ȱmeasuresȱ forȱwillingnessȱ toȱ takeȱupȱ lowȬthresholdȱemploymentȱandȱ toȱuseȱaȱ supervisedȱ inhalationȱ facilityȱwereȱaddedȱ toȱ theȱVIDUSȱquestionnaireȱandȱprovidedȱdataȱforȱtheȱanalysesȱinȱChaptersȱ6ȱandȱ7.ȱ 1.5 ConceptualȱFrameworkȱ Atȱtheȱbroadestȱ level,ȱthisȱresearchȱ isȱ informedȱbyȱaȱtheoreticalȱapproachȱcalledȱ theȱ ‘‘riskȱ environmentȱ framework’’.70ȱ ȱAlthoughȱprimarilyȱdevelopedȱ inȱ theȱ contextȱofȱ riskȱbehaviourȱrelatedȱ toȱHIVȱ infectionȱandȱoverdoseȱamongȱ injectionȱdrugȱusers,ȱ theȱ riskȱenvironmentȱframeworkȱandȱtheȱrelatedȱconceptȱofȱ‘‘situatedȱrationality’’ȱprovideȱaȱ usefulȱ theoreticalȱ basisȱ toȱ approachȱ theȱ problemȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ [seeȱ Figureȱ1.3].71,ȱ72ȱȱ ȱ 12 Inȱ reactionȱ toȱ anȱ observedȱ overrelianceȱ onȱ individuallyȱ orientedȱ modelsȱ ofȱ behaviourȱchangeȱthatȱappearedȱtoȱhaveȱlimitedȱsuccessȱinȱtheȱareaȱofȱHIVȱpreventionȱ andȱhealthȱpromotion,ȱgrowingȱnumbersȱofȱpublicȱhealthȱscholarsȱbeganȱemphasizingȱ theȱimportanceȱofȱconsideringȱtheȱroleȱthatȱsocial,ȱstructuralȱandȱenvironmentalȱfactorsȱ playedȱ inȱ shapingȱ healthȱ relatedȱ behavioursȱ amongȱ peopleȱ whoȱ useȱ drugs.73Ȭ79ȱ ȱ Inȱ particular,ȱRhodesȱproposedȱ thatȱ social,ȱ structuralȱandȱenvironmentalȱ factorsȱcreateȱaȱ ‘‘riskȱenvironment’’ȱthatȱmediatesȱbehaviour.70,ȱ80ȱExamplesȱofȱsocialȱfactorsȱincludeȱlocalȱ drugȱ useȱ practicesȱ andȱ peerȱ groupȱ norms.79ȱ Structuralȱ factorsȱ includeȱ economicȱ conditionsȱ (e.g.,ȱ employmentȱ opportunities),ȱ lawsȱ (e.g.,ȱ prohibitionȱ ofȱ drugs),ȱ socialȱ policiesȱ (e.g.,ȱ accessȱ toȱ lowȬthresholdȱ housing)ȱ andȱ localȱ policingȱ practices,ȱ whileȱ environmentalȱfactorsȱincludeȱfeaturesȱofȱtheȱbuiltȱenvironmentȱsuchȱasȱpublicȱinjectingȱ environments,ȱandȱneighbourhoodȬlevelȱconditionsȱsuchȱasȱdensityȱandȱdeprivation.70,ȱ80ȱȱ Rhodesȱarguesȱthatȱfocusingȱonȱtheȱinterplayȱofȱtheseȱfactorsȱandȱtheȱ‘‘riskȱenvironment’’ȱ thatȱ theyȱ formȱ isȱ aȱ betterȱ wayȱ toȱ conceptualizeȱ andȱ respondȱ toȱ theȱ healthȱ harmsȱ associatedȱwithȱdrugȱuse.79ȱȱ Unlikeȱconventionalȱapproachesȱinȱpublicȱhealthȱdominatedȱbyȱtheȱ‘‘healthȱbeliefȱ model’’,ȱtheȱ‘‘theoryȱofȱplannedȱbehaviour’’ȱandȱitsȱpredecessorȱ‘‘reasonedȱactionȱtheory’’,ȱ whichȱ locatedȱ responsibilityȱ forȱhealthȱ inȱ individualȱactors,81,ȱ 82ȱ ȱ theȱ riskȱenvironmentȱ approachȱgivesȱequalȱattentionȱtoȱcontextualȱfactorsȱthatȱshapeȱtheȱlivedȱexperiencesȱofȱ peopleȱwhoȱ useȱ drugs.70ȱ Fromȱ thisȱ perspective,ȱ responsibilityȱ forȱ riskȱ reductionȱ andȱ ȱ 13 healthȱpromotionȱ restsȱnotȱ justȱwithȱ individuals,ȱbutȱalsoȱwithȱ theȱ laws,ȱpolicies,ȱandȱ socialȱrelationsȱthatȱsurroundȱindividuals.ȱInȱturn,ȱtargetsȱforȱpolicyȱinterventionȱextendȱ intoȱ realmsȱ beyondȱ theȱ individualȱ toȱ includeȱ social,ȱ structuralȱ andȱ environmentalȱ factors.83,ȱ84ȱȱInȱtheȱcurrentȱproject,ȱdrugȬrelatedȱstreetȱdisorderȱisȱviewedȱthroughȱaȱriskȱ environmentȱ lensȱwhichȱsuggestsȱ thatȱatȱ itsȱcoreȱ theȱproblemȱofȱstreetȱdisorderȱ isȱnotȱ solelyȱ aȱmatterȱ ofȱ individualsȱ choosingȱ toȱ engageȱ inȱ undesirableȱ behaviour;ȱ rather,ȱ streetȱdisorderȱisȱshapedȱbyȱenvironmental,ȱsocialȱandȱstructuralȱconditions.ȱȱ Anotherȱimportantȱconceptȱinformingȱthisȱworkȱisȱaȱmodifiedȱversionȱofȱ‘‘rationalȱ choiceȱtheory’’ȱpreviouslyȱdescribedȱbyȱRhodesȱandȱcolleaguesȱasȱ‘‘situatedȱrationality’’.72,ȱ 85ȱȱRationalȱchoiceȱtheoryȱpresumesȱthatȱindividualsȱareȱprimarilyȱselfȬinterestedȱutilityȱ maximizersȱ thatȱmakeȱdecisionsȱandȱ actȱbasedȱonȱassessmentsȱofȱ theȱperceivedȱ costsȱ andȱbenefitsȱofȱavailableȱoptions.86,ȱ87ȱ ȱAlthoughȱtheȱproposedȱresearchȱprojectȱisȱbasedȱ inȱpartȱonȱ theseȱ assumptions,ȱ itȱ alsoȱ acknowledgesȱ thatȱ allȱdecisionsȱ andȱ actionsȱ areȱ influencedȱbyȱ social,ȱ structural,ȱ andȱ environmentalȱ conditions,ȱ andȱ thatȱ theseȱ factorsȱ areȱparticularlyȱrelevantȱinȱshapingȱtheȱperceptionsȱandȱexperiencesȱofȱpeopleȱwhoȱuseȱ illegalȱdrugs.ȱAsȱarticulatedȱbyȱRhodes,ȱ thisȱresultsȱ inȱaȱ ‘‘situatedȱrationality’’ȱwherebyȱ theȱbasisȱofȱdecisionȱmakingȱremainsȱutilityȱmaximizing,ȱbutȱisȱsituationȱspecificȱwithinȱ theȱ contextȱ andȱ confinesȱ ofȱ social,ȱ structural,ȱ andȱ environmentalȱ pressures.ȱ Inȱ turn,ȱ individuals’’ȱperceptionsȱandȱassessmentsȱofȱtheȱcostsȱandȱbenefitsȱofȱavailableȱoptionsȱ areȱnotȱuniversalȱandȱareȱlikelyȱtoȱchangeȱoverȱtime.88ȱȱȱ ȱ 14 Guidedȱ byȱ theȱ conceptȱ ofȱ ‘‘situatedȱ rationality’’,ȱ thisȱ researchȱ proposesȱ thatȱ despiteȱ theȱ individualȱ andȱ communityȱ harmsȱ associatedȱwithȱ it,ȱ engagingȱ inȱ drugȬ relatedȱstreetȱdisorderȱservesȱvariousȱ‘‘rational’’ȱpurposesȱinȱtheȱlivesȱofȱpeopleȱwhoȱuseȱ drugsȱwhenȱsocial,ȱstructuralȱandȱenvironmentalȱ factorsȱareȱ takenȱ intoȱaccount.ȱFromȱ thisȱperspective,ȱ theȱ typesȱ ofȱ interventionsȱ thatȱ areȱ likelyȱ toȱ beȱ successfulȱ inȱ gettingȱ individualsȱ toȱ reduceȱ engagementȱ inȱ streetȱ disorderȱ areȱ onesȱ thatȱ engageȱ streetȬ involvedȱdrugȱusersȱ andȱprovideȱ alternativesȱ thatȱ fitȱwithȱdrugȱusers’’ȱprioritiesȱ andȱ enableȱ themȱ toȱ reduceȱbehavioursȱ thatȱgenerateȱ streetȱdisorder.ȱToȱbeȱeffective,ȱ theseȱ interventionsȱmustȱalsoȱsuccessfullyȱinfluenceȱdrugȱusers’’ȱperceptionsȱandȱassessmentsȱ ofȱ theȱ costsȱ andȱ benefitsȱ ofȱ availableȱ optionsȱ inȱ favourȱ ofȱ alternativesȱ thatȱ areȱ lessȱ harmfulȱtoȱtheȱindividualȱandȱtheȱbroaderȱcommunity.ȱThisȱframeworkȱisȱtheȱbasisȱforȱ theȱanalysesȱthatȱaddressȱobjectivesȱthree,ȱfourȱandȱfiveȱandȱFigureȱ1.3ȱoutlinesȱtheȱthreeȱ respectiveȱareasȱofȱintervention.ȱ 1.6 Summaryȱ ThisȱthesisȱconsistsȱofȱeightȱChapters.ȱChapterȱ1ȱprovidesȱaȱbackgroundȱtoȱdrugȬ relatedȱ streetȱ disorderȱ andȱ problemsȱ associatedȱ withȱ it.ȱ Itȱ alsoȱ presentsȱ theȱ studyȱ objectives,ȱ studyȱ design,ȱ andȱ theȱ conceptualȱ frameworkȱ ofȱ theȱ thesis.ȱ Chapterȱ 2ȱ providesȱ aȱ reviewȱ ofȱ theȱ scientificȱ literatureȱ onȱ drugȬrelatedȱ streetȱ disorder.ȱ Thisȱ includesȱaȱ summaryȱofȱmeasuresȱusedȱ toȱoperationalizeȱstreetȱdisorder,ȱasȱwellȱasȱanȱ overviewȱofȱtheȱimpactsȱofȱpreviousȱpolicyȱapproachesȱthatȱhaveȱbeenȱimplementedȱtoȱ ȱ 15 addressȱthisȱissue.ȱChapterȱ3ȱisȱtheȱfirstȱdataȱdrivenȱanalysisȱandȱitȱdescribesȱtheȱhealthȱ andȱsocialȱimpactsȱofȱexposureȱtoȱdrugȬrelatedȱstreetȱdisorder.ȱChaptersȱ5Ȭ7ȱexploreȱtheȱ potentialȱ impactsȱofȱ threeȱpolicyȱ interventionsȱ toȱ reduceȱdrugȬrelatedȱ streetȱdisorder.ȱ Potentialȱ interventionsȱthatȱwillȱbeȱexploredȱrelateȱtoȱhousingȱstructuresȱ(theȱpotentialȱ impactȱofȱprovidingȱprivateȱ spaceȱonȱ timeȱ spentȱ socializingȱ inȱ anȱopenȱdrugȱ sceneȱ–– Chapterȱ 5),ȱ economicȱ opportunitiesȱ (theȱpotentialȱ impactȱ ofȱprovidingȱ lowȬthresholdȱ employmentȱonȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱ––Chapterȱ6)ȱandȱ drugȱ consumptionȱ facilitiesȱ (theȱ potentialȱ impactȱ ofȱ providingȱ supervisedȱ inhalationȱ roomsȱonȱpublicȱcrackȱcocaineȱsmokingȱ––Chapterȱ7).ȱToȱassessȱ theȱpotentialȱ impactȱofȱ theseȱthreeȱinterventions,ȱtheseȱanalysesȱrelyȱonȱmeasuresȱofȱparticipants’’ȱ‘‘willingness’’ȱ toȱ changeȱ theirȱ behaviourȱ basedȱ onȱ opportunitiesȱ relatedȱ toȱ accessȱ toȱ privateȱ space,ȱ employment,ȱ andȱ drugȱ consumptionȱ environments.ȱ Therefore,ȱ anȱ additionalȱ analyisȱ wasȱundertakenȱtoȱdetermineȱwhetherȱwillingnessȱmeasuresȱwereȱreasonableȱpredictorsȱ ofȱactualȱbehaviourȱ(Chapterȱ4).ȱȱȱ ȱFigureȱ1.1ȱTypesȱofȱdrugȬrelatedȱstreetȱdisorderȱ Drug-Related Street Disorder Public Drug Use •• i.e. using drugs in public areas Public Intoxication & Loitering •• i.e., socializing on the street while intoxicated Income Generating Activities •• Drug Dealing •• Sex Work •• Panhandling •• Squeegeeing •• Binning, Recycling, Street Vending ȱ Figureȱ1.2ȱProblemsȱassociatedȱwithȱdrugȬrelatedȱstreetȱdisorderȱ Economic x Discourages retail activity & development x Erodes economic vitality x Undermines urban renewal efforts Public Safety x Violence associated with drug markets x Aggressive behaviour when under the influence of illicit drugs x Discarded drug paraphernalia x Disorder may encourage additional crime (broken windows theory) Public Health x Disorder linked with poor health outcomes at neighbourhood level x Engagement in disorderly activities often poses risks to individuals (e.g. increased risk of overdose, infectious disease, soft tissue damage, violence…… etc.) ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 16 ȱȱȱFigureȱ1.3ȱSchematicȱofȱtheoreticalȱframeworkȱ ȱ ȱ ȱ ȱ ȱ ȱ Engage to Enable Change •• Focus on changing the social, structural and environmental conditions that foster disorder •• Objective: enable positive change in behaviours by decreasing barriers and providing alternatives perceived as having greater benefit Policing •• Crackdowns •• Legislation against disorder •• Incarceration Spatial Design •• Barriers and restrictions to accessing public space Housing •• Increase access to private space Low-threshold Employment •• Viable income generation opportunities Inhalation Rooms •• Alternative drug consumption environments Documented Outcomes Expected Outcomes •• Displacement of disorder to surrounding areas •• Ineffective in reducing overall prevalence of disorder •• Discriminatory policing practices •• Exacerbates marginalization Individual Behaviour (e.g. personal choice, deviance, laziness) Coercion •• Deterrence based •• Objective: make disorder more costly and less attractive Expected Outcomes Expected Outcomes Root of Problem Ļ Public Intoxication Ļ Loitering Ļ Outdoor Socializing Ļ Drug dealing Ļ Sex-work Ļ Panhandling Ļ Squeegeeing Ļ Recycling, Binning, Vending Ļ Public drug use Tools to Address the Problem Framework for Risk Environment and Situated Rationality Approach to Street Disorder Framework for Conventional Responses to Street Disorder Approaches to Address Problem Problem: Drug-Related Street Disorder •• Reduce overall prevalence of disorder •• Protect the health of individuals and communities Individual Behaviour & Social, Structural, & Environmental Conditions (e.g. poor access to housing; lack of employment opportunities; marginalization of drug users) ȱ 17 ȱ 18 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ CHAPTER 2: ȱ DRUGȬRELATEDȱSTREETȱDISORDER:ȱAȱREVIEWȱOFȱ MEASURESȱANDȱPOLICYȱRESPONSES1ȱ 2.1 Introductionȱ CitizensȱinȱurbanȱcentresȱthroughoutȱtheȱworldȱconsistentlyȱidentifyȱdrugȬrelatedȱ streetȱdisorderȱ asȱ aȱprimaryȱ concernȱ inȱ theirȱ community,25,ȱ 42,ȱ 89,ȱ 90ȱ ȱ andȱ inȱ someȱ areasȱ streetȱ disorderȱ isȱ rankedȱ asȱ aȱ greaterȱ concernȱ thanȱ homicide,ȱ sexualȱ assault,ȱ andȱ robbery.40,ȱ 50,ȱ 91ȱ ȱ Inȱ turn,ȱ governmentsȱ inȱmanyȱ urbanȱ environmentsȱ areȱ increasinglyȱ directingȱ theirȱattentionȱ toȱstreetȱdisorderȱandȱareȱ introducingȱ targetedȱpublicȱpoliciesȱ inȱattemptsȱtoȱeliminateȱorȱcontrolȱpublicȱdisorder,ȱparticularlyȱdisorderȱassociatedȱwithȱ illegalȱdrugȱmarketsȱandȱtheȱuseȱofȱillegalȱdrugs.ȱ MarkersȱofȱdrugȬrelatedȱstreetȱdisorderȱincludeȱpublicȱdrugȱuse,ȱstreetȬlevelȱdrugȱ trafficking,ȱdrugȬrelatedȱ litter,ȱpublicȱ intoxicationȱandȱ loitering,ȱstreetȬbasedȱsexȱwork,ȱ panhandling,ȱ squeegeeȱ cleaning,ȱ andȱ engagingȱ inȱ ‘‘binning’’,ȱ recycling,ȱ salvagingȱ andȱ unsanctionedȱstreetȱvendingȱ(collectingȱbottlesȱandȱotherȱgoodsȱfromȱallies,ȱdumpstersȱ andȱotherȱpublicȱareasȱthatȱareȱreturnedȱforȱrefundȱorȱsoldȱonȱtheȱstreetȱforȱprofit).2Ȭ6,ȱ8Ȭ10,ȱ 25,ȱ 40,ȱ 53,ȱ 89Ȭ92ȱAlthoughȱstreetȱdisorderȱ isȱnotȱaȱnewȱphenomenon,ȱpolicyȬmakersȱ inȱmanyȱ urbanȱareasȱhaveȱbeenȱunableȱtoȱsuccessfullyȱmanageȱtheseȱbehavioursȱandȱcontinueȱtoȱ ȱ 1ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.ȱMcArthur,ȱ D.ȱDrugȬrelatedȱstreetȱdisorder:ȱAȱreviewȱofȱpolicyȱresponses.ȱȱ ȱ 19 struggleȱ toȱdetermineȱhowȱ toȱbestȱ respondȱ toȱ thisȱpersistentȱpolicyȱ issue.ȱToȱprovideȱ evidenceȬbasedȱdirectionȱforȱpolicyȬmakers,ȱaȱreviewȱofȱliteratureȱonȱdrugȬrelatedȱstreetȱ disorderȱwasȱconducted.ȱStreetȱdisorderȱisȱaȱbroadȱtopicȱencompassingȱmanyȱactivitiesȱ andȱareasȱofȱresearch.ȱToȱmanageȱ theȱbreadthȱofȱavailableȱ literature,ȱ theȱscopeȱofȱ thisȱ reviewȱconcentratesȱonȱmethodsȱofȱmeasuringȱstreetȱdisorderȱandȱtheȱimpactsȱofȱcurrentȱ interventionsȱintroducedȱtoȱaddressȱstreetȱdisorder.ȱTheȱobjectivesȱofȱthisȱreviewȱareȱto:ȱ 1)ȱ identifyȱ andȱ summarizeȱ methodsȱ thatȱ haveȱ beenȱ previouslyȱ employedȱ toȱ operationalizeȱandȱmeasureȱdrugȬrelatedȱstreetȱdisorder,ȱandȱ2)ȱprovideȱanȱoverviewȱofȱ evidenceȱdocumentingȱ theȱ impactsȱofȱstrategiesȱ thatȱhaveȱbeenȱ implementedȱ inȱurbanȱ settingsȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorder.ȱȱȱȱ 2.2 ReviewȱMethodsȱ Publishedȱ studiesȱ forȱ thisȱ reviewȱwereȱ identifiedȱbyȱ conductingȱ computerizedȱ searchesȱ ofȱ Medline,ȱ PubMed,ȱ Scienceȱ Citationȱ Indexȱ Expanded,ȱ Socialȱ Sciencesȱ Citationȱ Index,ȱandȱPAISȱ (PublicȱAffairsȱ InformationȱServices).ȱSearchȱ termsȱ includedȱ ““publicȱ disorder””,ȱ ““publicȱ drugȱ use””,ȱ ““streetȬlevelȱ drugȱ dealing””,ȱ ““panhandling””,ȱ ““publicȱintoxication””,ȱ““streetȬlevelȱsexȬwork””ȱ““brokenȱwindows””,ȱ““orderȬmaintenance””,ȱ ““qualityȬofȬlifeȱ policing””,ȱ andȱ ““crimeȱ preventionȱ throughȱ environmentalȱ design””.ȱ Additionalȱmaterialsȱwereȱlocatedȱbyȱreviewingȱbibliographiesȱofȱrelevantȱpublications.ȱ Whileȱ theȱ reviewȱ focusedȱ onȱ peerȬreviewedȱ literature,ȱ someȱ considerationȱwasȱ alsoȱ ȱ 20 givenȱ toȱpertinentȱgovernmentȱ andȱpublicȱ agencyȱ reports.ȱTheȱ searchȱwasȱ limitedȱ toȱ Englishȱlanguageȱpublicationsȱandȱthereȱwereȱnoȱtimeȱperiodȱrestrictionsȱonȱmaterials.ȱȱ 2.3 ReviewȱFindings:ȱMeasuringȱDrugȬRelatedȱStreetȱDisorderȱ Studiesȱ ofȱ streetȱ disorderȱ haveȱ utilizedȱ aȱ numberȱ ofȱ approachesȱ toȱmeasureȱ physicalȱandȱsocialȱmarkersȱofȱpublicȱdisorder.ȱSelectedȱ fromȱ theȱbroaderȱ literatureȱofȱ publicȱdisorder,ȱthisȱsectionȱoutlinesȱmeasurementȱapproachesȱappropriateȱtoȱtheȱstudyȱ ofȱdrugȬrelatedȱstreetȱdisorder.ȱOneȱcommonȱapproachȱtoȱmeasureȱpublicȱdisorderȱisȱtoȱ useȱperceptionsȱofȱstreetȱdisorderȱreportedȱbyȱindividualsȱwhoȱresideȱinȱorȱareȱinȱsomeȱ wayȱ exposedȱ toȱ aȱ geographicallyȱ definedȱ areaȱ ofȱ interest.ȱ Surveys,ȱ qualitativeȱ interviewsȱandȱ focusȱgroupsȱwithȱresidents,ȱ localȱmerchants,ȱ localȱpoliceȱandȱrelevantȱ cityȱworkersȱhaveȱallȱbeenȱusedȱinȱstudiesȱofȱpublicȱdisorderȱtoȱelicitȱperceptionsȱofȱtheȱ frequencyȱandȱprevalenceȱofȱstreetȱdisorder.2,ȱ53,ȱ68,ȱ92ȱOneȱbenefitȱofȱthisȱapproachȱisȱthatȱ dataȱ onȱ aȱ wideȱ rangeȱ ofȱ activitiesȱ relevantȱ toȱ drugȬrelatedȱ streetȱ disorderȱ canȱ beȱ collected;ȱ asȱ well,ȱ recruitingȱ aȱ sampleȱ ofȱ civiliansȱ isȱ highlyȱ feasibleȱ forȱ mostȱ investigators.ȱHowever,ȱevidenceȱsuggestsȱthatȱperceivedȱmeasuresȱofȱdisorderȱmayȱbeȱ influencedȱ byȱ fearȱ ofȱ crimeȱ andȱ previousȱ victimizationȱ experiencesȱwhichȱwillȱ biasȱ someȱmeasuresȱofȱperceptionsȱofȱdisorder.1,ȱ93ȱȱ OtherȱstudiesȱhaveȱdirectlyȱsurveyedȱandȱinterviewedȱlocalȱdrugȱusersȱorȱstreetȬ involvedȱpersonsȱasȱaȱmeansȱofȱcollectingȱselfȬreportedȱ levelsȱofȱengagementȱ inȱdrugȬ relatedȱstreetȱdisorder.6,ȱ7,ȱ10,ȱ56ȱThisȱapproachȱisȱbeneficialȱasȱitȱcanȱcaptureȱaȱwideȱrangeȱ ȱ 21 ofȱ activitiesȱ relevantȱ toȱ drugȬrelatedȱ streetȱ disorderȱ andȱ willȱ captureȱ activitiesȱ notȱ directlyȱobservedȱbyȱothers.ȱHowever,ȱrecallȱissuesȱandȱsociallyȱdesirableȱreportingȱmayȱ weakenȱ theȱ reliabilityȱofȱ selfȬreportedȱmeasuresȱofȱ engagementȱ inȱdrugȬrelatedȱ streetȱ disorder.94ȱAsȱwell,ȱ obtainingȱ aȱ representativeȱ sampleȱ ofȱ streetȬinvolvedȱ drugȱ usersȱ requiresȱconsiderableȱresourcesȱandȱmayȱnotȱbeȱfeasibleȱinȱsomeȱsettings.ȱȱȱ Officialȱ dataȱ capturingȱ theȱ numberȱ ofȱ policingȱ responsesȱ toȱ orȱ arrestsȱ forȱ disorderlyȱactivitiesȱ canȱalsoȱbeȱusedȱasȱanȱ indicatorȱofȱ streetȱdisorder.53ȱAȱbenefitȱofȱ usingȱ officialȱ dataȱ isȱ thatȱ itȱ isȱ alreadyȱ collectedȱ andȱ generallyȱ readilyȱ available.ȱ However,ȱthereȱareȱaȱnumberȱofȱ limitationsȱwithȱthisȱapproach.ȱForȱone,ȱmanyȱactsȱofȱ disorderȱ doȱ notȱ getȱ reportedȱ toȱ police.ȱ Inȱ addition,ȱ officialȱ statisticsȱ areȱ directlyȱ influencedȱbyȱ theȱ levelȱofȱpolicingȱactivity;ȱhence,ȱ theyȱmayȱ reflectȱpolicingȱeffortsȱorȱ focusȱmoreȱthanȱtheȱprevalenceȱorȱincidenceȱofȱdisorderlyȱactivities.ȱ49,ȱ95ȱFurthermore,ȱinȱ manyȱ jurisdictionsȱpoliceȱofficers’’ȱperformancesȱareȱgaugedȱbyȱarrestȱstatistics,ȱwhichȱ generatesȱaȱpotentialȱsourceȱofȱbias.96,ȱ97ȱȱ Streetȱdisorderȱhasȱalsoȱbeenȱmeasuredȱbyȱtheȱnumberȱofȱcivilianȱcomplaintȱcallsȱ madeȱtoȱemergencyȱservices,ȱtipȱlines,ȱandȱcityȱofficialsȱregardingȱdisorderlyȱactivities.2,ȱ 53,ȱ91ȱComparedȱtoȱofficialȱstatisticsȱthisȱapproachȱisȱoftenȱconsideredȱaȱbetterȱindicatorȱofȱ disorderȱasȱ itȱ isȱnotȱbiasȱbyȱtheȱ levelȱofȱpoliceȱactivity.91ȱHowever,ȱcomplainȱcallsȱonlyȱ captureȱ aȱ limitedȱ rangeȱ ofȱ disorderlyȱ activities,ȱ typicallyȱ onlyȱ veryȱ disruptiveȱ behaviours.ȱȱ ȱ 22 Anotherȱrecognizedȱbutȱ labourȱ intensiveȱapproachȱtoȱmeasuringȱstreetȱdisorderȱ isȱ throughȱ ‘‘Systematicȱ Socialȱ Observations’’ȱ (SSO).92,ȱ 98ȱ SSOȱ involvesȱ usingȱ multipleȱ independentȱmeansȱ toȱ systematicallyȱ recordȱ observations,ȱwhichȱ areȱ replicatedȱ overȱ time.1,ȱ 53ȱ Typically,ȱ SSOȱ involvesȱ drivingȱ throughȱ aȱ neighbourhoodȱwithȱ aȱ recordingȱ videoȱcameraȱasȱwellȱasȱtrainedȱobservers,ȱeachȱofȱwhomȱareȱrecordingȱtheȱnumberȱofȱ presentȱ indicatorsȱofȱ streetȱdisorderȱonȱeachȱ streetȱblock.ȱWhileȱ theȱ trainedȱobserversȱ areȱ recordingȱ observationsȱ inȱ realȱ time,ȱ theȱ videoȱ providesȱ aȱ permanentȱ recordȱ thatȱ allowsȱ codingȱ andȱ measuresȱ toȱ beȱ replicatedȱ byȱ independentȱ observers.ȱ Forȱ drugȬ relatedȱstreetȱdisorderȱpotentialȱrelevantȱindicatorsȱincludeȱtheȱpresenceȱandȱfrequencyȱ of:ȱ injectionȱ relatedȱdebris;ȱpeopleȱ injectingȱdrugsȱ inȱpublic;ȱpeopleȱsmokingȱdrugsȱ inȱ public;ȱ intoxicatedȱ individualsȱ loiteringȱ orȱ congregating;ȱ individualsȱ panhandlingȱ orȱ squeegeeȬcleaning;ȱ individualsȱwhoȱ appearȱ toȱ beȱ sellingȱ sex;ȱ andȱ individualsȱ goingȱ throughȱ streetȱgarbage,ȱ collectingȱbottles,ȱorȱvending.53ȱAnȱ importantȱ strengthȱofȱ thisȱ approachȱisȱthatȱtheȱvideoȱrecordingȱallowsȱforȱtheȱcodingȱofȱindicatorsȱofȱdisorderȱtoȱbeȱ replicatedȱwhichȱ canȱ detectȱ observerȱ biasȱ andȱ errorsȱ inȱ differentialȱ classificationȱ orȱ differentialȱ measurementȱ ofȱ objectsȱ andȱ events;ȱ thisȱ providesȱ greaterȱ reliabilityȱ ofȱ recordedȱobservations.92,ȱ98ȱFurthermore,ȱtheȱSSOȱapproachȱcapturesȱmoreȱindicatorsȱofȱ disorderȱ thanȱ officialȱ statisticsȱ orȱ civilianȱ complaintȱ calls.ȱ Inȱ addition,ȱ SSOȱ isȱ notȱ vulnerableȱtoȱbiasesȱofȱperceivedȱmeasuresȱofȱdisorderȱasȱitȱcapturesȱdirectlyȱobservedȱ eventsȱofȱdisorder.97ȱ ȱThereȱare,ȱhowever,ȱlimitationsȱtoȱtheȱSSOȱapproach.ȱSpecifically,ȱ ȱ 23 SSOȱ isȱ costlyȱ andȱ veryȱ labourȬintensive.99ȱ Inȱ addition,ȱ SSOȱ isȱ vulnerableȱ toȱ observerȱ effects.97,ȱ98ȱ Aȱ variationȱ onȱ SSOȱ isȱ basicȱ observationȱ ofȱ streetȱ disorderȱ inȱ whichȱ trainedȱ observersȱpassȱthroughȱanȱareaȱofȱinterestȱandȱcodeȱeventsȱandȱobservationsȱrelevantȱtoȱ streetȱdisorder.ȱTheȱdifference,ȱhowever,ȱisȱthatȱtheseȱobservationsȱareȱnotȱreplicatedȱorȱ verifiedȱbyȱvideoȱorȱanyȱotherȱpermanentȱ recordȱofȱ events.ȱDirectȱobservationȱ isȱ lessȱ costlyȱ thanȱ SSOȱ andȱ canȱ captureȱ aȱwideȱ rangeȱ ofȱ relevantȱ indicatorsȱ ofȱdrugȬrelatedȱ streetȱdisorder,ȱwhichȱisȱbeneficial.ȱHowever,ȱdirectȱobservation,ȱlikeȱSSO,ȱisȱvulnerableȱ toȱpotentialȱobserverȱeffects.ȱȱTheȱkeyȱcomponentsȱofȱeachȱmeasurementȱapproachȱandȱ studiesȱinȱwhichȱeachȱmethodȱhasȱbeenȱutilizedȱareȱsummarizedȱinȱTableȱ2.1.ȱȱȱȱ ȱȱ 24 Tableȱ2.1ȱSummaryȱofȱmeasuresȱappropriateȱforȱdrugȬrelatedȱstreetȱdisorderȱ Measurement Description Strengths Limitations Studies Perceived x Surveys, qualitative interviews, and focus groups with residents, local merchants, police, city workers and others exposed to neighbourhood or area of interest x Questions relate to prevalence and frequency of indicators of interest x Gathering data is highly feasible x Can capture wide range of activities relevant to drug- related street disorder x Perceptions of disorder can be influenced by fear and past experience of victimization, hence reports of disorder may be biased x Skogan 199040 x Zimmer 199068 x Perkins et al. 199293 x Perkins & Taylor 1996100 x Ross et al. 200055 x Sampson & Raudenbush 200453 x Salmon et al. 2007101 x Cusick & Kimber 200742 Self-Report x Surveys of active drug users (or street-involved persons) to assess engagement in drug- related street disorder x Can capture activities not directly observed by others x Can capture wide range of activities relevant to drug- related street disorder x Resource intensive to recruit representative sample x Socially desirable reporting x Recall issues x Lee & Farrell 200356 x Navarro & Leonard 20046 x DeBeck et al. 20077 x Shannon et al. 200760 x DeBeck et al. 20093 Official Statistics x Police responses and arrests for disorderly activities x Data already compiled, often readily available x Reflects police efforts x Potential tampering of statistics x Limited range of activities recorded x Green 1995102 x Weisburd & Mazerolle 200091 x Sampson & Raudenbush 200453  Civilian Complaint Calls x Complaint calls to 911, city officials & tip lines re: disorderly activities x Not biased by police activity x Limited range of activities recorded; only particularly disruptive behaviours x Sherman & Weisburd 1995103 x Cohen et al. 200354 x Weisburd & Mazerolle 200091 Systematic Social Observation x Multiple independent systematically recorded observations replicated over time x Involves filming and having trained observers record observations in log x Can measure wide range of aspects of street disorder x Filming allows for replication & greater reliability x Captures observed rather than perceived measures  x Labour intensive and expensive x Potential for observer effects x Reiss 197198 x Sampson & Raudenbush 19991 x Sampson & Raudenbush 200453  Direct Observation x Trained observers pass through area of interest and code events and observations relevant to street disorder x Like SSO, avoids potential perception bias x Can capture wide range of activities relevant to drug- related street disorder  x Potential for observer effects x Unlike SSO, reliability of measures and classification of observations are not easily verified x Perkins 199293 x Koper 199597 x Sherman & Weisburd 1995103 x Perkins & Taylor 1996100 x Cohen et al. 200052 x Caughy et al. 200199 x Wood et al. 2004104 ȱȱ 25 2.4 ReviewȱFindings:ȱRespondingȱtoȱDrugȬRelatedȱStreetȱDisorderȱ Aȱ reviewȱ ofȱ theȱ publishedȱ literatureȱ identifiedȱ aȱ rangeȱ ofȱ policyȱ responsesȱ implementedȱ toȱ addressȱdrugȬrelatedȱ streetȱdisorderȱ (seeȱTableȱ 2.2).ȱTheseȱ responsesȱ primarilyȱ fitȱ intoȱ theȱ categoriesȱ ofȱ lawȱ enforcementȱ (policeȱ crackȬdownȱ campaigns,ȱ orderȬmaintenanceȱ policing,ȱ problemȬorientedȱ policing,ȱ hotȬspotȱ policingȱ andȱ increasingȱ policeȱ powersȱ throughȱ legislation)ȱ environmentalȱ design,ȱ andȱ engagingȱ interventionsȱ consistentȱwithȱ publicȱ healthȱ principlesȱ (supervisedȱ injectionȱ facilities,ȱ addictionȱ treatment,ȱandȱ lowȬthresholdȱemploymentȱprograms).ȱ ȱAsȱoutlinedȱ inȱTableȱ 2.2,ȱsomeȱresponsesȱtargetȱaȱbroadȱrangeȱofȱactivitiesȱthatȱgenerateȱstreetȱdisorderȱwhileȱ othersȱfocusȱonȱparticularȱbehavioursȱorȱcomponentsȱofȱdisorder.ȱAnȱoverviewȱofȱeachȱ responseȱ andȱ currentȱ evidenceȱ ofȱ itsȱ impactsȱ areȱ presentedȱ below.ȱ Evidenceȱ ofȱ theȱ impactsȱofȱeachȱresponseȱareȱalsoȱsummarizedȱinȱTableȱ2.3.ȱȱ 2.4.1 LawȱEnforcementȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorderȱ 2.4.1.1 PoliceȱCrackȬDownȱCampaignsȱ Policeȱ crackȬdownȱ campaignsȱ areȱaȱwidelyȱ employedȱ responseȱ toȱdrugȬrelatedȱ streetȱ disorder62Ȭ64ȱ andȱ canȱ beȱ describedȱ asȱ temporaryȱ dramaticȱ increasesȱ inȱ policeȱ presenceȱ toȱ increaseȱ theȱ threatȱ ofȱ apprehensionȱ andȱ punishmentȱ forȱ criminalȱ orȱ misdemeanourȱoffences.105ȱPoliceȱcrackȬdownsȱcanȱbeȱoffenseȬspecificȱsuchȱasȱtargetingȱ parkingȱviolationsȱorȱdrunkȱdriving.ȱAlternatively,ȱtheyȱcanȱbeȱgeographicallyȱfocusedȱ andȱinvolveȱtheȱstrictȱenforcementȱofȱallȱtypesȱofȱoffencesȱinȱoneȱparticularȱarea.ȱTacticsȱ usedȱ inȱpoliceȱcrackȬdownsȱofȱopenȱairȱdrugȱmarketsȱ includeȱ increasingȱpoliceȱpatrolȱ ȱȱ 26 andȱ surveillance,ȱ raidingȱ drugȱ dealingȱ locations,ȱ andȱ increasingȱ arrestsȱ forȱ observedȱ drugȱtransactions,ȱundercoverȱdrugȱbuys,ȱandȱunrelatedȱmisdemeanourȱviolations.63,ȱ105,ȱ 106ȱȱ Studiesȱ evaluatingȱ theȱ impactȱ ofȱ policeȬcrackdownsȱ haveȱ foundȱ thatȱ theyȱ areȱ generallyȱeffectiveȱinȱreducingȱdrugȱmarketȱactivityȱduringȱandȱoftenȱimmediatelyȱafterȱ crackȬdownȱ operations.63,ȱ 107ȱHowever,ȱ visibleȱ reductionsȱ inȱ drugȱmarketȱ activityȱ areȱ usuallyȱ temporary,ȱ andȱ theȱ deterrentȱ effectȱ rarelyȱ lastsȱ afterȱ theȱ interventionȱ hasȱ ceased.62,ȱ105,ȱ108ȱStudiesȱexploringȱtheȱimpactȱofȱcrackȬdownȱcampaignsȱonȱtheȱpriceȱandȱ frequencyȱofȱdrugȱuseȱamongȱlocalȱdrugȱusersȱfoundȱnoȱdiscernableȱimpacts,ȱsuggestingȱ thatȱ theȱ impactsȱ ofȱ crackȬdownsȱ areȱ limitedȱ toȱ theȱ visibleȱ reductionȱ ofȱ drugȬrelatedȱ streetȱdisorder.69,ȱ109ȱDespiteȱtheȱmoderateȱbenefitsȱofȱpoliceȱcrackȬdownsȱonȱtheȱvisibilityȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱ theseȱ approachesȱ haveȱ beenȱ associatedȱwithȱ aȱwideȱ rangeȱofȱseriousȱnegativeȱconsequences.ȱ Oneȱ ofȱ theȱmostȱ wellȬdocumentedȱ unintendedȱ consequencesȱ ofȱ policeȱ crackȬ downȱcampaignsȱisȱdisplacement.69,ȱ110ȱResearchȱtoȱdateȱsuggestsȱthatȱtypicallyȱpolicingȱ effortsȱdoȱnotȱdecreaseȱtheȱoverallȱprevalenceȱofȱdisorderlyȱactivity,ȱbutȱinsteadȱdisplaceȱ itȱtoȱsurroundingȱareas.48,ȱ62,ȱ64,ȱ67Ȭ69,ȱ107,ȱ108ȱȱThisȱcanȱhaveȱaȱnumberȱofȱnegativeȱimplicationsȱ forȱ theȱ individualsȱ engagingȱ inȱ disorderlyȱ activity,ȱ asȱ wellȱ asȱ forȱ theȱ surroundingȱ communitiesȱwhereȱtheȱactivityȱrelocates.62,ȱ 111,ȱ 112ȱInȱparticular,ȱdisplacementȱ interruptsȱ andȱdiscouragesȱ contactȱ betweenȱmarginalizedȱdrugȱusersȱ andȱ healthȱ services107ȱ andȱ ȱȱ 27 mayȱincreaseȱtheȱriskȱofȱfatalȱdrugȱoverdoseȱasȱinjectionȱdrugȱusersȱhaveȱbeenȱfoundȱtoȱ relocateȱtoȱmoreȱisolatedȱlocationsȱduringȱperiodsȱofȱpoliceȱcrackȬdowns.113,ȱ114ȱ Byȱdisruptingȱdrugȱmarkets,ȱpoliceȱcrackȬdownsȱhaveȱalsoȱbeenȱassociatedȱwithȱ increasingȱ levelsȱ ofȱ violenceȱ inȱ surroundingȱ area.62,ȱ 108,ȱ 115ȱ Furthermore,ȱhighȱ levelsȱ ofȱ policeȱmisconductȱhaveȱbeenȱdocumentedȱduringȱperiodsȱofȱcrackȬdowns,ȱspecifically,ȱ unnecessaryȱuseȱofȱ forceȱandȱ illegalȱsearches.116ȱOtherȱconcerningȱ findingsȱ includeȱ theȱ impactȱofȱ crackȬdownsȱonȱ injectingȱpracticesȱ amongȱ injectionȱdrugȱusers.ȱ Itȱhasȱbeenȱ reportedȱ thatȱ crackȬdownsȱ reduceȱ injectionȱ drugȱ users’’ȱ accessȱ toȱ HIVȱ preventionȱ suppliesȱ (condoms,ȱ syringes),106,ȱ 107ȱ andȱ fearȱ ofȱ policeȱ searchesȱ makeȱ drugȱ injectorsȱ reluctanceȱtoȱcarryȱcleanȱsyringes.63,ȱ64,ȱ107,ȱ116ȱReducedȱaccessȱtoȱandȱfearȱofȱcarryingȱHIVȱ preventionȱ suppliesȱ increasesȱ theȱ chancesȱ ofȱ engagingȱ inȱ unprotectedȱ sexȱ andȱ usedȱ syringeȱ sharingȱ whichȱ areȱ theȱ leadingȱ routesȱ ofȱ transmissionȱ forȱ HIVȱ andȱ otherȱ infectiousȱ diseases.117,ȱ 118ȱ ȱ Inȱ responseȱ toȱ increasedȱ policeȱ surveillanceȱ ofȱ openȱ drugȱ scenesȱduringȱcrackȬdowns,ȱ IDUȱalsoȱ reportȱbeingȱmoreȱ likelyȱ toȱ rushȱ theirȱ injectionsȱ whichȱoftenȱresultsȱinȱskippingȱimportantȱoverdoseȱandȱHIVȱpreventionȱstepsȱasȱwellȱasȱ otherȱsafetyȱmeasures.62,ȱ63,ȱ106,ȱ107ȱTheȱpressureȱtoȱrushȱinjectionsȱdueȱtoȱfearȱofȱpoliceȱhasȱ alsoȱbeenȱfoundȱtoȱdiscourageȱsafeȱneedleȱandȱsyringeȱdisposalȱasȱinjectorsȱreportȱbeingȱ reluctantȱtoȱcarryȱtheirȱusedȱsyringesȱtoȱsafeȱdepositȱlocations.62,ȱ64,ȱ107ȱInȱsomeȱsettingsȱtoȱ preventȱbeingȱarrestedȱbyȱpoliceȱduringȱcrackȬdowns,ȱdrugȱusersȱhaveȱbeenȱ foundȱ toȱ storeȱ drugsȱ inȱ theirȱmouthȱ orȱ nasalȱ cavitiesȱ andȱwillȱ swallowȱ drugsȱwhenȱ theyȱ areȱ ȱȱ 28 stoppedȱbyȱpoliceȱ toȱavoidȱhavingȱdrugsȱdiscovered.64ȱTheseȱbehavioursȱposeȱ risksȱofȱ spreadingȱinfectionsȱasȱwellȱasȱaccidentalȱoverdose.ȱ Otherȱ concerningȱ outcomesȱ associatedȱ withȱ policeȱ crackȬdownsȱ includeȱ increasingȱ stigmaȱ andȱmarginalizationȱ ofȱpeopleȱwhoȱuseȱdrugs,ȱwhichȱ isȱ associatedȱ withȱincreasingȱHIVȱriskȱandȱunderminingȱimportantȱpublicȱhealthȱobjectives,ȱasȱwellȱasȱ increasingȱratesȱofȱarrestȱandȱ incarcerationȱamongȱpeopleȱwhoȱuseȱdrugs.106ȱAlthoughȱ arrestingȱ andȱ incarceratingȱ largerȱ numbersȱ ofȱ individualsȱ mayȱ provideȱ shortȬtermȱ benefitsȱbyȱ limitingȱ theirȱopportunityȱtoȱengageȱ inȱdisorderlyȱbehaviour,ȱ incarcerationȱ isȱ associatedȱ withȱ manyȱ negativeȱ individualȱ andȱ communityȱ consequences.ȱ Theseȱ includeȱdisruptingȱfamilyȱstructures,ȱincreasingȱalienationȱandȱstigma,ȱincreasingȱrisksȱ ofȱHIVȱ infectionȱ andȱotherȱhealthȱharmsȱ includingȱ fatalȱdrugȱoverdose,ȱ andȱ creatingȱ barriersȱ toȱ labourȱmarketȱparticipation,ȱallȱofȱwhichȱdamageȱcommunityȱ tiesȱandȱmayȱ actuallyȱperpetuateȱfurtherȱdisorderlyȱandȱcriminalȱbehaviour.119Ȭ1252,ȱ124,ȱ125ȱ Inȱ summary,ȱ currentȱ evidenceȱ suggestsȱ thatȱpoliceȱ crackȬdownȱ campaignsȱ canȱ reduceȱ theȱ visibilityȱ ofȱ streetȱ disorderȱ butȱ thoseȱ benefitsȱ areȱ associatedȱwithȱmanyȱ seriousȱnegativeȱunintendedȱconsequences.ȱ 2.4.1.2 OrderȬMaintenanceȱPolicingȱBasedȱonȱtheȱBrokenȱWindowsȱTheoryȱ Anotherȱ lawȱenforcementȱapproachȱ thatȱ isȱ relevantȱ toȱstreetȱdisorderȱ isȱ ‘‘orderȬ maintenanceȱ policing’’.ȱ Thisȱ approachȱ isȱ rootedȱ inȱ theȱ ‘‘brokenȱwindowsȱ theory’’ȱ andȱ focusesȱ onȱ theȱ aggressiveȱ enforcementȱ ofȱ misdemeanourȱ violationsȱ asȱ aȱ meansȱ ofȱ maintainingȱorderȱinȱpublicȱareas.50ȱTheȱcentralȱpremiseȱofȱtheȱbrokenȱwindowsȱtheoryȱ ȱȱ 29 isȱ thatȱstreetȱdisorder,ȱ includingȱpanhandling,ȱpublicȱdrugȱdealing,ȱ litter,ȱandȱgraffiti,ȱ makesȱneighbourhoodsȱ susceptibleȱ toȱmoreȱ seriousȱ crime.ȱTheȱproposedȱmechanismsȱ byȱ whichȱ theseȱ formsȱ ofȱ disorderȱ wouldȱ breedȱ seriousȱ crimeȱ areȱ multifaceted.ȱ Specifically,ȱitȱisȱsuggestedȱthatȱpublicȱdisorderȱsendsȱsignalsȱtoȱpotentialȱcriminalsȱthatȱ residentsȱ inȱ ‘‘disorderly’’ȱ neighbourhoodsȱ areȱ apatheticȱ andȱunlikelyȱ toȱ beȱ vigilantȱ ofȱ suspiciousȱ activityȱ inȱ theirȱ community.ȱ Thisȱ isȱ saidȱ toȱmakeȱ theseȱ neighbourhoodsȱ appealingȱ targetsȱ forȱ moreȱ seriousȱ crime.ȱ Additionally,ȱ itȱ isȱ suggestedȱ thatȱ publicȱ disorderȱdetersȱnonȬcriminallyȬinvolvedȱcitizensȱ fromȱoccupyingȱpublicȱspaces,ȱwhichȱ inȱ turnȱ leadsȱ toȱunmonitoredȱenvironmentsȱ thatȱ furtherȱencourageȱpotentialȱcriminalsȱ toȱ offend.50ȱ Theȱ brokenȱwindowsȱ theoryȱ suggestsȱ thatȱ toȱ reduceȱ seriousȱ crimeȱ andȱ protectȱpublicȱsafetyȱitȱisȱcriticalȱforȱpoliceȱofficersȱtoȱfocusȱtheirȱeffortsȱonȱmaintainingȱ strictȱorderȱinȱpublicȱareasȱandȱaggressivelyȱenforceȱallȱmisdemeanourȱviolations.ȱThisȱ typeȱ ofȱ orderȬmaintenanceȱ policingȱ basedȱ onȱ theȱ brokenȱwindowȱ theoryȱ hasȱ gainedȱ tractionȱinȱmanyȱpolicyȱcirclesȱandȱitsȱemphasisȱonȱpoliceȱtargetingȱandȱpunishingȱactsȱ ofȱ disorderȱ hasȱ beenȱ incorporatedȱ intoȱ theȱ policingȱ cultureȱ ofȱmanyȱ urbanȱ areas.126ȱ Althoughȱ theȱ chiefȱ objectiveȱ ofȱ orderȬmaintenanceȱ policingȱ isȱ toȱ deterȱmoreȱ seriousȱ formsȱofȱcrime,ȱitsȱtargetȱisȱstreetȱdisorder.ȱTherefore,ȱaȱpresentationȱofȱresearchȱrelatedȱ toȱ theȱ impactsȱ ofȱ orderȬmaintenanceȱ policingȱ isȱ relevantȱ toȱ thisȱ reviewȱ ofȱ policyȱ responsesȱtoȱstreetȱdisorder.ȱȱȱ TheȱmostȱwidelyȱcitedȱexampleȱofȱorderȬmaintenanceȱpolicingȱhasȱbeenȱinȱNewȱ YorkȱCityȱ(NYC)ȱinȱtheȱearlyȱ1990sȱunderȱMayorȱRudolphȱGiuliani.49,ȱ68,ȱ92ȱFollowingȱtheȱ ȱȱ 30 implementationȱofȱNYC’’sȱorderȬmaintenanceȱpolicingȱ initiative,ȱmisdemeanourȱarrestȱ ratesȱ inȱ theȱ cityȱ increasedȱ significantly,49,ȱ 127ȱ andȱ throughoutȱ theȱ 1990sȱ theȱ physicalȱ appearanceȱ ofȱdisorderȱ onȱ theȱ streetsȱdecreasedȱdramaticallyȱ andȱ theȱ rateȱ ofȱ seriousȱ crime,ȱ includingȱ homicides,ȱ declined.49,ȱ 128ȱ Asȱ aȱ result,ȱ NYC’’sȱ orderȬmaintenanceȱ policingȱinitiativeȱisȱoftenȱcitedȱasȱanȱexampleȱofȱtheȱeffectivenessȱofȱorderȬmaintenanceȱ policingȱ andȱ theȱ brokenȱ windowsȱ theoryȱ andȱ hasȱ beenȱ usedȱ toȱ legitimizeȱ theȱ employmentȱ ofȱ thisȱ approachȱ towardsȱ streetȱdisorderȱ inȱ jurisdictionsȱ asȱ farȱ awayȱ asȱ GreatȱBritain.48,ȱ49ȱ Theȱ apparentȱ successȱ ofȱ Newȱ York’’sȱ policingȱ initiativeȱ has,ȱ however,ȱ beenȱ widelyȱcontestedȱandȱmanyȱcompetingȱexplanationsȱhaveȱbeenȱputȱforwardȱtoȱaccountȱ forȱtheȱdramaticȱreductionȱinȱcriminalȱactivityȱinȱNYC.49,ȱ124,ȱ128ȱȱTheseȱincludeȱchangesȱinȱ patternsȱofȱcrackȱcocaineȱuseȱandȱdistributionȱandȱchangesȱ inȱ theȱAmericanȱeconomyȱ andȱ labourȱmarkets.ȱ 48,ȱ 49,ȱ 128ȱ ȱFurthermore,ȱ theȱdeclineȱ inȱ ratesȱofȱhomicideȱandȱotherȱ seriousȱcrimeȱwasȱnotȱexclusiveȱtoȱNYC,ȱnorȱdidȱitȱbeginȱafterȱNYC’’sȱorderȬmaintenanceȱ policingȱinitiativeȱwasȱimplemented.ȱIndeed,ȱnationalȱhomicidesȱratesȱbeganȱtoȱdeclineȱ inȱ1991ȱ(twoȱyearsȱbeforeȱNYC’’sȱinitiativeȱwasȱintroduced),48,ȱ92ȱandȱotherȱcitiesȱthatȱdidȱ notȱ implementȱ newȱ policingȱ practicesȱ experiencedȱ similar,ȱ andȱ atȱ timesȱ evenȱmoreȱ dramatic,ȱdeclinesȱthanȱthoseȱobservedȱinȱNYC.48,ȱ92,ȱ127ȱ ȱInȱaddition,ȱaggressiveȱpolicingȱ initiativesȱthatȱhaveȱbeenȱimplementedȱinȱpreviousȱtimeȱperiodsȱhaveȱactuallyȱcoincidedȱ withȱ increasesȱ inȱhomicideȱrates.48ȱTheseȱobservationsȱsuggestȱthatȱaggressiveȱpolicingȱ ȱȱ 31 ofȱstreetȱdisorderȱisȱneitherȱaȱnecessaryȱnorȱaȱsufficientȱelementȱtoȱreduceȱhomicideȱandȱ otherȱseriousȱcrime.ȱȱ Theseȱ factorsȱ highlightȱ thatȱ thereȱ areȱmultipleȱ potentialȱ explanationsȱ forȱ theȱ reductionȱ inȱ crimeȱ observedȱ inȱNYC.ȱWhenȱ takenȱ togetherȱ itȱ suggestsȱ thatȱ theȱ linksȱ betweenȱNewȱYork’’sȱorderȬmaintenanceȱpolicingȱ initiativeȱandȱsupportȱforȱtheȱbrokenȱ windowsȱ theoryȱ areȱ unconvincing.ȱ Indeed,ȱ toȱ dateȱ thereȱ isȱ noȱ reliableȱ scientificȱ evidenceȱ inȱ theȱpeerȬreviewȱ literatureȱ toȱvalidateȱ theȱaccuracyȱofȱ theȱbrokenȱwindowsȱ theory.ȱAlthoughȱaȱnumberȱofȱlargeȱscaleȱstudiesȱreportȱaȱtenuousȱrelationshipȱbetweenȱ markersȱofȱpublicȱdisorderȱandȱ robbery,ȱafterȱadjustingȱ forȱ importantȱneighbourhoodȱ characteristicsȱsuchȱasȱpovertyȱandȱrace,ȱ theseȱstudiesȱ foundȱnoȱsignificantȱconnectionȱ betweenȱ streetȱ disorderȱ andȱ allȱ otherȱmarkersȱ ofȱ seriousȱ crime,ȱ includingȱ homicide,ȱ burglary,ȱphysicalȱassault,ȱsexualȱassault,ȱandȱpurseȬsnatching/pickȬpocketing.1,ȱ40,ȱ92,ȱ129ȱ Studiesȱ specificȱ toȱNYCȱundertakenȱ byȱKellingȱ andȱ Sousaȱ (2001)ȱ andȱCormanȱ andȱMocanȱ (2005)ȱ reportedȱ significantȱ inverseȱ relationshipsȱ betweenȱmisdemeanourȱ arrestsȱandȱratesȱofȱviolentȱcrime.130,ȱ131ȱȱHowever,ȱaȱlaterȱstudyȱbyȱHarcourtȱandȱLudwigȱ (2006)ȱthatȱusedȱimprovedȱmeasuresȱforȱkeyȱindicatorsȱandȱattemptedȱtoȱaddressȱotherȱ weaknessesȱinȱtheȱKellingȱandȱCormanȱstudiesȱwasȱunableȱtoȱreplicateȱtheseȱfindings.132ȱ AȱmoreȱrecentȱstudyȱbyȱMessnerȱandȱcolleaguesȱ(2007)ȱanalysedȱmisdemeanourȱarrestsȱ andȱhomicideȱ ratesȱdisaggregatedȱ intoȱgunȬrelatedȱ andȱnonȬgunȬrelatedȱhomicidesȱ inȱ NewȱYorkȱCity.49ȱTheyȱfoundȱthatȱwhileȱmisdemeanourȱarrestsȱwereȱinverselyȱrelatedȱtoȱ ȱȱ 32 gunȬrelatedȱhomicides,ȱ thereȱwasȱnoȱ relationshipȱbetweenȱmisdemeanourȱarrestsȱandȱ nonȬgunȬrelatedȱ homicidesȱ inȱ Newȱ Yorkȱ City.ȱ Theȱ failureȱ toȱ detectȱ aȱ relationshipȱ betweenȱmisdemeanourȱarrestsȱandȱbothȱtypesȱofȱhomicidesȱindicatesȱthatȱNewȱYork’’sȱ ‘‘qualityȬofȬlife’’ȱinitiativeȱdoesȱnotȱlendȱsupportȱtoȱtheȱbrokenȱwindowsȱtheory.ȱȱ Althoughȱ theȱ evidenceȬbaseȱ toȱ supportȱ theȱ crimeȱ reductionȱ benefitsȱ ofȱ orderȬ maintenanceȱ policingȱ isȱ unconvincing,ȱ similarȱ toȱ policeȱ crackȬdownȱ campaigns,ȱ itsȱ impactȱonȱreducingȱtheȱvisibleȱsignsȱofȱdisorderȱappearȱtoȱbeȱsuccessful.49,ȱ124ȱHowever,ȱ alsoȱ similarȱ toȱ policeȱ crackȬdownȱ campaigns,ȱ orderȬmaintenanceȱ policingȱ hasȱ beenȱ associatedȱ withȱ aȱ numberȱ ofȱ unintendedȱ negativeȱ impacts.ȱ Theseȱ includeȱ displacement,48,ȱ67,ȱ68ȱasȱwellȱasȱracialȱprofilingȱandȱprejudicialȱenforcementȱofȱlaws.ȱForȱ instance,ȱ oneȱ studyȱ analysingȱ theȱ applicationȱ ofȱ Newȱ York’’sȱ orderȬmaintenanceȱ initiativeȱfoundȱthatȱinsteadȱofȱallocatingȱpolicingȱeffortsȱbasedȱonȱtheȱlevelȱofȱphysicalȱ disorderȱ presentȱ inȱ aȱ neighbourhood,ȱ policingȱ attentionȱ wasȱ concentratedȱ inȱ neighbourhoodsȱ withȱ largeȱ ethnicȱ minorityȱ populations.ȱ Asȱ aȱ result,ȱ thisȱ orderȬ maintenanceȱpolicingȱinitiativeȱexposedȱneighbourhoodsȱcharacterizedȱbyȱpovertyȱandȱ socialȱdisadvantageȱ toȱ theȱ highestȱ levelsȱ ofȱpolicing.127ȱGivenȱ theseȱ findingsȱ itȱ isȱ notȱ surprisingȱ thatȱorderȬmaintenanceȱpolicingȱ initiativesȱhaveȱalsoȱbeenȱ foundȱ toȱ leadȱ toȱ theȱ disproportionateȱ incarcerationȱ ofȱ minorityȱ groups.133ȱ Asȱ previouslyȱ noted,ȱ incarcerationȱisȱassociatedȱwithȱmanyȱharmsȱincludingȱincreasedȱstigmaȱandȱheightenedȱ risksȱforȱHIVȱinfectionȱandȱotherȱnegativeȱhealthȱoutcomes.119Ȭ125ȱȱ ȱȱ 33 OrderȬmaintenanceȱ policingȱ hasȱ alsoȱ beenȱ linkedȱ withȱ policeȱ misconductȱ includingȱcorruption,ȱexcessiveȱuseȱofȱforceȱandȱhumanȱrightsȱabuses.40,ȱ48,ȱ49,ȱ49,ȱ116,ȱ124ȱTheȱ numberȱofȱ civilȱ rightsȱ claimsȱ filedȱagainstȱNewȱYorkȱpoliceȱ forȱ abusiveȱ conductȱwasȱ reportedȱtoȱhaveȱincreasedȱbyȱ75%ȱinȱtheȱyearsȱfollowingȱtheȱintroductionȱofȱtheȱcity’’sȱ orderȬmaintenanceȱ initiative.ȱ Inȱ addition,ȱ civilianȱ complaintsȱ filedȱwithȱ theȱ Civilianȱ ComplaintȱReviewȱBoardȱ increasedȱbyȱ60%ȱduringȱthisȱperiod.124ȱItȱ isȱnoteworthyȱ thatȱ alsoȱ duringȱ thisȱ timeȱ Sanȱ Diego,ȱ whichȱ didȱ notȱ implementȱ aggressiveȱ orderȬ maintenanceȱ policing,ȱ experiencedȱ aȱ reductionȱ inȱ complaintsȱ filedȱ againstȱ itsȱ policeȱ force,ȱevenȱthoughȱtheȱcityȱalsoȱenjoyedȱreductionsȱinȱitsȱcrimeȱratesȱcomparableȱtoȱNewȱ YorkȱCity.124ȱ ȱSurgesȱ inȱpoliceȱmisconductȱ complaintsȱhaveȱbeenȱ foundȱ toȱundermineȱ trustȱandȱgoodȱrelationsȱwithȱcitizensȱandȱmayȱcreateȱhostilityȱinȱaȱcommunity.48,ȱ134ȱ AȱreviewȱofȱevidenceȱindicatesȱthatȱorderȬmaintenanceȱpolicingȱandȱpoliceȱcrackȬ downȱ campaignsȱ shareȱ manyȱ ofȱ theȱ sameȱ unintendedȱ negativeȱ impactsȱ whileȱ producingȱlimitedȱbenefitsȱthatȱdoȱnotȱtranslateȱintoȱtheȱlongȬtermȱsustainableȱreductionȱ ofȱstreetȱdisorder,ȱorȱotherȱindicatorsȱofȱcrime.ȱ 2.4.1.3 ProblemȱOrientedȱPolicingȱ ProblemȬorientedȱ policingȱ canȱ beȱ describedȱ asȱ aȱ collaborative,ȱ communityȱ orientedȱ approachȱ toȱ policingȱ whereȱ theȱ roleȱ ofȱ policeȱ includesȱ engagingȱwithȱ theȱ communitiesȱ theyȱ workȱ inȱ toȱ considerȱ theȱ rootȱ causesȱ ofȱ crimeȱ andȱ disorderȱ andȱ identifyȱpotentialȱsolutionsȱwhichȱareȱ thenȱ implementedȱandȱevaluated.49,ȱ 135ȱWithȱ thisȱ approachȱ theȱ primaryȱ emphasisȱ forȱ policeȱ officersȱ isȱ toȱworkȱ toȱ preventȱ crimeȱ andȱ ȱȱ 34 addressȱ neighbourhoodȱ crimeȱ issues.92ȱ ȱ Althoughȱ studiesȱ evaluatingȱ theȱ impactsȱ ofȱ problemȬorientedȱ policingȱ reportȱ areȱ limited,136,ȱ 137ȱ someȱ positiveȱ effectsȱ onȱ reducingȱ streetȱ disorderȱ haveȱ beenȱ documented,138ȱ andȱ aȱ recentȱ metaȬanalysisȱ ofȱ problemȬ orientedȱpolicingȱ interventionsȱ foundȱ theyȱhadȱaȱsignificant,ȱalthoughȱmarginal,ȱeffectȱ onȱstreetȱdisorder.139ȱDespiteȱtheseȱpositiveȱfindings,ȱreviewȱauthorsȱacknowledgeȱthatȱ theȱevidenceȬbaseȱtoȱsupportȱproblemȬorientedȱpolicingȱisȱweakȱandȱconcludeȱthatȱthereȱ isȱ insufficientȱ evidenceȱ toȱ supportȱ theȱ levelȱ ofȱ endorsementȱ governmentsȱ andȱpoliceȱ agenciesȱ haveȱ beenȱ directingȱ towardsȱ problemȬorientedȱ policing.139ȱNoȱ studiesȱwereȱ identifiedȱ thatȱ documentȱ negativeȱ consequencesȱ associatedȱ withȱ problemȬorientedȱ policing.ȱȱ 2.4.1.4 HotȬSpotȱPolicingȱ Oneȱ variationȱ ofȱ theseȱ aforementionedȱ lawȱ enforcementȱ basedȱ approachesȱ isȱ ‘‘hotȬspot’’ȱ policingȱwhichȱ involvesȱ concentratingȱ policingȱ effortsȱ inȱ areasȱwithȱ highȱ levelsȱofȱdrugȱmarketȱactivityȱandȱdisorder.91,ȱ 97ȱ ȱPolicingȱ tacticsȱwithinȱ theȱ ‘‘hotȬspot’’ȱ approachȱvaryȱwidelyȱandȱincludeȱpoliceȱcrackȬdownsȱandȱraids,95,ȱ140ȱproblemȬorientedȱ policing,141ȱandȱ increasedȱpatrolȱandȱsurveillance.97,ȱ 142ȱAȱnumberȱofȱstudiesȱevaluatingȱ theȱ impactsȱ ofȱ variousȱ typesȱ ofȱ ‘‘hotȬspot’’ȱ policingȱ reportȱ measurableȱ shortȬtermȱ reductionsȱ inȱmarkersȱofȱ streetȱdisorder,97,ȱ 138,ȱ 142ȱ includingȱdisorderȬrelatedȱemergencyȱ callsȱ forȱ services,140ȱandȱdrugȱdealingȱ inȱ theȱarea.95ȱConsistentȱwithȱ studiesȱofȱ specificȱ policingȱ approaches,ȱ thereȱ wasȱ littleȱ evidenceȱ toȱ suggestȱ thatȱ theseȱ effectsȱ wereȱ sustainedȱlongȬterm.ȱAlthoughȱoneȱstudyȱhadȱaȱpostȱinterventionȱassessmentȱperiodȱofȱ ȱȱ 35 sevenȱmonthsȱandȱ foundȱ sustainedȱ effectȱatȱ thisȱ time,ȱotherȱ studiesȱnotedȱ thatȱ initialȱ reductionsȱ inȱ streetȱ disorderȱ largelyȱ disappearedȱ onceȱ theȱ targetedȱ enforcementȱ campaignȱ ceased.95ȱ Twoȱ studiesȱ wereȱ identifiedȱ thatȱ consideredȱ whetherȱ policingȱ interventionsȱ inȱ twoȱ particularȱ instancesȱ wereȱ accompaniedȱ withȱ displacementȱ ofȱ disorderȱandȱfoundȱnoȱevidenceȱofȱsignificantȱdisplacement.138,ȱ140ȱNoȱotherȱstudiesȱwereȱ identifiedȱ thatȱ consideredȱ unintendedȱ negativeȱ consequencesȱ specificȱ toȱ hotȬspotȱ policing;ȱ however,ȱ theȱ unintendedȱ consequencesȱ associatedȱ withȱ theȱ previouslyȱ describedȱ lawȱ enforcementȱ approachesȱ (i.e.,ȱ policeȱ crackȬdownȱ campaigns,ȱ orderȬ maintenanceȱ policing)ȱ wouldȱ stillȱ beȱ relevantȱ toȱ theȱ hotȬspotȱ interventionsȱ thatȱ employedȱtheseȱapproaches.ȱȱ 2.4.1.5 IncreasingȱPoliceȱPowersȱThroughȱLegislationȱ Increasingȱpoliceȱpowersȱthroughȱlegislationȱspecificallyȱdesignedȱtoȱprovideȱlawȱ enforcementȱ officersȱwithȱ additionalȱpowersȱ toȱ regulateȱ activitiesȱ inȱpublicȱ spacesȱ isȱ anotherȱ lawȱ enforcementȱ basedȱ approachȱ thatȱ hasȱ beenȱ usedȱ toȱ addressȱ streetȱ disorder.43,ȱ143,ȱ144ȱAlthoughȱthisȱenforcementȱtacticȱcanȱbeȱimplementedȱtoȱsupportȱpoliceȱ crackȬdownsȱ orȱ orderȬmaintenanceȱ approaches,ȱ itȱ canȱ alsoȱ beȱ implementedȱ independently.ȱCommonȱelementsȱofȱlegislativeȱinitiatives,ȱsuchȱasȱtheȱ‘‘SafeȱStreetsȱAct’’ȱ inȱOntarioȱ andȱBritishȱColumbia,ȱCanada,ȱ includingȱplacingȱ restrictionsȱ onȱ theȱ time,ȱ mannerȱandȱlocationȱthatȱpanhandlingȱmayȱoccur.8ȱTheseȱtypesȱofȱlegislativeȱmeasuresȱ allowȱ lawȱenforcementȱofficersȱtoȱmoreȱdirectlyȱ interveneȱandȱcontrolȱpeopleȱengagedȱ inȱ certainȱ disorderlyȱ behaviours.ȱ Theȱ useȱ ofȱ additionalȱ powersȱ grantedȱ throughȱ ȱȱ 36 legislativeȱ initiativesȱ hasȱ beenȱ notedȱ toȱ accomplishȱ reductionsȱ inȱmarkersȱ ofȱ streetȱ disorder.68,ȱ 97,ȱ 105,ȱ 124,ȱ 140ȱ However,ȱ legislationȱ banningȱ orȱ strictlyȱ regulatingȱ certainȱ behavioursȱ(suchȱasȱpanhandling)ȱinȱpublicȱspacesȱhasȱinȱmanyȱinstancesȱbeenȱfoundȱtoȱ violateȱ civilȱ liberties.8,ȱ 133ȱ ȱNoȱ studiesȱwereȱ identifiedȱ thatȱ assessȱ theȱ impactȱ ofȱ thisȱ approachȱonȱdisplacementȱorȱotherȱpotentialȱrelevantȱimpacts.ȱȱ 2.4.1.6 SummaryȱofȱLawȱEnforcementȱBasedȱApproachesȱ Despiteȱmoderateȱ benefitsȱ inȱ theȱ visibleȱ reductionȱ ofȱ streetȱ disorder,ȱ currentȱ evidenceȱ suggestsȱ thatȱmostȱ lawȱ enforcementȱ basedȱ approachesȱ areȱ associatedȱwithȱ seriousȱunintendedȱconsequences,ȱwhichȱ includeȱdisplacingȱstreetȱdisorder,ȱ increasingȱ violence,ȱpoliceȱmisconduct,ȱcompromisingȱHIVȱandȱdrugȱoverdoseȱprevention,ȱracialȱ profiling,ȱ increasingȱ stigmaȱ andȱ discrimination,ȱ andȱ increasingȱ overallȱ incarcerationȱ ratesȱamongȱvulnerableȱdrugȱusingȱpopulations.ȱTheȱextentȱofȱ theseȱnegativeȱ impactsȱ appearsȱtoȱoverwhelmȱtheȱmarginalȱbenefitsȱofȱdrugȱlawȱenforcementȱandȱsuggestsȱthatȱ alternativeȱapproachesȱareȱurgentlyȱrequired.ȱ 2.4.2 EnvironmentalȱDesignȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorderȱ Givenȱ theȱ limitsȱ ofȱ conventionalȱ lawȱ enforcementȱ basedȱ approaches,ȱ ‘‘Crimeȱ PreventionȱThroughȱEnvironmentalȱDesign’’ȱ(CPTED),ȱalsoȱknownȱasȱ‘‘SituationalȱCrimeȱ Prevention’’,ȱhasȱ receivedȱ increasingȱ attentionȱ asȱ aȱpotentialȱmethodȱ toȱ controlȱdrugȬ relatedȱstreetȱdisorder.25,ȱ42,ȱ67,ȱ83ȱȱByȱwayȱofȱstrategiesȱrelatedȱtoȱterritorialityȱ(definedȱasȱ ensuringȱ thatȱ allȱ spacesȱ haveȱ aȱ clearlyȱ definedȱ andȱ apparentȱ purpose),ȱ surveillance,ȱ accessȱcontrol,ȱandȱtargetȱhardeningȱ(definedȱasȱmakingȱ locationsȱdifficultȱtoȱaccessȱorȱ ȱȱ 37 penetrate),ȱCPTEDȱproposesȱthatȱalteringȱfeaturesȱofȱtheȱbuiltȱenvironmentȱcanȱincreaseȱ theȱperceivedȱ costsȱofȱ committingȱ criminalȱorȱdisorderlyȱactsȱ (i.e.,ȱ increaseȱperceivedȱ riskȱofȱapprehension),ȱwhichȱ inȱ turnȱdetersȱcrimeȱandȱundesirableȱbehavioursȱsuchȱasȱ streetȱdisorder.ȱ145,ȱ146ȱȱAȱkeyȱassumptionȱinherentȱinȱCPTEDȱisȱthatȱpotentialȱoffendersȱorȱ disorderlyȱ peopleȱ makeȱ rationalȱ calculatedȱ decisionsȱ aboutȱ theȱ potentialȱ costsȱ andȱ benefitsȱ ofȱ theirȱ actionsȱ thatȱ canȱ beȱ manipulatedȱ throughȱ changesȱ toȱ theȱ builtȱ environment.ȱȱ Typicalȱdesignȱ featuresȱ toȱdeterȱcrimeȱandȱdisorderȱ include:ȱ installingȱ lighting,ȱ fences,ȱ gates,ȱ andȱ closedȱ circuitȱ televisionȱ cameras,ȱ asȱwellȱ asȱ alteringȱ landscapesȱ toȱ increaseȱvisibilityȱ andȱ removeȱpotentialȱhidingȱ spots.42,ȱ 145,ȱ 146ȱ ȱ Inȱ theȱ contextȱofȱdrugȬ relatedȱ streetȱ disorder,ȱ proposedȱ designȱ featuresȱ toȱ deterȱ activitiesȱ relatedȱ toȱ publicȱ disorderȱinvolveȱremovingȱpublicȱwaterȱtapsȱtoȱrestrictȱaccessȱtoȱwaterȱforȱdrinkingȱandȱ washing,ȱ restrictingȱ accessȱ toȱ restrooms,ȱ lockingȱ unsecuredȱ garbageȱ dumpsters,ȱ andȱ blockingȱaccessȱtoȱprotectedȱareasȱwhereȱpeopleȱcanȱsitȱorȱlieȱdown.2,ȱ25,ȱ67ȱȱOneȱstrengthȱ ofȱenvironmentalȱdesignȱapproachesȱ isȱthatȱcomparedȱtoȱ lawȱenforcementȱapproaches,ȱ theyȱareȱtypicallyȱinexpensiveȱandȱeasyȱtoȱimplement.ȱ Existingȱ evaluationȱ studiesȱ ofȱ environmentalȱ designȱ interventionsȱ haveȱ beenȱ undertakenȱtoȱassessȱtheirȱimpactȱonȱdeterringȱcriminalȱbehavioursȱspecificȱtoȱpropertyȱ crime,ȱtheftȱandȱrobberyȱandȱdoȱnotȱdirectlyȱconsiderȱbehavioursȱassociatedȱwithȱdrugȬ relatedȱ streetȱ disorder.145,ȱ 146ȱ Nevertheless,ȱ thereȱ isȱ limitedȱ evidenceȱ suggestingȱ thatȱ ȱȱ 38 environmentalȱdesignȱmayȱplayȱaȱ roleȱ inȱ reducingȱcertainȱcrimesȱ inȱcertainȱsituationsȱ andȱ thatȱ potentialȱ effectsȱ areȱ likelyȱmediatedȱ byȱ socialȱ andȱ economicȱ factors.83,ȱ 146Ȭ148ȱ However,ȱtoȱdateȱnoneȱofȱtheseȱstudiesȱprovideȱevidenceȱthatȱempiricallyȱdemonstratesȱ theȱ effectivenessȱ ofȱ environmentalȱ designȱ inȱ crimeȱ reductionȱ andȱ noȱ evidenceȱwasȱ locatedȱthatȱsuggestsȱenvironmentalȱdesignȱreducesȱstreetȱdisorder.145,ȱ146ȱ ȱ Althoughȱ theȱ evidenceȬbaseȱ surroundingȱ environmentalȱ designȱ isȱ limited,146ȱ concernsȱidentifiedȱwithȱemployingȱenvironmentalȱdesignȱstrategiesȱincludeȱdisplacingȱ undesirableȱ behavioursȱ andȱ negativelyȱ impactingȱ minorityȱ groups.ȱ Similarȱ toȱ lawȱ enforcementȱbasedȱinterventions,ȱenvironmentalȱdesignȱinterventionsȱhaveȱbeenȱfoundȱ toȱdisplaceȱundesirableȱbehaviourȱ toȱ surroundingȱ areas.147ȱ ȱAsȱpreviouslyȱmentioned,ȱ displacementȱisȱknownȱtoȱhaveȱaȱnumberȱofȱnegativeȱhealthȱconsequencesȱbothȱforȱtheȱ individualsȱengagedȱinȱtheȱdisorderlyȱbehaviour,ȱasȱwellȱasȱforȱtheȱcommunitiesȱwhereȱ theȱ behaviourȱ relocates.62,ȱ 67,ȱ 69,ȱ 106,ȱ 110ȱ ȱ Furthermore,ȱ asȱ withȱ orderȬmaintenanceȱ approaches,ȱeffortsȱtoȱregulateȱandȱcontrolȱpublicȱspacesȱthroughȱsurveillanceȱandȱotherȱ environmentalȱ designȱ featuresȱ haveȱ beenȱ foundȱ toȱ disproportionatelyȱ affectȱ andȱ excludeȱ marginalizedȱ populations.83ȱ Whileȱ environmentalȱ designȱ interventionsȱ areȱ typicallyȱinexpensiveȱandȱeasyȱtoȱimplement,ȱthereȱisȱnoȱevidenceȱtoȱsuggestȱthatȱtheyȱ reduceȱdisorderlyȱactivityȱandȱthereȱisȱevidenceȱtoȱsuggestȱtheyȱdisplaceȱbehaviourȱandȱ negativelyȱaffectȱmarginalizedȱpopulations.ȱ ȱȱ 39 2.4.3 EngagingȱInterventionsȱthatȱEnableȱBehaviourȱChangeȱ Comparedȱwithȱlawȱenforcementȱandȱenvironmentalȱdesignȱinterventions,ȱwhichȱ areȱ largelyȱ coerciveȱ inȱ theirȱ approachesȱ toȱ deterringȱ disorderlyȱ behaviour,ȱ engagingȱ interventionsȱ thatȱ enableȱ behaviourȱ changeȱ representȱ aȱdifferentȱ typeȱ ofȱ responseȱ toȱ drugȬrelatedȱ streetȱdisorder.ȱEngagingȱ interventionsȱareȱ consistentȱwithȱpublicȱhealthȱ principlesȱ andȱ recognizeȱ theȱ importanceȱ ofȱ promotingȱ andȱ enablingȱ behavioursȱ thatȱ protectȱ healthȱ andȱ limitȱ risks.ȱ Examplesȱ ofȱ engagingȱ interventionsȱ includeȱ manyȱ addictionsȬfocusedȱpublicȱhealthȱprogramsȱthatȱaimȱtoȱengageȱmarginalizedȱdrugȱusingȱ populationsȱandȱconnectȱthemȱwithȱappropriateȱhealthȱandȱsocialȱservices.149ȱAlthoughȱ fewȱofȱ theseȱengagingȱaddictionsȬfocusedȱpublicȱhealthȱprogramsȱareȱ implementedȱ toȱ specificallyȱaddressȱstreetȱdisorder,ȱthereȱareȱaȱnumberȱthatȱhaveȱbeenȱevaluatedȱinȱtheȱ contextȱ ofȱ streetȱ disorder.ȱ Theseȱ includeȱ supervisedȱ injectionȱ facilities,ȱ addictionȱ treatmentȱprograms,ȱandȱlowȬthresholdȱemploymentȱprograms.ȱȱ 2.4.3.1 SupervisedȱInjectionȱFacilitiesȱ Supervisedȱ injectionȱ facilitiesȱ (SIFs)ȱ representȱ anȱ engagingȱ interventionȱ thatȱ isȱ explicitlyȱ intendedȱ toȱ addressȱ aspectsȱ ofȱ drugȬrelatedȱ streetȱ disorder.20,ȱ 150,ȱ 151ȱ Byȱ providingȱ aȱ hygienicȱ environmentȱwhereȱdrugȱusersȱ canȱ injectȱ illegalȱdrugsȱwithoutȱ fearȱ ofȱ arrestȱ orȱharassment,ȱ SIFsȱ offerȱ aȱuniqueȱ alternativeȱ forȱ streetȬbasedȱ injectionȱ drugȱusers.ȱ20,ȱ150,ȱ151152ȱWithinȱSIFs,ȱclientsȱareȱprovidedȱwithȱsterileȱinjectingȱequipmentȱ andȱemergencyȱinterventionȱinȱtheȱeventȱofȱanȱaccidentalȱoverdose,ȱasȱwellȱasȱmedicalȱ ȱȱ 40 careȱeitherȱonȱsiteȱorȱthroughȱreferral.153,ȱ154ȱȱThereȱareȱnowȱapproximatelyȱ65ȱsanctionedȱ supervisedȱdrugȱconsumptionȱfacilitiesȱinȱoperationȱinternationally.155ȱȱ TheȱimpactȱofȱSIFsȱonȱstreetȱdisorderȱhasȱbeenȱrigorouslyȱevaluatedȱinȱAustraliaȱ andȱ Canadaȱ usingȱ bothȱ communityȱ perceptionȱ surveysȱ andȱ directȱ observationȱ techniques.ȱ Resultsȱ suggestȱ thatȱ SIFsȱ areȱ effectiveȱ inȱ reducingȱ bothȱ observedȱ andȱ perceivedȱmeasuresȱofȱpublicȱ injectionȱdrugȱuseȱ andȱ injectionȱ relatedȱdebrisȱ inȱ areasȱ surroundingȱ injectionȱ facilities.101,ȱ 104ȱVancouverȬbasedȱstudiesȱhaveȱsoughtȱ toȱmeasureȱ potentialȱunintendedȱnegativeȱ consequencesȱofȱSIFsȱbutȱ foundȱnoȱadverseȱ changesȱ inȱ communityȱdrugȱuseȱpatterns,156ȱnoȱincreasesȱinȱinitiationȱintoȱinjectionȱdrugȱuse,157ȱandȱ noȱ increasesȱ inȱ drugȬrelatedȱ crimeȱ associatedȱwithȱ theȱ establishmentȱ ofȱVancouver’’sȱ SIF.158ȱ Despiteȱevidenceȱofȱpositiveȱ impactsȱonȱ theȱreductionȱofȱstreetȱdisorderȱandȱnoȱ evidenceȱ ofȱ adverseȱ impacts,ȱ theȱ coverageȱ ofȱ SIFsȱ remainsȱminuteȱ comparedȱ toȱ theȱ prevalenceȱofȱpublicȱdrugȱuseȱandȱdrugȬrelatedȱ streetȱdisorder.ȱSIFsȱ inȱAustraliaȱandȱ Canadaȱ areȱ singleȱ pilotȱ trialȱ facilitiesȱ andȱ areȱ notȱ comprehensiveȱ programsȱ ofȱ supervisedȱ injecting.ȱ Capacityȱ constraintsȱ resultingȱ inȱ longȱwaitȱ timesȱ toȱ accessȱ theȱ Vancouverȱ injectionȱ facilityȱ haveȱ beenȱ identifiedȱ asȱ aȱ leadingȱ factorȱ contributingȱ toȱ publicȱdrugȱuseȱamongȱlocalȱinjectors.159ȱToȱdate,ȱnoȱSIFsȱhaveȱbeenȱimplementedȱinȱtheȱ UnitedȱStates.ȱ ȱȱ 41 2.4.3.2 AddictionȱTreatmentȱ Addictionȱ treatmentȱ programsȱ areȱ anotherȱ highlyȱ relevantȱ engagingȱ publicȱ healthȱ interventionȱ inȱtheȱcontextȱofȱstreetȱdisorder.ȱThereȱareȱmanyȱdifferentȱtypesȱofȱ addictionȱ treatmentȱ includingȱ behaviouralȱ andȱ pharmacologicalȱ treatmentsȱ (drugȱ substitutionȱ andȱ maintenanceȱ therapies),ȱ andȱ theȱ objectivesȱ ofȱ addictionȱ treatmentȱ rangeȱfromȱreducingȱillicitȱdrugȱuseȱtoȱfullȱabstinenceȱfromȱallȱdrugȱuse.160ȱȱ Reducingȱ drugȱ dependenceȱ andȱ useȱ throughȱ substitution,ȱ maintenance,ȱ orȱ abstinenceȬbasedȱ addictionȱ treatmentsȱ haveȱ allȱ beenȱ foundȱ toȱ limitȱ participationȱ inȱ drugȬrelatedȱstreetȱdisorder,ȱparticularlyȱparticipationȱ inȱdisorderlyȱincomeȱgenerationȱ activities.161Ȭ165ȱ Inȱ particular,ȱ aȱ wideȱ bodyȱ ofȱ literatureȱ hasȱ foundȱ thatȱ methadoneȱ maintenanceȱ isȱ anȱ effectiveȱ treatmentȱ forȱ opiodȱ addictionȱ andȱ isȱ associatedȱ withȱ reductionsȱ inȱ participationȱ inȱ disorderlyȱ incomeȱ generationȱ activities.162ȱ Similarly,ȱ heroinȱmaintenanceȱ trialsȱ includingȱ theȱmostȱ recentȱNorthȱAmericanȱOpiateȱMedicationȱ Initiativeȱ(NAOMI)ȱtrial,ȱfoundȱthatȱprescribingȱ injectableȱdiacetylmorphineȱ(theȱactiveȱ ingredientȱinȱheroin)ȱreducedȱtheȱuseȱofȱandȱneedȱtoȱpurchaseȱillicitȱstreetȱdrugs,ȱwhichȱ hasȱaȱdirectȱpositiveȱimpactȱonȱreducingȱparticipationȱ inȱdisorderlyȱincomeȱgenerationȱ activities.163ȱȱȱ Althoughȱtheȱ linksȱbetweenȱaddictionȱtreatmentȱandȱreductionsȱ inȱparticipationȱ inȱdisorderlyȱ incomeȱgenerationȱactivitiesȱareȱwellȱestablished,ȱtheȱ longȬtermȱdrugȱuseȱ patternsȱofȱinjectionȱdrugȱusersȱsuggestȱthatȱdrugȱaddictionȱisȱoftenȱaȱchronicȱrelapsingȱ conditionȱandȱaddictionȱtreatmentȱsuccessȱisȱtypicallyȱperiodicȱandȱfollowedȱbyȱperiodsȱ ȱȱ 42 ofȱ relapseȱ intoȱ drugȱ use.166Ȭ169ȱ Furthermore,ȱ thereȱ areȱ currentlyȱ noȱ substitutionȱ orȱ maintenanceȱ treatmentȱ therapiesȱ forȱstimulantȱdrugȱusers.ȱTheȱoverallȱeffectivenessȱofȱ currentȱ addictionȱ treatmentȱmodalitiesȱ toȱ reduceȱ participationȱ inȱ disorderlyȱ incomeȱ generationȱactivitiesȱisȱlimited.ȱ 2.4.3.3 LowȬThresholdȱEmploymentȱProgramsȱ TheȱeffectsȱofȱdrugȱaddictionȱandȱstreetȬentrenchmentȱoftenȱmakeȱitȱdifficultȱforȱ illicitȱdrugȱusersȱtoȱobtainȱandȱretainȱformalȱemployment.ȱFormalȱemploymentȱtypicallyȱ requiresȱemployeesȱtoȱabstainȱfromȱdrugȱuseȱandȱfollowȱaȱregularȱworkȱscheduleȱwhichȱ isȱ oftenȱ unrealisticȱ forȱ manyȱ streetȬbasedȱ drugȱ users.33,ȱ 170Ȭ174ȱ Givenȱ theȱ barriersȱ toȱ engagingȱ inȱ formalȱ employment,ȱ itȱ isȱ commonȱ forȱdrugȱusersȱ toȱ resortȱ toȱprohibitedȱ incomeȱ generationȱ strategiesȱ thatȱ contributeȱ toȱ drugȬrelatedȱ streetȱ disorder.7,ȱ 171ȱ Althoughȱ thereȱ areȱ employmentȱ programsȱ targetedȱ towardsȱ peopleȱwhoȱ useȱ drugs,ȱ theyȱareȱoftenȱ integratedȱ intoȱaddictionȱ treatmentȱprogramsȱandȱ intendedȱ toȱ supportȱ addictionȱrecovery.172ȱAsȱaȱresult,ȱtheseȱtypesȱofȱemploymentȱprogramsȱareȱinaccessibleȱ forȱactiveȱdrugȱusersȱandȱareȱthereforeȱunableȱtoȱaddressȱdisorderlyȱincomeȱgenerationȱ activities.ȱȱ Conversely,ȱlowȬthresholdȱemploymentȱprogramsȱareȱanȱalternativeȱstrategyȱthatȱ initialȱ researchȱ suggestsȱ canȱ engageȱ streetȬinvolvedȱ drugȱ usersȱ andȱ reduceȱ theirȱ participationȱ inȱsomeȱ typesȱofȱdisorderlyȱ incomeȱgenerationȱactivities.ȱTheȱconceptȱofȱ ‘‘lowȬthreshold’’ȱisȱtoȱcreateȱprogramsȱthatȱareȱeasilyȱaccessibleȱforȱactiveȱdrugȱusersȱandȱ aȱkeyȱcomponentȱofȱlowȬthresholdȱprogramsȱisȱthatȱtheyȱdoȱnotȱrequireȱabstinenceȱfromȱ ȱȱ 43 drugȱuse.ȱAnȱ evaluationȱofȱaȱ jewelleryȱmakingȱ economicȱ empowermentȱprogramȱ forȱ womenȱ whoȱ useȱ illicitȱ drugsȱ foundȱ theȱ programȱ wasȱ associatedȱ withȱ significantȱ reductionsȱinȱengagingȱinȱsexȱwork.175ȱȱ Additionalȱ studiesȱ evaluatingȱ theȱ impactsȱ ofȱ lowȬthresholdȱ employmentȱ programsȱonȱdisorderlyȱincomeȱgenerationȱwereȱnotȱlocatedȱandȱtheȱprevalenceȱofȱtheseȱ initiativesȱ appearsȱ sparse.ȱHowever,ȱ aȱ limitedȱnumberȱ ofȱ lowȬthresholdȱ employmentȱ opportunitiesȱ inȱVancouver,ȱCanadaȱwereȱ identified.ȱTheseȱ includeȱaȱcommunityȱcaféȱ andȱ cateringȱ socialȱ enterpriseȱ companyȱ thatȱ offersȱ anȱ estimatedȱ nineȱ lowȬthresholdȱ employmentȱ positions,176,ȱ 177ȱ asȱ wellȱ asȱ anȱ organizationȱ thatȱ processesȱ recyclableȱ containersȱ whichȱ providesȱ roughlyȱ 33ȱ lowȬthresholdȱ positions178,ȱ 179ȱ andȱ aȱ photoȱ calendarȱ projectȱ initiatedȱ byȱ aȱ socialȱ justiceȱ organizationȱ thatȱ offersȱ aȱ programȱ forȱ residentsȱofȱVancouver’’sȱdrugȱuseȱepicentreȱtoȱbecomeȱvendorsȱandȱsellȱcalendarsȱandȱ books.180Ȭ182ȱActiveȱdrugȱuseȱdoesȱnotȱprecludeȱparticipationȱinȱanyȱofȱtheseȱemploymentȱ opportunities.ȱGivenȱ initialȱpositiveȱ findingsȱofȱ lowȬthresholdȱ employmentȱprogramsȱ onȱdisorderlyȱincomeȱgenerationȱinȱotherȱsettings,ȱevaluatingȱtheȱ impactsȱofȱtheȱaboveȱ identifiedȱ lowȬthresholdȱemploymentȱprogramsȱ inȱVancouverȱappearsȱwarranted.ȱTheȱ expansionȱ ofȱ lowȬthresholdȱ employmentȱ opportunitiesȱ mayȱ presentȱ anȱ importantȱ opportunityȱ toȱ significantlyȱ reduceȱparticipationȱ inȱcomponentsȱofȱdrugȬrelatedȱ streetȱ disorder.ȱ ȱȱ 44 2.5 ConclusionsȱandȱNextȱStepsȱ Theȱ findingsȱ ofȱ thisȱ reviewȱ indicateȱ thatȱ althoughȱ lawȱ enforcementȬbasedȱ approachesȱareȱtheȱmostȱcommonlyȱemployedȱresponseȱtoȱdrugȬrelatedȱstreetȱdisorder,ȱ theirȱ impactsȱ areȱ typicallyȱ shortȬtermȱ andȱ areȱ oftenȱ accompaniedȱ byȱ negativeȱ unintendedȱconsequences,ȱincludingȱdisplacementȱandȱaȱrangeȱofȱharmfulȱpublicȱhealthȱ andȱcommunityȱ impacts.ȱSimilarly,ȱalthoughȱenvironmentalȱdesignȱ interventionsȱmayȱ haveȱlimitedȱimpactȱonȱtheȱvisibleȱreductionȱofȱstreetȱdisorder,ȱtheseȱmarginalȱgainsȱareȱ associatedȱwithȱunintendedȱconsequencesȱincludingȱdisplacementȱandȱtheȱexclusionȱofȱ marginalizedȱpopulations.ȱConversely,ȱinterventionsȱthatȱareȱinȱlineȱwithȱpublicȱhealthȱ principlesȱ andȱ engageȱ drugȱ usersȱ toȱ enableȱ themȱ toȱ changeȱ theirȱ behaviourȱ areȱ notȱ associatedȱwithȱseriousȱunintendedȱnegativeȱconsequences;ȱhowever,ȱ theirȱ impactsȱonȱ streetȱ disorderȱ areȱ restrictedȱ byȱ aȱ numberȱ ofȱ factors.ȱ Inȱ theȱ casesȱ ofȱ SIFsȱ andȱ lowȬ thresholdȱemployment,ȱlimitedȱcoverageȱappearsȱtoȱbeȱaȱkeyȱconstraintȱsuggestingȱthatȱ theȱ expansionȱ andȱ furtherȱ developmentȱ ofȱ theseȱ interventionsȱ shouldȱ beȱ pursued.ȱ Whileȱ thereȱ isȱ aȱ needȱ toȱ scaleȱ upȱ andȱ expandȱ existingȱ interventionsȱ thatȱ haveȱ aȱ demonstratedȱ positiveȱ impactȱ onȱ theȱ reductionȱ ofȱ markersȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱ givenȱ theȱ identifiedȱ limitationsȱwithȱ theȱ currentȱ rangeȱ ofȱ interventionsȱ toȱ addressȱdrugȬrelatedȱ streetȱdisorder,ȱ considerationȱ forȱunderexploredȱ andȱ innovativeȱ interventionsȱshouldȱalsoȱbeȱaȱpriorityȱforȱhealthȱandȱpolicyȱresearch.ȱȱ ȱȱ 45 2.5.1 UnderexploredȱandȱInnovativeȱEngagingȱApproachesȱ Specificȱengagingȱpublicȱhealthȱprogramsȱimplementedȱforȱpurposesȱunrelatedȱtoȱ streetȱ disorderȱ canȱ directlyȱ impactȱ theȱ prevalenceȱ ofȱ drugȬrelatedȱ streetȱ disorder;ȱ however,ȱ inȱ manyȱ instancesȱ thisȱ impactȱ hasȱ notȱ beenȱ recognized.ȱ LowȬthresholdȱ supportiveȱ housingȱ isȱ anȱ exampleȱ ofȱ anȱ engagingȱ interventionȱ thatȱ hasȱ beenȱ underexploredȱ inȱ connectionȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱWhileȱ theȱ benefitsȱ ofȱ providingȱ lowȬthresholdȱ supportiveȱhousingȱ forȱmarginalizedȱpopulationsȱ haveȱ longȱ beenȱ recognizedȱ inȱ theȱ contextȱ ofȱ physicalȱ andȱ mentalȱ health,183ȱ theȱ relationshipȱ betweenȱ lowȬthresholdȱ housing,ȱ accessȱ toȱ privateȱ spaceȱ andȱ engagementȱ inȱ publicȱ disorderȱhasȱnotȱbeenȱfullyȱexplored.ȱIndeed,ȱhomelessnessȱhasȱbeenȱfoundȱtoȱbeȱaȱkeyȱ predictorȱ ofȱ publicȱ injectionȱ drugȱ useȱ andȱ surveysȱ ofȱ individualsȱ engagedȱ inȱ otherȱ disorderlyȱ behavioursȱ repeatedlyȱ identifyȱ thisȱ populationȱ asȱ underȬhoused,3,ȱ 6ȱ suggestingȱthatȱusingȱdrugsȱandȱloiteringȱinȱpublicȱspacesȱmayȱbeȱaȱfunctionȱofȱhavingȱ limitedȱ accessȱ toȱ privateȱ space.ȱ Hence,ȱ lowȬthresholdȱ housingȱ programsȱ mayȱ haveȱ potentialȱ toȱgreatlyȱ reduceȱsomeȱdisorderlyȱactivitiesȱ ifȱ theyȱprovideȱ individualsȱwithȱ privateȱspacesȱthatȱaccommodateȱsocializingȱandȱdrugȱuse.ȱȱ Basedȱ onȱ theȱ successesȱ ofȱ opiodȱ maintenanceȱ andȱ substitutionȱ treatmentȱ therapies,ȱ oneȱ promisingȱ areaȱ forȱ innovativeȱ explorationȱ isȱ developingȱ drugȱ substitutionȱandȱmaintenanceȱaddictionȱ treatmentȱprogramsȱ forȱstimulantȱdrugȱusers.ȱ Similarly,ȱ basedȱ onȱ theȱ successesȱ ofȱ SIFs,ȱ theȱ potentialȱ forȱ supervisedȱ inhalationȱ facilitiesȱ toȱ provideȱ alternativeȱ locationsȱ forȱ crackȱ cocaineȱ andȱ methamphetamineȱ ȱȱ 46 smokersȱtoȱconsumeȱdrugsȱshouldȱbeȱevaluated.ȱInhalationȱfacilitiesȱoperateȱinȱEurope;ȱ however,ȱtheirȱimpactȱonȱstreetȱdisorderȱhasȱnotȱbeenȱformallyȱevaluated.ȱ 2.5.2 Summaryȱ Inȱsummary,ȱ thisȱ reviewȱ findsȱ thatȱ lawȱenforcementȱandȱenvironmentalȱdesignȱ basedȱinterventionsȱdoȱnotȱappropriatelyȱmanageȱorȱmeaningfullyȱreduceȱdrugȬrelatedȱ streetȱdisorderȱwhileȱengagingȱinterventionsȱconsistentȱwithȱpublicȱhealthȱprinciplesȱareȱ notȱ associatedȱwithȱ seriousȱunintendedȱ consequencesȱ butȱ tendȱ toȱ beȱ limitedȱ inȱ theirȱ impactȱdueȱinȱpartȱtoȱlimitedȱcoverage.ȱBasedȱonȱtheȱsuccessȱofȱengagingȱpublicȱhealthȱ approaches,ȱ furtherȱ researchȱ shouldȱ beȱ directedȱ towardsȱ identifyingȱ innovativeȱ interventionsȱ toȱ addressȱ streetȱ disorderȱ asȱ wellȱ asȱ assessingȱ theȱ impactȱ thatȱ underexploredȱpublicȱhealthȱbasedȱ interventionsȱmightȱhaveȱonȱreducingȱengagementȱ inȱstreetȱdisorder.ȱȱȱ ȱTableȱ2.2ȱDescriptionȱofȱpolicyȱapproaches Policy Response Type of Approach Description Public Drug Use Street Drug Dealing Sex Work Pan handling Binning Vending Loiter- ing Police crack-down campaigns* Law Enforcement x Temporary sudden increase in policing efforts either in one geographic area or targeted towards one type of offence63 x Often targeted at open drug markets and involves increasing police patrol and surveillance105 X X X   X Order-maintenance policing* Law Enforcement x Strict enforcement of any minor bi-law, or misdemeanour offences, with chief objective of reducing more serious crime (informed by ‘broken windows theory’50) X X X X X X Problem-oriented policing Law Enforcement x Police officers partner with community members to jointly prevent crime and address neighbourhood crime issues135, 139 X X X X X X Hot-spot policing* Law Enforcement x Sub-section of enforcement approaches: involves increasing police patrol and presence in areas with concentrated crime and disorder91, 97 x Police tactics with hot-spot approaches vary and include order-maintenance policing or crack-down campaigns or other (problem-oriented policing) X X X   X Increasing police powers through legislation Law Enforcement x Increase powers of police to regulate activities in public spaces (prohibits public sleeping, panhandling, loitering), example: ‘Safe Streets Act’ in British Columbia and Ontario, Canada    X X X Environmental design Environment-al Design x Alters built environment to deter undesirable behaviours in public X X X X X X Supervised injection facilities Engaging Intervention x Provides hygienic, sanctioned indoor space to inject illicit drugs X     X Addiction treatment Engaging Intervention x Aimed at reducing or eliminating illicit drug use x Wide range of approaches including behavioural and pharmacological treatments160 X X X X X Low-threshold employment Engaging Intervention x Employment programs that do not require employees to be abstinent from drugs  X X X X 47 ȱ ȱTableȱ2.3ȱEvidenceȱofȱimpactsȱofȱpolicyȱapproaches Policy Response Observed Impacts Observed Unintended Negative Impacts Law Enforcement Based Approaches Police crack-down campaigns* x Reduced drug market activity during operation63, 107 x Visible reduction only temporary, deterrent effect not lasting62, 105, 105, 108 x No change in drug prices or frequency of drug use among local IDU69, 109   x Displacement62, 64, 69, 107, 108 x Discourages contact between IDU and health services107 x Increases violence in area62, 108, 115 x Associated with police misconduct (unnecessary force, illegal searches)116 x Discourages safe injecting practices –police searches make IDU reluctance to carry syringes,63, 64, 107, 116 reduces access to HIV prevention supplies (condoms, syringes),106, 107 and increased police surveillance leads to rushed injecting which means skipping HIV and overdose prevention steps and other safety measures, as well as62, 63, 106, 107 discourages safe needle and syringe disposal62, 64, 107 x Encourages nasal storage, increases risk of accidental overdose and spread of infections64 x Increases risk of fatal drug overdose as injectors choose more isolated locations113, 114 x Increases stigma and contributes to inequalities that are determinants of HIV risk106 x Increases vulnerability to incarceration which is risk environment for HIV106 Order- maintenance policing* x Reductions in visible signs of street disorder49, 124 x Credited with reductions in homicide and violence crimes130, 131 but findings are contested49, 132 x Displacement48, 67, 68 x Racial profiling and prejudicial enforcement of laws127 x Disproportionate incarceration of minority groups133 x Increases risk of incarceration which is associated with many harms including increasing stigma, risks for HIV acquisition and other health harms119-125 x Associated with increased civil rights complaints124 Problem-oriented policing* x Moderate reductions in disorder139, 184 x Evidence-base limited136, 137, 139 x No identified unintended consequences 48 ȱ ȱȱ 49 Policy Response Observed Impacts Observed Unintended Negative Impacts Hot-spot policing x Deterrent effect during hot-spot crack-down campaign95, 97, 142 x Moderate reductions in disorder after hot-spot crack- down campaign140, 141 x Moderate reductions in disorder after hot-spot problem-oriented campaign138, 141 x No identified unintended consequences associated specifically with hot-spot approach; however, hot-spot approach is paired with other policing approaches (i.e., crack-down campaign) and the unintended consequences of those policing strategies would be relevant Increasing police powers through legislation x Reductions in markers of street disorder.68, 97, 105, 124, 140 x Associated with civil liberty violations8, 133 Environmental Design Environmental design* x No studies specifically evaluating impact on street disorder145, 146 x Some evidence indicating might reduce some measures of crime in certain situations83, 146-148 x Displacement83, 145, 147 x Disproportionately affects and excludes marginalized populations83 Engaging Interventions that Enable Behaviour Change Supervised injection facilities x Associated with reductions in observed and perceived measures of markers of street disorder101, 104 x No evidence of adverse changes in community drug use patterns,156 nor increases in initiation into injection drug use,157 nor increases in drug-related crime158 x No identified unintended consequences  Addiction treatment x Associated with reductions in disorderly income generation161-165 x Among high intensity drug users treatment success is typically periodic and followed by periods of relapse back into drug use166-169 x No identified unintended consequences Low-threshold employment x Associated with reductions in engagement in some disorderly income generation activities175 x Evaluation studies of low-threshold employment program limited x No identified unintended consequences  *Note:ȱTheȱoutcomesȱofȱinterestȱforȱmanyȱofȱtheȱstudiesȱevaluatingȱtheȱimpactȱofȱtheseȱinterventionsȱwereȱcrimeȱratesȱnotȱstreetȱdisorder. ȱȱ 50 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ CHAPTER 3: ȱ AȱDOSEȬDEPENDENTȱRELATIONSHIPȱBETWEENȱEXPOSUREȱ TOȱAȱSTREETȬBASEDȱDRUGȱSCENEȱANDȱHEALTHȬRELATEDȱ HARMSȱAMONGȱPEOPLEȱWHOȱUSEȱINJECTIONȱDRUGS2ȱ 3.1 Introductionȱ Inȱmanyȱurbanȱareasȱglobally,ȱstreetȱdisorderȱrelatedȱtoȱtheȱuseȱandȱtradeȱofȱillicitȱ drugsȱ isȱaȱgrowingȱpublicȱpolicyȱ concern.25,ȱ 40,ȱ 42,ȱ 50,ȱ 89Ȭ91ȱCommonȱ signsȱofȱdrugȬrelatedȱ streetȱ disorderȱ includeȱ theȱ consumptionȱ ofȱ illegalȱ drugsȱ inȱ publicȱ areasȱ andȱ publicȱ intoxicationȱ (i.e.,ȱ loiteringȱorȱsocializingȱ inȱpublicȱspacesȱwhileȱunderȱ theȱ influenceȱofȱ drugs).1Ȭ6ȱ Inȱ addition,ȱ activitiesȱ includingȱ streetȬlevelȱ drugȱ dealing,ȱ streetȬbasedȱ sexȱ work,ȱpanhandling,ȱandȱengagingȱ inȱ ‘‘binning’’,ȱ recycling,ȱsalvagingȱandȱunsanctionedȱ streetȬvendingȱ areȱ examplesȱofȱ everydayȱ incomeȱgenerationȱ strategiesȱusedȱbyȱmanyȱ streetȬbasedȱdrugȱusersȱwhichȱ furtherȱcontributeȱ toȱstreetȱdisorder.2,ȱ 3,ȱ 8Ȭ10ȱTheȱphysicalȱ locationsȱwhereȱtheseȱdisorderlyȱactivitiesȱareȱhighlyȱconcentratedȱareȱoftenȱreferredȱtoȱ asȱ ‘‘drugȱ scenes’’ȱandȱareȱwidelyȱ recognizedȱandȱwellȱdescribedȱ inȱmanyȱurbanȱareas,ȱ includingȱ Vancouver,ȱ Canada,ȱ whereȱ aȱ largeȱ openȱ drugȱ sceneȱ hasȱ persistedȱ forȱ decades.185Ȭ189ȱȱ ȱ 2ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublication.ȱDeBeck,ȱK.,ȱWood,ȱE.,ȱ Zhang,ȱR.,ȱBuxton,ȱJ.,ȱMontaner,ȱJ.,ȱKerr,ȱT.ȱAȱdoseȬdependentȱrelationshipȱbetweenȱ exposureȱtoȱaȱstreetȬbasedȱdrugȱsceneȱandȱhealthȬrelatedȱharmsȱamongȱpeopleȱwhoȱ useȱinjectionȱdrugs.ȱ ȱȱ 51 Toȱdate,ȱtheȱharmfulȱimpactsȱofȱdrugȬrelatedȱstreetȱdisorderȱareȱmostȱfrequentlyȱ discussedȱinȱreferenceȱtoȱtheirȱnegativeȱeffectsȱonȱsurroundingȱcommunities.25,ȱ40ȱȱItȱhasȱ beenȱ reportedȱ thatȱwhenȱ questioned,ȱ aȱ highȱproportionȱ ofȱurbanȱ citizensȱ rankȱ streetȱ disorderȱasȱaȱtopȱconcernȱinȱtheirȱcommunity,ȱoftenȱaboveȱveryȱseriousȱcrimesȱincludingȱ homicide,ȱsexualȱassaultȱandȱrobbery.25,ȱ40,ȱ42,ȱ50,ȱ89Ȭ91ȱȱIndeed,ȱtheȱatmosphereȱofȱstreetȬlevelȱ drugȱdealingȱcanȱbeȱintimidatingȱforȱtheȱgeneralȱpublicȱandȱmayȱdiscourageȱtheȱuseȱofȱ publicȱ spacesȱ inȱ theȱvicinityȱofȱ streetȬbasedȱdrugȱ scenes.48,ȱ 49,ȱ 143ȱ ȱHighȱ levelsȱofȱ streetȱ disorderȱhaveȱalsoȱbeenȱlinkedȱtoȱdepressedȱretailȱactivityȱandȱeconomicȱinvestmentȱinȱ surroundingȱareas.8,ȱ40Ȭ45ȱȱ WhileȱtheȱcommunityȱimpactsȱofȱdrugȬrelatedȱstreetȱdisorderȱareȱgenerallyȱwellȱ understood,ȱ lesserȱattentionȱhasȱbeenȱgivenȱ toȱ theȱpotentialȱhealthȱandȱsocialȱ impactsȱ thatȱ exposureȱ toȱ andȱ immersionȱ inȱ streetȬbasedȱ drugȱ scenesȱ hasȱ onȱ streetȬinvolvedȱ peopleȱwhoȱuseȱillicitȱdrugs.190ȱȱExistingȱpublicȱhealthȱresearchȱhasȱdocumentedȱaȱwideȱ rangeȱofȱhealthȱrisksȱassociatedȱwithȱengagingȱ inȱspecificȱdisorderlyȱactivities,ȱsuchȱasȱ streetȬbasedȱsexȱwork,57,ȱ58,ȱ191ȱtheȱuseȱofȱinjectionȱdrugsȱinȱpublicȱareas,3,ȱ61,ȱ83ȱandȱstreetȬ levelȱdrugȱdealing;4,ȱ 192ȱhowever,ȱ theseȱstudiesȱ focusedȱonȱspecificȱbehavioursȱandȱdidȱ notȱ considerȱ theȱ roleȱ thatȱ exposureȱ toȱdrugȱ scenesȱ itselfȱmayȱplayȱ inȱ shapingȱhealthȱ behavioursȱandȱoutcomes.ȱȱ Toȱ addressȱ thisȱ gapȱ andȱ provideȱ improvedȱ understandingsȱ ofȱ theȱ impactsȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱweȱ soughtȱ toȱ assessȱwhetherȱ exposureȱ toȱ drugȬrelatedȱ ȱȱ 52 streetȱdisorder,ȱinȱtheȱformȱofȱVancouver’’sȱwellȬdescribedȱstreetȬbasedȱdrugȱscene,ȱwasȱ associatedȱwithȱmarkersȱofȱvulnerabilityȱtoȱharmȱandȱadverseȱhealthȱoutcomesȱsuchȱasȱ unstableȱhousing,ȱhighȱ intensityȱdrugȱuse,ȱexposureȱ toȱviolence,ȱandȱencountersȱwithȱ lawȱenforcement.ȱWeȱalsoȱsoughtȱtoȱdetermineȱwhetherȱtheȱlevelȱofȱdrugȱsceneȱexposureȱ wasȱ associatedȱ withȱ varyingȱ degreesȱ ofȱ vulnerabilityȱ toȱ harmȱ andȱ adverseȱ healthȱ outcomes.ȱ Itȱ wasȱ hopedȱ thatȱ theseȱ findingsȱ wouldȱ informȱ moreȱ effectiveȱ policyȱ interventionsȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorder.ȱ 3.2 Methodsȱ Dataȱ forȱ thisȱ studyȱwereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱdescriptionȱ ofȱ theȱ studyȱpleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱ ȱTheȱpresentȱstudyȱ isȱrestrictedȱtoȱVIDUSȱparticipantsȱseenȱforȱstudyȱfollowȬupȱ duringȱtheȱperiodȱofȱDecemberȱ2005ȱtoȱMarchȱ2009,ȱasȱtheȱmeasureȱforȱourȱoutcomeȱofȱ interestȱwasȱavailableȱonlyȱforȱthisȱperiod.ȱȱ Theȱ primaryȱ outcomeȱ ofȱ interestȱ forȱ thisȱ analysisȱwasȱ ‘‘drugȱ sceneȱ exposure’’,ȱ broadlyȱ definedȱ asȱ spendingȱ timeȱ onȱ theȱ streetȱ inȱ Vancouver’’sȱ drugȱ useȱ epicenter,ȱ whichȱ isȱ aȱwellȬdescribedȱ andȱdefinedȱ areaȱofȱ theȱ cityȱ referredȱ toȱ asȱ theȱ ‘‘Downtownȱ Eastside’’.14,ȱ 193ȱ ȱOurȱmeasureȱ forȱ thisȱvariableȱwasȱbasedȱonȱ responsesȱ toȱ theȱquestion:ȱ ““Onȱaverage,ȱhowȱmanyȱhoursȱaȱdayȱdoȱyouȱspendȱonȱtheȱstreet?””ȱToȱcaptureȱexposureȱ toȱdrugȱscenesȱandȱnotȱgeneralȱexposureȱtoȱcityȱstreetsȱweȱlimitedȱourȱmeasureȱofȱdrugȱ sceneȱexposureȱtoȱparticipantsȱthatȱresidedȱinȱorȱfrequentlyȱvisitedȱ(dailyȱorȱ2Ȭ3ȱtimesȱaȱ ȱȱ 53 week)ȱ Vancouver’’sȱ drugȱ useȱ epicenter.ȱ Becauseȱ weȱ wereȱ interestedȱ inȱ assessingȱ whetherȱ theȱ levelȱofȱdrugȱ sceneȱexposureȱwasȱassociatedȱwithȱdifferingȱ levelsȱofȱ riskȱ behaviourȱandȱharm,ȱweȱ createdȱ fourȱ categoriesȱofȱdrugȱ sceneȱexposure.ȱWeȱdefinedȱ ourȱreferenceȱcategoryȱofȱ‘‘noȱexposure’’ȱtoȱincludeȱallȱindividualsȱwhoȱdidȱnotȱresideȱinȱ orȱfrequentlyȱvisitȱVancouver’’sȱdrugȱuseȱepicenter,ȱasȱwellȱasȱindividualsȱwhoȱreportedȱ spendingȱnoȱmoreȱthanȱanȱaverageȱofȱ1ȱhourȱorȱlessȱonȱtheȱstreetȱeachȱdayȱoverȱtheȱlastȱ sixȱmonths.ȱAfterȱ examiningȱ theȱ distributionȱ ofȱ oneȱ smallȱ crossȬsectionalȱ sampleȱ ofȱ reportsȱofȱtheȱnumberȱofȱhoursȱspentȱonȱtheȱstreet,ȱweȱdividedȱtheȱresponsesȱintoȱthreeȱ groupsȱ ofȱ similarȱ size.ȱ Theseȱ areȱ referredȱ toȱ asȱ theȱ ‘‘low’’,ȱ ‘‘moderate’’,ȱ andȱ ‘‘high’’ȱ exposureȱ groups,ȱ whichȱ includedȱ individualsȱ thatȱ residedȱ inȱ orȱ frequentlyȱ visitedȱ Vancouver’’sȱdrugȱuseȱepicenterȱandȱspentȱonȱaverageȱbetweenȱ2Ȭ6,ȱ7Ȭ15,ȱandȱmoreȱthanȱ 15ȱhoursȱonȱtheȱstreetȱeachȱdayȱoverȱtheȱlastȱsixȱmonths,ȱrespectively.ȱ Explanatoryȱ variablesȱ ofȱ interestȱ includedȱ socioȬdemographicȱ information:ȱ genderȱ (femaleȱ vs.ȱmale),ȱ ageȱ (perȱ yearȱ older),ȱAboriginalȱ ancestryȱ (yesȱ vs.ȱ no)ȱ andȱ unstableȱhousing,ȱdefinedȱasȱlivingȱinȱaȱsingleȱoccupancyȱroomȱinȱhotel,ȱaȱtreatmentȱorȱ recoveryȱhouse,ȱjail,ȱshelterȱorȱhostel,ȱorȱhavingȱnoȱfixedȱaddressȱforȱtheȱlastȱsixȱmonthsȱ (yesȱvs.ȱno).ȱDrugȱuseȱandȱriskȱbehaviourȱvariablesȱconsideredȱreferȱtoȱbehavioursȱinȱtheȱ pastȱsixȱmonthsȱandȱincluded:ȱdailyȱcocaineȱinjectionȱ(yesȱvs.ȱno),ȱdailyȱheroinȱinjectionȱ (yesȱvs.ȱno),ȱdailyȱcrackȱcocaineȱsmokingȱ (yesȱvs.ȱno),ȱnonȬfatalȱoverdoseȱ (yesȱvs.ȱno),ȱ andȱsyringeȱsharingȱdefinedȱasȱborrowingȱorȱlendingȱsyringesȱalreadyȱusedȱbyȱsomeoneȱ elseȱ toȱ injectȱ drugsȱ (yesȱ vs.ȱ no).ȱOtherȱ factorsȱ consideredȱ included:ȱ encountersȱwithȱ ȱȱ 54 policeȱ inȱ theȱ lastȱmonth,ȱdefinedȱ asȱbeingȱquestioned,ȱ searchedȱorȱ stoppedȱbyȱpoliceȱ (yesȱvs.ȱno),ȱbeingȱaȱvictimȱofȱviolence,ȱdefinedȱasȱbeingȱphysicallyȱassaultedȱ (yesȱvs.ȱ no),ȱhavingȱmultipleȱsexȱpartnersȱ(yesȱvs.ȱno),ȱengagingȱinȱanyȱunprotectedȱsexȱ(yesȱvs.ȱ no),ȱhavingȱregularȱemployment,ȱdefinedȱasȱhavingȱaȱregularȱorȱtemporaryȱjobȱ(yesȱvs.ȱ no),ȱ sexȱ tradeȱ involvement,ȱ definedȱ asȱ exchangingȱ sexȱ forȱmoney,ȱ shelter,ȱ drugsȱ orȱ otherȱ commoditiesȱ (yesȱ vs.ȱ no),ȱ participationȱ inȱ drugȱ dealingȱ (yesȱ vs.ȱ no),ȱ andȱ participationȱ inȱanyȱaddictionȱ treatmentȱprogram,ȱdefinedȱasȱreportingȱbeingȱenrolledȱ inȱ methadoneȱ treatment,ȱ aȱ detoxificationȱ program,ȱ aȱ recoveryȱ house,ȱ aȱ residentialȱ addictionȱtreatmentȱcentreȱorȱengagingȱwithȱanȱaddictionsȱcounselorȱorȱparticipatingȱinȱ peerȱ supportȱprogramsȱ suchȱ asȱNarcoticsȱAnonymousȱ (yesȱvs.ȱno).ȱUnlessȱotherwiseȱ stated,ȱ allȱ behaviouralȱ variablesȱ referȱ toȱ theȱ previousȱ sixȱmonths.ȱ Toȱ accountȱ forȱ aȱ potentialȱseasonalȱinfluenceȱonȱtheȱamountȱofȱtimeȱindividualsȱspendȱonȱtheȱstreet,ȱweȱ alsoȱincludedȱaȱcategoricalȱvariableȱrepresentingȱtheȱmonthȱthatȱparticipantsȱcompletedȱ ourȱ study.ȱ Thisȱ helpedȱ ensureȱ thatȱ ourȱ analysisȱ adjustedȱ forȱ seasonalȱ variationsȱ inȱ responses.ȱ Toȱ identifyȱ factorsȱ associatedȱwithȱdrugȱ sceneȱ exposureȱ andȱ considerȱwhetherȱ theȱlevelȱofȱexposureȱwasȱassociatedȱwithȱvaryingȱdegreesȱofȱvulnerabilityȱtoȱharmȱandȱ adverseȱhealthȱoutcomes,ȱweȱconstructedȱthreeȱseparateȱregressionȱmodels.ȱAllȱmodelsȱ usedȱ theȱ ‘‘noȱexposure’’ȱcategoryȱasȱ theȱ referenceȱcategory.ȱTheȱ firstȱmodelȱconsideredȱ theȱ ‘‘lowȱ exposure’’ȱ category,ȱ theȱ secondȱmodelȱ consideredȱ theȱ ‘‘moderateȱ exposure’’ȱ ȱȱ 55 categoryȱandȱtheȱthirdȱmodelȱconsideredȱtheȱ ‘‘highȱexposure’’ȱcategoryȱasȱtheȱexposureȱ ofȱinterest.ȱ Sinceȱ analysesȱ ofȱ factorsȱ potentiallyȱ associatedȱwithȱ ourȱ outcomesȱ ofȱ interestȱ includedȱ serialȱmeasuresȱ forȱ eachȱ subject,ȱweȱ usedȱ generalizedȱ estimatingȱ equationsȱ (GEE)ȱ forȱ binaryȱ outcomesȱ withȱ logitȱ linkȱ forȱ theȱ analysisȱ ofȱ correlatedȱ dataȱ toȱ determineȱfactorsȱassociatedȱwithȱeachȱlevelȱofȱdrugȱsceneȱexposureȱthroughoutȱtheȱ40Ȭ monthȱ followȬupȱ period.194ȱ Theseȱ methodsȱ providedȱ standardȱ errorsȱ adjustedȱ byȱ multipleȱ observationsȱ perȱ personȱ usingȱ anȱ exchangeableȱ correlationȱ structure.ȱ Therefore,ȱdataȱfromȱeveryȱparticipantȱfollowȬupȱvisitȱwereȱconsideredȱinȱtheseȱanalysesȱ andȱweȱwereȱableȱtoȱaccommodateȱchangesȱinȱcategoriesȱoverȱtime.ȱMissingȱdataȱwereȱ addressedȱ throughȱ theȱ GEEȱ estimatingȱ mechanismȱ whichȱ usesȱ allȱ availableȱ pairsȱ method.ȱ Allȱ nonȬmissingȱ pairsȱ ofȱ dataȱ areȱ usedȱ inȱ theȱ estimatorsȱ ofȱ theȱ workingȱ correlationȱparameters.ȱȱ Asȱ aȱ firstȱ step,ȱGEEȱunivariateȱ analysesȱwereȱ conductedȱ toȱ obtainȱunadjustedȱ oddsȱratiosȱandȱ95%ȱconfidenceȱintervalsȱforȱvariablesȱofȱinterestȱandȱeachȱlevelȱofȱdrugȱ sceneȱ exposure.ȱ Inȱ orderȱ toȱ adjustȱ forȱ potentialȱ confounding,ȱ allȱ variablesȱ thatȱwereȱ associatedȱwithȱ theȱ dependentȱ variableȱ atȱ pȱ <ȱ 0.05ȱ inȱGEEȱ univariateȱ analysesȱwereȱ enteredȱinȱeachȱmultivariateȱlogisticȱGEEȱmodel.ȱAlthoughȱallȱmultivariateȱmodelsȱwereȱ runȱ independently,ȱ allȱ variablesȱ thatȱ reachedȱ significanceȱ atȱ anyȱ levelȱ ofȱdrugȱ sceneȱ exposureȱinȱunivariateȱanalysesȱwereȱincludedȱinȱeachȱmultivariateȱmodel.ȱThisȱwasȱtoȱ ȱȱ 56 ensureȱ thatȱallȱ threeȱmodelsȱadjustedȱ forȱ theȱsameȱvariablesȱallowingȱ forȱcomparisonsȱ betweenȱ multivariateȱ models.ȱ Allȱ statisticalȱ analysesȱ wereȱ performedȱ usingȱ SASȱ softwareȱversionȱ9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ 3.3 Resultsȱ Duringȱtheȱstudyȱperiodȱaȱtotalȱofȱ1,486ȱparticipantsȱcompletedȱfollowȬupȱvisits,ȱ includingȱ 527ȱ (35%)ȱ womenȱ andȱ 497ȱ (33%)ȱ personsȱ whoȱ identifiedȱ asȱ beingȱ ofȱ Aboriginalȱ ancestry.ȱ Theȱ medianȱ ageȱ ofȱ participantsȱ atȱ baselineȱ wasȱ 42ȱ yearsȱ (interquartileȱ rangeȱ [IQR]ȱ =ȱ 35Ȭ48).ȱThisȱ sampleȱ contributedȱ 3,994ȱ observations:ȱ 1,237ȱ observationsȱ fitȱ theȱcriteriaȱ forȱnoȱexposure,ȱ1,121ȱobservationsȱ fitȱ theȱcriteriaȱ forȱ lowȱ exposure,ȱ779ȱobservationsȱfitȱtheȱcriteriaȱforȱmoderateȱexposureȱandȱ757ȱobservationsȱ fitȱtheȱcriteriaȱforȱhighȱdrugȱsceneȱexposure.ȱTheȱmedianȱnumberȱofȱfollowȬupȱvisitsȱwasȱ 3ȱ (IQR=ȱ 2Ȭ4),ȱ andȱ 1157ȱ (77.9%)ȱ participantsȱ completedȱ atȱ leastȱ twoȱ studyȱ visits.ȱ Theȱ baselineȱcharacteristicsȱofȱ theȱstudyȱsampleȱstratifiedȱbyȱ levelȱofȱdrugȱsceneȱexposureȱ areȱpresentedȱ inȱTableȱ3.1.ȱ Inȱ thisȱbaselineȱ table,ȱ characteristicsȱ forȱ individualsȱ fittingȱ theȱ criteriaȱ forȱ eitherȱ low,ȱmoderateȱ orȱ highȱdrugȱ sceneȱ exposureȱwereȱmeasuredȱ atȱ theirȱfirstȱvisitȱ(duringȱtheȱstudyȱperiod,ȱDecȱ2005ȱ––Marchȱ2009)ȱwhichȱinvolvedȱaȱreportȱ ofȱlow,ȱmoderateȱorȱhighȱdrugȱsceneȱexposure.ȱCharacteristicsȱforȱparticipantsȱinȱtheȱ‘‘noȱ exposure’’ȱcategoryȱwereȱmeasuredȱfromȱtheȱfirstȱstudyȱvisitȱduringȱtheȱstudyȱperiod.ȱ TheȱunivariateȱGEEȱanalysesȱofȱbehaviouralȱandȱsocioȬdemographicȱvariablesȱareȱ presentedȱinȱTableȱ3.2,ȱandȱtheȱmultivariateȱGEEȱanalysesȱareȱshownȱinȱTableȱ3.3.ȱFigureȱ ȱȱ 57 3.1ȱshowsȱaȱselectionȱofȱbehaviouralȱandȱdrugȱuseȱ factorsȱassociatedȱwithȱeachȱofȱ theȱ threeȱ levelsȱ ofȱdrugȱ sceneȱ exposureȱ (note:ȱunstableȱhousingȱwasȱnotȱ includedȱ inȱ theȱ figureȱ dueȱ toȱ theȱ largeȱ scaleȱ differenceȱ inȱAOR).ȱ Inȱmultivariateȱ analyses,ȱ unstableȱ housingȱwasȱ significantlyȱ associatedȱwithȱ allȱ levelsȱ ofȱ drugȱ sceneȱ exposureȱ andȱ theȱ strengthȱofȱ theȱassociationȱ increasedȱ fromȱ lowȱ (adjustedȱoddsȱ ratioȱ [AOR]ȱ=ȱ3.10,ȱCI:ȱ 2.52––3.80)ȱ toȱmoderateȱ (AORȱ=ȱ3.73,ȱCI:ȱ 2.92––4.77)ȱ toȱhighȱ exposureȱ (AORȱ=ȱ9.50,ȱCI:ȱ 6.36––14.20).ȱ Similarly,ȱ theȱ associationsȱ betweenȱ drugȱ sceneȱ exposureȱ andȱ drugȱ useȱ practicesȱ increasedȱwithȱ levelȱ ofȱ exposure.ȱDailyȱ crackȱ cocaineȱ useȱwasȱ significantlyȱ associatedȱwithȱallȱ levelsȱofȱdrugȱ sceneȱ exposureȱandȱ thisȱassociationȱ increasedȱ fromȱ lowȱ(AORȱ=1.49,ȱCI:ȱ1.20Ȭ1.85)ȱtoȱmoderateȱ(AORȱ=1.90,ȱCI:ȱ1.50Ȭ2.40)ȱtoȱhighȱexposureȱ (AORȱ=2.70,ȱCI:ȱ2.07Ȭ3.52).ȱDailyȱheroinȱ injectionȱwasȱnotȱsignificantlyȱassociatedȱwithȱ lowȱdrugȱsceneȱexposureȱ(AORȱ=0.82,ȱCI:ȱ0.63Ȭ1.08),ȱbutȱbecameȱsignificantlyȱassociatedȱ withȱmoderateȱ exposureȱ (AORȱ =1.43,ȱ CI:ȱ 1.07Ȭ1.91),ȱ andȱ theȱ strengthȱ ofȱ associationȱ increasedȱwithȱhighȱexposureȱ(AORȱ=1.84,ȱCI:ȱ1.37Ȭ2.47).ȱDailyȱcocaineȱinjectionȱwasȱnotȱ significantlyȱ associatedȱwithȱ lowȱ (AORȱ =0.87,ȱCI:ȱ 0.60Ȭ1.26)ȱ orȱmoderateȱ drugȱ sceneȱ exposureȱ(AORȱ=1.09,ȱCI:ȱ0.72Ȭ1.64)ȱbutȱbecameȱsignificantȱwithȱhighȱexposureȱ(AORȱ=ȱ 1.73,ȱCI:ȱ1.15Ȭ2.61).ȱLikewise,ȱbeingȱaȱvictimȱofȱviolence,ȱhavingȱencountersȱwithȱpolice,ȱ andȱinvolvementȱinȱdrugȱdealingȱwereȱnotȱassociatedȱwithȱlowȱdrugȱsceneȱexposureȱbutȱ becameȱ significantȱ forȱ bothȱmoderateȱ andȱ highȱ exposureȱ (seeȱ Tableȱ 3.3).ȱAboriginalȱ ancestryȱalsoȱwasȱnotȱsignificantlyȱassociatedȱwithȱlowȱdrugȱsceneȱexposureȱbutȱbecameȱ significantȱ withȱ bothȱ moderateȱ andȱ highȱ exposure.ȱ Regularȱ employmentȱ wasȱ ȱȱ 58 significantlyȱ negativelyȱ associatedȱwithȱ allȱ levelsȱ ofȱ drugȱ sceneȱ exposure.ȱAlthoughȱ addictionȱ treatmentȱwasȱnotȱsignificantlyȱassociatedȱwithȱ lowȱdrugȱsceneȱexposure,ȱ itȱ becameȱsignificantlyȱnegativelyȱassociatedȱwithȱmoderateȱandȱhighȱexposure.ȱȱ 3.4 Discussionȱ Inȱ thisȱ studyȱweȱ foundȱ thatȱ drugȱ sceneȱ exposureȱwasȱ associatedȱ inȱ aȱ doseȬ dependentȱ fashionȱwithȱmultipleȱmarkersȱofȱvulnerabilityȱtoȱharmȱandȱadverseȱhealthȱ outcomes,ȱ includingȱ beingȱ unstablyȱ housed,ȱ beingȱ aȱ victimȱ ofȱ violence,ȱ havingȱ encountersȱwithȱpoliceȱandȱparticipatingȱinȱdrugȱdealing.ȱDrugȱsceneȱexposureȱwasȱalsoȱ associatedȱwithȱhigherȱintensityȱdrugȱuse.ȱIndividualsȱwhoȱreportedȱhighȱlevelsȱofȱdrugȱ sceneȱ exposureȱwereȱ significantlyȱmoreȱ likelyȱ toȱ injectȱ cocaineȱandȱheroinȱonȱaȱdailyȱ basis,ȱ andȱdailyȱ crackȱ cocaineȱ smokingȱwasȱ significantlyȱ associatedȱwithȱ allȱ levelsȱofȱ drugȱ sceneȱ exposure.ȱTheseȱ associations,ȱ inȱmostȱ instances,ȱ alsoȱ increasedȱ inȱ aȱdoseȬ dependentȱ fashionȱwithȱ greaterȱ exposureȱ toȱ drugȱ scenes.ȱ Theȱ doseȬdependentȱ effectȱ wasȱparticularlyȱstrongȱforȱunstableȱhousing,ȱintensityȱofȱdrugȱuseȱandȱencountersȱwithȱ police.ȱ Ourȱ analysisȱ furtherȱ foundȱ thatȱ employmentȱ andȱ addictionȱ treatmentȱ wereȱ associatedȱwithȱdecreasedȱdrugȱsceneȱexposure.ȱȱ Ourȱ findingȱ thatȱpeopleȱwithȱgreaterȱ levelsȱofȱdrugȱ sceneȱexposureȱwereȱmoreȱ likelyȱ toȱbeȱhigherȱ intensityȱdrugȱusersȱandȱhaveȱmultipleȱmarkersȱofȱvulnerabilityȱ isȱ consistentȱwithȱ aȱ broaderȱ literatureȱ highlightingȱ theȱ relationshipȱ betweenȱ structuralȱ environmentalȱfactorsȱ(i.e.,ȱdrugȱuseȱsettingsȱandȱtheȱlawsȱandȱpoliciesȱregulatingȱdrugȱ ȱȱ 59 use)ȱandȱhealthȱbehavioursȱandȱoutcomes.71,ȱ 73,ȱ 75Ȭ78,ȱ 78,ȱ 79,ȱ 84,ȱ 190,ȱ 195Ȭ197ȱ ȱHowever,ȱpreviousȱ workȱlookingȱatȱtheȱimpactȱofȱdrugsȱscenesȱhasȱhistoricallyȱfocusedȱonȱinvolvementȱinȱ drugȱscenesȱinȱtheȱcontextȱofȱspecificȱbehavioursȱsuchȱasȱincomeȱgenerationȱacts,4,ȱ7,ȱ10,ȱ57Ȭ59ȱ publicȱ injecting61Ȭ65ȱ andȱdrugȱ sceneȱ roles.186ȱ ȱOurȱ studyȱ isȱuniqueȱ inȱ thatȱ itȱ considersȱ exposureȱtoȱdrugȱscenesȱindependentȱofȱengagementȱinȱspecificȱactivities.ȱȱ Aȱ keyȱ implicationȱ ofȱ ourȱ findingsȱ isȱ thatȱ theȱ negativeȱ impactsȱ ofȱ streetȬbasedȱ drugȱ scenesȱ areȱ notȱ feltȱ onlyȱ byȱ surroundingȱ communitiesȱ andȱ theȱ generalȱ public.ȱ Rather,ȱstreetȬbasedȱdrugȱscenesȱhaveȱsignificantȱnegativeȱhealthȱandȱsocialȱimplicationsȱ forȱpeopleȱwhoȱareȱexposedȱtoȱthem,ȱandȱtheseȱnegativeȱeffectsȱappearȱtoȱincreaseȱwithȱ greaterȱ levelsȱ ofȱ drugȱ sceneȱ exposure.ȱ ȱ Thisȱ suggestsȱ thatȱ effortsȱ toȱ reduceȱ streetȱ disorderȱhaveȱpotentialȱtoȱbenefitȱpeopleȱwhoȱareȱengagedȱinȱdrugȱscenes,ȱasȱwellȱasȱtheȱ broaderȱcommunity.ȱ ȱ Itȱ isȱ importantȱ toȱ recognizeȱ that,ȱ toȱdate,ȱ interventionsȱ toȱaddressȱdrugȬrelatedȱ streetȱdisorderȱhaveȱlargelyȱreliedȱonȱlawȱenforcementȱbasedȱapproachesȱthatȱhaveȱbeenȱ shownȱtoȱbeȱlimitedȱinȱtheirȱabilityȱtoȱmeaningfullyȱaddressȱstreetȱdisorder.62,ȱ63,ȱ69,ȱ106,ȱ110,ȱ 198Ȭ200ȱȱFurthermore,ȱmanyȱlawȱenforcementȱbasedȱstrategiesȱhaveȱalsoȱbeenȱlinkedȱwithȱ negativeȱ individualȱandȱ communityȱoutcomes.59,ȱ 59,ȱ 107,ȱ 111,ȱ 133ȱ ȱ Innovativeȱ solutionsȱ thatȱ bothȱ reduceȱ drugȬrelatedȱ streetȱ disorderȱ andȱ protectȱ theȱ healthȱ ofȱ peopleȱ whoȱ areȱ engagedȱinȱdrugȱscenesȱareȱthereforeȱrequired.ȱȱ ȱȱ 60 Inȱtheȱcurrentȱanalysis,ȱtheȱrelationshipȱbetweenȱemploymentȱandȱreducedȱdrugȱ sceneȱ exposureȱ isȱ consistentȱ withȱ previousȱ researchȱ demonstratingȱ theȱ positiveȱ influenceȱofȱemploymentȱonȱsocialȱintegrationȱandȱhealthȱoutcomes172,ȱ201Ȭ203ȱandȱsuggestsȱ thatȱ interventionsȱ inȱ thisȱ areaȱmayȱ helpȱ toȱ addressȱ streetȱ disorderȱ andȱ drugȱ sceneȱ exposure.ȱ ȱHowever,ȱ existingȱ employmentȱ programsȱ forȱ peopleȱwhoȱ useȱ drugsȱ areȱ oftenȱlinkedȱwithȱaddictionȱtreatmentȱobjectivesȱandȱintendedȱtoȱengageȱparticipantsȱinȱ regularȱ steadyȱ employmentȱ andȱ abstinenceȱ fromȱ illicitȱ drugȱ use.172,ȱ 204ȱ ȱ Theseȱ programmaticȱ conditionsȱ andȱ goalsȱ areȱ notȱ suitableȱ orȱ realisticȱ forȱ manyȱ streetȱ entrenchedȱdrugȱusers.170,ȱ 175ȱ ȱAlternatively,ȱ lowȬthresholdȱemploymentȱprogramsȱ thatȱ doȱ notȱ requireȱ abstinenceȱ fromȱ drugȱ useȱmayȱ provideȱ importantȱ benefitsȱ forȱ IDU,ȱ includingȱ aȱ reductionȱ inȱ exposureȱ toȱ streetȬbasedȱdrugȱ scenes.175,ȱ 205,ȱ 206ȱ ȱTheȱpotentialȱ relationshipȱ betweenȱ streetȱ disorderȱ andȱ lowȬthresholdȱ employmentȱ isȱ anȱ areaȱ thatȱ shouldȱbeȱconsideredȱforȱfutureȱstudy.ȱ Ourȱ findingsȱ relatedȱ toȱ unstableȱ housingȱ provideȱ additionalȱ directionȱ forȱ theȱ developmentȱofȱpolicyȱoptionsȱ thatȱmightȱhelpȱ toȱaddressȱexposureȱ toȱstreetȱdisorder.ȱ Specifically,ȱ providingȱ stableȱ housingȱ toȱ homelessȱ peopleȱ whoȱ useȱ drugsȱ isȱ oneȱ promisingȱapproachȱtoȱdecreaseȱstreetȱdisorderȱandȱexposureȱtoȱdrugȱscenes.ȱHowever,ȱ itȱisȱnotableȱthatȱinȱadditionȱtoȱoutrightȱhomelessnessȱourȱdefinitionȱofȱunstableȱhousingȱ includedȱ livingȱ inȱ singleȱ roomȱ occupancyȱ hotelsȱ asȱwellȱ asȱ treatmentȱ andȱ recoveryȱ homes,ȱsuggestingȱthatȱitȱisȱnotȱjustȱpeopleȱwhoȱareȱhomelessȱwhoȱareȱgeneratingȱstreetȱ disorder.ȱ Forȱ instance,ȱ spaceȱ constraintsȱ andȱ regulatoryȱ policiesȱwithinȱ singleȱ roomȱ ȱȱ 61 occupancyȱ hotelsȱ andȱ recoveryȱ housesȱ (i.e.,ȱ guestȱ fees,ȱ andȱ bansȱ onȱ substanceȱ useȱ and/orȱintoxicationȱonȱtheȱpremises)ȱmayȱdeterȱdrugȱusersȱfromȱspendingȱtimeȱinȱtheirȱ placeȱofȱresidenceȱandȱtherebyȱcontributeȱtoȱstreetȱdisorder.207ȱ ȱFurtherȱexaminationȱofȱ theȱ roleȱ thatȱ spaceȱ constraintsȱ andȱ restrictiveȱ regulatoryȱ policiesȱ mayȱ playȱ inȱ encouragingȱexposureȱtoȱdrugȱscenesȱwouldȱbeȱbeneficial.ȱȱ Finally,ȱourȱ findingȱ thatȱ thoseȱmoreȱ involvedȱ inȱ theȱ localȱdrugȱsceneȱwereȱ lessȱ likelyȱtoȱbeȱreceivingȱaddictionȱtreatmentȱsuggestsȱthatȱeffortsȱtoȱencourageȱaccessȱandȱ engagementȱ inȱ addictionȱ treatmentȱ mayȱ furtherȱ helpȱ toȱ reduceȱ streetȱ disorder.ȱ Innovativeȱ addictionȱ treatmentȱmethodsȱmayȱ beȱ requiredȱ asȱ theȱ longȬtermȱdrugȱuseȱ patternsȱ ofȱ IDUȱ suggestȱ thatȱ currentȱ treatmentȱ modalitiesȱ haveȱ limitedȱ successȱ inȱ sustainingȱ injectionȱ cessationȱ amongȱ aȱ largeȱproportionȱ ofȱ establishedȱ injectionȱdrugȱ users.166ȱFurthermore,ȱ theȱrapidȱ increaseȱ inȱcrackȱcocaineȱuseȱ inȱourȱstudyȱsettingȱandȱ elsewhereȱsuggestsȱthatȱaddictionȱtreatmentȱforȱstimulantȱusersȱisȱanȱemergingȱpriority.ȱ Inȱ theȱVancouverȱsetting,ȱourȱanalysisȱalsoȱsuggestsȱ thatȱ toȱbeȱeffective,ȱ interventionsȱ mustȱbeȱculturallyȱsensitiveȱandȱappropriateȱforȱAboriginalȱpeopleȱwhoȱuseȱdrugs.ȱȱThisȱ willȱ likelyȱ requireȱ tailoringȱ interventionsȱ withȱ theȱ directȱ inputȱ ofȱ drugȱ usersȱ whoȱ identifyȱasȱbeingȱofȱAboriginalȱancestry.ȱȱȱ Thereȱ areȱaȱnumberȱofȱ limitationsȱ inȱourȱ study.ȱFirstly,ȱourȱ studyȱ sampleȱwasȱ communityȱ recruitedȱ andȱ notȱ aȱ randomȱ sampleȱ ofȱ peopleȱ whoȱ injectȱ drugs.ȱ Itȱ is,ȱ however,ȱ believedȱ toȱ beȱ reflectiveȱ ofȱ theȱ populationȱ ofȱ injectionȱ drugȱ usersȱ inȱ theȱ ȱȱ 62 community.208ȱȱSecondly,ȱalthoughȱtheȱcurrentȱstudyȱshowsȱthatȱdrugȱsceneȱexposureȱisȱ associatedȱwithȱmultipleȱ riskȱ factorsȱ forȱnegativeȱhealthȱ outcomes,ȱ theȱnatureȱ ofȱ ourȱ observationalȱ studyȱ canȱ notȱ untangleȱ whetherȱ theseȱ relationshipsȱ areȱ revealingȱ antecedentȱ causes,ȱ orȱ consequencesȱ ofȱ exposureȱ toȱ drugȱ scenes.ȱ ȱ Withȱ respectȱ toȱ antecedentȱ causes,ȱ theȱ relationshipȱ betweenȱ housingȱ andȱ drugȱ sceneȱ exposureȱ isȱ consistentȱ withȱ aȱ wellȱ establishedȱ literatureȱ demonstratingȱ thatȱ housingȱ isȱ aȱ keyȱ influenceȱonȱhealthȱstatusȱamongȱdrugȱusingȱpopulations.183,ȱ209Ȭ211ȱInȱourȱstudyȱcontext,ȱ unstableȱ housingȱ conditionsȱ (whichȱ includedȱ outrightȱ homelessness)ȱ mayȱ leadȱ toȱ exposureȱtoȱandȱimmersionȱinȱopenȱdrugȱscenes.ȱHowever,ȱindividualsȱwhoȱareȱstablyȱ housedȱmayȱbecomeȱinvolvedȱinȱopenȱdrugȱscenesȱthroughȱotherȱmechanismsȱandȱthisȱ immersionȱ mayȱ haveȱ aȱ destabilizingȱ influenceȱ thatȱ couldȱ leadȱ toȱ deteriorationȱ inȱ housingȱstatus.ȱSimilarly,ȱourȱanalysesȱcanȱnotȱdetermineȱwhetherȱtheȱelevatedȱintensityȱ ofȱdrugȱuseȱthatȱcoincidesȱwithȱexposureȱisȱbecauseȱhighȱintensityȱdrugȱuseȱpredisposesȱ individualsȱ toȱ becomeȱ immersedȱ inȱ openȱdrugȱ scenes,ȱ orȱ ifȱ exposureȱ toȱdrugȱ scenesȱ leadsȱ toȱ heightenedȱ drugȱ use.ȱ ȱ However,ȱ despiteȱ uncertaintyȱ regardingȱ theȱ causalȱ directionȱofȱ theȱobservedȱ relationships,ȱ itȱ remainsȱ clearȱ thatȱ exposureȱ toȱ streetȬbasedȱ drugȱscenesȱ isȱassociatedȱwithȱpublicȱhealthȱharms.ȱAnotherȱ limitationȱofȱourȱstudyȱ isȱ thatȱseveralȱofȱourȱmeasuresȱareȱbasedȱonȱselfȬreportingȱandȱareȱthereforeȱvulnerableȱtoȱ sociallyȱ desirableȱ respondingȱ andȱ recallȱ bias.ȱ Inȱ theȱ currentȱ studyȱ sociallyȱ desirableȱ respondingȱmayȱhaveȱledȱtoȱanȱunderestimationȱofȱriskȱbehaviourȱandȱexposureȱtoȱdrugȱ scenesȱ suggestingȱ thatȱ ourȱ estimatesȱ areȱ conservative.ȱ Althoughȱ recallȱ issuesȱ areȱ ȱȱ 63 particularlyȱrelevantȱtoȱourȱmeasuresȱforȱexposureȱtoȱstreetȱdisorder,ȱweȱhaveȱnoȱreasonȱ toȱ suspectȱ thisȱwouldȱ systematicallyȱdifferȱ amongȱ exposuresȱofȱ interest.ȱTherefore,ȱ ifȱ recallȱissuesȱareȱpresentȱweȱwouldȱsuspectȱthisȱwouldȱbiasȱourȱresultsȱtowardsȱtheȱnull.ȱȱȱȱ Inȱ summary,ȱ increasedȱexposureȱ toȱ streetȬbasedȱdrugȱ scenesȱ isȱassociatedȱwithȱ increasedȱvulnerabilityȱandȱintensityȱofȱaddiction,ȱsuggestingȱthatȱbothȱindividualȱdrugȱ usersȱ andȱ surroundingȱ communitiesȱ areȱnegativelyȱ impactedȱbyȱ streetȱdisorder.ȱThisȱ suggestsȱ thatȱ reducingȱ streetȱ disorderȱ andȱ exposureȱ toȱ itȱ canȱ haveȱ aȱwideȱ rangeȱ ofȱ publicȱ healthȱ andȱ communityȱ benefits.ȱ Theseȱ findingsȱ highlightȱ importantȱ opportunitiesȱforȱpolicyȱinterventionsȱtoȱaddressȱexposureȱtoȱstreetȱdisorderȱinȱtheȱareasȱ ofȱemployment,ȱhousingȱandȱaddictionȱtreatment.ȱȱ ȱTableȱ3.1ȱBaselineȱcharacteristicsȱofȱsampleȱstratifiedȱbyȱlevelȱofȱdrugȱsceneȱexposureȱ [nȱ=ȱ1486]ȱ  Levelȱofȱdrugȱsceneȱexposureȱa Characteristicȱbȱ NoȱExposureȱ n=ȱ490,ȱnȱ(%)ȱ LowȱExposureȱ n=ȱ405,ȱnȱ(%)ȱ ModerateȱExpo.ȱ n=ȱ277,ȱnȱ(%)ȱ Highȱ Exposureȱ n=ȱ314,ȱnȱ(%)ȱ Medianȱageȱ(IQR)ȱȱ 43ȱ(36Ȭ49) 43ȱ(38Ȭ49) 42ȱ(35Ȭ48) 38ȱ(31Ȭ44) FemaleȱGenderȱȱ 183ȱ (37) 136ȱ (34) 91ȱ (33) 117ȱ (37) AboriginalȱAncestryȱȱ 139ȱ (28) 129ȱ (32) 98ȱ (35) 131ȱ (42) UnstableȱHousingȱcȱȱ 219ȱ (45) 325ȱ (80) 237ȱ (86) 302ȱ (96) DailyȱCocaineȱInjectȱcȱ 36ȱ (7) 28ȱ (7) 29ȱ (10) 53ȱ (17) DailyȱHeroinȱInjectȱcȱ 79ȱ (16) 70ȱ (17) 88ȱ (32) 149ȱ (47) DailyȱCrackȱUseȱcȱ 119ȱ (24) 146ȱ (36) 152ȱ (55) 212ȱ (68) Overdoseȱ(nonȬfatal)ȱcȱ 25ȱ (5) 16ȱ (4) 21ȱ (8) 31ȱ (10) SyringeȱSharingȱcȱ 46ȱ (9) 24ȱ (6) 17ȱ (6) 33ȱ (11) Encountersȱw/ȱPoliceȱdȱ 80ȱ (16) 92ȱ (23) 106ȱ (38) 144ȱ (46) VictimȱofȱViolenceȱcȱ 58ȱ (12) 83 (20) 79ȱ (29) 93ȱ (30) MultipleȱSexȱPartnerȱcȱ 64ȱ (13) 69ȱ (17) 64ȱ (23) 75ȱ (24) UnprotectedȱSexȱcȱ 161ȱ (33) 123ȱ (30) 89ȱ (32) 87ȱ (28) RegȱEmploymentȱcȱ 175ȱ (36) 88ȱ (22) 62ȱ (22) 45ȱ (14) SexȱWorkȱcȱ 38ȱ (8) 59ȱ (15) 48ȱ (17) 58ȱ (18) DrugȱDealingȱcȱ 90ȱ (18) 98ȱ (24) 112ȱ (40) 169ȱ (54) InȱTreatmentȱcȱ 277ȱ (57) 222ȱ (55) 115ȱ (42) 120ȱ (38) Notes:ȱaȱLevelsȱofȱdrugȱsceneȱexposureȱwereȱdefinedȱbasedȱonȱtheȱaverageȱnumberȱofȱhoursȱparticipantsȱ reportedȱspendingȱonȱtheȱstreetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicenterȱinȱtheȱpreviousȱsixȱmonths:ȱ ””noȱdrugȱ sceneȱexposure””ȱ includedȱ reportsȱofȱ1ȱhourȱorȱ less;ȱ““lowȱexposure””ȱ includedȱ reportsȱofȱ2Ȭ6ȱ hours;ȱ““moderateȱexposure””ȱ includedȱ reportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱ includedȱ reportsȱofȱ moreȱthanȱ15ȱhours.ȱbCharacteristicsȱforȱindividualsȱinȱtheȱlow,ȱmoderateȱandȱhighȱdrugȱsceneȱexposureȱ categoriesȱwereȱmeasuredȱ atȱ theirȱ firstȱvisitȱ (duringȱ theȱ studyȱperiod,ȱDecȱ 2005ȱ ––Marchȱ 2009)ȱwhichȱ involvedȱaȱreportȱofȱdrugȱsceneȱexposure.ȱCharacteristicsȱforȱparticipantsȱinȱtheȱ‘‘noȱexposure’’ȱcategoryȱ wereȱmeasuredȱ fromȱ theȱ firstȱ studyȱ visitȱ duringȱ theȱ studyȱ period;ȱ cȱDenotesȱ activitiesȱ orȱ situationsȱ referringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱmonth. ȱ ȱ 64 ȱTableȱ3.2ȱUnivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure*ȱ ȱ GEEaȱforȱLowȱvs.ȱNoȱ Exposureȱ ȱ GEEȱforȱModerateȱvs.ȱ NoȱExposureȱ ȱ GEEȱforȱHighȱvs.ȱNoȱ Exposureȱ ȱ Characteristicȱ ORȱ(95%ȱCI)ȱbȱ pȬvalue ORȱ(95%ȱCI)ȱ pȬvalueȱ ORȱ(95%ȱCI)ȱ pȬvalue OlderȱAgeȱȱ 1.00 (0.99 - 1.02)ȱ 0.457ȱ 0.99ȱ(0.97ȱȬȱ1.00)ȱ 0.017ȱ 0.95ȱ(0.93ȱȬȱ0.96)ȱ <.001ȱ Perȱyearȱolderȱ ȱ ȱ ȱ ȱ ȱ ȱ Genderȱȱ 0.87 (0.71 - 1.07)ȱ 0.183ȱ 0.95ȱ(0.76ȱȬȱ1.19)ȱ 0.659ȱ 1.03ȱ(0.81ȱȬȱ1.30)ȱ 0.836ȱ Femaleȱvs.ȱMaleȱ ȱ ȱ ȱ ȱ ȱ ȱ AboriginalȱAncestryȱȱ 1.11 (0.90 - 1.36)ȱ 0.330ȱ 1.34ȱ(1.06ȱȬȱ1.68)ȱ 0.013ȱ 1.52ȱ(1.19ȱȬȱ1.93)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ UnstableȱHousingȱcȱ 3.29 (2.71 - 4.01)ȱ <.001ȱ 4.22ȱ(3.36ȱȬȱ5.31)ȱ <.001ȱ 11.25ȱ(7.97Ȭ15.88)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱCocaineȱInjectȱcȱ 1.07 (0.76 - 1.51)ȱ 0.680ȱ 1.37ȱ(0.99ȱȬȱ1.91)ȱ 0.060ȱ 1.95ȱ(1.46ȱȬȱ2.59)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱHeroinȱInjectȱcȱ 0.99 (0.78 - 1.27)ȱ 0.963ȱ 2.19ȱ(1.71ȱȬȱ2.80)ȱ <.001ȱ 3.09ȱ(2.45ȱȬȱ3.89)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱCrackȱUseȱcȱ 1.87 (1.53 - 2.27)ȱ <.001ȱ 2.71ȱ(2.20ȱȬȱ3.33)ȱ <.001ȱ 4.09ȱ(3.32ȱȬȱ5.04)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ Overdoseȱ(nonȬfatal)ȱcȱ 0.74 (0.49 - 1.12)ȱ 0.152ȱ 1.32ȱ(0.94ȱȬȱ1.87)ȱ 0.108ȱ 1.38ȱ(1.04ȱȬȱ1.84)ȱ 0.026ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ SyringeȱSharingȱcȱ 0.96 (0.68 - 1.33)ȱ 0.788ȱ 1.19ȱ(0.84ȱȬȱ1.68)ȱ 0.318ȱ 1.16ȱ(0.86ȱȬȱ1.56)ȱ 0.331ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ EncountersȱwithȱPoliceȱdȱ 1.36 (1.10 - 1.69)ȱ 0.004ȱ 2.01ȱ(1.63ȱȬȱ2.48)ȱ <.001ȱ 2.30ȱ(1.88ȱȬȱ2.82)ȱ <.001ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ VictimȱofȱViolenceȱcȱ 1.22 (0.97 - 1.53)ȱ 0.092ȱ 1.76ȱ(1.45ȱȬȱ2.13)ȱ <.001ȱ 1.70ȱ(1.42ȱȬȱ2.02)ȱ <.001ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ MultipleȱSexȱPartnersȱcȱ 1.09 (0.86 - 1.38)ȱ 0.477ȱ 1.34ȱ(1.05ȱȬȱ1.72)ȱ 0.019ȱ 1.44ȱ(1.17ȱȬȱ1.78)ȱ <.001ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ UnprotectedȱSexȱcȱ 0.88 (0.73 - 1.06)ȱ 0.176ȱ 0.92ȱ(0.76ȱȬȱ1.12)ȱ 0.420ȱ 0.92ȱ(0.76ȱȬȱ1.10)ȱ 0.347ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ RegularȱEmploymentȱcȱ 0.67 (0.55 - 0.81)ȱ <.001ȱ 0.61ȱ(0.50ȱȬȱ0.75)ȱ <.001ȱ 0.47ȱ(0.39ȱȬȱ0.57)ȱ <.001ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ SexȱWorkȱcȱ 1.70 (1.29 - 2.23)ȱ <.001ȱ 1.99ȱ(1.50ȱȬȱ2.65)ȱ <.001ȱ 2.09ȱ(1.56ȱȬȱ2.79)ȱ <.001ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ DrugȱDealingȱcȱ 1.37 (1.12 - 1.67)ȱ 0.002ȱ 2.06ȱ(1.66ȱȬȱ2.55)ȱ <.001ȱ 2.91ȱ(2.40ȱȬȱ3.55)ȱ <.001ȱ Yesȱvs.ȱNoȱ   ȱ ȱ ȱ ȱ AddictionȱTreatmentȱcȱ 1.10 (0.92 - 1.30)ȱ 0.293ȱ 0.75ȱ(0.63ȱȬȱ0.91)ȱ 0.003ȱ 0.68ȱ(0.56ȱȬȱ0.82)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱȱ ȱ Note:ȱ aGEEȱ =ȱ Generalizedȱ Estimatingȱ Equation;ȱ bORȱ =ȱ Oddsȱ Ratio;ȱ CIȱ =ȱ Confidenceȱ Interval;ȱ cȱ Denotesȱ activitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ month.*Levelsȱ ofȱdrugȱ sceneȱ exposureȱwereȱdefinedȱ basedȱ onȱ theȱnumberȱ ofȱhoursȱparticipantsȱ reportedȱ spendingȱonȱaverageȱonȱ theȱstreetȱeachȱdayȱ inȱVancouver’’sȱdrugȱuseȱepicenterȱ inȱ theȱpreviousȱsixȱmonths:ȱ ””noȱdrugȱsceneȱexposure””ȱincludedȱreportsȱofȱ1ȱhourȱorȱless;ȱ““lowȱexposure””ȱincludedȱreportsȱofȱ2Ȭ6ȱhours;ȱ ““moderateȱexposure””ȱincludedȱreportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱincludedȱreportsȱofȱmoreȱthanȱ15ȱ hours.ȱȱ ȱ ȱ ȱ 65 ȱTableȱ3.3ȱMultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure*ȱ ȱ GEEȱforȱLowȱvs.ȱNoȱ Exposureȱ ȱ GEEȱforȱModerateȱvs.ȱNoȱ Exposureȱ ȱ GEEȱforȱHighȱvs.ȱNoȱ Exposureȱ ȱ Characteristicȱ AORȱȱ(95%ȱCI)ȱbȱ pȬvalueȱ AORȱ(95%ȱCI)ȱ pȬvalueȱ AORȱ(95%ȱCI)ȱ pȬvalueȱ OlderȱAgeȱȱ 1.01ȱ(1.00ȱȬȱ1.02)ȱ 0.071ȱ 1.00ȱ(0.99ȱȬȱ1.02)ȱ 0.684ȱ 0.97ȱ(0.96ȱȬȱ0.99)ȱ <.001ȱ Perȱyearȱolderȱ ȱ ȱ ȱ ȱ ȱ ȱ AboriginalȱAncestryȱȱ 1.19ȱ(0.96ȱȬȱ1.48)ȱ 0.105ȱ 1.52ȱ(1.18ȱȬȱ1.95)ȱ 0.001ȱ 1.74ȱ(1.30ȱȬȱ2.34)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ UnstableȱHousingȱcȱȱ 3.10ȱ(2.52ȱȬȱ3.80)ȱ <.001ȱ 3.73ȱ(2.92ȱȬȱ4.77)ȱ <.001ȱ 9.50ȱ(6.36ȱȬȱ14.20)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱCocaineȱInjectȱcȱ 0.87ȱ(0.60ȱȬȱ1.26)ȱ 0.461ȱ 1.09ȱ(0.72ȱȬȱ1.64)ȱ 0.680ȱ 1.73ȱ(1.15ȱȬȱ2.61)ȱ 0.009ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱHeroinȱInjectȱcȱ 0.82ȱ(0.63ȱȬȱ1.08)ȱ 0.154ȱ 1.43ȱ(1.07ȱȬȱ1.91)ȱ 0.014ȱ 1.84ȱ(1.37ȱȬȱ2.47)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱCrackȱUseȱcȱ 1.49ȱ(1.20ȱȬȱ1.85)ȱ <.001ȱ 1.90ȱ(1.50ȱȬȱ2.40)ȱ <.001ȱ 2.70ȱ(2.07ȱȬȱ3.52)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ Overdoseȱ(nonȬfatal)ȱcȱ 0.62ȱ(0.40ȱȬȱ0.96)ȱ 0.031ȱ 0.94ȱ(0.62ȱȬȱ1.44)ȱ 0.783ȱ 0.85ȱ(0.57ȱȬȱ1.25)ȱ 0.400ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ EncountersȱwithȱPoliceȱdȱ 1.25ȱ(0.99ȱȬȱ1.57)ȱ 0.061ȱ 1.63ȱ(1.28ȱȬȱ2.08)ȱ <.001ȱ 2.11ȱ(1.62ȱȬȱ2.75)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ VictimȱofȱViolenceȱcȱ 1.12ȱ(0.88ȱȬȱ1.44)ȱ 0.365ȱ 1.50ȱ(1.19ȱȬȱ1.89)ȱ <.001ȱ 1.49ȱ(1.14ȱȬȱ1.95)ȱ 0.003ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ MultipleȱSexȱPartnersȱcȱ 1.05ȱ(0.82ȱȬȱ1.36)ȱ 0.693ȱ 1.11ȱ(0.83ȱȬȱ1.49)ȱ 0.489ȱ 1.17ȱ(0.85ȱȬȱ1.61)ȱ 0.341ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ RegularȱEmploymentȱcȱ 0.77ȱ(0.63ȱȬȱ0.94)ȱ 0.010ȱ 0.75ȱ(0.60ȱȬȱ0.95)ȱ 0.015ȱ 0.50ȱ(0.38ȱȬȱ0.65)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ SexȱWorkȱcȱ 1.44ȱ(1.08ȱȬȱ1.92)ȱ 0.013ȱ 1.63ȱ(1.20ȱȬȱ2.21)ȱ 0.002ȱ 1.28ȱ(0.88ȱȬȱ1.86)ȱ 0.202ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ DrugȱDealingȱcȱ 1.05ȱ(0.84ȱȬȱ1.33)ȱ 0.655ȱ 1.35ȱ(1.05ȱȬȱ1.73)ȱ 0.019ȱ 1.46ȱ(1.14ȱȬȱ1.87)ȱ 0.003ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ AddictionȱTreatmentȱcȱ 1.04ȱ(0.86ȱȬȱ1.25)ȱ 0.688ȱ 0.69ȱ(0.56ȱȬȱ0.85)ȱ <.001ȱ 0.58ȱ(0.45ȱȬȱ0.75)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ Note:ȱ aGEEȱ=ȱGeneralizedȱEstimatingȱEquation;ȱ bAORȱ=ȱAdjustedȱOddsȱRatio;ȱCIȱ=ȱConfidenceȱ Interval;ȱ cȱDenotesȱ activitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱmonth.ȱ *Levelsȱ ofȱ drugȱ sceneȱ exposureȱwereȱ definedȱ basedȱ onȱ theȱ numberȱ ofȱ hoursȱ participantsȱ reportedȱ spendingȱ onȱ averageȱ onȱ theȱ streetȱ eachȱ dayȱ inȱVancouver’’sȱ drugȱ useȱ epicenterȱ inȱ theȱ previousȱ sixȱmonths:ȱ ””noȱ drugȱ sceneȱ exposure””ȱ includedȱreportsȱofȱ1ȱhourȱorȱ less;ȱ““lowȱexposure””ȱ includedȱreportsȱofȱ2Ȭ6ȱhours;ȱ““moderateȱexposure””ȱ includedȱreportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱincludedȱreportsȱofȱmoreȱthanȱ15ȱhours.ȱ **Theȱ‘‘noȱexposure’’ȱcategoryȱincludedȱ1,237ȱobservations,ȱtheȱ‘‘lowȱexposure’’ȱcategoryȱincludedȱ1,121ȱobservations,ȱ theȱ ‘‘moderateȱ exposure’’ȱ categoryȱ includedȱ 779ȱ observations,ȱ andȱ theȱ ‘‘highȱ exposure’’ȱ categoryȱ includedȱ 757ȱ observations.ȱ ȱ***Allȱmodelsȱwereȱadjustedȱforȱtheȱmonthȱeachȱinterviewȱwasȱconducted.ȱ ȱ ȱ 66 ȱFigureȱ3.1ȱFactorsȱassociatedȱwithȱdrugȱsceneȱexposureȱ Factors Associated with Drug Scene Exposure 0 1 2 3 4 Low Med High Low Med High Low Med High Low Med High Low Med High Low Med High Low Med High Low Med High Daily Cocaine Injection Daily Heroin Injection Daily Crack Use Drug Dealing Encounters with Police Victim of Violence Regular Employment Addiction Treatment Levels of Drug Scene Exposure Ad ju st ed  O dd s R at io ȱ *Levelsȱ ofȱ drugȱ sceneȱ exposureȱ wereȱ definedȱ basedȱ onȱ theȱ numberȱ ofȱ hoursȱ participantsȱ reportedȱ spendingȱonȱaverageȱonȱtheȱstreetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicentreȱinȱtheȱpreviousȱsixȱmonths.ȱ Allȱaboveȱestimatesȱusedȱtheȱreferenceȱcategoryȱofȱ””noȱdrugȱsceneȱexposure””ȱdefinedȱasȱspendingȱ1ȱhourȱ orȱlessȱinȱVancouver’’sȱdrugȱscene.ȱ““Lowȱexposure””ȱincludedȱreportsȱofȱ2Ȭ6ȱhours;ȱ““moderateȱexposure””ȱ includedȱreportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱincludedȱreportsȱofȱmoreȱthanȱ15ȱhours.ȱȱ **Allȱmodelsȱwereȱadjustedȱforȱandȱincludedȱtheȱfollowingȱvariables:ȱage,ȱAboriginalȱancestry,ȱunstableȱ housing,ȱdailyȱcocaineȱinjection,ȱdailyȱheroinȱinjection,ȱdailyȱcrackȱcocaineȱuse,ȱdrugȱoverdose,ȱencountersȱ withȱ police,ȱ victimȱ ofȱ violence,ȱmultipleȱ sexȱ partners,ȱ regularȱ employment,ȱ sexȱwork,ȱ drugȱ dealing,ȱ addictionȱtreatment,ȱandȱmonthȱinterviewȱwasȱconducted.ȱ ȱ 67 ȱȱ 68 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ CHAPTER 4: ȱ THEȱVALIDITYȱOFȱREPORTINGȱWILLINGNESSȱTOȱUSEȱAȱ SUPERVISEDȱINJECTINGȱFACILITYȱONȱSUBSEQUENTȱPROGRAMȱ USEȱAMONGȱPEOPLEȱWHOȱUSEȱINJECTIONȱDRUGS3ȱ 4.1 Introductionȱ Illicitȱdrugȱuseȱcontinuesȱtoȱbeȱassociatedȱwithȱaȱbroadȱrangeȱofȱhealthȱandȱsocialȱ harmsȱ andȱ thereȱ isȱ growingȱ recognitionȱ thatȱ innovativeȱ interventionsȱ areȱ neededȱ toȱ addressȱproblemsȱinȱthisȱarea,ȱincludingȱdrugȬrelatedȱstreetȱdisorder.197,ȱ212Ȭ214ȱHowever,ȱ illicitȱdrugȱuse,ȱandȱparticularlyȱinjectionȱdrugȱuse,ȱisȱhighlyȱstigmatized,215Ȭ217ȱandȱitȱcanȱ beȱ difficultȱ toȱ determineȱ ifȱ aȱ proposedȱ interventionȱwillȱ beȱ acceptedȱ byȱ drugȱ usingȱ communities.218Ȭ221ȱ Oneȱ strategyȱ thatȱ hasȱ beenȱ employedȱ toȱ assessȱ theȱ levelȱ ofȱ acceptanceȱ ofȱ innovativeȱhealthȱprograms,ȱsuchȱasȱsupervisedȱinjectionȱfacilitiesȱ(SIF)ȱwhereȱinjectionȱ drugȱusersȱ canȱbringȱpreȬobtainedȱ illicitȱdrugsȱ andȱ injectȱunderȱ theȱ supervisionȱ ofȱ aȱ nurse,ȱhasȱbeenȱtoȱsurveyȱtheȱtargetȱpopulationȱandȱmeasureȱtheirȱwillingnessȱtoȱuseȱtheȱ proposedȱservice.222Ȭ224ȱAlthoughȱ thisȱapproachȱhasȱbeenȱusedȱ toȱdetermineȱacceptanceȱ ofȱsaferȱsupervisedȱinjectionȱfacilitiesȱinȱseveralȱsettingsȱincludingȱVancouver,ȱMontreal,ȱ SanȱFrancisco,ȱLondon,ȱIreland,ȱMelbourneȱandȱSydney,193,ȱ222,ȱ225Ȭ230ȱtheȱvalidityȱofȱtheseȱ ȱ 3ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱKerr,ȱT.,ȱ Lai,ȱC.,ȱBuxton,ȱJ.,ȱMontaner,ȱJ.,ȱWood,ȱE.ȱTheȱvalidityȱofȱreportingȱwillingnessȱtoȱuseȱ aȱsupervisedȱinjectingȱfacilityȱonȱsubsequentȱprogramȱuseȱamongȱpeopleȱuseȱwhoȱ useȱinjectionȱdrugs.ȱ ȱȱ 69 surveysȱhasȱnotȱbeenȱfullyȱevaluated.ȱToȱassessȱwhetherȱwillingnessȱmeasuresȱmayȱbeȱ effectiveȱ toolsȱ forȱplanningȱ theȱdeliveryȱofȱpublicȱhealthȱprogramsȱ forȱ injectionȱdrugȱ userȱ populationsȱ andȱ helpȱ determineȱ theȱ feasibilityȱ ofȱ innovativeȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder,ȱ weȱ soughtȱ toȱ determineȱ whetherȱmeasuresȱ ofȱ willingnessȱcollectedȱpriorȱtoȱtheȱopeningȱofȱaȱCanadianȱSIFȱaccuratelyȱpredictedȱ laterȱ useȱofȱtheȱprogram.ȱȱ 4.2 Methodsȱ Dataȱ forȱ thisȱ studyȱwereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱdescriptionȱ ofȱ theȱ studyȱpleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱInȱtheȱprimaryȱanalysis,ȱweȱassessedȱwhetherȱreportsȱofȱwillingnessȱtoȱuseȱaȱSIFȱ beforeȱtheȱprogramȱopenedȱwereȱassociatedȱwithȱsubsequentȱselfȬreportedȱattendanceȱatȱ theȱfacilityȱafterȱ itȱwasȱestablishedȱ inȱtheȱDowntownȱEastsideȱ(DTES)ȱofȱVancouverȱ inȱ Septemberȱ2003.ȱInitialȱwillingnessȱmeasuresȱwereȱassessedȱduringȱtheȱpreȬSIFȱperiodȱofȱ Decemberȱ2001ȱ––ȱMayȱ2003ȱbasedȱonȱ theȱquestion:ȱ““Ifȱaȱ supervisedȱ safeȱ injectionȱ siteȱ wasȱavailable,ȱwouldȱyouȱuseȱ it?””ȱ ȱ ‘‘Yes’’ȱ responsesȱwereȱcomparedȱ toȱ ‘‘No’’ȱ responses,ȱ andȱ individualsȱwhoȱ repliedȱ thatȱ theyȱwereȱ ‘‘Unsure’’ȱwereȱ assessedȱ inȱ subȬanalyses.ȱ AttendanceȱatȱtheȱfacilityȱwasȱmeasuredȱduringȱtheȱpostȬSIFȱperiodȱofȱDecemberȱ2003ȱ––ȱ Novemberȱ2005ȱbasedȱonȱtheȱquestion:ȱ““HaveȱyouȱeverȱusedȱtheȱInSiteȱSIS?””ȱȱ Ourȱ primaryȱ analysisȱ soughtȱ toȱ determineȱ whetherȱ thereȱ wasȱ aȱ significantȱ relationshipȱbetweenȱourȱmainȱdependentȱvariableȱofȱ interestȱ (attendanceȱ atȱ theȱ SIF)ȱ ȱȱ 70 andȱourȱprimaryȱindependentȱvariableȱ(priorȱreportȱofȱwillingnessȱtoȱattendȱaȱSIF).ȱToȱ considerȱthisȱassociationȱwhileȱevaluatingȱpotentialȱconfounders,ȱweȱaȱprioriȱselectedȱaȱ rangeȱ ofȱ secondaryȱ explanatoryȱ independentȱvariablesȱhypothesizedȱ toȱbeȱ associatedȱ withȱbothȱattendanceȱandȱinitialȱwillingnessȱtoȱattendȱbasedȱonȱpreviousȱresearch.193,ȱ222,ȱ 231ȱSecondaryȱexplanatoryȱ factorsȱ included:ȱageȱ (youngerȱ thanȱ39ȱyrsȱofȱageȱvs.ȱolder);ȱ genderȱ (femaleȱ vs.ȱmale);ȱ unstableȱ housing,ȱ definedȱ asȱ livingȱ inȱ aȱ singleȱ occupancyȱ roomȱinȱaȱhotel,ȱaȱtreatmentȱorȱrecoveryȱhouse,ȱjail,ȱshelterȱorȱhostel,ȱorȱhavingȱnoȱfixedȱ addressȱ forȱ theȱ lastȱ sixȱ months,ȱ (yesȱ vs.ȱ no);ȱ frequentȱ exposureȱ toȱ theȱ Downtownȱ Eastsideȱ(DTES),ȱwhichȱisȱVancouver’’sȱwellȱdescribedȱdrugȱuseȱepicentreȱandȱwhereȱtheȱ VancouverȱSIFȱisȱsituated,193ȱwasȱdefinedȱasȱresidingȱinȱorȱvisitingȱtheȱDTESȱatȱleastȱ2Ȭ3ȱ timesȱperȱweekȱ (yesȱvs.ȱno);ȱdailyȱcocaineȱ injectionȱ (yesȱvs.ȱno);ȱdailyȱheroinȱ injectionȱ (yesȱvs.ȱno);ȱdailyȱcrackȱcocaineȱsmokingȱ (yesȱvs.ȱno);ȱnonȬfatalȱoverdoseȱ (yesȱvs.ȱno);ȱ andȱusingȱinjectionȱdrugsȱinȱpublicȱlocations,ȱsuchȱasȱcityȱstreets,ȱparksȱandȱalleysȱ(yesȱ vs.ȱno).ȱAllȱdrugȱuseȱandȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱmonthȱperiodȱ andȱwereȱmeasuredȱatȱparticipantsȇȱfirstȱstudyȱvisitȱduringȱourȱstudyȱperiod.ȱȱ Asȱaȱ firstȱstep,ȱweȱcomparedȱbaselineȱcharacteristicsȱstratifiedȱbyȱattendanceȱatȱ theȱVancouverȱSIF.ȱWeȱusedȱPearson’’sȱChiȬSquareȱ testȱ forȱdichotomousȱvariablesȱandȱ theȱMannȬWhitneyȱ testȱ forȱ continuousȱ variables.ȱWeȱwereȱ primarilyȱ concernedȱwithȱ identifyingȱwhetherȱthereȱwasȱanȱindependentȱrelationshipȱbetweenȱ justȱtwoȱvariablesȱ (attendanceȱatȱtheȱSIFȱandȱpriorȱreportȱofȱwillingnessȱtoȱattendȱaȱSIF).ȱToȱaddressȱthis,ȱ weȱ usedȱ aȱ backwardsȱ selectionȱ processȱ withȱ automatedȱ procedures,ȱ previouslyȱ ȱȱ 71 describedȱ byȱMaldonadoȱ andȱGreenland232ȱ andȱRothmanȱ andȱGreenland,233ȱwhichȱ isȱ specificȱ toȱ fittingȱmultivariateȱmodelsȱ inȱ theseȱ instances.ȱ Specifically,ȱ weȱ beganȱ byȱ includingȱ allȱ variablesȱ inȱ aȱ fixedȱ model.ȱ Weȱ subsequentlyȱ generatedȱ aȱ seriesȱ ofȱ confoundingȱmodelsȱbyȱremovingȱsecondaryȱvariablesȱoneȱatȱaȱtime.ȱForȱeachȱofȱtheseȱ models,ȱweȱassessedȱtheȱrelativeȱchangeȱinȱtheȱcoefficientȱforȱourȱprimaryȱindependentȱ variableȱofȱinterestȱ(priorȱwillingnessȱtoȱuseȱaȱSIF).ȱTheȱsecondaryȱvariableȱthatȱresultedȱ inȱtheȱsmallestȱabsoluteȱrelativeȱchangeȱ inȱtheȱcoefficientȱofȱ ‘‘priorȱwillingnessȱtoȱuseȱaȱ SIF’’ȱwasȱ thenȱ removed.ȱThisȱapproachȱallowedȱusȱ toȱ identifyȱ theȱsecondaryȱvariablesȱ thatȱhadȱ theȱstrongestȱ influenceȱonȱ theȱcoefficientȱ forȱourȱprimaryȱvariableȱofȱ interest.ȱ Usingȱthisȱautomatedȱprocedure,ȱsecondaryȱvariablesȱcontinuedȱtoȱbeȱremovedȱuntilȱtheȱ smallestȱrelativeȱchangeȱinȱtheȱcoefficientȱofȱ‘‘priorȱwillingnessȱtoȱuseȱaȱSIF’’ȱexceededȱ5%ȱ ofȱ theȱvalueȱofȱ theȱcoefficient.ȱTheȱ finalȱmodelȱ includedȱpriorȱwillingnessȱ toȱuseȱaȱSIFȱ andȱallȱremainingȱsecondaryȱexplanatoryȱvariables.ȱ Toȱfurtherȱexploreȱtheȱrelationshipȱbetweenȱinitialȱwillingnessȱandȱlaterȱuseȱofȱaȱ SIF,ȱweȱ conductedȱaȱnumberȱofȱ subȬanalyses.ȱFirst,ȱamongȱ individualsȱwhoȱ reportedȱ thatȱ theyȱhadȱnotȱattendedȱ theȱSIF,ȱweȱassessedȱratesȱofȱnonȬinjectionȱdrugȱuseȱ inȱ theȱ pastȱ sixȱmonthsȱ duringȱ theȱ postȬSIFȱ period,ȱ asȱ wellȱ asȱ infrequentȱ exposureȱ toȱ theȱ neighbourhoodȱwhereȱ theȱ supervisedȱ injectionȱ siteȱwasȱ located.ȱ Infrequentȱ exposureȱ wasȱdefinedȱasȱnotȱresidingȱinȱtheȱDowntownȱEastsideȱandȱvisitingȱtheȱneighbourhoodȱ lessȱthanȱmonthly.ȱWeȱthenȱsoughtȱtoȱidentifyȱfactorsȱassociatedȱwithȱnotȱattendingȱtheȱ SIFȱamongȱparticipantsȱwhoȱ initiallyȱreportedȱaȱwillingnessȱ toȱuseȱ theȱ facility.ȱFactorsȱ ȱȱ 72 thatȱ weȱ hypothesizedȱ mightȱ beȱ associatedȱ withȱ notȱ attendingȱ theȱ Vancouverȱ SIFȱ included:ȱ ageȱ (youngerȱ thanȱ 39ȱ yrsȱ ofȱ ageȱ vs.ȱ older),ȱ genderȱ (femaleȱ vs.ȱ male);ȱ infrequentȱexposureȱtoȱtheȱDTESȱ(yesȱvs.ȱno);ȱinfrequentȱcocaineȱinjectionȱ(<ȱdailyȱvs.ȱ>ȱ daily);ȱandȱ infrequentȱheroinȱ injectionȱ(<ȱdailyȱvs.ȱ>ȱdaily);ȱbeingȱrecentlyȱ incarceratedȱ (yesȱvs.ȱno)ȱandȱ recentlyȱbeingȱ involvedȱ inȱanyȱkindȱofȱaddictionȱ treatmentȱprogramȱ (yesȱvs.ȱno).ȱAllȱvariables,ȱincludingȱourȱoutcomeȱofȱinterest,ȱreferȱtoȱbehavioursȱinȱtheȱ previousȱsixȱmonths.ȱȱ Sinceȱ forȱ thisȱ analysisȱweȱwereȱ interestedȱ inȱ identifyingȱmultipleȱ factorsȱ thatȱ mightȱbeȱassociatedȱwithȱnotȱusingȱtheȱSIF,ȱweȱdidȱnotȱuseȱtheȱpreviousȱmodelȱbuildingȱ protocolȱwhichȱisȱdesignedȱtoȱadjustȱforȱconfoundingȱandȱdetermineȱwhetherȱthereȱisȱanȱ independentȱrelationshipȱbetweenȱ justȱ twoȱ factorsȱofȱ interest.ȱ ȱAnotherȱdistinguishingȱ featureȱofȱ thisȱsubȬanalysisȱwasȱ thatȱ itȱ focusedȱonȱ theȱpostȬSIFȱ followȬupȱperiodȱofȱ24ȱ months,ȱandȱweȱhadȱmultipleȱobservationsȱperȱpersonȱforȱfactorsȱpotentiallyȱassociatedȱ withȱ notȱ usingȱ theȱ SIFȱ asȱ wellȱ asȱ serialȱ measuresȱ forȱ eachȱ subject.ȱ Therefore,ȱ toȱ determineȱ factorsȱ associatedȱwithȱ ourȱ outcomeȱ ofȱ interestȱ throughoutȱ theȱ entireȱ 24Ȭ monthȱ followȬupȱ periodȱweȱ usedȱ generalizedȱ estimatingȱ equationsȱ (GEE)ȱ forȱ binaryȱ outcomesȱwithȱlogitȱlinkȱforȱtheȱanalysisȱofȱcorrelatedȱdata.194ȱTheseȱmethodsȱprovidedȱ standardȱ errorsȱ adjustedȱbyȱmultipleȱobservationsȱperȱpersonȱusingȱ anȱ exchangeableȱ correlationȱ structure.ȱWithȱ thisȱ approachȱdataȱ fromȱ everyȱparticipantȱ followȬupȱ visitȱ wereȱ consideredȱ inȱ thisȱ analysis.ȱ Missingȱ dataȱ wereȱ addressedȱ throughȱ theȱ GEEȱ ȱȱ 73 estimatingȱmechanismȱwhichȱusesȱtheȱallȱavailableȱpairsȱmethod.ȱAllȱnonȬmissingȱpairsȱ ofȱdataȱareȱusedȱinȱtheȱestimatorsȱofȱtheȱworkingȱcorrelationȱparameters.ȱȱ Asȱ aȱ firstȱ step,ȱGEEȱunivariateȱ analysesȱwereȱ conductedȱ toȱ obtainȱunadjustedȱ oddsȱratiosȱandȱ95%ȱconfidenceȱintervalsȱforȱvariablesȱofȱinterest.ȱInȱorderȱtoȱadjustȱforȱ potentialȱconfounding,ȱallȱvariablesȱthatȱwereȱpȱ<ȱ0.05ȱinȱGEEȱunivariateȱanalysesȱwereȱ enteredȱintoȱaȱmultivariateȱlogisticȱGEEȱmodel.ȱAllȱstatisticalȱanalysesȱwereȱperformedȱ usingȱSASȱsoftwareȱversionȱ9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ 4.3 Resultsȱ Aȱtotalȱofȱ640ȱindividualsȱwereȱseenȱforȱstudyȱfollowȬupȱduringȱtheȱpreȬSIFȱstudyȱ periodȱ (seeȱ Figureȱ 4.1.).ȱ Inȱ theȱ preȬSIFȱ periodȱ 344ȱ (54%)ȱ participantsȱ reportedȱ beingȱ willingȱ toȱ useȱ aȱ SIF,ȱ 256ȱ reportedȱ beingȱ unwillingȱ (40%)ȱ andȱ 40ȱ (6%)ȱwereȱ unsure.ȱ Amongȱtheȱ’’unsure’’ȱgroupȱ11ȱ(28%)ȱwereȱnotȱseenȱforȱstudyȱfollowȬupȱduringȱtheȱpostȬ SIFȱstudyȱperiod,ȱandȱofȱtheȱremainingȱ29ȱ ‘‘unsure’’ȱindividuals,ȱ18ȱ(62%)ȱsubsequentlyȱ usedȱ theȱ facility.ȱ Amongȱ theȱ 600ȱ participantsȱwhoȱ reportedȱ eitherȱ beingȱwillingȱ orȱ unwillingȱtoȱuseȱaȱSIF,ȱ158ȱ(70ȱandȱ88ȱrespectively)ȱwereȱnotȱseenȱforȱstudyȱfollowȬupȱ duringȱ theȱpostȬSIFȱ studyȱperiodȱandȱwereȱ thereforeȱexcludedȱ fromȱ furtherȱanalyses.ȱ ThoseȱlostȱtoȱfollowȬupȱwereȱsignificantlyȱlessȱlikelyȱtoȱreportȱbeingȱwillingȱtoȱuseȱaȱSIFȱ (pȱ<ȱ0.001).ȱTheȱremainingȱ442ȱparticipantsȱwereȱincludedȱinȱourȱprimaryȱcomparisonȱofȱ thoseȱ thatȱ reportedȱ yesȱ vs.ȱ noȱwillingness.ȱ Amongȱ theȱ 274ȱ participantsȱwithinȱ thisȱ groupȱ whoȱ reportedȱ beingȱ initiallyȱ willingȱ toȱ useȱ aȱ SIF,ȱ 198ȱ (72%)ȱ laterȱ reportedȱ ȱȱ 74 attendingȱ theȱSIF,ȱwhileȱ91ȱ (54%)ȱofȱ thoseȱwhoȱwereȱ initiallyȱunwillingȱreportedȱ laterȱ attendingȱ theȱ SIF.ȱ Theȱ characteristicsȱ ofȱ theȱ studyȱ sampleȱ stratifiedȱ byȱ reportedȱ attendanceȱatȱtheȱSIFȱareȱpresentedȱinȱTableȱ4.1.ȱTheȱunivariateȱanalysesȱofȱbehaviouralȱ andȱsocioȬdemographicȱvariablesȱareȱalsoȱpresentedȱ inȱTableȱ4.1.ȱ Initialȱwillingnessȱ toȱ useȱaȱSIFȱwasȱ significantlyȱassociatedȱwithȱ laterȱuseȱofȱ theȱ facilityȱ (oddsȱ ratioȱ [OR]ȱ=ȱ 2.20,ȱ95%ȱconfidenceȱintervalȱ[CI]ȱ1.47Ȭ3.30).ȱTheȱresultsȱofȱtheȱfinalȱmultivariateȱlogisticȱ regressionȱareȱshownȱinȱTableȱ4.2.ȱOurȱprimaryȱexplanatoryȱvariable,ȱinitialȱwillingnessȱ toȱuseȱaȱSIF,ȱremainedȱindependentlyȱassociatedȱwithȱattendingȱtheȱSIFȱ(AdjustedȱOddsȱ Ratioȱ[AOR]ȱ=1.67,ȱ95%ȱCI:ȱ1.09Ȭ2.55).ȱȱUnstableȱhousingȱ(AORȱ=ȱ1.54,ȱ95%ȱCIȱ1.01Ȭ2.34)ȱ andȱusingȱinjectionȱdrugsȱinȱpublicȱwereȱalsoȱindependentlyȱassociatedȱwithȱusingȱtheȱ SIFȱ(AORȱ=ȱ2.35,ȱ95%ȱCIȱ1.46Ȭ3.77).ȱȱ InȱsubȬanalyses,ȱweȱfoundȱthatȱamongȱparticipantsȱwhoȱdidȱnotȱattendȱtheȱSIF,ȱ31ȱ (19%)ȱ reportedȱ atȱ someȱ pointȱ duringȱ theȱ postȬSIFȱ studyȱ periodȱ thatȱ theyȱ hadȱ notȱ injectedȱdrugsȱinȱtheȱpreviousȱsixȱmonth.ȱSimilarly,ȱduringȱtheȱsameȱperiodȱandȱamongȱ theȱsameȱgroup,ȱ32ȱ(21%)ȱindividualsȱreportedȱinfrequentȱexposureȱtoȱtheȱDTES.ȱȱ InȱtheȱsubȬanalysisȱrestrictedȱtoȱtheȱ274ȱindividualsȱwhoȱinitiallyȱreportingȱbeingȱ willingȱ toȱ useȱ aȱ SIFȱ (seeȱ Tableȱ 4.3),ȱ beingȱ youngerȱ thanȱ 39ȱ yearsȱ ofȱ age,ȱ infrequentȱ exposureȱ toȱ theȱ DTES,ȱ infrequentȱ cocaineȱ injection,ȱ infrequentȱ heroinȱ injectionȱ andȱ engagementȱinȱanyȱaddictionȱtreatmentȱprogramȱwereȱsignificantlyȱassociatedȱwithȱnotȱ usingȱ theȱ SIFȱ inȱ univariateȱ GEEȱ analyses.ȱ Inȱmultivariateȱ GEEȱ analyses,ȱ infrequentȱ ȱȱ 75 exposureȱtoȱtheȱDTESȱ(AORȱ=ȱ1.89,ȱ95%ȱCI:ȱ1.31Ȭ2.71),ȱinfrequentȱcocaineȱinjectionȱ(AORȱ =ȱ1.54,ȱ95%ȱCI:ȱ1.13Ȭ2.09),ȱandȱinfrequentȱheroinȱinjectionȱ(AORȱ=ȱ2.37,ȱ95%ȱCI:ȱ1.77Ȭ3.17)ȱ wereȱ significantlyȱ positivelyȱ associatedȱwithȱ notȱ usingȱ theȱ SIF,ȱwhileȱ beingȱ youngerȱ thanȱ 39ȱ yearsȱ ofȱ ageȱ (AORȱ =ȱ 0.03,ȱ 95%ȱ CI:ȱ 0.01Ȭ0.05)ȱ wasȱ significantlyȱ negativelyȱ associatedȱwithȱnotȱusingȱtheȱSIF.ȱȱ 4.4 Discussionȱ Ourȱ studyȱ foundȱ thatȱ initialȱ willingnessȱ toȱ useȱ aȱ SIFȱ wasȱ independentlyȱ associatedȱwithȱ subsequentȱ attendanceȱ atȱ Vancouver’’sȱ SIF,ȱ evenȱ afterȱ adjustingȱ forȱ otherȱdeterminantsȱofȱwillingness.ȱWeȱalsoȱ foundȱ thatȱnotȱactivelyȱ injectingȱdrugs,ȱasȱ wellȱ asȱ infrequentȱ exposureȱ toȱ theȱneighbourhoodȱwhereȱVancouver’’sȱ SIFȱ isȱ located,ȱ wereȱfactorsȱthatȱappearȱtoȱnegativelyȱinfluenceȱwhetherȱindividualsȱuseȱaȱSIFȱfollowingȱ aȱreportȱofȱbeingȱwillingȱtoȱuseȱtheȱprogramȱbeforeȱitȱopened.ȱȱ Theseȱ findingsȱ areȱ largelyȱ consistentȱ withȱ aȱ broadȱ literatureȱ suggestingȱ thatȱ behaviouralȱ intentionȱ isȱ aȱ reasonableȱpredictorȱ ofȱ laterȱ action.234,ȱ 235ȱ Indeed,ȱ intentionȱ measuresȱhaveȱbeenȱfoundȱtoȱbeȱcorrelatedȱwithȱhealthȬrelatedȱbehavioursȱinȱaȱnumberȱ ofȱareasȱincludingȱadolescentȱsmoking,ȱillicitȱdrugȱuse,ȱandȱsexualȱhealth.236Ȭ241ȱAlthoughȱ behaviouralȱ willingnessȱ isȱ consideredȱ toȱ beȱ distinctȱ fromȱ behaviouralȱ intention,ȱ asȱ willingnessȱ isȱ typicallyȱ conceivedȱ inȱ relationȱ toȱwhatȱ anȱ individualȱ isȱwillingȱ toȱ doȱ whileȱ intentionȱ reflectsȱwhatȱanȱ individualȱplansȱ toȱdo,235,ȱ 240ȱ someȱ studiesȱ reportȱ thatȱ ȱȱ 76 comparedȱtoȱintentionȱmeasures,ȱwillingnessȱmeasuresȱareȱactuallyȱbetterȱpredictorsȱofȱ behaviours.235,ȱ236,ȱ242,ȱ243ȱ Similarly,ȱwhileȱourȱstudyȱindicatesȱthatȱwillingnessȱpredictsȱfutureȱSIFȱuse,ȱitȱisȱ alsoȱ noteworthyȱ thatȱ changesȱ inȱ personalȱ circumstances,ȱ includingȱ cessationȱ fromȱ injectionȱdrugȱuse,ȱ lowerȱ intensityȱ injectionȱdrugȱuseȱandȱ infrequentȱ exposureȱ toȱ theȱ DTES,ȱappearȱtoȱhaveȱanȱexpectedȱdeterrentȱeffectȱonȱSIFȱuse.ȱIndeed,ȱactivelyȱinjectingȱ drugsȱ isȱaȱprerequisiteȱ forȱusingȱ theȱSIF,ȱandȱ theȱSIFȱhasȱbeenȱ shownȱ toȱ attractȱhighȱ intensityȱdrugȱinjectors.244ȱInȱtheȱcontextȱofȱusingȱaȱSIFȱthereȱareȱaȱnumberȱofȱfactorsȱthatȱ couldȱ influenceȱ anȱ individual’’sȱ behaviour,ȱ i.e.ȱwhetherȱ orȱ notȱ theyȱ useȱ theȱ SIF.ȱ Forȱ example,ȱtravelȱandȱwaitingȱtimesȱandȱoperatingȱregulationsȱsuchȱasȱaȱbanȱonȱassistedȱ injectionsȱcouldȱconstrainȱindividualsȱandȱhinderȱtheirȱabilityȱtoȱuseȱtheȱfacilityȱdespiteȱ anȱ initialȱwillingnessȱorȱ intentionȱ toȱuseȱ it.ȱ Indeed,ȱpreviousȱ studiesȱhaveȱ foundȱ thatȱ IDUȱ identifyȱ travelȱ timeȱ toȱ theȱ SIFȱ fromȱwhereȱ theyȱ resideȱ andȱpurchaseȱdrugsȱ asȱ aȱ significantȱ barrierȱ toȱ visitingȱ theȱ facility.245ȱ Clearly,ȱ situationalȱ factorsȱwillȱ influenceȱ whetherȱanȱ individualȱwillȱuseȱaȱsupervisedȱ injectionȱfacility;ȱhowever,ȱweȱfoundȱthatȱ despiteȱ theseȱmultipleȱ factors,ȱwillingnessȱmeasuresȱareȱmeaningfulȱ indicatorsȱofȱ laterȱ SIFȱuse.ȱȱ Theseȱfindingsȱhaveȱimplicationsȱforȱtheȱvalidityȱofȱwillingnessȱstudiesȱthatȱhaveȱ beenȱ conductedȱ inȱ otherȱ settingsȱ toȱ assessȱ theȱ acceptabilityȱ ofȱ establishingȱ SIFs.ȱ Forȱ instance,ȱaȱwillingnessȱstudyȱconductedȱamongȱIDUȱinȱSanȱFranciscoȱrecentlyȱreportedȱ ȱȱ 77 thatȱ 85%ȱ ofȱ localȱ IDUȱwereȱwillingȱ toȱ useȱ aȱ SIF.225ȱOurȱ studyȱ suggestsȱ thatȱ policyȱ plannersȱinȱSanȱFranciscoȱcanȱbeȱconfidentȱthatȱthisȱmeasureȱisȱaȱgoodȱindicatorȱofȱclientȱ uptakeȱshouldȱaȱSIFȱbeȱestablishedȱinȱthatȱarea.ȱȱ Ourȱ findingsȱ areȱ alsoȱ relevantȱ toȱ theȱplanningȱ ofȱ otherȱ typesȱ ofȱpublicȱ healthȱ programsȱ andȱ servicesȱ forȱ injectionȱ drugȱ userȱ populationsȱ asȱ theyȱ suggestȱ thatȱ willingnessȱmeasuresȱareȱrelativelyȱaccurateȱmarkersȱofȱaȱpopulation’’sȱintentionȱtoȱuseȱaȱ particularȱ service.ȱWeȱ shouldȱnoteȱ thatȱdirectlyȱengagingȱwithȱpeopleȱwhoȱuseȱdrugsȱ andȱassessingȱwillingnessȱpriorȱ toȱ theȱestablishmentȱofȱaȱhealthȱserviceȱorȱprogramȱ isȱ consistentȱwithȱaȱgrowingȱrecognitionȱofȱtheȱimportanceȱofȱinvolvingȱtargetȱpopulationsȱ inȱ theȱ planningȱ andȱ deliveryȱ ofȱ healthȱ andȱ socialȱ services,ȱ particularlyȱ amongȱ vulnerableȱ populations.216,ȱ 246ȱ Althoughȱ assessingȱ willingnessȱ isȱ notȱ aȱ substituteȱ forȱ meaningfulȱ involvement,ȱweȱ suggestȱ itȱcanȱbeȱaȱusefulȱ firstȱ stepȱ inȱengagingȱaȱ targetȱ populationȱinȱserviceȱdesignȱandȱdelivery.ȱ Ourȱstudyȱhasȱaȱnumberȱofȱpotentialȱlimitations.ȱFirstly,ȱourȱmeasuresȱreliedȱonȱ selfȬreportȱwhichȱ canȱ beȱ subjectȱ toȱ sociallyȱ desirableȱ reportingȱ andȱ recallȱ bias.ȱMostȱ importantly,ȱ sociallyȱ desirableȱ reportingȱ couldȱ haveȱ inflatedȱ ourȱ measureȱ ofȱ SIFȱ attendanceȱ givenȱ itsȱ widespreadȱ supportȱ andȱ acceptanceȱ amongȱ localȱ drugȱ users.ȱ Anotherȱpotentialȱ limitationȱ ofȱ ourȱ studyȱ isȱ theȱ generalizabilityȱ ofȱ ourȱ findings.ȱTheȱ Vancouverȱ InjectionȱDrugȱUsersȱStudyȱ isȱnotȱ aȱ randomizedȱ sampleȱofȱ injectionȱdrugȱ usersȱandȱmayȱnotȱbeȱreflectiveȱofȱotherȱdrugȱuserȱpopulations.ȱAlthoughȱthisȱmustȱbeȱ ȱȱ 78 takenȱ intoȱ considerationȱ whenȱ extrapolatingȱ theseȱ findingsȱ toȱ otherȱ locationsȱ andȱ populationsȱ ofȱ drugȱ users,ȱ asȱ mentionedȱ previously,ȱ priorȱ researchȱ hasȱ shownȱ willingnessȱtoȱbeȱgoodȱpredictorȱofȱhealthȱrelatedȱbehaviour.235ȱȱȱȱ Inȱsummary,ȱweȱfoundȱthatȱindividualsȱwhoȱindicatedȱthatȱtheyȱwereȱwillingȱtoȱ useȱaȱSIFȱwereȱmoreȱlikelyȱtoȱlaterȱattendȱtheȱVancouverȱSIFȱonceȱitȱwasȱopened,ȱevenȱ afterȱweȱ adjustedȱ forȱ factorsȱ expectedȱ toȱ beȱ associatedȱwithȱwillingness.ȱ Theseȱ dataȱ suggestȱthatȱwillingnessȱmeasuresȱmayȱbeȱvalidȱtoolsȱforȱplanningȱtheȱdeliveryȱofȱhealthȱ servicesȱ amongȱ injectionȱ drugȱ userȱ populationsȱ andȱ shouldȱ beȱ consideredȱ byȱ futureȱ healthȱprogramȱplanners.ȱ ȱTableȱ4.1ȱCharacteristicsȱofȱstudyȱpopulationȱstratifiedȱbyȱattendanceȱatȱVancouver’’sȱ supervisedȱinjectionȱfacilityȱ(n=442)ȱ AttendedȱSIF Univariateȱ Characteristicȱaȱ Yesȱn=ȱ289,ȱnȱ(%) Noȱn=ȱ153,ȱnȱ(%) ȱ ORȱbȱ(95%ȱCI)ȱcȱ pȬvalueȱ PriorȱWillingnessȱtoȱUseȱSIFȱ ȱ ȱ ȱ ȱ Yesȱ 198ȱ(69)ȱ 76ȱ(50)ȱ ȱ 2.20ȱȱ(1.47ȱ––ȱ3.30)ȱ <0.001 Noȱ 91ȱ(31)ȱ 77ȱ(50)ȱ ȱ ȱ Youngerȱthanȱ39ȱYrsȱofȱAgeȱdȱȱ ȱ ȱ ȱ ȱ Yesȱ 160ȱ(55)ȱ 60ȱ(39)ȱ ȱ 1.92ȱȱ(1.29ȱ––ȱ2.86)ȱ <0.001 Noȱ 129ȱ(45)ȱ 93ȱ(61)ȱ ȱ ȱ FemaleȱGenderȱȱ ȱ ȱ ȱ ȱ Yesȱ 122ȱ(42)ȱ 64ȱ(42)ȱ ȱ 1.02ȱȱ(0.68ȱ––ȱ1.51)ȱ 0.938 Noȱ 167ȱ(58)ȱ 89ȱ(58)ȱ ȱ ȱ UnstableȱHousingȱdȱ ȱ ȱ ȱ ȱ Yesȱ 162ȱ(56)ȱ 64ȱ(42)ȱ ȱ 1.77ȱȱ(1.19ȱ––ȱ2.64)ȱ 0.005 Noȱ 127ȱ(44)ȱ 89ȱ(58)ȱ ȱ ȱ FrequentȱExposureȱtoȱDTESȱdȱ ȱ ȱ ȱ ȱ Yesȱ 163ȱ(56)ȱ 77ȱ(50)ȱ ȱ 1.28ȱȱ(0.86ȱ––ȱ1.89)ȱ 0.223 Noȱ 126ȱ(44)ȱ 76ȱ(50)ȱ ȱ ȱ DailyȱCocaineȱInjectionȱdȱ ȱ ȱ ȱ ȱ Yesȱ 94ȱ(33)ȱ 31ȱ(20)ȱ ȱ 1.90ȱȱ(1.19ȱ––ȱ3.02)ȱ 0.007 Noȱ 195ȱ(67)ȱ 122ȱ(80)ȱ ȱ ȱ DailyȱHeroinȱInjectionȱdȱ ȱ ȱ ȱ ȱ Yesȱ 95ȱ(33)ȱ 24ȱ(16)ȱȱȱȱ ȱ 2.63ȱȱ(1.60ȱ––ȱ4.34)ȱ <0.001 Noȱ 194ȱ(67)ȱ 129ȱ(84)ȱ ȱ ȱ DailyȱCrackȱUseȱdȱ ȱ ȱ ȱ ȱ Yesȱ 153ȱ(53)ȱ 57ȱ(37)ȱ ȱ 1.89ȱȱ(1.27ȱ––ȱ2.83)ȱ 0.002 Noȱ 136ȱ(47)ȱ 96ȱ(63)ȱ ȱ ȱ Overdoseȱ(nonȬfatal)ȱdȱ ȱ ȱ ȱ ȱ Yesȱ 21ȱ(7)ȱ 1ȱ(1)ȱ ȱ 11.91ȱȱ(1.59ȱ––ȱ89.42)ȱ 0.016 Noȱ 268ȱ(93)ȱ 152ȱ(99)ȱ ȱ ȱ PublicȱInjectingȱdȱ ȱ ȱ ȱ ȱ Yesȱ 142ȱ(49)ȱ 36ȱ(24)ȱ ȱ 3.14ȱȱ(2.02ȱ––ȱ4.87)ȱ <0.001 Noȱ 147ȱ(51)ȱ 117ȱ(76)ȱ ȱ ȱ Note:ȱaȱAllȱexplanatoryȱvariablesȱmeasuredȱatȱfirstȱstudyȱvisitȱduringȱstudyȱperiod;ȱbȱORȱ=ȱOddsȱRatio;ȱcȱCIȱ=ȱ ConfidenceȱInterval;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ ȱ ȱ ȱ ȱ ȱ 79 ȱTableȱ4.2ȱMultivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ attendingȱVancouver’’sȱsupervisedȱinjectionȱfacilityȱ(n=442)ȱ Characteristicȱaȱ Adjustedȱ OddsȱRatio (95%ȱConfidenceȱInterval)ȱ pȬvalue PriorȱWillingnessȱtoȱUseȱSIFȱ 1.67ȱ ȱ(1.09ȱ––ȱ2.55)ȱ 0.019 UnstableȱHousingȱb 1.54ȱ ȱ(1.01ȱ––ȱ2.34)ȱ 0.044 DailyȱCocaineȱInjectionȱbȱ 1.52ȱ ȱ(0.93ȱ––ȱ2.48)ȱ 0.095 DailyȱHeroinȱInjectionȱbȱ 1.63ȱ ȱ(0.95ȱ––ȱ2.81)ȱ 0.076 PublicȱInjectingȱb 2.35ȱ ȱ(1.46ȱ––ȱ3.77)ȱ <0.001 Note:ȱaAllȱexplanatoryȱvariablesȱwereȱmeasuredȱatȱfirstȱstudyȱvisitȱduringȱstudyȱperiod;ȱȱ bDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱȱȱ *Overdoseȱwasȱnotȱconsideredȱinȱthisȱmodelȱdueȱtoȱlowȱfrequencyȱcounts. ȱ ȱ ȱȱ ȱ Tableȱ4.3ȱGEEȱanalysisȱofȱfactorsȱassociatedȱwithȱnotȱusingȱtheȱsupervisedȱinjectionȱ facilityȱinȱtheȱlastȱsixȱmonthsȱ(n=76)ȱamongȱthoseȱwhoȱinitiallyȱreportedȱbeingȱ willingȱtoȱuseȱtheȱfacilityȱ(n=274)ȱ ȱ Univariateȱȱ ȱȱȱ Multivariateȱ Characteristicȱaȱ ORbȱȱ(95%ȱCIc) pȬvalueȱ AORdȱ(95%ȱCI)ȱ pȬvalue Youngerȱthanȱ39ȱYrsȱofȱAgeȱ Yesȱvs.ȱNoȱ 1.65ȱ(1.18ȱ––ȱ2.29) ȱ 0.003ȱ 1.68ȱ(1.21ȱ––ȱ2.34)ȱ 0.002 Genderȱȱ Femaleȱvs.ȱMaleȱ 1.09ȱ(0.75ȱ––ȱ1.58) 0.660ȱ InfrequentȱExposureȱtoȱDTESȱeȱȱ Yesȱvs.ȱNoȱ 1.93ȱ(1.38ȱ––ȱ2.71) <0.001ȱ 1.86ȱ(1.30ȱ––ȱ2.66)ȱ <0.001 InfrequentȱCocaineȱInjectionȱeȱ <ȱdailyȱvs.ȱ>ȱdailyȱȱ 1.82ȱ(1.36ȱ––ȱ2.44) <0.001ȱ 1.52ȱ(1.12ȱ––ȱ2.06)ȱ 0.007 InfrequentȱHeroinȱInjectionȱeȱ <ȱdailyȱvs.ȱ>ȱdailyȱ 2.80ȱ(2.11ȱ––ȱ3.71) <0.001ȱ 2.46ȱ(1.84ȱ––ȱ3.28)ȱ <0.001 Incarcerationȱeȱ Yesȱvs.ȱNoȱ 0.78ȱ(0.59ȱ––ȱ1.09) 0.141ȱ AnyȱAddictionȱTreatmentȱeȱ Yesȱvs.ȱNoȱ 1.42ȱ(1.05ȱ––ȱ1.93) 0.024ȱ 1.23ȱ(0.90ȱ––ȱ1.68)ȱ 0.185 Note:ȱaȱVariableȱmeasuresȱcollectedȱbetweenȱDecemberȱ2003ȱ––ȱNovemberȱ2005;ȱbORȱ=ȱOddsȱ Ratio;ȱcCIȱ=ȱConfidenceȱInterval;ȱdAORȱ=ȱAdjustedȱOddsȱRatio;ȱȱeȱDenotesȱactivitiesȱorȱsituationsȱ referringȱtoȱpreviousȱ6ȱmonths.ȱȱ ȱ ȱ 80 ȱFigureȱ4.1ȱStudyȱsampleȱ ȱȱ Included in statistical analyses n=442 Initial Sample Pre-SIF Period N=640 Willing N=344 57% Attend N=198 72% No Attend N=76 28% Not seen post SIF N=70 20% Not Willing N=256 43% Attend N=91 54% No Attend N=77 46% Not seen post SIF N=88 34% Unsure N=40 6% Attend N=18 62% No Attend N=11 38% Not Seen post SIF N=11 28%N=168 38% N=29 N=600 N=274 62% ȱ 81 ȱȱ 82 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ CHAPTER 5: ȱ SOCIALIZINGȱINȱANȱOPENȱDRUGȱSCENE:ȱTHEȱ RELATIONSHIPȱBETWEENȱACCESSȱTOȱPRIVATEȱSPACEȱANDȱ STREETȱDISORDER4ȱ 5.1 Introductionȱ DrugȬrelatedȱ streetȱ disorder,ȱ includingȱ publicȱ drugȱ useȱ andȱ intoxicationȱ andȱ loiteringȱ inȱ publicȱ areas,ȱ negativelyȱ impactsȱ neighbourhoodȱ businessesȱ andȱ surroundingȱ communitiesȱ andȱ canȱ detractȱ fromȱ theȱ enjoymentȱ ofȱ publicȱ spaces.40Ȭ42ȱ DrugȬrelatedȱ streetȱ disorderȱ isȱ aȱ burdenȱ forȱ lawȱ enforcementȱ agenciesȱ andȱ recentȱ evidenceȱ suggestsȱ thatȱexposureȱ toȱ streetȬbasedȱdrugȱ scenesȱposesȱ risksȱ toȱ individualȱ drugȱusers.49,ȱ68,ȱ247ȱPolicyȱresponsesȱtoȱaddressȱstreetȱdisorderȱinȱopenȱdrugȱscenesȱhave,ȱ toȱdate,ȱ largelyȱ reliedȱonȱ lawȱ enforcementȱmeasuresȱ toȱdeterȱdisorderlyȱbehaviourȱ inȱ publicȱsettings.62,ȱ68,ȱ127ȱ Inȱ someȱ areasȱ withȱ concentratedȱ drugȱ andȱ streetȱ disorderȱ problems,ȱ policeȱ agenciesȱhaveȱinitiatedȱcrackdownȱcampaigns,ȱwhichȱinvolveȱtargetingȱpolicingȱeffortsȱ onȱ drugȬrelatedȱ streetȱ disorder.62,ȱ 68,ȱ 127ȱ Increasedȱ policeȱ presenceȱ andȱ patrolȱ andȱ arrestingȱ individualsȱ forȱdisorderlyȱ behavioursȱ areȱ someȱ keyȱ featuresȱ ofȱ crackȬdownȱ campaigns.62ȱ ȱ InȱCanada,ȱ someȱprovincesȱhaveȱ alsoȱ introducedȱ legislationȱ specificȱ toȱ ȱ 4ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱWood,ȱE.,ȱ Qi,ȱJ.,ȱMcArthur,ȱD.,ȱMontaner,ȱJ.,ȱKerr,ȱT.ȱSocializingȱinȱanȱopenȱdrugȱscene:ȱTheȱ relationshipȱbetweenȱaccessȱtoȱprivateȱspaceȱandȱstreetȱdisorder.ȱ ȱȱ 83 streetȱdisorder.ȱ Forȱ instance,ȱ legislationȱ inȱ severalȱCanadianȱprovincesȱ (i.e.,ȱ theȱ ‘‘Safeȱ StreetsȱAct’’ȱ inȱOntarioȱ andȱBritishȱColumbia)ȱprovideȱ lawȱ enforcementȱ officersȱwithȱ additionalȱ toolsȱ toȱ limitȱ solicitingȱ inȱ publicȱ locations.8,ȱ 144ȱAlthoughȱ lawȱ enforcementȱ measuresȱhaveȱbeenȱfoundȱtoȱreduceȱtheȱvisualȱpresenceȱofȱstreetȱdisorder,97,ȱ105,ȱ140ȱtheseȱ effectsȱ areȱ typicallyȱ shortȬlivedȱ andȱ areȱ oftenȱ associatedȱ withȱ unintendedȱ negativeȱ consequences.69ȱ Theseȱ includeȱ displacingȱ disorderlyȱ behaviourȱ toȱ surroundingȱ areasȱ andȱdisplacingȱillicitȱdrugȱusersȱawayȱfromȱhealthȱandȱsocialȱservices.107,ȱ110,ȱ112,ȱ125,ȱ133,ȱ144,ȱ248Ȭ 250ȱȱGivenȱtheȱapparentȱlimitationsȱofȱlawȱenforcementȱbasedȱapproaches,ȱthereȱisȱaȱneedȱ toȱidentifyȱnovelȱinterventionsȱwithȱpotentialȱtoȱaddressȱstreetȱdisorder.ȱȱ Toȱdate,ȱpolicyȬmakersȱandȱresearchersȱhaveȱgivenȱ limitedȱconsiderationȱ toȱ theȱ potentialȱroleȱthatȱtheȱstructureȱofȱtheȱhousingȱavailableȱtoȱpeopleȱwhoȱareȱentrenchedȱ inȱdrugȱscenesȱmayȱplayȱinȱinfluencingȱtheȱamountȱofȱtimeȱindividualsȱspendȱonȱpublicȱ streetsȱ andȱwhetherȱ changingȱ thisȱ structureȱmightȱ impactȱ theȱ amountȱ ofȱ timeȱ drugȱ usersȱ spendȱ inȱ theȱ openȱdrugȱ scene.ȱRestrictionsȱ onȱ socializingȱ inȱ residentialȱ spaces,ȱ eitherȱthroughȱspaceȱconstraintsȱorȱregulationsȱthatȱimposeȱbarriersȱtoȱhavingȱguestsȱinȱ privateȱvenues,ȱmayȱinadvertentlyȱcontributeȱtoȱstreetȱdisorder.ȱ Therefore,ȱweȱsoughtȱtoȱexamineȱtheȱrelationshipȱbetweenȱtimeȱspentȱsocializingȱ inȱVancouver’’sȱopenȱdrugȱsceneȱandȱaccessȱtoȱprivateȱspaceȱamongȱlocalȱinjectionȱdrugȱ usersȱ (IDU).ȱWeȱhypothesizedȱ thatȱ spendingȱ timeȱ socializingȱ inȱ theȱopenȱdrugȱ sceneȱ wouldȱ beȱ associatedȱwithȱ havingȱ limitedȱ accessȱ toȱ privateȱ space.ȱWeȱ alsoȱ soughtȱ toȱ ȱȱ 84 assessȱwhetherȱIDUȱwhoȱreportȱfrequentlyȱsocializingȱinȱVancouver’’sȱopenȱdrugȱsceneȱ wouldȱbeȱwillingȱtoȱreduceȱtheȱamountȱofȱtimeȱspentȱsocializingȱinȱthisȱlocationȱifȱtheyȱ wereȱofferedȱmoreȱaccessȱtoȱprivateȱindoorȱspace.ȱ 5.2 Methodsȱ Dataȱ forȱ thisȱ studyȱwereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱdescriptionȱ ofȱ theȱ studyȱpleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱTheȱpresentȱanalysesȱareȱrestrictedȱtoȱVIDUSȱparticipantsȱseenȱforȱstudyȱfollowȬ upȱduringȱtheȱperiodȱofȱJuneȱ2008ȱtoȱJuneȱ2009ȱasȱmeasuresȱforȱkeyȱvariablesȱofȱinterestȱ areȱavailableȱonlyȱforȱthisȱperiod.ȱIfȱindividualsȱwereȱseenȱforȱmultipleȱstudyȱfollowȬupȱ visitsȱduringȱthisȱstudyȱperiodȱonlyȱdataȱfromȱtheirȱfirstȱvisitȱwereȱused.ȱ Inȱourȱ initialȱanalysisȱ theȱoutcomeȱofȱ interestȱwasȱ spendingȱ timeȱ socializingȱ inȱ Vancouver’’sȱopenȱdrugȱmarketȱscene.ȱToȱmeasureȱ‘‘socializing’’ȱweȱaskedȱrespondentsȱtoȱ estimateȱtheȱaverageȱnumberȱofȱhoursȱtheyȱspendȱonȱtheȱstreetȱeachȱday,ȱandȱthenȱweȱ askedȱ themȱ toȱ specifyȱ howȱmanyȱ ofȱ thoseȱ hoursȱ onȱ averageȱwereȱ spentȱ socializing.ȱ Becauseȱweȱwereȱ interestedȱ inȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ asȱ anȱ indicatorȱ ofȱ drugȬrelatedȱstreetȱdisorderȱ (andȱnotȱsimplyȱspendingȱ timeȱanywhereȱ inȱ theȱcity),ȱweȱ restrictedȱourȱdefinitionȱofȱsocializingȱtoȱindividualsȱwhoȱreportedȱspendingȱanȱaverageȱ ofȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializingȱandȱwhoȱeitherȱresidedȱ inȱorȱ frequentlyȱvisitȱ(atȱleastȱtwoȱtimesȱperȱweek)ȱVancouver’’sȱdrugȱuseȱepicenter,ȱwhichȱisȱaȱ wellȱ definedȱ andȱ describedȱ areaȱ ofȱ theȱ cityȱ knownȱ asȱ theȱDowntownȱ Eastside.69ȱAllȱ ȱȱ 85 respondentsȱwhoȱdidȱnotȱfrequentlyȱvisitȱorȱresideȱinȱVancouver’’sȱdrugȱuseȱepicenterȱorȱ whoȱreportedȱspendingȱ lessȱthanȱthreeȱhoursȱonȱaverageȱsocializingȱonȱtheȱstreetȱeachȱ dayȱwereȱincludedȱinȱtheȱcomparisonȱgroup.ȱȱ Theȱprimaryȱexplanatoryȱvariableȱofȱ interestȱ forȱ theȱ initialȱanalysisȱwasȱhavingȱ ‘‘limitedȱprivateȱspaceȱforȱsocializing’’.ȱIndividualsȱwhoȱansweredȱ““no””ȱtoȱtheȱquestion:ȱ ““Doȱyouȱhaveȱaȱprivateȱ indoorȱspaceȱ forȱsocializingȱwithȱ friendsȱandȱacquaintances?””ȱ wereȱ includedȱ inȱ thisȱcategory.ȱBecauseȱweȱwantedȱ toȱ includeȱanȱobjectiveȱmarkerȱ inȱ ourȱmeasureȱofȱaccessȱtoȱprivateȱspaceȱforȱsocializingȱweȱalsoȱconsideredȱtheȱnumberȱofȱ guestsȱindividualsȱwereȱallowedȱtoȱhaveȱinȱtheirȱresidenceȱatȱoneȱtimeȱandȱallȱreportsȱofȱ beingȱallowedȱ lessȱ thanȱ threeȱguestsȱatȱoneȱ timeȱwereȱ includedȱ inȱ theȱ ‘‘limitedȱprivateȱ space’’ȱcategoryȱevenȱifȱrespondentsȱinitiallyȱreportedȱ““yes””ȱtoȱhavingȱprivateȱspaceȱforȱ socializing.ȱ Similarly,ȱ ifȱ otherȱ significantȱ barriersȱ toȱ havingȱ guestsȱ inȱ theirȱ residenceȱ wereȱreportedȱ theseȱ individualsȱwereȱalsoȱ includedȱ inȱ theȱcategoryȱofȱhavingȱ ‘‘limitedȱ privateȱspaceȱ forȱsocializing’’.ȱSignificantȱbarriersȱ includedȱ ‘‘guestȱ fees’’ȱ (typicallyȱ$5Ȭ10ȱ perȱguest),ȱ timeȱ restrictionsȱonȱvisitors,ȱ restrictionsȱonȱ theȱappearanceȱofȱguestsȱ (e.g.,ȱ visitorsȱmustȱbeȱwellȱgroomed,ȱ canȱnotȱappearȱ intoxicated)ȱandȱ theȱ requirementȱ thatȱ guestsȱ mustȱ showȱ pictureȱ ID.ȱ Participantsȱ thatȱ reportedȱ ““yes””ȱ toȱ havingȱ accessȱ toȱ privateȱ spaceȱ andȱ reportedȱ noneȱ ofȱ theȱ aboveȱ restrictionsȱ toȱ havingȱ guestsȱ wereȱ includedȱinȱtheȱcomparisonȱgroup.ȱȱ ȱȱ 86 Toȱdetermineȱwhetherȱthereȱwasȱaȱsignificantȱrelationshipȱbetweenȱourȱoutcomeȱ ofȱ interestȱ andȱ ourȱ primaryȱ explanatoryȱ variableȱ weȱ aȱ prioriȱ selectedȱ aȱ rangeȱ ofȱ secondaryȱ explanatoryȱ variablesȱ weȱ hypothesizedȱ mightȱ beȱ associatedȱ withȱ bothȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ andȱ havingȱ accessȱ toȱ privateȱ space.ȱ Secondaryȱ explanatoryȱfactorsȱincluded:ȱageȱ(perȱyearȱolder);ȱgenderȱ(femaleȱvs.ȱmale);ȱAboriginalȱ ancestryȱ(yesȱvs.ȱno);ȱdailyȱcocaineȱinjectionȱ(yesȱvs.ȱno);ȱdailyȱheroinȱinjectionȱ(yesȱvs.ȱ no);ȱdailyȱ crackȱ cocaineȱ smokingȱ (yesȱvs.ȱno);ȱbingeȱdrugȱuse,ȱdefinedȱasȱaȱperiodȱofȱ usingȱ drugsȱmoreȱ oftenȱ thanȱ usualȱ (yesȱ vs.ȱ no);ȱ sexȱ tradeȱ involvement,ȱ definedȱ asȱ exchangingȱ sexȱ forȱ money,ȱ shelter,ȱ drugsȱ orȱ otherȱ commoditiesȱ (yesȱ vs.ȱ no);ȱ participationȱ inȱdrugȱdealingȱ (yesȱvs.ȱno);ȱhavingȱbeenȱemployedȱ (yesȱvs.ȱno);ȱhavingȱ beenȱincarceratedȱ(yesȱvs.ȱno);ȱparticipationȱinȱanyȱaddictionȱtreatmentȱprogramȱ(yesȱvs.ȱ no);ȱandȱeverȱtestingȱpositiveȱforȱHIVȱ(whichȱinȱourȱsettingȱmightȱinfluenceȱtheȱtypesȱofȱ housingȱ optionsȱ available)ȱ (yesȱ vs.ȱ no).ȱ Unlessȱ otherwiseȱ stated,ȱ allȱ drugȱ useȱ andȱ behaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȬmonthȱperiod.ȱToȱaccountȱforȱaȱpotentialȱ seasonalȱ influenceȱ onȱ theȱ aboutȱ ofȱ timeȱ individualsȱ spendȱ onȱ theȱ street,ȱ weȱ alsoȱ includedȱaȱcategoricalȱvariableȱrepresentingȱtheȱmonthȱthatȱparticipantsȱcompletedȱourȱ studyȱquestionnaire.ȱThisȱ insuredȱ thatȱourȱanalysisȱadjustedȱ forȱ seasonalȱvariationȱ inȱ responses.ȱȱ Weȱalsoȱsoughtȱtoȱassessȱtheȱrelationshipȱbetweenȱsocializingȱandȱdifferentȱtypesȱ ofȱhousingȱstatuses.ȱToȱdoȱthisȱweȱcreatedȱaȱcategoricalȱvariableȱforȱhousingȱwithȱ‘‘stableȱ housing’’ȱ asȱ theȱ referenceȱ andȱ conductedȱ univariateȱ analysesȱ forȱ housingȱ statusȱ andȱ ȱȱ 87 socializing.ȱCategoriesȱforȱhousingȱstatusȱwereȱmutuallyȱexclusiveȱandȱbasedȱonȱwhereȱ participantsȱwereȱ residingȱ atȱ theȱ timeȱ ofȱ theȱ interview.ȱ Categoriesȱ included:ȱ stableȱ housing,ȱ definedȱ asȱ livingȱ inȱ aȱ houseȱ orȱ apartment;ȱ singleȱ roomȱ occupancyȱ (SRO),ȱ definedȱasȱaȱsingleȱroomȱinȱaȱhotel;ȱshelter,ȱdefinedȱasȱsleepingȱinȱtemporaryȱsheltersȱforȱ homelessȱindividualsȱwhichȱareȱtypicallyȱonlyȱopenȱatȱnight;ȱnoȱfixedȱaddress,ȱdefinedȱ asȱhavingȱnoȱstableȱresidence,ȱ includingȱsleepingȱonȱ theȱstreetȱasȱwellȱasȱstayingȱwithȱ friendsȱorȱacquaintancesȱonȱaȱshortȱtermȱbasis,ȱi.e.,ȱ‘‘couchȱsurfing’’;ȱtreatmentȱcentreȱorȱ recoveryȱ house,ȱ definedȱ asȱ livingȱ inȱ residentialȱ addictionȱ treatmentȱ centresȱ orȱ transitionalȱaddictionȱtreatmentȱrecoveryȱhouses;ȱjail,ȱdefinedȱasȱbeingȱincarceratedȱinȱaȱ prison;ȱandȱother,ȱwhichȱ includesȱsituationsȱ thatȱdidȱnotȱ fitȱ intoȱ theȱaboveȱcategories.ȱȱ Becauseȱhousingȱstatusȱandȱaccessȱtoȱprivateȱspaceȱareȱcloselyȱassociated,ȱthisȱvariableȱ wasȱ notȱ includedȱ asȱ aȱ secondaryȱ outcomeȱ ofȱ interestȱ inȱ theȱ analysisȱ assessingȱ theȱ relationshipȱbetweenȱsocializingȱandȱaccessȱtoȱprivateȱspace.ȱȱȱȱ Toȱassessȱ theȱ relationshipȱbetweenȱsocializingȱandȱaccessȱ toȱprivateȱspace,ȱasȱaȱ firstȱstepȱweȱconductedȱunivariateȱanalysesȱforȱourȱprimaryȱandȱsecondaryȱoutcomesȱofȱ interestȱstratifiedȱbyȱsocializingȱ inȱtheȱopenȱdrugȱscene.ȱWeȱusedȱPearson’’sȱchiȬsquareȱȱ testȱ forȱ dichotomousȱ variablesȱ andȱ theȱMannȬWhitneyȱ testȱ forȱ continuousȱ variables.ȱ Fisher’’sȱexactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱwasȱlessȱthanȱorȱequalȱ toȱfive.ȱToȱfitȱourȱmultivariateȱmodel,ȱweȱusedȱaȱbackwardsȱselectionȱprocessȱpreviouslyȱ describedȱbyȱMaldonadoȱandȱGreenland232ȱandȱRothmanȱandȱGreenland.233ȱSpecifically,ȱ weȱbeganȱwithȱallȱoutcomesȱofȱinterestȱinȱaȱfullȱmodel.ȱUsingȱanȱautomatedȱprocedure,ȱ ȱȱ 88 weȱ subsequentlyȱ generatedȱ aȱ seriesȱ ofȱ confoundingȱ modelsȱ byȱ removingȱ eachȱ secondaryȱ factorȱ ofȱ interestȱoneȱ atȱ aȱ time.ȱForȱ eachȱ ofȱ theseȱmodelsȱweȱ assessedȱ theȱ relativeȱ changeȱ inȱ theȱ coefficientȱ forȱ ourȱprimaryȱ factorȱ ofȱ interestȱ (limitedȱ accessȱ toȱ privateȱspace).ȱTheȱsecondaryȱoutcomeȱofȱinterestȱthatȱresultedȱinȱtheȱsmallestȱabsoluteȱ relativeȱchangeȱinȱtheȱcoefficientȱforȱ‘‘limitedȱaccessȱtoȱprivateȱspace’’ȱwasȱthenȱremoved.ȱ Thisȱapproachȱallowedȱusȱ toȱ identifyȱ theȱsecondaryȱoutcomesȱofȱ interestȱ thatȱhadȱ theȱ strongestȱ influenceȱ onȱ theȱ coefficientȱ forȱ ourȱ primaryȱ variableȱ ofȱ interestȱ whileȱ removingȱthoseȱthatȱhadȱtheȱweakestȱrelationshipȱwithȱ‘‘limitedȱaccessȱtoȱprivateȱspace’’.ȱ Secondaryȱvariablesȱ continuedȱ toȱbeȱ removedȱ throughȱ thisȱprocessȱuntilȱ theȱ smallestȱ relativeȱchangeȱinȱtheȱcoefficientȱofȱ‘‘limitedȱaccessȱtoȱprivateȱspace’’ȱexceededȱ5%ȱofȱtheȱ valueȱofȱtheȱcoefficient.ȱTheȱfinalȱmodelȱincludedȱlimitedȱaccessȱtoȱprivateȱspaceȱandȱallȱ remainingȱsecondaryȱexplanatoryȱvariables.ȱ Inȱsecondaryȱanalysis,ȱweȱsoughtȱ toȱassessȱandȱ identifyȱ factorsȱassociatedȱwithȱ willingnessȱ toȱ relocateȱ toȱ indoorȱprivateȱ locationsȱ ifȱsuchȱspacesȱwereȱmadeȱavailableȱ amongȱ participantsȱwhoȱ reportedȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ andȱwhoȱ haveȱ limitedȱ accessȱ toȱ privateȱ indoorȱ space.ȱ Toȱmeasureȱwillingnessȱ toȱ relocateȱweȱ askedȱ participantsȱ““Wouldȱyouȱspendȱ lessȱtimeȱsocializingȱonȱtheȱstreetȱ ifȱyouȱhadȱaȱprivateȱ indoorȱ spaceȱ (orȱ moreȱ privateȱ indoorȱ space)ȱ forȱ socializingȱ withȱ friendsȱ andȱ acquaintances?””ȱ Theȱ geographicȱ locationȱ ofȱ whereȱ privateȱ indoorȱ spaceȱ mightȱ beȱ locatedȱwasȱnotȱspecifiedȱandȱnoȱadditionalȱdescriptionȱofȱtheȱtypeȱofȱprivateȱspaceȱwasȱ given.ȱ Variablesȱ ofȱ interestȱ forȱ secondaryȱ analysisȱ includedȱ allȱ variablesȱ (withȱ theȱ ȱȱ 89 exceptionȱofȱ limitedȱaccessȱ toȱprivateȱspace)ȱ fromȱ theȱprimaryȱanalysis,ȱ inȱadditionȱ toȱ otherȱriskȱfactorsȱthatȱmayȱinfluenceȱwillingnessȱtoȱrelocate.ȱSpecifically,ȱweȱconsideredȱ selfȬreportsȱ ofȱ recentȱ nonȬfatalȱ overdoseȱ eventsȱ (yesȱ vs.ȱ no),ȱ borrowingȱ andȱ lendingȱ syringesȱalreadyȱusedȱtoȱinjectȱdrugsȱ(yesȱvs.ȱno),ȱhavingȱmultipleȱsexȱpartnersȱ(yesȱvs.ȱ no)ȱandȱHIVȱpositiveȱserostatusȱ(yesȱvs.ȱno).ȱWeȱalsoȱconsideredȱrecentȱencountersȱwithȱ policeȱ(lastȱ30ȱdays)ȱandȱbeingȱaȱrecentȱvictimȱofȱviolence,ȱasȱindividualsȱentrenchedȱinȱ drugȱ marketȱ scenesȱ haveȱ beenȱ identifiedȱ asȱ beingȱ particularlyȱ vulnerableȱ toȱ theseȱ experiences.247ȱ Toȱ assessȱ whetherȱ theȱ levelȱ ofȱ socializingȱ influencedȱ willingnessȱ toȱ relocateȱweȱalsoȱconsideredȱtheȱnumberȱofȱhoursȱparticipantsȱreportedȱsocializingȱinȱtheȱ openȱdrugȱsceneȱasȱaȱcontinuousȱvariableȱ(perȱadditionalȱhourȱreported).ȱAsȱinȱprimaryȱ analysis,ȱunlessȱ otherwiseȱ stated,ȱ allȱdrugȱuseȱ andȱ behaviouralȱ variablesȱ referȱ toȱ theȱ previousȱ sixȬmonthȱperiod.ȱAsȱ aȱ firstȱ step,ȱweȱusedȱunivariateȱ analysesȱ toȱdetermineȱ factorsȱassociatedȱwithȱwillingnessȱ toȱ relocate.ȱCategoricalȱexplanatoryȱvariablesȱwereȱ analyzedȱusingȱPearson’’sȱchiȬsquareȱtestȱandȱcontinuousȱvariablesȱwereȱanalyzedȱusingȱ theȱMannȬWhitneyȱtest.ȱFisher’’sȱexactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱ wasȱ lessȱ thanȱorȱequalȱ toȱ five.ȱAllȱvariablesȱ thatȱwereȱassociatedȱwithȱ theȱdependentȱ variableȱatȱpȱ<ȱ0.05ȱ inȱunivariateȱanalysesȱwereȱ thenȱenteredȱ inȱaȱmultivariateȱ logisticȱ model.ȱAsȱwithȱtheȱprimaryȱanalysis,ȱweȱalsoȱcreatedȱaȱcategoricalȱvariableȱforȱhousingȱ statusȱandȱconductedȱunivariateȱanalysesȱtoȱassessȱtheȱrelationshipȱbetweenȱwillingnessȱ toȱrelocateȱandȱdifferentȱtypesȱofȱhousingȱstatuses.ȱSimilarly,ȱgivenȱtheȱcloseȱassociationȱ betweenȱ numberȱ ofȱ hoursȱ socializingȱ andȱ housingȱ statusȱ thisȱ variableȱ wasȱ notȱ ȱȱ 90 consideredȱinȱtheȱmultivariateȱmodel.ȱAllȱstatisticalȱanalysesȱwereȱperformedȱusingȱSASȱ softwareȱversionȱ9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ 5.3 Resultsȱ Duringȱtheȱstudyȱperiodȱaȱtotalȱofȱ1,121ȱparticipantsȱcompletedȱfollowȬupȱvisits,ȱ includingȱ 396ȱ (35%)ȱ womenȱ andȱ 396ȱ (35%)ȱ personsȱ whoȱ identifiedȱ asȱ beingȱ ofȱ Aboriginalȱ ancestry.ȱ Theȱmedianȱ ageȱ ofȱ allȱ participantsȱwasȱ 44ȱ yearsȱ (interquartileȱ rangeȱ [IQR]ȱ=ȱ38Ȭ50),ȱandȱ theȱhousingȱ statusesȱofȱ studyȱparticipantsȱareȱdisplayedȱ inȱ Figureȱ5.1.ȱAmongȱourȱsampleȱofȱ1,121ȱparticipants,ȱ477ȱindividualsȱ(43%)ȱfitȱtheȱcriteriaȱ forȱsocializingȱinȱtheȱopenȱdrugȱscene.ȱȱTheȱcharacteristicsȱofȱtheȱstudyȱsampleȱstratifiedȱ byȱsocializingȱinȱtheȱopenȱdrugȱsceneȱareȱpresentedȱinȱTableȱ5.1ȱandȱtheȱdistributionȱofȱ theȱwholeȱsampleȱbyȱhousingȱstatusȱandȱaccessȱtoȱprivateȱspaceȱisȱdisplayedȱinȱFigureȱ 5.2.ȱȱ Univariateȱ associationsȱ betweenȱ differentȱ typesȱ ofȱ housingȱ statusesȱ andȱ socializingȱ areȱ presentedȱ inȱ Tableȱ 5.2.ȱWhenȱ comparedȱ toȱ participantsȱ withȱ stableȱ housingȱtheȱnoȱfixedȱaddressȱcategoryȱwasȱalmostȱsevenȱtimesȱmoreȱlikelyȱtoȱsocializeȱ inȱtheȱopenȱdrugȱscene,ȱwhileȱ individualsȱ livingȱ inȱSROsȱandȱsheltersȱwereȱoverȱthreeȱ timesȱ moreȱ likelyȱ toȱ socialize.ȱ Theȱ univariateȱ analysesȱ ofȱ associationsȱ betweenȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ andȱ otherȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ areȱ presentedȱ inȱ Tableȱ 5.1.ȱ Havingȱ limitedȱ accessȱ toȱ privateȱ spaceȱ forȱ socializingȱwasȱsignificantlyȱassociatedȱwithȱsocializingȱ inȱ theȱopenȱdrugȱsceneȱ (Oddsȱ ȱȱ 91 Ratioȱ [OR]ȱ =ȱ 2.85,ȱ 95%ȱ Confidenceȱ Intervalȱ [CI]:ȱ 2.11Ȭ3.86).ȱ Theȱ resultsȱ ofȱ theȱ finalȱ multivariateȱ logisticȱ regressionȱ areȱ shownȱ inȱ Tableȱ 5.3.ȱ Theȱ primaryȱ explanatoryȱ variable,ȱ limitedȱ accessȱ toȱ privateȱ space,ȱ remainedȱ independentlyȱ associatedȱ withȱ socializingȱinȱtheȱopenȱdrugȱsceneȱ(AdjustedȱOddsȱRatioȱ[AOR]ȱ=2.33,ȱ95%ȱCI:ȱ1.68Ȭ3.24)ȱ afterȱadjustingȱ forȱAboriginalȱancestry,ȱdailyȱ crackȱ cocaineȱuse,ȱbingeȱdrugȱuse,ȱdrugȱ dealingȱandȱengagementȱinȱanyȱaddictionȱtreatment.ȱȱ Inȱ subȬanalysis,ȱ 256ȱ (65%)ȱofȱ theȱ 392ȱparticipantsȱ thatȱ reportedȱhavingȱ limitedȱ accessȱ toȱ privateȱ spaceȱ andȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ alsoȱ reportedȱ beingȱ willingȱtoȱrelocateȱifȱtheyȱwereȱprovidedȱwithȱmoreȱaccessȱtoȱprivateȱindoorȱspace.ȱTheȱ characteristicsȱofȱtheseȱindividualsȱstratifiedȱbyȱwillingnessȱtoȱrelocateȱareȱpresentedȱinȱ Tableȱ 5.4.ȱ Univariateȱ associationsȱ betweenȱ differentȱ typesȱ ofȱ housingȱ statusesȱ andȱ willingnessȱtoȱrelocateȱareȱpresentedȱinȱTableȱ5.5.ȱWhenȱcomparedȱtoȱparticipantsȱwithȱ stableȱ housingȱ theȱ noȱ fixedȱ addressȱ categoryȱwasȱ overȱ tenȱ timesȱmoreȱ likelyȱ toȱ beȱ willingȱtoȱrelocate,ȱwhileȱindividualsȱlivingȱinȱSROsȱandȱsheltersȱwereȱtwoȱandȱsixȱtimesȱ moreȱ likelyȱ toȱ relocateȱ respectively.ȱ Theȱ univariateȱ analysesȱ ofȱ associationsȱ betweenȱ willingnessȱ toȱ relocateȱ andȱ otherȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ areȱ presentedȱ inȱTableȱ 5.4.ȱ Factorsȱ thatȱwereȱ significantlyȱ associatedȱwithȱwillingnessȱ toȱ relocateȱinclude:ȱnumberȱofȱhoursȱspentȱsocializingȱ(ORȱ=1.05,ȱ95%ȱCI:ȱ1.01ȱ––ȱ1.09);ȱageȱ (ORȱ=0.97,ȱ95%ȱCI:ȱ0.95ȱ––ȱ0.99);ȱdailyȱheroinȱ injectionȱ (ORȱ=2.71,ȱ95%ȱCI:ȱ1.60ȱ––ȱ4.64);ȱ encountersȱwithȱpoliceȱ (ORȱ=1.90,ȱ95%ȱCI:ȱ1.19ȱ––ȱ3.04);ȱandȱbeingȱaȱvictimȱofȱviolenceȱ (ORȱ=2.01,ȱ95%ȱCI:ȱ1.15ȱ––ȱ3.53).ȱ Inȱmultivariateȱ logisticȱ regression,ȱpresentedȱ inȱTableȱ ȱȱ 92 5.6,ȱdailyȱheroinȱ injectionȱ (AORȱ=2.27,ȱ95%ȱCI:ȱ1.28Ȭ3.88)ȱandȱbeingȱaȱ recentȱvictimȱofȱ violenceȱ(AORȱ=1.81,ȱ95%ȱCI:ȱ1.02Ȭ3.23)ȱwereȱindependentlyȱassociatedȱwithȱwillingnessȱ toȱrelocate.ȱȱ 5.4 Discussionȱ Inȱ theȱpresentȱ studyȱweȱ foundȱ that,ȱ amongȱ localȱ injectionȱdrugȱusers,ȱ havingȱ limitedȱprivateȱspaceȱwasȱsignificantlyȱassociatedȱwithȱspendingȱanȱaverageȱofȱthreeȱorȱ moreȱhoursȱperȱdayȱsocializingȱinȱtheȱopenȱdrugȱscene.ȱThisȱassociationȱpersistedȱafterȱ adjustmentȱ forȱaȱrangeȱofȱpotentialȱconfoundingȱ factors.ȱ ȱSocializingȱ inȱ theȱopenȱdrugȱ sceneȱwasȱalsoȱindependentlyȱpositivelyȱassociatedȱwithȱdailyȱcrackȱcocaineȱuse,ȱbingeȱ drugȱuseȱandȱdrugȱdealing,ȱwhileȱaddictionȱ treatmentȱwasȱnegativelyȱassociatedȱwithȱ socializingȱinȱthisȱenvironment.ȱȱTheȱmajorityȱ(65%)ȱofȱthoseȱwhoȱhadȱlimitedȱaccessȱtoȱ privateȱ spaceȱandȱ spendȱ significantȱ timeȱ socializingȱ inȱ theȱopenȱdrugȱ sceneȱ reportedȱ thatȱ theyȱwouldȱ beȱwillingȱ toȱ relocateȱ awayȱ fromȱ theȱ openȱ drugȱ sceneȱ ifȱ theyȱwereȱ providedȱwithȱprivateȱspaceȱforȱsocializing.ȱItȱisȱnotableȱthatȱdailyȱheroinȱinjectorsȱandȱ individualsȱwhoȱwereȱrecentȱvictimsȱofȱviolenceȱreportedȱbeingȱmostȱwillingȱtoȱrelocateȱ socializingȱ activities.ȱ Whenȱ comparedȱ toȱ IDUȱ whoȱ livedȱ inȱ stableȱ housing,ȱ studyȱ participantsȱwhoȱ livedȱ inȱSROs,ȱ sheltersȱandȱhadȱnoȱ fixedȱaddressȱwereȱ significantlyȱ moreȱlikelyȱtoȱsocializeȱinȱtheȱopenȱdrugȱsceneȱandȱwereȱsignificantlyȱmoreȱlikelyȱtoȱbeȱ willingȱtoȱrelocate.ȱȱ ȱȱ 93 Theseȱ findingsȱ areȱ consistentȱwithȱ existingȱ dataȱ highlightingȱ thatȱ openȱ drugȱ scenesȱ andȱ congregationsȱ ofȱ drugȱ usersȱ oftenȱ existȱ inȱ locationsȱ whereȱ ratesȱ ofȱ homelessnessȱandȱunstableȱhousingȱareȱaȱproblemȱamongȱdrugȱuserȱpopulations.40,ȱ152,ȱ251ȱ Althoughȱ theȱ linksȱ betweenȱ homelessnessȱ andȱ streetȱ disorderȱ haveȱ beenȱ previouslyȱ described,3,ȱ6,ȱ152ȱtoȱourȱknowledgeȱourȱstudyȱisȱtheȱfirstȱtoȱhighlightȱthatȱaȱlackȱofȱaccessȱ toȱ privateȱ spaceȱ isȱ likelyȱ playingȱ aȱ roleȱ inȱ generatingȱ streetȱ disorderȱ inȱ openȱ drugȱ scenes.ȱ Aȱ centralȱ implicationȱ ofȱ theseȱ findingsȱ isȱ thatȱ providingȱ streetȬinvolvedȱ drugȱ usersȱwithȱareasȱwhereȱtheyȱcanȱsocializeȱinȱcomfortȱandȱprivacyȱmayȱofferȱpotentialȱtoȱ reduceȱaȱcomponentȱofȱdrugȬrelatedȱstreetȱdisorder.ȱ ȱTheȱbenefitsȱofȱ relocatingȱstreetȬ involvedȱ individualsȱ toȱ indoorȱ locationsȱbyȱprovidingȱhousingȱorȱ creatingȱalternativeȱ venuesȱforȱsocializingȱappearsȱparticularlyȱvaluableȱgivenȱtheȱburdenȱthatȱdrugȬrelatedȱ streetȱdisorderȱposesȱ forȱ lawȱ enforcementȱagenciesȱandȱ surroundingȱ communities,ȱasȱ wellȱasȱpotentialȱharmsȱthatȱexposureȱtoȱdrugȱscenesȱposesȱtoȱdrugȱusersȱthemselves.3,ȱ68ȱȱ Althoughȱ itȱcanȱbeȱchallengingȱtoȱprovideȱhousingȱforȱsomeȱchaoticȱdrugȱusingȱ individuals,ȱthereȱisȱaȱgrowingȱbodyȱofȱliteratureȱwhichȱsuggestsȱthatȱapproachesȱsuchȱ asȱtheȱ““housingȱfirst””ȱmodel,ȱwhichȱprovideȱdrugȱusingȱ individualsȱwithȱ independentȱ stableȱ housingȱ regardlessȱ ofȱ theirȱ drugȱ useȱ practices,ȱ areȱ moreȱ successfulȱ thanȱ abstinenceȬbasedȱsupportiveȱhousingȱinȱretainingȱandȱstabilizingȱactiveȱdrugȱusers.252Ȭ254ȱ Ourȱ studyȱ suggestsȱ thatȱ ifȱ theseȱhousingȱmodelsȱ canȱaccommodateȱactiveȱdrugȱusersȱ ȱȱ 94 andȱ provideȱ housingȱ withȱ socialȱ spacesȱ forȱ thisȱ population,ȱ theyȱ couldȱ playȱ anȱ importantȱroleȱinȱtheȱreductionȱofȱstreetȱdisorder.ȱȱItȱisȱimportantȱtoȱrecognize,ȱhowever,ȱ thatȱthereȱareȱpotentialȱunintendedȱharmsȱthatȱmightȱresultȱfromȱrelocatingȱactiveȱdrugȱ usersȱintoȱprivateȱindoorȱlocations,ȱparticularlyȱifȱtheseȱlocationsȱareȱunsupervisedȱandȱ doȱnotȱhaveȱsafeguardsȱtoȱmanageȱbehavioursȱthatȱmightȱbeȱassociatedȱwithȱactiveȱdrugȱ use,ȱ suchȱ asȱdrugȱ overdoseȱ eventsȱ orȱ illicitȱdrugȱdealingȱwhichȱ isȱ oftenȱ linkedȱwithȱ violenceȱgivenȱtheȱunregulatedȱnatureȱofȱtheȱillicitȱdrugȱmarket.46ȱȱȱ Toȱ addressȱ risksȱ associatedȱ withȱ activeȱ drugȱ use,ȱ thereȱ mayȱ beȱ aȱ roleȱ forȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ integratedȱ intoȱ supportiveȱ housingȱ models.ȱ Indeed,ȱ theȱ integrationȱ ofȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ inȱ oneȱ supportiveȱ housingȱ facilityȱ forȱ peopleȱ withȱ HIV/AIDSȱ inȱ Vancouverȱ hasȱ beenȱ shownȱ toȱ beȱ successfulȱinȱreducingȱriskyȱdrugȱuseȱpracticesȱonȱtheȱpremises.255ȱFurthermore,ȱinȱourȱ studyȱ settingȱaȱnumberȱofȱnonȬprofitȱhousingȱ societiesȱhaveȱbeenȱableȱ toȱ successfullyȱ provideȱsupportiveȱhousingȱforȱindividualsȱwhoȱactivelyȱuseȱdrugsȱandȱhaveȱbeenȱableȱ toȱmanageȱbehavioursȱassociatedȱwithȱillicitȱdrugȱuse.256,ȱ257ȱWithinȱtheseȱmodels,ȱspecialȱ considerationȱisȱgivenȱtoȱensuringȱthatȱresidents’’ȱhealthȱandȱphysicalȱsecurityȱneedsȱareȱ met.ȱInȱparticular,ȱmeasuresȱareȱtakenȱtoȱaccommodateȱandȱaddressȱtheȱrisksȱassociatedȱ withȱ drugȱ use,ȱ includingȱ drugȱ useȱ whichȱ normallyȱ wouldȱ takeȱ placeȱ inȱ outdoorȱ locationsȱwithinȱtheȱopenȱdrugȱscene.256ȱTheȱPortlandȱHotelȱSocietyȱ isȱanȱexampleȱofȱaȱ housingȱproviderȱthatȱmanagesȱroughlyȱ450ȱhousingȱunitsȱinȱtheȱDTES,ȱtheȱmajorityȱofȱ whichȱareȱoccupiedȱbyȱindividualsȱwhoȱactivelyȱuseȱdrugȱandȱwhoȱfitȱtheȱdescriptionȱofȱ ȱȱ 95 ‘‘hardȱ toȱ house’’.256ȱ Theȱ clientȬcentredȱ philosophyȱ ofȱ theȱ Portlandȱ Hotelȱ Societyȱ isȱ creditedȱwithȱenablingȱ themȱ toȱbuildȱ relationshipsȱwithȱ theirȱclientsȱ thatȱ facilitateȱ theȱ protectionȱofȱclients’’ȱphysicalȱsecurityȱandȱpromoteȱclients’’ȱoverallȱwellȬbeing.256,ȱ258,ȱ259ȱȱ Althoughȱ thereȱ isȱnowȱaȱwideȱ literatureȱsuggestingȱ thatȱ lowȬthresholdȱhousingȱ optionsȱ inȱ lineȱwithȱaȱhousingȱ firstȱmodelȱsuccessfullyȱsupportȱandȱretainȱ individualsȱ withȱhighȱintensityȱaddictionȱand,ȱasȱourȱstudyȱindicates,ȱhaveȱpotentialȱtoȱreduceȱstreetȱ disorder,ȱlowȬthresholdȱhousingȱcurrentlyȱmakesȱupȱonlyȱaȱsmallȱproportionȱofȱexistingȱ housingȱunits.11,ȱ260ȱOurȱdataȱaddȱtoȱexistingȱevidenceȱhighlightingȱtheȱneedȱtoȱincreaseȱ theȱ supplyȱ ofȱ lowȬthresholdȱ supportiveȱ housingȱ thatȱ includesȱ safeguardsȱ toȱmanageȱ behavioursȱassociatedȱwithȱactiveȱ illicitȱdrugȱuseȱ includingȱdrugȱoverdoseȱeventsȱandȱ drugȱdealingȱandȱaccompanyingȱrisksȱforȱviolence.261,ȱ262ȱȱȱȱȱ Thereȱ areȱ aȱ numberȱ ofȱ limitationsȱ inȱ thisȱ study.ȱ Inȱ particular,ȱ Vancouver’’sȱ housingȱ situationȱ andȱ openȱ drugȱ sceneȱ haveȱ uniqueȱ featuresȱ thatȱ mayȱ limitȱ theȱ generalizabilityȱ ofȱ theseȱ finding.ȱHowever,ȱ drugȬrelatedȱ streetȱ disorderȱ andȱ lackȱ ofȱ supportiveȱhousingȱforȱdrugȱusingȱpopulationsȱareȱissuesȱinȱmanyȱotherȱurbanȱsettingsȱ andȱ thereforeȱ theȱ findingsȱofȱ thisȱstudyȱmayȱbeȱrelevantȱ toȱotherȱareas.ȱ Inȱaddition,ȱaȱ numberȱofȱourȱmeasuresȱwereȱbasedȱuponȱselfȬreportȱdataȱandȱareȱthereforeȱvulnerableȱ toȱ recallȱ biasȱ andȱ socialȱdesirableȱ responding.ȱ Inȱ thisȱ study,ȱ issuesȱwithȱ recallȱ couldȱ haveȱresultedȱinȱanȱoverȬȱorȱunderestimationȱofȱtheȱnumberȱofȱhoursȱspentȱonȱtheȱstreetȱ socializing,ȱ suggestingȱ thatȱ ifȱ recallȱ issuesȱwereȱpresentȱ theyȱwouldȱhaveȱbiasedȱ ourȱ ȱȱ 96 resultȱ towardsȱ theȱ null.ȱ Ifȱ socialȱ desirableȱ respondingȱwasȱ anȱ issueȱweȱ suspectȱ thisȱ responseȱbiasȱwouldȱhaveȱledȱtoȱanȱunderreportingȱofȱtheȱnumberȱofȱhoursȱspentȱonȱtheȱ street,ȱwhichȱ inȱ turnȱmayȱhaveȱ ledȱ toȱ anȱunderestimationȱofȱ theȱ associationȱbetweenȱ accessȱ toȱ privateȱ spaceȱ andȱ socializingȱ inȱ theȱ openȱ drugȱ scene.ȱ Finally,ȱ ourȱ secondȱ analysisȱ reliedȱ onȱ willingnessȱ responsesȱ andȱ doesȱ notȱ representȱ actualȱ behaviourȱ change.ȱThereȱareȱ likelyȱmultipleȱfactorsȱthatȱcontributeȱtoȱsocializingȱ inȱpublicȱspacesȱ andȱ providingȱ privateȱ spaceȱ mayȱ notȱ changeȱ thisȱ behaviour.ȱ However,ȱ previousȱ analysesȱevaluatingȱ theȱvalidityȱofȱ reportingȱwillingnessȱ toȱuseȱaȱsupervisedȱ injectionȱ facilityȱ onȱ subsequentȱ ratesȱ ofȱ useȱ amongȱ illicitȱ injectionȱ drugȱ usersȱ foundȱ thatȱ willingnessȱmeasuresȱwereȱreasonableȱpredictorsȱofȱlaterȱbehaviour.263ȱ Inȱ summary,ȱ ourȱ dataȱ indicateȱ thatȱ aȱ lackȱ ofȱ accessȱ toȱ privateȱ spaceȱ amongȱ peopleȱwhoȱuseȱdrugsȱmayȱ contributeȱ toȱ streetȱdisorderȱ inȱ openȱdrugȱ scenes.ȱ Studyȱ findingsȱ furtherȱ suggestȱ thatȱ increasingȱ accessȱ toȱ privateȱ spacesȱ thatȱ accommodateȱ socializingȱ amongȱ activeȱ drugȱ usersȱ andȱ includeȱ safeguardsȱ toȱmanageȱ behavioursȱ associatedȱwithȱactiveȱ illicitȱdrugȱuseȱhasȱpotentialȱ toȱreduceȱoneȱcomponentȱofȱstreetȱ disorder.ȱ LowȬthresholdȱ supportiveȱ housingȱ approachesȱ basedȱ onȱ theȱ housingȱ firstȱ modelȱappearȱtoȱofferȱimportantȱopportunitiesȱtoȱmeetȱtheseȱobjectives.ȱ ȱ ȱTableȱ 5.1ȱUnivariateȱ analysesȱofȱ factorsȱ associatedȱwithȱ socializingȱ inȱVancouver’’sȱ openȱdrugȱsceneȱamongȱinjectionȱdrugȱusersȱ(n=1121)ȱ ȱ Socializesȱinȱopenȱdrugȱsceneȱaȱ ȱ Univariateȱ Characteristicȱ Yesȱn=ȱ477,ȱnȱ(%)ȱ Noȱn=ȱ644,ȱnȱ(%)ȱ ȱ ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ LimitedȱPrivateȱSpaceȱdȱ ȱ ȱ ȱȱ Yesȱ 407ȱ(85)ȱ 432ȱ(67)ȱ 2.85ȱȱ(2.11ȱ––ȱ3.86)ȱ <0.001 Noȱ 70ȱ(15)ȱ 212ȱ(33)ȱ ȱ Ageȱ(Median,ȱIQR)ȱcȱ ȱ ȱ ȱ ȱ Perȱyearȱolderȱ 43ȱ(37Ȭ49)ȱ 45ȱ(39Ȭ52)ȱ ȱ 0.97ȱȱ(0.96ȱ––ȱ0.98)ȱ <0.001 FemaleȱGenderȱȱ ȱ ȱ ȱ Yesȱ 173ȱ(36)ȱ 223ȱ(35)ȱ 1.07ȱȱ(0.84ȱ––ȱ1.38)ȱ 0.570 Noȱ 304ȱ(64)ȱ 421ȱ(65)ȱ ȱ AboriginalȱAncestryȱȱ ȱ ȱ ȱ Yesȱ 196ȱ(41)ȱ 200ȱ(31)ȱ 1.55ȱȱ(1.21ȱ––ȱ1.98)ȱ <0.001 Noȱ 281ȱ(59)ȱ 444ȱ(69)ȱ ȱ DailyȱCocaineȱInjectionȱdȱ ȱ ȱ ȱ Yesȱ 53ȱ(11)ȱ 45ȱ(7)ȱ 1.66ȱȱ(1.10ȱ––ȱ2.52)ȱ 0.016 Noȱ 424ȱ(89)ȱ 599ȱ(93)ȱ ȱ DailyȱHeroinȱInjectionȱdȱ ȱ ȱ ȱ Yesȱ 121ȱ(25)ȱ 97ȱ(15)ȱ 1.92ȱȱ(1.42ȱ––ȱ2.58)ȱ <ȱ0.001 Noȱ 356ȱ(75)ȱ 547ȱ(85)ȱ ȱ DailyȱCrackȱUseȱdȱ ȱ ȱ ȱ Yesȱ 261ȱ(55)ȱ 187ȱ(29)ȱȱȱȱ 2.95ȱȱ(2.30ȱ––ȱ3.78)ȱ <ȱ0.001 Noȱ 216ȱ(45)ȱ 457ȱ(71)ȱ ȱ BingeȱDrugȱUsedȱ ȱ ȱ ȱ Yesȱ 233ȱ(49)ȱ 198ȱ(31)ȱ 2.15ȱȱ(1.68ȱ––ȱ2.75)ȱ <ȱ0.001 Noȱ 244ȱ(51)ȱ 446ȱ(69)ȱ ȱ SexȱTradeȱdȱ ȱ ȱ ȱ Yesȱ 68ȱ(14)ȱ 53ȱȱȱȱ(8)ȱ 1.85ȱȱ(1.27ȱ––ȱ2.71)ȱ 0.001 Noȱ 409ȱ(86)ȱ 591ȱ(92)ȱ ȱ DrugȱDealingȱdȱ ȱ ȱ ȱ Yesȱ 186ȱ(39)ȱ 135ȱ(21)ȱ 2.41ȱȱ(1.85ȱ––ȱ3.14)ȱ <0.001 Noȱ 291ȱ(61)ȱ 509ȱ(79)ȱ ȱ Employmentȱdȱ ȱ ȱ ȱ Yesȱ 86ȱ(18)ȱ 160ȱ(25)ȱ 0.67ȱȱ(0.50ȱ––ȱ0.89)ȱ 0.006 Noȱ 391ȱ(82)ȱ 484ȱ(75)ȱ ȱ RecentȱIncarcerationȱdȱ ȱ ȱ ȱ Yesȱ 72ȱ(15)ȱ 65ȱ(10)ȱ 1.58ȱȱ(1.11ȱ––ȱ2.27)ȱ 0.012 Noȱ 405ȱ(85)ȱ 579ȱ(90)ȱ ȱ AnyȱAddictionȱTreatmentȱdȱ ȱ ȱ ȱ Yesȱ 243ȱ(51)ȱ 394ȱ(61)ȱȱȱȱ 0.66ȱȱ(0.52ȱ––ȱ0.84)ȱ <0.001 Noȱ 234ȱ(49)ȱ 250ȱ(39)ȱ ȱ HIVȱPositiveȱdȱ ȱ ȱ ȱ Yesȱ 151ȱ(32)ȱ 214ȱ(34)ȱ 0.93ȱȱ(0.72ȱ––ȱ1.19)ȱ 0.558 Noȱ 322ȱ(68)ȱ 423ȱ(66)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Note:ȱaȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱdrugȱuseȱ epicentreȱandȱspendingȱonȱaverageȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializing.;ȱbȱORȱ=ȱOddsȱ Ratio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱcȱIQR=ȱInterȱQuartileȱRange;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱ previousȱ6ȱmonths.ȱ ȱ 97 ȱTableȱ 5.2ȱUnivariateȱanalysisȱofȱhousingȱ statusȱ andȱ socializingȱ inȱVancouver’’sȱ openȱdrugȱsceneȱamongȱinjectionȱdrugȱusersȱ ȱ Socializesȱinȱopenȱdrugȱsceneȱa ȱ Univariateȱ Characteristicȱ Yesȱn=ȱ477,ȱ nȱ(%)ȱ Noȱn=ȱ644,ȱ nȱ(%)ȱ ȱ ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ HousingȱStatusȱcȱ ȱ ȱ ȱ ȱ StableȱHousingȱ 78ȱ(22)ȱ 273ȱ(78)ȱ ȱ ȬȱReferenceȬȱ RoomȱinȱHotelȱ(SRO)ȱ 225ȱ(48)ȱ 245ȱ(52)ȱ ȱ 3.21ȱȱ(2.36ȱ––ȱ4.38)ȱ <0.001ȱ Shelterȱ 19ȱ(48)ȱ 21ȱ(52)ȱ ȱ 3.17ȱȱ(1.62ȱ––ȱ6.19)ȱ <0.001ȱ NoȱFixedȱAddress/Street 146ȱ(66)ȱ 75ȱ(34)ȱ ȱ 6.81ȱȱ(4.68ȱ––ȱ9.92)ȱ <0.001ȱ TreatmentȱRecovery*ȱȱ 5ȱ(29)ȱ 12ȱ(71)ȱ ȱ 1.46ȱȱ(0.39ȱ––ȱ4.61)ȱ 0.552ȱ Jailȱ(Prison)**ȱ 0ȱ(0)ȱ 4ȱ(100)ȱ ȱ 0.67ȱȱ(0.00ȱ––ȱ5.40)ȱ 0.738ȱ Other*ȱ 4ȱ(22)ȱ 14ȱ(82)ȱ ȱ 1.00ȱȱ(0.23ȱ––ȱ3.31)ȱ 1.000ȱ Note:ȱaȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱdrugȱ useȱepicenterȱandȱspendingȱonȱaverageȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializing.;ȱbORȱ =ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱcȱDenotesȱcurrentȱstatus.ȱ *pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱlessȱthanȱ5. **ȱExactȱlogisticȱmodelȱusedȱdueȱtoȱpresenceȱofȱzeroȱcell.ȱ ȱ ȱ Tableȱ 5.3ȱ Multivariateȱ logisticȱ regressionȱ analysisȱ ofȱ primaryȱ andȱ secondaryȱ factorsȱ associatedȱwithȱ socializingaȱ inȱVancouver’’sȱopenȱdrugȱ sceneȱamongȱinjectionȱdrugȱusersȱ(n=1121)ȱ Characteristicȱ Adjustedȱ OddsȱRatioȱ (95%ȱConfidenceȱInterval)ȱ pȬvalue LimitedȱPrivateȱSpaceȱbȱ 2.33ȱ ȱ(1.68ȱ––ȱ3.24)ȱ <0.001 AboriginalȱAncestryȱȱ 1.59 ȱ(1.21ȱ––ȱ2.09)ȱ <0.001 DailyȱCrackȱUseȱbȱ 1.79 ȱ(1.34ȱ––ȱ2.39)ȱ <0.001 BingeȱDrugȱUseȱbȱ 1.80 ȱ(1.36ȱ––ȱ2.38)ȱ <0.001 DrugȱDealingȱbȱ 1.62 ȱ(1.19ȱ––ȱ2.20)ȱ 0.002 AnyȱAddictionȱTreatmentȱbȱ 0.63 ȱ(0.49ȱ––ȱ0.82)ȱ <0.001 Note:ȱaȱSocializingȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱdrugȱuseȱepicenterȱ andȱspendingȱonȱaverageȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializing.;ȱbȱDenotesȱ activitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ *Finalȱmodelȱadjustedȱforȱtheȱmonthȱthatȱtheȱinterviewȱwasȱconducted ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 98 ȱTableȱ5.4ȱUnivariateȱanalysesȱofȱ injectionȱdrugȱusersȱ thatȱhaveȱ limitedȱ accessȱ toȱprivateȱspaceȱandȱengageȱ inȱsocializingaȱ inȱVancouver’’sȱopenȱ drugȱsceneȱstratifiedȱbyȱwillingnessȱtoȱrelocateȱ(n=392)ȱ ȱ Willingȱtoȱrelocateȱsocializingȱȱ ȱ Univariateȱȱ Characteristicȱ Yesȱn=256,nȱ(%) Noȱn=136,ȱnȱ(%) ȱ ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ HoursȱSocializingȱc,ȱdȱ 8ȱ (4Ȭ12)ȱ 6ȱ ȱ(4Ȭ12)ȱ ȱ 1.05ȱ(1.01ȱ––ȱ1.09)ȱ 0.025ȱ Ageȱ(perȱyearȱolder)ȱ 43ȱ (36Ȭ48)ȱ 46ȱ ȱ(40Ȭ50)ȱ ȱ 0.97ȱ(0.95ȱ––ȱ0.99)ȱ 0.013ȱ FemaleȱGenderȱȱ ȱ ȱ ȱ ȱ ȱ ȱ yYesȱ 96ȱ (37)ȱ 51 (37)ȱ ȱ 1.00ȱ(0.65ȱ––ȱ1.54)ȱ 1.000ȱ Noȱ 160ȱ (63)ȱ 85 (63)ȱ ȱ ȱ ȱ AboriginalȱAncestryȱȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 104ȱ (41)ȱ 54 (40)ȱ ȱ 1.04ȱ(0.68ȱ––ȱ1.59)ȱ 0.860ȱ Noȱ 152ȱ (59)ȱ 82 (60)ȱ ȱ ȱ DailyȱCocaineȱInjectionȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 23ȱ ȱȱ(9)ȱ 20 (15)ȱ ȱ 0.57ȱ(0.30ȱ––ȱ1.09)ȱ 0.085ȱ Noȱ 233ȱ (91)ȱ 116 (85)ȱ ȱ ȱ DailyȱHeroinȱInjectionȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 85ȱ (33)ȱ 21 (15)ȱ ȱ 2.72ȱ(1.60ȱ––ȱ4.64)ȱ <0.001ȱ Noȱ 171ȱ (67)ȱ 115 (85)ȱ ȱ ȱ DailyȱCrackȱUseȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 157ȱ (61)ȱ 71 (52)ȱ ȱ 1.45ȱ(0.95ȱ––ȱ2.21)ȱ 0.081ȱ Noȱ 99ȱ (39)ȱ 65 (48)ȱ ȱ ȱ BingeȱDrugȱUseȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 130ȱ (51)ȱ 64 (47)ȱ ȱ 1.16ȱ(0.77ȱ––ȱ1.76)ȱ 0.483ȱ Noȱ 126ȱ (49)ȱ 72 (53)ȱ ȱ ȱ Overdoseȱ(nonȬfatal)ȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 17ȱ ȱȱ(7)ȱ 6 ȱȱ(4)ȱ ȱ 1.54ȱ(0.59ȱ––ȱ4.00)ȱ 0.371ȱ Noȱ 239ȱ (93)ȱ 130 (96)ȱ ȱ ȱ EncountersȱwithȱPoliceȱeȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 97ȱ (38)ȱ 33 (24)ȱ ȱ 1.90ȱ(1.19ȱ––ȱ3.04)ȱ 0.006ȱ Noȱ 159ȱ (62)ȱ 103 (76)ȱ ȱ ȱ VictimȱofȱViolenceȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 63ȱ (25)ȱ 19 (14)ȱ ȱ 2.01ȱ(1.15ȱ––ȱ3.53)ȱ 0.014ȱ Noȱ 193ȱ (75)ȱ 117 (86)ȱ ȱ ȱ SyringeȱSharing*ȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 7ȱ ȱȱ(3)ȱ 3 ȱȱ(2)ȱ ȱ ȱȱ1.25ȱ(0.28ȱ––ȱ7.59)ȱ 1.000ȱ Noȱ 249ȱ (97)ȱ 133 (98)ȱ ȱ ȱ SexȱTradeȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 44ȱ (17)ȱ 18 (13)ȱ ȱ 1.36ȱ(0.75ȱ––ȱ2.46)ȱ 0.307ȱ Noȱ 212ȱ (83)ȱ 118 (87)ȱ ȱ ȱ DrugȱDealingȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 111ȱ (43)ȱ 47 (35)ȱ ȱ 1.45ȱ(0.94ȱ––ȱ2.23)ȱ 0.091ȱ Noȱ 145ȱ (57)ȱ 89 (65)ȱ ȱ ȱ Employmentȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 44ȱ (17)ȱ 18 (13)ȱ ȱ 1.36ȱ(0.75ȱ––ȱ2.46)ȱ 0.307ȱ Noȱ 212ȱ (83)ȱ 118 (87)ȱ ȱ ȱ RecentȱIncarcerationȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 48ȱ (19)ȱ 16 (12)ȱ ȱ 1.73ȱ(0.94ȱ––ȱ3.18)ȱ 0.075ȱ Noȱ 208ȱ (81)ȱ 120 (88)ȱ ȱ ȱ AnyȱAddictionȱTreatmentȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 122ȱ (48)ȱ 72 (53)ȱ ȱ 0.81ȱ(0.53ȱ––ȱ1.23)ȱ 0.319ȱ Noȱ 134ȱ (52)ȱ 64 (47)ȱ ȱ ȱ MultipleȱSexȱPartnersȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 52ȱ (20)ȱ 24 (18)ȱ ȱ 1.19ȱ(0.70ȱ––ȱ2.03)ȱ 0.525ȱ Noȱ 204ȱ (80)ȱ 112 (82)ȱ ȱ ȱ HIVȱPositiveȱȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 77ȱ (30)ȱ 48 (36)ȱ ȱ 0.79ȱ(0.51ȱ––ȱ1.23)ȱ 0.292ȱ Noȱ 177ȱ (70)ȱ 87 (64)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Note:ȱaȱSocializingȱwasȱdefinedȱasȱspendingȱonȱave.ȱ3+ȱhrsȱonȱtheȱstreetȱeachȱday;ȱbȱORȱ=ȱ Oddsȱ Ratio,ȱ CI=Confidenceȱ Interval;ȱ cȱ Denotesȱ activitiesȱ orȱ situationsȱ referringȱ toȱ previousȱ 6ȱ months;ȱ dȱ ‘‘Hoursȱ Socializing’’ȱ wasȱ definedȱ asȱ aȱ continuousȱ variableȱ &ȱ measuredȱperȱadditionalȱhr;ȱeȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱmonth.ȱ *pȬvalueȱ andȱ 95%ȱCIȱ reportedȱ fromȱ Fisher’’sȱ Exactȱ Testȱ asȱ 25%ȱ ofȱ cellsȱ hadȱ expectedȱ countsȱlessȱthanȱ5.ȱ ȱ 99 ȱTableȱ 5.5ȱUnivariateȱ analysisȱ ofȱhousingȱ statusȱ andȱwillingnessȱ toȱ relocateȱ amongȱ injectionȱdrugȱusersȱ Willingȱtoȱrelocateȱ socializingȱ ȱ Univariateȱ Characteristicȱ Yesȱn=256,ȱ n(%)ȱ Noȱn=ȱ136,ȱ n(%)ȱ ORbȱȱ(95%ȱCI)ȱ pȬvalue HousingȱStatusȱcȱ ȱ ȱ ȱ ȱ StableȱHousingȱ 14ȱ(35)ȱ 26ȱ(65)ȱ ȱ ȬȱReferenceȬȱ RoomȱinȱHotelȱ(SRO)ȱ 106ȱ(56)ȱ 84ȱ(44)ȱ ȱ 2.34ȱȱ(1.15ȱ––ȱȱ4.77)ȱ 0.017 Shelter*ȱ 13ȱ(76)ȱ 4ȱ(24)ȱ ȱ 6.04ȱȱ(1.45ȱ––29.37)ȱ 0.008 NoȱFixedȱAddress/Street 117ȱ(85)ȱ 21ȱ(15)ȱ ȱ 10.35ȱȱ(4.67––ȱ23.00)ȱ <0.001 TreatmentȱRecovery**ȱȱ 4(100)ȱ 0ȱ(0)ȱ ȱ 8.95ȱ(1.05ȱ––ȱȱinfinity) 0.045 Jailȱ ȬȱȱȱȬȱ ȬȱȱȱȬȱ ȱ ȱ Other*ȱ 2ȱ(67)ȱ 1ȱ(33)ȱ ȱ 3.71ȱȱ(0.31ȱ––ȱ44.66)ȱ 0.545 Note:ȱaȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱ drugȱ useȱ epicenterȱ andȱ spendingȱ onȱ averageȱ threeȱ orȱmoreȱ hoursȱ onȱ theȱ streetȱ eachȱ dayȱ socializing.;ȱbORȱ=ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱcȱDenotesȱcurrentȱstatus.ȱ **pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱ lessȱthanȱ5.**ȱExactȱlogisticȱmodelȱusedȱdueȱtoȱpresenceȱofȱzeroȱcell.ȱ ȱ ȱ Tableȱ 5.6ȱ Multivariateȱ logisticȱ regressionȱ analysisȱ ofȱ factorsȱ associatedȱ withȱ willingnessȱtoȱrelocateȱsocializingȱactivityaȱamongȱinjectionȱdrugȱusersȱ(n=392)ȱ Characteristicȱ Adjustedȱ OddsȱRatio (95%ȱConfidenceȱInterval)ȱ pȬvalue HoursȱSocializingȱȱb,ȱcȱ 1.02 ȱ(0.98ȱ––ȱ1.07)ȱ 0.266 Ageȱ(perȱyearȱolder)ȱ 0.98 ȱ(0.96ȱ––ȱ1.01)ȱ 0.167 DailyȱHeroinȱInjectionȱbȱ 2.27 ȱ(1.28ȱ––ȱ3.88)ȱ 0.005 EncountersȱwithȱPoliceȱdȱ 1.47 ȱ(0.90ȱ––ȱ2.40)ȱ 0.124 VictimȱofȱViolenceȱbȱ 1.81 ȱ(1.02ȱ––ȱ3.23)ȱ 0.044 Note:ȱaȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱ drugȱ useȱ epicenterȱ andȱ spendingȱ onȱ averageȱ threeȱ orȱmoreȱ hoursȱ onȱ theȱ streetȱ eachȱ dayȱ socializing;ȱbȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱcȱ‘‘HoursȱSocializing’’ȱ wasȱdefinedȱasȱaȱcontinuousȱvariableȱandȱmeasuredȱperȱadditionalȱhour;ȱdȱDenotesȱactivitiesȱorȱ situationsȱreferringȱtoȱpreviousȱmonth.ȱ ȱ ȱ ȱ 100 ȱFigureȱ5.1ȱHousingȱstatusȱamongȱinjectionȱdrugȱusersȱ Housing Status SRO 41% Shelter/Hostel 4% NFA/Street 20% StableHousing 31% Jail 0%Other 2% Treatment RecoveryHouse 2% ȱ Note:ȱSROȱ––‘‘SingleȱRoomȱOccupancy’’ȱdefinedȱasȱaȱsingleȱroomȱinȱaȱhotelȱ Figureȱ 5.2ȱDistributionȱ ofȱ injectionȱ drugȱ usersȱ byȱ housingȱ statusȱ andȱ accessȱtoȱprivateȱspaceȱ 152 39 219 12 3 15 199 71 1 2 5 1 3 399 0 50 100 150 200 250 300 350 400 450 St ab le Ho us ing SR O Sh elt er /H os tel NF A/ St re et Tr ea tm en tR ec ov er yH ou se Ja il Ot he r Limited Private Space, n=839 Adequate Private Space, n=282 ȱ Note:ȱSROȱ––‘‘SingleȱRoomȱOccupancy’’ȱdefinedȱasȱaȱsingleȱroomȱinȱaȱhotelȱ ȱ ȱ 101 ȱȱ 102 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ CHAPTER 6: ȱ OPPORTUNITIESȱFORȱREDUCINGȱENGAGEMENTȱINȱ DISORDERLYȱINCOMEȱGENERATIONȱACTIVITIESȱAMONGȱ PEOPLEȱWHOȱINJECTȱILLICITȱDRUGS5ȱ 6.1 Introductionȱ Thereȱ areȱ manyȱ establishedȱ linksȱ betweenȱ chronicȱ illicitȱ drugȱ useȱ andȱ engagementȱinȱillegalȱincomeȱgenerationȱactivities.171,ȱ264Ȭ269ȱȱPeopleȱwhoȱuseȱillicitȱdrugsȱ andȱ areȱ strugglingȱ withȱ addictionȱ areȱ oftenȱ unableȱ toȱ acquireȱ andȱ sustainȱ formalȱ employment,ȱ andȱ yetȱ theȱ highȱ costsȱ associatedȱwithȱ obtainingȱ illicitȱ drugsȱ requiresȱ individualsȱ toȱ findȱmeansȱ ofȱ generatingȱ income.33,ȱ 170Ȭ174ȱ Givenȱ theseȱ constraints,ȱ theȱ incomeȱgenerationȱopportunitiesȱavailableȱtoȱillicitȱdrugȱusersȱfrequentlyȱinvolveȱillegalȱ activityȱandȱareȱoftenȱassociatedȱwithȱstreetȱdisorder.7,ȱ171ȱForȱexample,ȱcommonȱincomeȱ generationȱ strategiesȱ includeȱ streetȬbasedȱ sexȱwork,ȱ drugȱ dealing,ȱ panhandlingȱ andȱ recycling/salvaging/vendingȱwhichȱoftenȱtakeȱplaceȱonȱpublicȱstreetsȱandȱareȱgenerallyȱ consideredȱ toȱ beȱ undesirableȱ behavioursȱ fromȱ aȱ communityȱ perspective.4,ȱ 7Ȭ10ȱ ȱ Inȱ Vancouver,ȱCanadaȱ theseȱ typesȱ ofȱdisorderlyȱ incomeȱ generationȱ activitiesȱ areȱ aȱwellȱ describedȱ featureȱ ofȱ theȱ city’’sȱdrugȱuseȱ epicentreȱ knownȱ asȱ theȱDowntownȱEastsideȱ [DTES].4,ȱ7,ȱ10ȱ ȱ 5 Aȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱWood,ȱE.,ȱ Qi,ȱJ.,ȱMcArthur,ȱD.,ȱMontaner,ȱJ.,ȱKerr,ȱT.ȱOpportunitiesȱforȱreducingȱengagementȱinȱ streetȱbasedȱincomeȱgenerationȱactivitiesȱamongȱpeopleȱwhoȱinjectȱillicitȱdrugs. ȱȱ 103 Toȱdate,ȱpolicyȱ responsesȱ toȱ addressȱproblemsȱassociatedȱwithȱ illicitȱdrugȱuse,ȱ includingȱstreetȱdisorderȱresultingȱ fromȱ theȱ incomeȱgenerationȱactivitiesȱofȱ illicitȱdrugȱ users,ȱtypicallyȱrelyȱonȱlawȱenforcementȱtoȱdeterȱandȱmanageȱundesirableȱbehaviours.57,ȱ 198,ȱ200,ȱ212,ȱ270ȱȱHowever,ȱitȱhasȱbeenȱdocumentedȱthatȱinȱmanyȱinstancesȱlawȱenforcementȱ initiativesȱseekingȱtoȱreduceȱstreetȱdisorderȱresultȱinȱdisplacingȱdisorderlyȱbehaviourȱtoȱ surroundingȱ neighbourhoods,ȱ whichȱ mayȱ negativelyȱ impactȱ communitiesȱ and/orȱ separateȱ vulnerableȱ drugȱ usersȱ fromȱ familiarȱ healthȱ andȱ socialȱ services.62,ȱ 64,ȱ 69,ȱ 249ȱAȱ growingȱbodyȱofȱhealthȱresearchȱsuggestsȱthatȱinterventionsȱthatȱtargetȱtheȱbehaviourȱofȱ individuals,ȱ suchȱ asȱ lawȱ enforcement,ȱmayȱ beȱ ineffectiveȱ andȱ inadvertentlyȱ produceȱ harm,ȱasȱ theyȱ failȱ toȱ recognizeȱandȱaddressȱ theȱ roleȱ thatȱ socialȱ andȱ structuralȱ factorsȱ playȱinȱshapingȱbehaviour.73,ȱ74,ȱ76,ȱ197ȱIndeed,ȱinterventionsȱthatȱareȱlikelyȱtoȱhaveȱaȱmoreȱ lastingȱ andȱ positiveȱ influenceȱ areȱ onesȱ thatȱ seekȱ toȱ alterȱ theȱ socialȱ andȱ structuralȱ environmentȱ surroundingȱdrugȱusersȱasȱaȱmeansȱofȱ changingȱbehaviour.75,ȱ 77,ȱ 78ȱ Inȱ theȱ contextȱofȱdisorderlyȱ incomeȱgenerationȱactivities,ȱoneȱpotentialȱapproachȱ toȱreducingȱ streetȱdisorderȱ isȱ toȱ changeȱ theȱ structuralȱ environmentȱ surroundingȱ individualsȱwhoȱ useȱdrugsȱbyȱcreatingȱsanctionedȱlowȬthresholdȱemploymentȱopportunities.ȱȱ Inȱ Vancouver,ȱ Canadaȱ thereȱ areȱ aȱ smallȱ numberȱ ofȱ existingȱ lowȬthresholdȱ employmentȱopportunitiesȱavailableȱ toȱ individualsȱwhoȱactivelyȱuseȱ illicitȱdrugs.ȱForȱ example,ȱ inȱ theȱDTESȱofȱVancouverȱ aȱ communityȱ caféȱ andȱ cateringȱ socialȱ enterpriseȱ companyȱ providesȱ anȱ estimatedȱ nineȱ lowȬthresholdȱ employmentȱ positions,176,ȱ 177ȱ anȱ organizationȱ thatȱ processesȱ recyclableȱ containersȱ providesȱ roughlyȱ 33ȱ lowȬthresholdȱ ȱȱ 104 positions,178,ȱ 179ȱ aȱ localȱ drugȱ usersȱ groupȱ providesȱ aȱ smallȱ numberȱ ofȱ stipendsȱ forȱ volunteerȱ workȱ undertakenȱ byȱ theirȱ members271Ȭ273ȱ andȱ aȱ photoȱ calendarȱ projectȱ initiatedȱbyȱaȱsocialȱ justiceȱorganizationȱoffersȱaȱprogramȱ forȱresidentsȱofȱ theȱDTESȱ toȱ becomeȱ vendorsȱ andȱ sellȱ calendarsȱ andȱ books.180Ȭ182ȱ Despiteȱ theȱ existenceȱ ofȱ theseȱ opportunities,ȱtheȱnumberȱofȱlowȬthresholdȱemploymentȱpositionsȱisȱlimitedȱandȱthereȱ isȱlittleȱinformationȱavailableȱtoȱdetermineȱwhetherȱthereȱisȱaȱsignificantȱdemandȱforȱthisȱ typeȱofȱworkȱamongȱindividualsȱwhoȱcurrentlyȱengageȱinȱdisorderlyȱincomeȱgenerationȱ activities.ȱȱ Therefore,ȱweȱsoughtȱtoȱcharacterizeȱtheȱprevalenceȱandȱcorrelatesȱofȱengagingȱinȱ disorderlyȱ incomeȱ generationȱ activitiesȱ amongȱ aȱ communityȱ recruitedȱ cohortȱ ofȱ injectionȱdrugȱusersȱ(IDU)ȱinȱVancouver.ȱWeȱalsoȱsoughtȱtoȱidentifyȱaȱsubȬpopulationȱofȱ IDUȱwhoȱwouldȱbeȱwillingȱtoȱceaseȱengagingȱ inȱtheseȱactivitiesȱ ifȱotherȱ lowȬthresholdȱ workȱopportunitiesȱwereȱmadeȱavailableȱtoȱthem.ȱȱ 6.2 Methodsȱ Dataȱ forȱ thisȱ studyȱwereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱdescriptionȱ ofȱ theȱ studyȱpleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱTheȱpresentȱanalysesȱareȱrestrictedȱtoȱVIDUSȱparticipantsȱseenȱforȱstudyȱfollowȬ upȱduringȱtheȱperiodȱofȱNovemberȱ2008ȱtoȱJulyȱ2009ȱasȱtheȱmeasureȱforȱourȱoutcomeȱofȱ interestȱwasȱavailableȱonlyȱforȱthisȱperiod.ȱIfȱ individualsȱwereȱseenȱforȱmultipleȱstudyȱ followȬupȱvisitsȱduringȱthisȱstudyȱperiod,ȱonlyȱdataȱfromȱtheirȱfirstȱvisitȱwereȱused.ȱ ȱȱ 105 Allȱparticipantsȱ seenȱduringȱ ourȱ studyȱperiodȱwereȱ askedȱ toȱ identifyȱ allȱ theirȱ incomeȱsourcesȱsinceȱtheirȱlastȱstudyȱvisitȱandȱtoȱestimateȱtheȱaverageȱnumberȱofȱhoursȱ perȱweekȱtheyȱspentȱengagedȱinȱeachȱincomeȱgenerationȱactivity.ȱCategoriesȱofȱincomeȱ sourcesȱ includedȱ recyclingȱ (includesȱ salvagingȱ recyclableȱmaterialsȱ andȱunsanctionedȱ streetȱ vending),ȱ panhandling,ȱ squeegeeing,ȱ sexȱ tradeȱworkȱ andȱ drugȱ dealing.ȱOtherȱ categoriesȱofȱincomeȱsourcesȱincludedȱwelfareȱ(includingȱdisability,ȱpensionsȱandȱotherȱ formsȱ ofȱ governmentȱ transfers),ȱ familyȱ andȱ friends,ȱ regularȱ job,ȱ temporaryȱ workȱ (includingȱunderȱtheȱtableȱemployment)ȱandȱcriminalȱactivityȱ(categoryȱencompassesȱaȱ rangeȱofȱcriminalȱactivitiesȱincludingȱtheft,ȱbreakȱandȱentry,ȱrobberyȱandȱfraud).ȱȱ Inȱ ourȱ primaryȱ analysisȱ theȱ outcomeȱ ofȱ interestȱwasȱ engagingȱ inȱ ‘‘disorderlyȱ incomeȱgenerationȱactivities’’ȱdefinedȱasȱreportingȱanyȱofȱtheȱfollowingȱincomeȱsources:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱ drugsȱ andȱ exchangingȱ sexȱ forȱ money.ȱ Althoughȱweȱwereȱ unableȱ toȱ confirmȱ thatȱ allȱ reportedȱ drugȱ dealingȱ andȱ sexȱworkȱ activitiesȱ occurredȱ inȱ publicȱ settings,ȱ aȱ previousȱ studyȱ amongȱ VIDUSȱ participantsȱ foundȱ thatȱ bothȱ activitiesȱ areȱ independentlyȱ associatedȱ withȱ spendingȱ timeȱ inȱ Vancouver’’sȱopenȱdrugȱsceneȱsuggestingȱthatȱtheseȱactivitiesȱareȱlargelyȱstreetȬbased.247ȱ Toȱ characterizeȱ factorsȱ associatedȱwithȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activities,ȱweȱaȱprioriȱselectedȱaȱrangeȱofȱsocioȬdemographicȱandȱbehaviouralȱvariablesȱ thatȱweȱhypothesizedȱmightȱbeȱassociatedȱwithȱourȱoutcomeȱofȱinterest.ȱTheseȱincluded:ȱ ageȱ(perȱyearȱolder);ȱdailyȱexpenditureȱonȱdrugsȱ(perȱadditionalȱ$10);ȱgenderȱ(femaleȱvs.ȱ male);ȱAboriginalȱancestryȱ(yesȱvs.ȱno);ȱunstableȱhousing,ȱdefinedȱasȱcurrentlyȱlivingȱinȱ ȱȱ 106 aȱsingleȱoccupancyȱroomȱinȱaȱhotel,ȱaȱtreatmentȱorȱrecoveryȱhouse,ȱjail,ȱshelterȱorȱhostel,ȱ orȱhavingȱnoȱfixedȱaddressȱforȱtheȱ lastȱsixȱmonthsȱ(yesȱvs.ȱno);ȱhighȱschoolȱeducation,ȱ definedȱasȱcompletingȱhighȱschoolȱorȱobtainingȱequivalentȱdiplomaȱ(yesȱvs.ȱno);ȱhavingȱ regularȱemployment,ȱdefinedȱasȱhavingȱaȱ regularȱorȱ temporaryȱ jobȱ (yesȱvs.ȱno);ȱdailyȱ cocaineȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ heroinȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no);ȱ nonȬfatalȱ overdoseȱ (yesȱ vs.ȱ no),ȱ bingeȱ drugȱ use,ȱ definedȱ asȱ aȱ periodȱofȱusingȱdrugsȱmoreȱoftenȱthanȱusualȱ(yesȱvs.ȱno);ȱencountersȱwithȱpoliceȱinȱtheȱ lastȱmonth,ȱdefinedȱ asȱbeingȱquestioned,ȱ searchedȱ orȱ stoppedȱbyȱpoliceȱ (yesȱvs.ȱno);ȱ beingȱaȱvictimȱofȱviolenceȱ(yesȱvs.ȱno);ȱsyringeȱsharing,ȱdefinedȱasȱborrowingȱorȱlendingȱ syringesȱalreadyȱusedȱbyȱsomeoneȱelseȱtoȱinjectȱdrugsȱ(yesȱvs.ȱno);ȱusingȱinjectionȱdrugsȱ inȱpublicȱ locations,ȱsuchȱasȱcityȱstreets,ȱparksȱandȱalleysȱ (yesȱvs.ȱno);ȱengagingȱ inȱanyȱ unprotectedȱ sexȱ (yesȱ vs.ȱ no);ȱ beingȱ recentlyȱ incarceratedȱ (yesȱ vs.ȱ no);ȱ andȱ currentȱ enrolmentȱ inȱmethadoneȱ treatmentȱ (yesȱvs.ȱno).ȱUnlessȱotherwiseȱ stated,ȱallȱdrugȱuseȱ andȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱmonthȱperiod.ȱȱ Inȱ subȬanalysis,ȱweȱ soughtȱ toȱ assessȱ andȱ identifyȱ predictorsȱ ofȱwillingnessȱ toȱ ceaseȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱifȱalternativeȱlowȬthresholdȱ optionsȱwereȱmadeȱavailable.ȱToȱmeasureȱwillingnessȱtoȱceaseȱengagementȱinȱdisorderȱ incomeȱgenerationȱactivitiesȱweȱ askedȱparticipants:ȱ““Ifȱyouȱwereȱofferedȱ casualȱworkȱ thatȱdidȱnotȱinterfereȱwithȱyourȱwelfare,ȱwouldȱyouȱtakeȱit?””ȱandȱ““Ifȱyes,ȱareȱthereȱanyȱ incomeȱsourcesȱ inȱ theȱ lastȱ30ȱdaysȱ thatȱyouȱwouldȱeliminate?””ȱParticipantsȱwereȱ thenȱ askedȱ toȱ indicateȱwhichȱsourcesȱofȱ incomeȱ theyȱwouldȱ forgo.ȱVariablesȱofȱ interestȱ forȱ ȱȱ 107 secondaryȱ analysisȱ includedȱ allȱ variablesȱ fromȱ theȱ primaryȱ analysis,ȱ inȱ additionȱ toȱ engagementȱ inȱ specificȱ disorderlyȱ incomeȱ generationȱ activities,ȱ includingȱ recycling,ȱ panhandling,ȱ squeegeeing,ȱ drugȱ dealingȱ andȱ sexȱwork.ȱAsȱ inȱ theȱ primaryȱ analysis,ȱ unlessȱotherwiseȱstated,ȱallȱdrugȱuseȱandȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱ monthȱperiod.ȱȱ Forȱ bothȱ ourȱ primaryȱ andȱ secondaryȱ analyses,ȱ weȱ usedȱ univariateȱ andȱ multivariateȱstatisticsȱtoȱdetermineȱfactorsȱassociatedȱwithȱourȱoutcomesȱofȱinterest.ȱInȱ univariateȱanalysisȱcategoricalȱexplanatoryȱvariablesȱwereȱanalyzedȱusingȱPearson’’sȱchiȬ squareȱ testȱ andȱ continuousȱ variablesȱ wereȱ analyzedȱ usingȱ theȱMannȬWhitneyȱ test.ȱ Fisher’’sȱexactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱwasȱlessȱthanȱorȱequalȱ toȱfive.ȱToȱevaluateȱfactorsȱindependentlyȱassociatedȱwithȱourȱoutcomesȱofȱinterest,ȱallȱ variablesȱ thatȱwereȱ associatedȱwithȱ theȱ dependentȱ variableȱ atȱ pȱ <ȱ 0.05ȱ inȱ univariateȱ analysesȱwereȱ enteredȱ intoȱ theȱ respectiveȱmultivariateȱ logisticȱ regressionȱmodels.ȱAllȱ statisticalȱ analysesȱwereȱperformedȱusingȱ SASȱ softwareȱ versionȱ 9.1ȱ (SAS,ȱCary,ȱNC).ȱȱ AllȱpȬvaluesȱareȱtwoȱsided.ȱ 6.3 Resultsȱ Duringȱ theȱ studyȱperiodȱaȱ totalȱofȱ874ȱparticipantsȱ completedȱ followȬupȱvisits,ȱ includingȱ 310ȱ (35%)ȱ womenȱ andȱ 312ȱ (36%)ȱ personsȱ whoȱ identifiedȱ asȱ beingȱ ofȱ Aboriginalȱancestry.ȱTheȱmedianȱageȱofȱparticipantsȱwasȱ45ȱyearsȱ (interquartileȱ rangeȱ [IQR]ȱ=ȱ39Ȭ51).ȱAmongȱourȱsampleȱofȱ874ȱIDUȱaȱtotalȱofȱ418ȱ(48%)ȱreportedȱengagingȱinȱ ȱȱ 108 disorderlyȱincomeȱgenerationȱactivities.ȱTheȱmedianȱnumberȱofȱdisorderlyȱactivitiesȱthatȱ participantsȱ engagedȱ inȱwasȱ 1ȱ (IQRȱ =ȱ 1Ȭ1).ȱAsȱ displayedȱ inȱ Tableȱ 6.1,ȱ drugȱ dealingȱ (n=220,ȱ 25%)ȱ andȱ recyclingȱ (n=165,ȱ 19%)ȱwereȱ theȱmostȱ commonȱ typesȱ ofȱdisorderlyȱ incomeȱ generationȱ activity,ȱ andȱ theȱ medianȱ numberȱ ofȱ hoursȱ spentȱ engagedȱ inȱ disorderlyȱincomeȱgenerationȱactivitiesȱeachȱweekȱwasȱhighestȱforȱdrugȱdealingȱ(20ȱhrsȱ perȱweek,ȱIQRȱ=ȱ6Ȭ40).ȱTheȱcharacteristicsȱofȱtheȱstudyȱsampleȱstratifiedȱbyȱengagementȱ inȱdisorderlyȱincomeȱgenerationȱactivitiesȱareȱpresentedȱinȱTableȱ6.2.ȱȱ Amongȱ individualsȱ whoȱ reportedȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activities,ȱ 198ȱ (47%)ȱ indicatedȱ theyȱwouldȱ ceaseȱ engagingȱ inȱ thisȱ activityȱ ifȱ theyȱhadȱ accessȱtoȱlowȬthresholdȱemployment.ȱAsȱshownȱinȱTableȱ6.1,ȱamongȱthoseȱwhoȱreportedȱ incomeȱ fromȱ sexȱ tradeȱwork,ȱ51ȱ (63%)ȱ indicatedȱ theyȱwouldȱnoȱ longerȱengageȱ inȱ sexȱ tradeȱ workȱ ifȱ theyȱ hadȱ accessȱ toȱ lowȬthresholdȱ employment.ȱ Further,ȱ 97ȱ (44%)ȱȱ respondentsȱ whoȱ reportedȱ incomeȱ fromȱ drugȱ dealing,ȱ 21ȱ (37%)ȱ respondentsȱ whoȱ reportedȱengagingȱinȱpanhandlingȱandȱ48ȱ(29%)ȱrespondentsȱwhoȱengagedȱinȱrecyclingȱ reportedȱthatȱtheyȱwouldȱrefrainȱfromȱengagingȱinȱthoseȱdisorderlyȱincomeȱgenerationȱ activitiesȱifȱtheyȱhadȱaccessȱtoȱcausalȱemploymentȱopportunities.ȱ Theȱ univariateȱ analysesȱ ofȱ behaviouralȱ andȱ socioȬdemographicȱ variablesȱ associatedȱwithȱengagingȱ inȱdisorderlyȱ incomeȱgenerationȱactivitiesȱareȱalsoȱpresentedȱ inȱTableȱ6.2,ȱwhileȱ theȱresultsȱofȱtheȱmultivariateȱ logisticȱregressionȱanalysisȱofȱfactorsȱ associatedȱwithȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱareȱshownȱinȱTableȱ ȱȱ 109 6.3.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ included:ȱ regularȱ employmentȱ (adjustedȱ oddsȱ ratioȱ [AOR]ȱ =ȱ 0.48,ȱ 95%CI:ȱ 0.32Ȭ0.71);ȱ dailyȱ cocaineȱ injectionȱ (AORȱ =ȱ 1.98,ȱ 95%CI:ȱ 1.05Ȭ3.76);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (AORȱ =ȱ 3.11,ȱ 95%CI:ȱ 2.17Ȭ4.45);ȱ bingeȱ drugȱ useȱ (AORȱ =ȱ 1.55,ȱ 95%CI:ȱ 1.12Ȭ2.14),ȱ encountersȱwithȱpoliceȱ(AORȱ=ȱ2.45,ȱ95%CI:ȱ1.61Ȭ3.72);ȱbeingȱaȱvictimȱofȱviolenceȱ(AORȱ =ȱ1.68,ȱ95%CI:ȱ1.06Ȭ2.68);ȱ syringeȱ sharingȱ (AORȱ=ȱ4.50,ȱ95%CI:ȱ1.44Ȭ14.09);ȱandȱpublicȱ injectingȱ(AORȱ=ȱ2.03,ȱ95%CI:ȱ1.28Ȭ3.23).ȱ Forȱ ourȱ secondaryȱ analysis,ȱ theȱ univariateȱ resultsȱ ofȱ factorsȱ associatedȱ withȱ willingnessȱ toȱceaseȱengagingȱ inȱdisorderlyȱ incomeȱgenerationȱactivitiesȱareȱpresentedȱ inȱTableȱ 6.4ȱ andȱ theȱ resultsȱ ofȱ theȱmultivariateȱ logisticȱ regressionȱ analysisȱ ofȱ factorsȱ associatedȱwithȱwillingnessȱtoȱceaseȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱ areȱ shownȱ inȱ Tableȱ 6.5.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ included:ȱ sexȱworkȱ (AORȱ =ȱ 2.54,ȱ 95%CI:ȱ 1.32Ȭ4.88),ȱdrugȱdealingȱ (AORȱ =ȱ 1.86,ȱ 95%CI:ȱ 1.13Ȭ3.06),ȱ bingeȱ drugȱ useȱ (AORȱ =ȱ 1.56,ȱ 95%CI:ȱ 1.03Ȭ2.37),ȱ andȱ incarcerationȱ(AORȱ=ȱ1.88,ȱ95%CI:ȱ1.04Ȭ3.42).ȱ 6.4 Discussionȱ Amongȱ ourȱ sampleȱ ofȱ 874ȱ IDU,ȱ weȱ foundȱ thatȱ 48%ȱ reportedȱ engagingȱ inȱ aȱ disorderlyȱ incomeȱ generationȱ activityȱ inȱ theȱ lastȱ sixȱ months.ȱ Theȱ mostȱ commonȱ activitiesȱ reportedȱwereȱ drugȱ dealingȱ andȱ recyclingȱ (whichȱ includedȱ salvagingȱ andȱ unsanctionedȱstreetȱvending).ȱInȱaȱmultivariateȱanalysisȱpeopleȱwhoȱreportedȱengagingȱ ȱȱ 110 inȱdisorderlyȱincomeȱgenerationȱactivitiesȱwereȱmoreȱlikelyȱtoȱsmokeȱcrackȱcocaineȱonȱaȱ dailyȱbasisȱandȱinjectȱcocaineȱonȱaȱdailyȱbasis.ȱThisȱpopulationȱwasȱalsoȱmoreȱlikelyȱtoȱ engageȱ inȱbingeȱdrugȱuse,ȱhaveȱencountersȱwithȱpolice,ȱbeȱaȱvictimȱofȱviolence,ȱshareȱ usedȱ syringesȱ andȱ injectȱdrugsȱ inȱpublicȱ areas.ȱConversely,ȱ individualsȱwithȱ regularȱ employmentȱ wereȱ significantlyȱ lessȱ likelyȱ toȱ reportȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱactivities.ȱWeȱalsoȱfoundȱthatȱamongȱindividualsȱwhoȱengagedȱinȱdisorderlyȱ incomeȱgenerationȱactivities,ȱ47%ȱreportedȱthatȱtheyȱwouldȱbeȱwillingȱtoȱstopȱengagingȱ inȱtheseȱdisorderlyȱactivitiesȱifȱtheyȱwereȱofferedȱotherȱopportunitiesȱforȱlowȬthresholdȱ employment.ȱ Individualsȱengagedȱ inȱsexȱwork,ȱdrugȱdealing,ȱbingeȱdrugȱuse,ȱorȱwhoȱ wereȱ recentlyȱ incarcerated,ȱ wereȱ mostȱ interestedȱ inȱ ceasingȱ theirȱ engagementȱ inȱ disorderlyȱincomeȱgenerationȱactivities.ȱȱ Theseȱ findingsȱ supportȱ theȱ conclusionsȱ ofȱ previousȱ studiesȱ indicatingȱ thatȱ disorderlyȱincomeȱgenerationȱactivitiesȱareȱcommonȱamongȱillicitȱdrugȱusers.33,ȱ171,ȱ265,ȱ268ȱ Theȱ significantȱ associationsȱ betweenȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ andȱ dailyȱ crackȱ cocaineȱ smokingȱ andȱ dailyȱ cocaineȱ injectingȱ areȱ consistentȱ withȱaȱgrowingȱnumberȱofȱstudiesȱlinkingȱfrequentȱcocaineȱuseȱwithȱaȱgreaterȱlikelihoodȱ ofȱengagingȱinȱriskyȱbehaviours30Ȭ32ȱandȱillegalȱactivities.7,ȱ33ȱȱTheseȱassociationsȱsuggestȱ thatȱtheȱcompulsiveȱdrugȱacquisitionȱbehavioursȱassociatedȱwithȱcocaineȱaddictionȱmayȱ perpetuateȱ theȱneedȱ toȱgenerateȱ incomeȱ throughȱprohibitedȱmeans.ȱ Inȱparticular,ȱ theȱ relativelyȱ shortȱhalfȬlifeȱofȱ cocaineȱ comparedȱwithȱopioidsȱorȱmethamphetamineȱmayȱ contributeȱ toȱ anȱ increasedȱ frequencyȱ ofȱ drugȱ useȱ andȱ pressureȱ toȱ purchaseȱ largerȱ ȱȱ 111 quantitiesȱ ofȱ drugs.274ȱ Inȱ addition,ȱ theȱ negativeȱ psychiatricȱ effectsȱ ofȱ highȱ intensityȱ cocaineȱ useȱ mayȱ haveȱ destabilizingȱ influencesȱ thatȱ presentȱ barriersȱ toȱ engagingȱ inȱ formalȱ employment.33ȱ Indeed,ȱ previousȱ researchȱ foundȱ thatȱ frequentȱ crackȱ cocaineȱ smokingȱwasȱnegativelyȱassociatedȱwithȱattainingȱ formalȱemploymentȱamongȱ IDUȱ inȱ ourȱstudyȱsetting.173ȱȱ Ourȱfindingsȱfurtherȱindicateȱthatȱindividualsȱwhoȱengageȱinȱdisorderlyȱincomeȱ generationȱactivitiesȱareȱaȱvulnerableȱpopulationȱatȱriskȱforȱmultipleȱnegativeȱhealthȱandȱ socialȱoutcomes.ȱManyȱofȱtheȱbehavioursȱassociatedȱwithȱdisorderlyȱincomeȱgenerationȱ activities,ȱincludingȱdailyȱcocaineȱinjection,ȱdailyȱcrackȱcocaineȱsmoking,ȱbingeȱdrugȱuseȱ andȱ syringeȱ sharing,ȱ haveȱ allȱ beenȱ independentlyȱ linkedȱwithȱ increasedȱ riskȱ ofȱHIVȱ infectionȱinȱthisȱsetting.27,ȱ275,ȱ276ȱȱTheseȱfindingsȱunderscoreȱtheȱimportanceȱofȱidentifyingȱ interventionsȱtoȱreduceȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivities,ȱandȱourȱ studyȱfindingsȱfurtherȱsuggestȱthatȱthereȱisȱconsiderableȱwillingnessȱamongȱmanyȱIDUȱ toȱceaseȱengagingȱ inȱtheseȱactivitiesȱ ifȱtheyȱwereȱprovidedȱwithȱopportunitiesȱforȱ lowȬ thresholdȱemployment.ȱThisȱfindingȱisȱconsistentȱwithȱcurrentȱliteratureȱinȱtheȱdrugȱuseȱ fieldȱ thatȱ emphasizesȱ theȱ importanceȱ thatȱ structuralȱ factors,ȱ suchȱ asȱ employmentȱ opportunities,ȱ playȱ inȱ shapingȱ behaviour,ȱ andȱ supportsȱ assertionsȱ thatȱ interventionsȱ thatȱ changeȱ theȱ environmentȱ ofȱ drugȱ usersȱ canȱ reduceȱ theirȱ engagementȱ inȱ riskyȱ behaviour.75,ȱ77,ȱ78ȱȱ ȱȱ 112 Itȱ isȱnoteworthyȱ thatȱ inȱourȱ studyȱparticipationȱ inȱ sexȱworkȱwasȱ theȱ strongestȱ independentȱ predictorȱ ofȱwillingnessȱ toȱ takeȱ lowȬthresholdȱ employment.ȱ Givenȱ theȱ physicalȱdangersȱandȱhealthȱ risksȱassociatedȱwithȱ sexȱwork,ȱ itȱ isȱunderstandableȱ thatȱ participantȱengagedȱinȱsexȱworkȱwereȱmostȱlikelyȱtoȱbeȱwillingȱtoȱceaseȱengagingȱinȱthisȱ behaviourȱ ifȱgivenȱotherȱoptionsȱ toȱearnȱ income.10,ȱ 60ȱ Inȱadditionȱ toȱ theȱ inherentȱ risksȱ associatedȱ withȱ sexȱ work,ȱ numerousȱ studiesȱ haveȱ alsoȱ linkedȱ prohibitiveȱ sexȬworkȱ legislationȱ withȱ increasingȱ theȱ vulnerabilityȱ ofȱ sexȱ workersȱ andȱ underminingȱ theirȱ abilityȱ toȱ protectȱ theirȱ healthȱ andȱ physicalȱ security.57Ȭ59,ȱ 64ȱAlthoughȱ theȱ intentionȱ ofȱ prohibitiveȱsexȬworkȱ legislationȱ isȱ toȱdeterȱengagementȱ inȱ theȱactivity,ȱ itȱappearsȱ thatȱ theȱlawsȱthatȱareȱimplementedȱtoȱreduceȱtheȱharmsȱofȱsexȱworkȱareȱactuallyȱincreasingȱ risks.ȱTheȱ strongȱdemandȱ forȱ lowȬthresholdȱ employmentȱ foundȱ inȱ theȱ currentȱ studyȱ amongȱ individualsȱ engagedȱ inȱ sexȱ worksȱ suggestsȱ thatȱ thereȱ areȱ importantȱ opportunitiesȱ toȱ reduceȱ theȱ prevalenceȱ ofȱ thisȱ activityȱ throughȱ meansȱ thatȱ doȱ notȱ criminalizeȱsexȱworkersȱandȱcarryȱtheȱunanticipatedȱnegativeȱconsequencesȱofȱcriminalȱ justiceȱ interventions.ȱItȱ isȱ importantȱtoȱnote,ȱhowever,ȱthatȱtheȱ incomeȱearnedȱthroughȱ sexȱworkȱ isȱoftenȱmuchȱgreaterȱ thanȱ throughȱotherȱ incomeȱgenerationȱopportunities.ȱ Despiteȱ theȱ potentialȱ forȱ sexȱ workersȱ toȱ reduceȱ theirȱ engagementȱ inȱ sexȱ workȱ ifȱ alternativeȱ lowȬthresholdȱemploymentȱopportunitiesȱwhereȱmadeȱavailable,ȱ itȱ isȱ likelyȱ thatȱtheȱincentivesȱwillȱnotȱbeȱsufficientȱforȱsomeȱsexȱworkers.ȱInȱadditionȱtoȱsupportingȱ theȱdevelopmentȱofȱlowȬthresholdȱemploymentȱopportunities,ȱamendingȱlawsȱthatȱlimitȱ ȱȱ 113 theȱ abilityȱ ofȱ sexȱ workersȱ toȱ protectȱ theirȱ healthȱ andȱ physicalȱ safetyȱ shouldȱ beȱ simultaneouslyȱconsideredȱandȱpursued.ȱ IDUȱwhoȱengagedȱinȱdrugȱdealingȱwereȱalsoȱsignificantlyȱmoreȱwillingȱtoȱceaseȱ thisȱ incomeȱ generationȱ activityȱ ifȱ theyȱwereȱ givenȱ alternativeȱ opportunitiesȱ forȱ lowȬ thresholdȱ employment.ȱThisȱ findingȱ shouldȱbeȱofȱparticularȱ interestȱ toȱpolicyȬmakersȱ givenȱ theȱ highȱ costsȱ ofȱ drugȱ lawȱ enforcementȱ whichȱ attemptȱ toȱ deterȱ illicitȱ drugȱ productionȱandȱdistributionȱwithȱtheȱthreatȱofȱincarcerationȱandȱ legalȱpenaltiesȱwhich,ȱ toȱdate,ȱhaveȱbeenȱlimitedȱinȱtheirȱabilityȱtoȱpreventȱengagementȱinȱdrugȱdealingȱamongȱ IDUȱandȱotherȱsegmentsȱofȱtheȱgeneralȱpopulation.200,ȱ277,ȱ278ȱȱ Itȱ isȱ clearȱ fromȱ theȱ highȱ ratesȱ ofȱ engagementȱ inȱdisorderlyȱ incomeȱ generationȱ activitiesȱ reportedȱ inȱ ourȱ studyȱ thatȱ currentȱ directȱ andȱ indirectȱ prohibitionsȱ againstȱ behavioursȱ suchȱ asȱ drugȱ dealingȱ andȱ sexȱ workȱ areȱ notȱ successfullyȱ deterringȱ orȱ preventingȱ engagementȱ inȱ theseȱ activities.ȱHowever,ȱ itȱ isȱ interestingȱ toȱnoteȱ thatȱ sexȱ workȱandȱdrugȱdealing,ȱasȱwellȱasȱrecentȱincarceration,ȱwereȱallȱsignificantlyȱassociatedȱ withȱwillingnessȱ toȱceaseȱengagementȱ inȱdisorderlyȱ incomeȱgenerationȱactivities.ȱThisȱ mayȱsuggestȱ thatȱ theȱdeterrentȱ influenceȱofȱprohibitionsȱagainstȱdrugȱdealingȱandȱsexȱ workȱcouldȱbeȱsuccessfulȱ inȱsituationsȱwhereȱ IDUȱwereȱgivenȱopportunitiesȱ toȱchooseȱ otherȱ lessȱ riskyȱ incomeȱ generationȱ opportunities.ȱUnfortunately,ȱ itȱ currentlyȱ appearsȱ thatȱlessȱriskyȱincomeȱgenerationȱopportunitiesȱavailableȱtoȱmostȱIDUȱremainȱlimited.170,ȱ 173,ȱ174ȱȱȱȱ ȱȱ 114 Aȱ keyȱ implicationȱ ofȱ thisȱ studyȱ isȱ thatȱ creatingȱ lowȬthresholdȱ employmentȱ opportunitiesȱandȱsupportingȱexistingȱinitiativesȱthatȱcurrentlyȱprovideȱtheseȱpositionsȱ hasȱ potentialȱ toȱ reduceȱ bothȱ streetȱ disorderȱ andȱ healthȱ risksȱ currentlyȱ facedȱ byȱ individualsȱwhoȱ engageȱ inȱ disorderlyȱ incomeȱ generationȱ activities.ȱ ȱModelsȱ ofȱ lowȬ thresholdȱemploymentȱforȱactiveȱillicitȱdrugȱusersȱalreadyȱexistȱinȱourȱstudyȱsettingȱandȱ elsewhere;176,ȱ177,ȱ179,ȱ182,ȱ273ȱhowever,ȱourȱstudyȱsuggestsȱthatȱincreasingȱtheirȱcapacityȱandȱ availabilityȱhasȱpotentialȱtoȱreduceȱbothȱindividualȬȱandȱcommunityȬlevelȱharms.ȱ Thereȱareȱaȱnumberȱofȱlimitationsȱwithȱthisȱstudy.ȱFirstly,ȱVIDUSȱisȱnotȱaȱrandomȱ sampleȱofȱinjectionȱdrugȱusersȱandȱthereforeȱtheseȱfindingsȱmayȱnotȱgeneralizeȱtoȱotherȱ drugȱusingȱpopulations.ȱHowever,ȱtheȱassociationȱbetweenȱcrackȱcocaineȱsmokingȱandȱ streetȬbasedȱ incomeȱ generationȱ suggestsȱ thatȱ ourȱ findingsȱ areȱ likelyȱ notȱ specificȱ toȱ injectionȱdrugȱuseȱandȱmayȱbeȱ relevantȱ forȱcrackȱcocaineȱ smokersȱ thatȱdoȱnotȱhaveȱaȱ historyȱ ofȱ injecting.ȱ Secondly,ȱ thereȱ areȱ limitationsȱwithȱ combiningȱ differentȱ streetȬ basedȱ disorderlyȱ incomeȱ generationȱ activitiesȱ intoȱ oneȱ categoryȱ asȱ eachȱ ofȱ theseȱ activitiesȱisȱuniqueȱandȱlikelyȱattractsȱdifferentȱpopulations.ȱItȱisȱevidentȱfromȱtheȱsubȬ analysisȱ presentedȱ hereinȱ thatȱ thereȱ areȱ uniqueȱ characteristicsȱ amongȱ eachȱ group.ȱ Althoughȱitȱisȱcrudeȱtoȱcombineȱtheseȱveryȱdifferentȱactivities,ȱfromȱaȱpolicyȱperspectiveȱ itȱisȱmeaningfulȱtoȱprovideȱaȱpictureȱofȱtheȱnetȱfactorsȱassociatedȱwithȱtheseȱactivities,ȱasȱ wellȱasȱdirectionȱasȱtoȱwhetherȱaȱpotentialȱpolicyȱinterventionȱwillȱlikelyȱhaveȱanȱoverallȱ beneficialȱ impactȱdespiteȱ theȱdifferencesȱ amongȱ activities.ȱWhileȱ itȱwouldȱhaveȱ beenȱ idealȱtoȱsupplementȱourȱprimaryȱanalysisȱwithȱadditionalȱmodelsȱthatȱconsideredȱeachȱ ȱȱ 115 individualȱ incomeȱ generationȱ activityȱ separately,ȱ lowȱ eventȱ countsȱ precludedȱ theseȱ additionalȱcomparisons.ȱAȱthirdȱlimitationȱisȱthatȱmanyȱofȱourȱmeasuresȱreliedȱonȱselfȬ reportedȱinformationȱconcerningȱbehavioursȱthatȱareȱillegalȱand/orȱstigmatized,ȱsuchȱasȱ drugȱ dealing,ȱ sexȱworkȱ andȱ syringeȱ sharing,ȱ andȱ areȱ thereforeȱ vulnerableȱ toȱ socialȱ desirableȱ responding.ȱ Inȱ thisȱ presentȱ study,ȱ thisȱ couldȱ haveȱ resultedȱ inȱ anȱ underȬ reportingȱofȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱandȱassociatedȱrisksȱ resultingȱinȱconservativeȱestimatesȱofȱtheȱprevalenceȱofȱtheseȱactivitiesȱandȱrisks.ȱThereȱ areȱ otherȱ limitationsȱwithȱ ourȱmeasuresȱ ofȱ streetȬbasedȱ incomeȱ generationȱ activities.ȱ Specifically,ȱ theȱ amountȱ ofȱ moneyȱ earnedȱ throughȱ streetȬbasedȱ disorderlyȱ incomeȱ generationȱ activitiesȱ doesȱ notȱ accountȱ forȱ ‘‘inȬkind’’ȱ transactionsȱ orȱ nonȬmonetaryȱ contributionsȱ(i.e.,ȱexchangingȱsexȱforȱdrugs,ȱbeingȱpaidȱinȱdrugsȱratherȱthanȱmoneyȱforȱ drugȱ dealing,ȱ orȱ receivingȱ foodȱwhenȱ panhandling).ȱ Thisȱ couldȱ haveȱ alsoȱ ledȱ toȱ anȱ underȬreportingȱ ofȱ engagementȱ inȱ streetȬbasedȱ disorderlyȱ incomeȱ generation.ȱ Lastly,ȱ ourȱ studyȱ reliedȱ onȱwillingnessȱ responsesȱwhichȱ doȱ notȱ representȱ actualȱ behaviourȱ change.ȱ Thereȱ areȱ potentiallyȱ aȱ hostȱ ofȱ externalȱ factorsȱ thatȱmightȱ influenceȱ incomeȱ generationȱbehaviours,ȱsomeȱofȱwhichȱmayȱinvolveȱcomplexȱsocialȱnetworksȱandȱpowerȱ relations.ȱTherefore,ȱtheȱprovisionȱofȱlowȬthresholdȱemploymentȱcanȱnotȱbeȱexpectedȱtoȱ automaticallyȱ translateȱ intoȱ aȱ reductionȱ ofȱ streetȬbasedȱ incomeȱ generationȱ amongȱ allȱ participantsȱ thatȱ indicatedȱ aȱ willingnessȱ toȱ changeȱ theirȱ behaviour.ȱ However,ȱ itȱ isȱ importantȱ toȱ noteȱ thatȱ previousȱ analysesȱ evaluatingȱ theȱ validityȱ ofȱ reportingȱ willingnessȱtoȱuseȱaȱsupervisedȱinjectionȱfacilityȱonȱsubsequentȱratesȱofȱuseȱamongȱillicitȱ ȱȱ 116 injectionȱ drugȱ usersȱ foundȱ thatȱ willingnessȱ measuresȱ wereȱ reasonablyȱ accurateȱ predictorsȱofȱlaterȱbehaviourȱamongȱIDU.263ȱ Inȱ summary,ȱweȱ foundȱ thatȱ 48%ȱ ofȱ ourȱ sampleȱ ofȱ IDUȱ recentlyȱ engagedȱ inȱ disorderlyȱincomeȱgenerationȱactivities,ȱandȱtheseȱbehavioursȱwereȱassociatedȱwithȱhighȱ intensityȱstimulantȱdrugȱuseȱandȱvariousȱmarkersȱofȱrisk.ȱHowever,ȱweȱalsoȱfoundȱthatȱ aȱ highȱ percentageȱ ofȱ IDUȱ reportedȱ beingȱwillingȱ toȱ ceaseȱ engagementȱ inȱ disorderlyȱ incomeȱgenerationȱactivitiesȱ ifȱ theyȱhadȱoptionsȱ forȱ lowȬthresholdȱemployment.ȱTheseȱ findingsȱindicateȱthatȱlowȬthresholdȱemploymentȱmayȱofferȱimportantȱopportunitiesȱtoȱ reduceȱdrugȬrelatedȱstreetȱdisorderȱandȱassociatedȱharms.ȱȱȱ ȱTableȱ6.1ȱParticipationȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱ drugȱusersȱ(lastȱ30ȱdays)ȱ(n=874)ȱ IncomeȱSourceȱ Nȱ(%)ȱreportingȱ activityȱ Medianȱhrsȱperȱweekȱ engagedȱinȱactivity*ȱ(IQR)ȱ Nȱ(%)ȱwouldȱ ceaseȱtoȱengageȱinȱ activity**ȱ ȱȱȱ ȱ ȱ ȱ ȱ ȱ ȱ Recyclingȱ 165ȱ (19)ȱ 14 (8Ȭ30)ȱ 48ȱ (29)ȱ Panhandlingȱ 57ȱ (7)ȱ 14 (4.5Ȭ40)ȱ 21ȱ (37)ȱ Squeegeeingȱ 5ȱ (1)ȱ 5 (2Ȭ10)ȱ 0ȱ (0)ȱ DrugȱDealingȱ 220ȱ (25)ȱ 20 (6Ȭ40)ȱ 97ȱ (44)ȱ SexȱWorkȱ 81ȱ (9)ȱ 9 (3Ȭ21)ȱ 51ȱ (63)ȱ *ȱRefersȱtoȱnumberȱofȱhoursȱspentȱdoingȱtheȱactivityȱinȱtheȱaverageȱweek;ȱ**Indicatesȱparticipantsȱ thatȱwouldȱceaseȱtoȱengageȱinȱtheȱactivityȱifȱtheyȱhadȱotherȱopportunitiesȱforȱlowȬthresholdȱ employment.ȱ ȱ ȱ 117 ȱTableȱ 6.2ȱUnivariateȱ analysesȱ ofȱ factorsȱ associatedȱwithȱ engagingȱ inȱ disorderlyȱ incomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱusersȱ(n=874)ȱ ȱ Disorderlyȱincomeȱgenerationȱa ȱ Characteristicȱ Yesȱn=ȱ418,ȱnȱ(%)Noȱn=ȱ456,ȱnȱ(%)ȱ ȱ ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ Ageȱȱ ȱ ȱ ȱ ȱ Perȱyearȱolderȱ 43ȱ(38 ȱc ȱc ȱ DailyȱExpenditureȱonȱDrugsȱ Perȱadditionalȱ$10ȱ 50ȱ(30Ȭ100)ȱcȱ 30ȱ(10Ȭ60)ȱcȱ <0.001ȱ FemaleȱGenderȱȱ ȱ ȱ Yesȱ 165ȱ(39)ȱ 145ȱ(32)ȱ 0.018ȱ Noȱ 253ȱ(61)ȱ 311ȱ(68)ȱ AboriginalȱAncestryȱȱ Yesȱ 152ȱ(36)ȱ 160ȱ(35)ȱ 1.06ȱ(0.80ȱ––ȱ1.39)ȱ 0.694ȱ Noȱ 266ȱ(64)ȱ 296ȱ(65)ȱ UnstableȱHousingȱ(current)ȱȱ Yesȱ 110ȱ(26)ȱ 58ȱ(13)ȱ 2.45ȱ(1.73ȱ––ȱ3.48)ȱ <0.001ȱ Noȱ 308ȱ(74)ȱ 398ȱ(87)ȱ HighȱSchoolȱEducationȱȱ Yesȱ 199ȱ(48)ȱ 248ȱ(54)ȱ 0.045ȱ Noȱ 219ȱ(52) RegularȱEmploymentȱdȱ Yesȱ 55ȱ(13)ȱ 137ȱ(30)ȱ <0.001ȱ Noȱ 363ȱ(87) DailyȱCocaineȱInjectionȱdȱ Yesȱ 49ȱ(12)ȱ 18ȱȱȱ(4)ȱ <0.001 Noȱ 369ȱ(88)ȱ 438ȱ(96)ȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ 110ȱ(26)ȱ 43ȱȱȱ(9)ȱ 3.43ȱ(2.34ȱ––ȱ5.03)ȱ <ȱ0.001ȱ Noȱ 308ȱ(74)ȱ 413ȱ(91)ȱ DailyȱCrackȱSmokingȱdȱ ȱ ȱ Yesȱ 213ȱ(51)ȱ 74ȱ(16)ȱȱȱȱ 5.36ȱ(3.92ȱ––ȱ7.34)ȱ <ȱ0.001ȱ Noȱ 205ȱ(49)ȱ 382ȱ(84)ȱ Overdoseȱ(nonȬfatal)ȱdȱ Yesȱ 20ȱȱȱ(5)ȱ 7ȱȱȱ(2)ȱ 3.22ȱ(1.35ȱ––ȱ7.70)ȱ 0.006ȱ Noȱ 398ȱ(95)ȱ 449ȱ(98)ȱ BingeȱDrugȱUsedȱ Yesȱ 230ȱ(55)ȱ 150ȱ(33)ȱ <ȱ0.001ȱ Noȱ 188ȱ(45) EncountersȱwithȱPoliceȱdȱ Yesȱ 129ȱ(31)ȱ 50ȱ(11)ȱ <ȱ0.001ȱ Noȱ 289ȱ(69)ȱ 406ȱ(89)ȱ VictimȱofȱViolenceȱdȱ Yesȱ 84ȱ(20)ȱ 42ȱ(9)ȱ 2.48ȱ(1.66ȱ––ȱ3.69)ȱ <ȱ0.001ȱ Noȱ 334ȱ(80)ȱ 414ȱ(91)ȱ SyringeȱSharingȱdȱ Yesȱ 28ȱȱȱ(7)ȱ 4ȱȱȱ(1)ȱ 8.11ȱ(2.82ȱ––ȱ23.33) <ȱ0.001ȱ Noȱ 390ȱ(93)ȱ 452ȱ(99)ȱ PublicȱInjectingȱdȱ Yesȱ 148ȱ(35)ȱ 52ȱ(11)ȱȱȱȱ 4.26ȱ(3.00ȱ––ȱ6.05)ȱ <ȱ0.001ȱ Noȱ 270ȱ(65)ȱ 404ȱ(89)ȱ UnprotectedȱSexȱdȱ Yesȱ 113ȱ(27)ȱ 98ȱ(21)ȱ 0.056ȱ Noȱ 305ȱ(73) RecentȱIncarcerationȱdȱ Yesȱ 65ȱ(16)ȱ 30ȱȱȱ(7)ȱ <ȱ0.001ȱ Noȱ 353ȱ(84) MethadoneȱTreatmentȱ(current)ȱ Yesȱ 188ȱ(45)ȱ 218ȱ(48)ȱ ȱ 0.89ȱȱ(0.68ȱ––ȱ1.16)ȱ 0.402ȱ Noȱ 230ȱ(55) 238ȱ(52) ȱ Ȭ50) ȱ 46ȱ(41Ȭ51) ȱ ȱ 0.97ȱ(0.95ȱ––ȱ0.98)ȱ <0.001 ȱ ȱ ȱ ȱ ȱ 1.05ȱȱ(1.03ȱ––ȱ1.07)ȱ ȱ ȱ ȱ 1.40ȱ(1.06ȱ––ȱ1.85)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 0.76ȱȱ(0.58ȱ––ȱ0.99)ȱ ȱ 208ȱ(46)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 0.35ȱȱ(0.25ȱ––ȱ0.50)ȱ ȱ 319ȱ(70)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 3.23ȱ(1.85ȱ––ȱ5.64)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 2.50ȱ(1.90ȱ––ȱ3.28)ȱ ȱ 306ȱ(67)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 3.62ȱ(2.53ȱ––ȱ5.19)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 1.35ȱ(0.99ȱ––ȱ1.85)ȱ ȱ 358ȱ(79)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 2.61ȱ(1.66ȱ––ȱ4.12)ȱ ȱ 426ȱ(93)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Note:ȱaȱDisorderlyȱincomeȱgenerationȱincludes:ȱrecycling,ȱsqueegeeing,ȱpanhandling,ȱsellingȱdrugsȱandȱ engagingȱinȱsexȱwork;ȱbȱORȱ=ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱcȱMedianȱandȱInterquartileȱRange;ȱdȱ Denotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱsixȱmonths.ȱ ȱ 118 ȱTableȱ6.3ȱMultivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱ withȱparticipationȱ inȱdisorderlyȱ incomeȱgenerationȱ activitiesȱ aȱamongȱ injectionȱdrugȱusersȱ(n=874)ȱ Characteristicȱ Adjustedȱ Oddsȱ Ratioȱ (95%ȱ Confidenceȱ Interval)ȱ pȬvalueȱ OlderȱAgeȱȱ 1.00ȱ ȱ(0.98ȱ––ȱ1.02)ȱ 0.799ȱ FemaleȱGenderȱȱ 1.12 ȱ(0.79ȱ––ȱ1.57)ȱ 0.526ȱ UnstableȱHousingȱ(current)ȱȱ 0.96 ȱ(0.61ȱ––ȱ1.52)ȱ 0.864ȱ RegularȱEmploymentȱbȱ 0.48ȱ ȱ(0.32ȱ––ȱ0.71)ȱ <ȱ0.001ȱ HighȱSchoolȱEducationȱȱ 0.89ȱ ȱ(0.65ȱ––ȱ1.22)ȱ 0.474ȱ DailyȱExpenditureȱonȱDrugsȱb 1.01ȱ ȱ(1.00ȱ––ȱ1.03)ȱ 0.121ȱ DailyȱCocaineȱInjectȱbȱ 1.98 ȱ(1.05ȱ––ȱ3.76)ȱ 0.036ȱ DailyȱHeroinȱInjectȱbȱ 1.40 ȱ(0.86ȱ––ȱ2.26)ȱ 0.175ȱ DailyȱCrackȱSmokingȱbȱ 3.11 ȱ(2.17ȱ––ȱ4.45)ȱ <ȱ0.001ȱ Overdoseȱ(nonȬfatal)ȱbȱ 1.83 ȱ(0.67ȱ––ȱ5.01)ȱ 0.239ȱ BingeȱDrugȱUseȱbȱ 1.55 ȱ(1.12ȱ––ȱ2.14)ȱ 0.008ȱ EncountersȱwithȱPoliceȱbȱ 2.45 ȱ(1.61ȱ––ȱ3.72)ȱ <ȱ0.001ȱ VictimȱofȱViolenceȱbȱ 1.68 ȱ(1.06ȱ––ȱ2.68)ȱ 0.028ȱ SyringeȱSharingȱȱb*ȱ 4.50 ȱ(1.44ȱ––ȱ14.09)ȱ 0.010ȱ PublicȱInjectionȱbȱ 2.03 ȱ(1.28ȱ––ȱ3.23)ȱ 0.003ȱ Incarcerationȱȱbȱ 1.10ȱ ȱ(0.63ȱ––ȱ1.91)ȱ 0.740ȱ Note:ȱ aȱ Disorderlyȱ incomeȱ generationȱ activitiesȱ include:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱ drugs,ȱ andȱ engagingȱ inȱ sexȱ work.;ȱ bȱ Denotesȱ activitiesȱ orȱ situationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ *pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱ countsȱlessȱthanȱ5.ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 119 ȱTableȱ6.4ȱUnivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱtoȱ ceaseȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ amongȱ injectionȱdrugȱusersȱ(n=418)ȱ ȱ Willingȱtoȱceaseȱengagingȱinȱdisorderlyȱincomeȱgenerationȱaȱ ȱ Characteristicȱ Yesȱn=ȱ198,ȱnȱ(%)ȱ Noȱn=ȱ220,ȱnȱ(%)ȱ ȱ ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ Ageȱȱ ȱ ȱ ȱ ȱ ȱ Perȱyearȱolderȱ 43ȱ(37Ȭ49)ȱ 44ȱ(38Ȭ51)ȱ 0.98ȱ(0.96ȱ––ȱ1.00)ȱ 0.006ȱȱ ȱ 120 DailyȱExpenditureȱonȱ ȱ ȱ ȱ ȱ ȱDrugsȱ Perȱadditionalȱ$10ȱ 60ȱ(30Ȭ100)ȱcȱ 50ȱ(20Ȭ100)ȱcȱ ȱ 1.01ȱȱ(1.00ȱ––ȱ1.03)ȱ 0.073ȱ FemaleȱGenderȱȱ Yesȱ 88ȱ(44)ȱ 77ȱ(35)ȱ 1.49ȱ(1.00ȱ––ȱ2.20)ȱ 0.049ȱ Noȱ 110ȱ(56) 143ȱ(65) ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ AboriginalȱAncestryȱȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 81ȱ(41)ȱ 71ȱ(32)ȱ ȱ 1.45ȱ(0.9 ȱ––ȱ2.17)ȱ7 0.067ȱ Noȱ 117ȱ(59)ȱ 149ȱ(68)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ UnstableȱHousingȱ(current)ȱȱ Yesȱ 63ȱ(32)ȱ 47ȱ(21)ȱ 0.73ȱ(0.49ȱ––ȱ1.07)ȱ 0.105ȱ Noȱ 135ȱ(68)ȱ 173ȱ(79)ȱ HighȱSchoolȱEducationȱȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 86ȱ(43)ȱ 113ȱ(51)ȱ ȱ 0.76ȱȱ(0.58ȱ––ȱ0.99)ȱ 0.045ȱ Noȱ 112ȱ(57)ȱ 107ȱ(49)ȱ ȱ ȱ ȱ RegularȱEmploymentȱdȱ Yesȱ 23ȱ(12)ȱ 39ȱ(18)ȱ ȱ 0.61ȱȱ(0.35ȱ––ȱ1.06)ȱ 0.079ȱ Noȱ 175ȱ(88) 181ȱ(82) ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ SexȱWorkȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 52ȱ(26)ȱ 29ȱ(13)ȱȱȱȱ ȱ 2.34ȱ(1.42ȱ––ȱ3.88)ȱ <0.001ȱ Noȱ 146ȱ(74)ȱ 191ȱ(87)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ )ȱ ȱ ȱ ȱ ȱ DrugȱDealingȱdȱ Yesȱ 122ȱ(62)ȱ 98ȱ(45)ȱȱȱȱ 2.00ȱ(1.35ȱ––ȱ2.95 <0.001 Noȱ 76ȱ(38)ȱ 122ȱ(55)ȱ Recyclingȱȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 67ȱ(34)ȱ 98ȱ(45)ȱȱȱȱ ȱ 0.64ȱ(0.43ȱ––ȱ0.95)ȱ ȱ0.025ȱ Noȱ 131ȱ(66)ȱ 122ȱ(55)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 1.00ȱ(0.57ȱ––ȱ1.75)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Panhandlingȱdȱ Yesȱ 27ȱ(14)ȱ 30ȱ(14)ȱȱȱȱ 1.000 Noȱ 171ȱ(86) 190ȱ(86) DailyȱCocaineȱInjectionȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 24ȱ(12)ȱ 25ȱ(11)ȱ ȱ 1.08ȱ(0.59ȱ––ȱ1.95)ȱ ȱ0.810ȱ Noȱ 174ȱ(88)ȱ 195ȱ(89)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ 61ȱ(31)ȱ 49ȱ(22)ȱ 1.55ȱ(1.00ȱ––ȱ2.41)ȱ 0.048ȱ Noȱ 137ȱ(69)ȱ 171ȱ(78)ȱ DailyȱCrackȱSmokingȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 108ȱ(55)ȱ 105ȱ(48)ȱȱȱȱ ȱ 1.31ȱ(0.89ȱ––ȱ1.93)ȱ ȱ0.164ȱ Noȱ 90ȱ(45)ȱ 115ȱ(52)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Overdoseȱ(nonȬfatal)ȱdȱ Yesȱ 11ȱȱȱ(6)ȱ 9ȱȱȱ(4)ȱ 1.38ȱ(0.56ȱ––ȱ3.40)ȱ 0.484ȱ Noȱ 187ȱ(94)ȱ 221ȱ(96)ȱ BingeȱDrugȱUsedȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 125ȱ(63)ȱ 105ȱ(48)ȱ ȱ 1.88ȱ(1.27ȱ––ȱ2.77)ȱ ȱ0.002ȱ Noȱ 73ȱ(37)ȱ 115ȱ(52)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ0. ȱ ȱ ȱ EncountersȱwithȱPoliceȱdȱ Yesȱ 69ȱ(35)ȱ 60ȱ(27)ȱ 1.43ȱ(0.94ȱ––ȱ2.16)ȱ 094ȱ Noȱ 129ȱ(65)ȱ 160ȱ(73)ȱ VictimȱofȱViolenceȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 42ȱ(21)ȱ 42ȱ(19)ȱ ȱ 1.14ȱ(0.7 ȱ––ȱ1.84)ȱ1 ȱ0.589ȱ Noȱ 156ȱ(79)ȱ 178ȱ(81)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ SyringeȱSharingȱdȱ Yesȱ 14ȱȱȱ(7)ȱ 14ȱȱȱ(6)ȱ 1.12ȱ(0.52ȱ––ȱ2.41)ȱ 0.773ȱ Noȱ 184ȱ(93)ȱ 206ȱ(94)ȱ PublicȱInjectingȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 81ȱ(41)ȱ 67ȱ(30)ȱȱȱȱ ȱ 1.58ȱ(1.06ȱ––ȱ2.37)ȱ 0.026ȱ Noȱ 117ȱ(59)ȱ 153ȱ(70)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ UnprotectedȱSexȱdȱ Yesȱ 59ȱ(30)ȱ 54ȱ(25)ȱ 1.30ȱ(0.85ȱ––ȱ2.01)ȱ 0.227ȱ Noȱ 139ȱ(70) 166ȱ(75) RecentȱIncarcerationȱdȱ ȱ ȱ ȱ ȱ ȱ Yesȱ 43ȱ(22)ȱ 22ȱ(10)ȱ ȱ 2.50ȱ(1.4 ȱ––ȱ4.35)ȱ3 0.001ȱ Noȱ 155ȱ(78)ȱ 198ȱ(90)ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ MethadoneȱTreatmentȱ(current)ȱ Yesȱ 103ȱ(52)ȱ 95ȱ(43)ȱ 1.43ȱ(0.97ȱ––ȱ2.10)ȱ 0.071ȱ Noȱ 95ȱ(48)ȱ 125ȱ(57)ȱ Note:ȱ aȱ Disorderlyȱ incomeȱ generationȱ includes:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱdrugsȱandȱsexȱwork;ȱ bȱORȱ=ȱOddsȱRatio,ȱ ȱCIȱ=ȱConfidenceȱ Interval;ȱ cȱMedianȱandȱ InterȱQuartileȱRange;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ ȱTableȱ6.5ȱMultivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ willingnessȱ toȱ ceaseȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ amongȱ injectionȱdrugȱusersȱ(n=418)ȱ Characteristicȱ Adjustedȱ OddsȱRatioȱ (95%ȱConfidenceȱ Interval)ȱ pȬvalueȱ FemaleȱGenderȱȱ 1.00ȱ ȱ(0.60ȱ––ȱ1.67)ȱ 0.998ȱ UnstableȱHousingȱbȱ 1.35ȱ ȱ(0.80ȱ––ȱ2.28)ȱ 0.263ȱ SexȱWorkȱdȱ 2.54ȱ ȱ(1.32ȱ––ȱ4.88)ȱ 0.005ȱ DrugȱDealingȱdȱ 1.86ȱ ȱ(1.13ȱ––ȱ3.06)ȱ 0.014ȱ Recyclingȱȱdȱ 1.25ȱ ȱ(0.74ȱ––ȱ2.09)ȱ 0.405ȱ DailyȱHeroinȱInjectȱbȱ 1.05ȱ ȱ(0.63ȱ––ȱ1.74)ȱ 0.864ȱ BingeȱDrugȱUseȱbȱ 1.56ȱ ȱ(1.03ȱ––ȱ2.37)ȱ ȱ0.036ȱ PublicȱInjectionȱbȱ 1.09ȱ ȱ(0.66ȱ––ȱ1.80)ȱ 0.748ȱ Incarcerationȱbȱ 1.88ȱ ȱ(1.04ȱ––ȱ3.42)ȱ 0.037ȱ Note:ȱ aȱ Disorderlyȱ incomeȱ generationȱ includes:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱdrugs,ȱandȱengagingȱ inȱ sexȱwork.;ȱ bȱDenotesȱactivitiesȱorȱ situationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 121 ȱȱ 122 ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ CHAPTER 7: ȱ PUBLICȱCRACKȱCOCAINEȱUSEȱANDȱWILLINGNESSȱTOȱUSEȱAȱ SUPERVISEDȱINHALATIONȱFACILITY:ȱIMPLICATIONSȱFORȱ STREETȱDISORDER6ȱ 7.1 Introductionȱ Theȱuseȱ ofȱ illicitȱdrugsȱ inȱpublicȱ settings,ȱ includingȱ street,ȱ alleysȱ andȱparksȱ isȱ bothȱaȱpublicȱhealthȱandȱpublicȱorderȱconcernȱ inȱmanyȱurbanȱareas.6,ȱ 42,ȱ 91ȱToȱdate,ȱ theȱ useȱofȱ injectionȱdrugsȱ inȱpublicȱ settingsȱhasȱ receivedȱ theȱmostȱattentionȱ fromȱpolicyȬ makersȱandȱpublicȱhealthȱresearchers.5,ȱ42ȱPublicȱinjectingȱisȱknownȱtoȱpresentȱproblemsȱ forȱ citizensȱwhoȱ resideȱ inȱ orȱ aroundȱ areasȱwhereȱ publicȱ drugȱ useȱ isȱ prevalent,ȱ andȱ scientificȱ studiesȱ haveȱ documentedȱ thatȱ usingȱ injectionȱ drugsȱ inȱ publicȱ settingsȱ canȱ discourageȱsaferȱinjectingȱpracticesȱresultingȱinȱmanyȱpublicȱhealthȱproblems,ȱincludingȱ increasedȱriskȱforȱdrugȱoverdoseȱeventsȱandȱHIVȱandȱotherȱbloodȬborneȱinfections.61Ȭ64,ȱ83ȱ Asȱaȱresult,ȱsomeȱcitiesȱhaveȱ implementedȱsupervisedȱ injectionȱ facilitiesȱwhichȱaimȱ toȱ provideȱ anȱ alternativeȱ injectingȱ environmentȱ thatȱ reducesȱ bothȱ theȱ healthȱ risksȱ associatedȱwithȱ injectionȱdrugȱuseȱandȱ theȱstreetȱdisorderȱ itȱcanȱgenerate.20,ȱ 150,ȱ 151,ȱ 153,ȱ 154ȱ Whileȱ supervisedȱ injectionȱ facilitiesȱ haveȱ beenȱ notedȱ toȱ haveȱmeasurableȱ successȱ inȱ achievingȱ theseȱpublicȱhealthȱandȱpublicȱorderȱobjectives,ȱ theȱuseȱofȱ inhalableȱdrugs,ȱ ȱ 6ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱBuxton,ȱJ.,ȱ Kerr,ȱT.,ȱQi,ȱJ.,ȱMontaner,ȱJ.,ȱWood,ȱE.ȱPublicȱcrackȱuseȱandȱwillingnessȱtoȱuseȱaȱ supervisedȱinhalationȱfacility:ȱImplicationsȱforȱstreetȱdisorder.ȱ ȱȱ 123 particularlyȱ crackȱ cocaineȱ smoking,ȱ hasȱ beenȱ growingȱ inȱ popularityȱ inȱmanyȱ streetȬ basedȱdrugȱscenesȱacrossȱCanada.26,ȱ27,ȱ29ȱIndeed,ȱtheȱpopularityȱofȱcrackȱcocaineȱandȱeaseȱ ofȱ administrationȱ throughȱ smokingȱ hasȱ madeȱ publicȱ crackȱ cocaineȱ useȱ aȱ commonȱ featureȱ ofȱ theȱ streetsȱ inȱ Vancouver’’sȱ drugȱ useȱ epicentre,ȱ knownȱ asȱ theȱ Downtownȱ Eastside.279ȱ Publicȱ crackȱ cocaineȱ smokingȱ isȱ posingȱ aȱ growingȱ burdenȱ forȱ lawȱ enforcementȱagenciesȱresponsibleȱforȱmaintainingȱpublicȱorder.280ȱInȱaddition,ȱtheȱhealthȱ andȱ socialȱ harmsȱ associatedȱwithȱ crackȱ cocaineȱ smokingȱ areȱ extensive.ȱComparedȱ toȱ otherȱ drugȱ userȱ populations,ȱ crackȱ cocaineȱ usersȱ areȱmoreȱ likelyȱ toȱ engageȱ inȱ riskyȱ behaviours30Ȭ32ȱ andȱ illegalȱ activities7,ȱ 33ȱ andȱ toȱ experienceȱ homelessness29ȱ andȱ healthȱ problems,29,ȱ34Ȭ37ȱyetȱareȱlessȱlikelyȱtoȱaccessȱhealthȱandȱsocialȱservices.38ȱȱItȱhasȱalsoȱbeenȱ recentlyȱdocumentedȱthatȱdailyȱcrackȱcocaineȱsmokersȱareȱatȱaȱfourȬfoldȱgreaterȱriskȱofȱ contractingȱHIVȱcomparedȱtoȱtheirȱdrugȱusingȱpeersȱwhoȱsmokeȱcrackȱcocaineȱlessȱoftenȱ orȱnotȱatȱall.27ȱ Givenȱtheȱdramaticȱriseȱinȱcrackȱcocaineȱsmokingȱandȱtheȱpublicȱorderȱandȱpublicȱ healthȱconcernsȱassociatedȱwithȱ it,ȱ theȱneedȱ forȱ targetedȱ interventionsȱ forȱpeopleȱwhoȱ smokeȱ crackȱ cocaineȱ isȱ unambiguous.ȱ Oneȱ potentialȱ interventionȱ thatȱ isȱ receivingȱ increasingȱ attentionȱ fromȱ publicȱ healthȱ officials,ȱ healthȱ researchersȱ andȱ localȱ communityȱ groupsȱ isȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ similarȱ toȱVancouver’’sȱ supervisedȱ injectionȱ siteȱ butȱ thatȱ accommodateȱ crackȱ cocaineȱ smoking.27,ȱ 281Ȭ285ȱ Theȱ Canadianȱ Institutesȱ ofȱ Healthȱ Researchȱ recentlyȱ approvedȱ fundingȱ toȱ conductȱ aȱ randomizedȱ controlȱ trialȱ toȱ evaluateȱ theȱ impactȱofȱaȱ supervisedȱ inhalationȱ facilityȱonȱ ȱȱ 124 accessȱ toȱ medicalȱ andȱ socialȱ services,ȱ particularlyȱ addictionȱ treatment,ȱ amongȱ VancouverȬbasedȱ crackȱ cocaineȱ smokers.286ȱ Previousȱ studiesȱ haveȱ assessedȱ generalȱ willingnessȱ amongȱ localȱ drugȱ usersȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facility;287,ȱ 288ȱ however,ȱtheseȱstudiesȱwereȱnotȱprimarilyȱconcernedȱwithȱstreetȱdisorderȱandȱthereforeȱ didȱ notȱ considerȱ theȱ specificȱ risksȱ associatedȱwithȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areas,ȱnorȱdidȱ theyȱassessȱwillingnessȱ toȱuseȱanȱ inhalationȱ facilityȱamongȱpublicȱcrackȱ cocaineȱsmokersȱexclusively.ȱThereforeȱweȱconductedȱaȱstudyȱ focusedȱonȱpublicȱcrackȱ cocaineȱ smokersȱ toȱ identifyȱ factorsȱ associatedȱwithȱ thisȱ practice.ȱWeȱ alsoȱ soughtȱ toȱ assessȱwillingnessȱ toȱ useȱ anȱ inhalationȱ facilityȱ amongȱ individualsȱwhoȱ smokeȱ crackȱ cocaineȱinȱpublicȱareasȱtoȱdetermineȱtheȱpotentialȱimpactȱaȱsupervisedȱinhalationȱfacilityȱ mightȱhaveȱonȱstreetȱdisorderȱinȱVancouver,ȱCanada.ȱ 7.2 Methodsȱ Dataȱ forȱ thisȱ studyȱwereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱdescriptionȱ ofȱ theȱ studyȱpleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱTheȱpresentȱanalysesȱareȱrestrictedȱtoȱVIDUSȱparticipantsȱwhoȱreportedȱsmokingȱ crackȱcocaineȱinȱtheȱlastȱsixȱmonths,ȱandȱwereȱseenȱforȱstudyȱfollowȬupȱvisitsȱduringȱtheȱ periodȱofȱNovemberȱ2008ȱandȱJuneȱ2009ȱasȱmeasuresȱforȱoneȱofȱourȱoutcomesȱofȱinterestȱ areȱavailableȱonlyȱforȱthisȱsampleȱperiod.ȱȱ Inȱourȱ firstȱanalysisȱamongȱcrackȱcocaineȱsmokers,ȱ theȱoutcomeȱofȱ interestȱwasȱ usingȱ drugsȱ (nonȬinjection)ȱ inȱ publicȱ areasȱ inȱ theȱ lastȱ sixȱ months.ȱ Asȱ inȱ previousȱ ȱȱ 125 analyses,ȱpublicȱareasȱincludedȱcityȱstreets,ȱparks,ȱpublicȱwashrooms,ȱparkingȱlots,ȱclubsȱ orȱbarsȱandȱabandonedȱbuildings.3ȱToȱcharacterizeȱourȱoutcomeȱofȱ interestȱweȱaȱprioriȱ selectedȱ aȱ rangeȱ ofȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ weȱ hypothesizedȱ mightȱbeȱassociatedȱwithȱ smokingȱ crackȱ cocaineȱ inȱpublicȱ areas.ȱTheseȱ included:ȱageȱ (perȱ yearȱ older);ȱ genderȱ (femaleȱ vs.ȱmale);ȱAboriginalȱAncestryȱ (yesȱ vs.ȱ no);ȱ limitedȱ accessȱ toȱ privateȱ space,ȱdefinedȱ asȱ answeringȱ ““no””ȱ toȱ theȱ question:ȱ ““Doȱ youȱ haveȱ aȱ privateȱindoorȱspaceȱforȱsocializingȱwithȱfriendsȱandȱacquaintances?””ȱorȱreportingȱthatȱ theȱ numberȱ ofȱ guestsȱ theyȱwereȱ allowedȱ toȱ haveȱ inȱ theirȱ residenceȱ atȱ oneȱ timeȱwasȱ restrictedȱ toȱ lessȱ thanȱ three289ȱ (yesȱ vs.ȱ no);ȱ dailyȱ cocaineȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ heroinȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no);ȱ nonȬfatalȱ overdose,ȱselfȱ identifiedȱbyȱparticipantsȱ(yesȱvs.ȱno),ȱencountersȱwithȱpoliceȱ inȱtheȱ lastȱ month,ȱdefinedȱasȱbeingȱquestioned,ȱsearchedȱorȱstoppedȱbyȱpoliceȱ(yesȱvs.ȱno);ȱbeingȱaȱ victimȱ ofȱ violenceȱ definedȱ asȱ beingȱ physicallyȱ assaultedȱ (yesȱ vs.ȱ no);ȱ sexȱ tradeȱ involvement,ȱdefinedȱasȱexchangingȱsexȱforȱmoney,ȱshelter,ȱdrugsȱorȱotherȱcommoditiesȱ (yesȱvs.ȱno);ȱandȱparticipationȱinȱdrugȱdealingȱ(yesȱvs.ȱno).ȱUnlessȱotherwiseȱstated,ȱallȱ drugȱuseȱandȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱmonthȱperiod.ȱȱ Inȱaȱsecondȱanalysis,ȱweȱsoughtȱtoȱassessȱandȱidentifyȱpredictorsȱofȱwillingnessȱtoȱ useȱaȱsupervisedȱinhalationȱroom.ȱBecauseȱweȱwereȱparticularlyȱconcernedȱwithȱpublicȱ drugȱ use,ȱweȱ restrictedȱ ourȱ sampleȱ toȱ crackȱ cocaineȱ smokersȱ thatȱ reportedȱ recentlyȱ usingȱnonȬinjectionȱdrugsȱinȱpublicȱareas.ȱToȱmeasureȱwillingnessȱweȱaskedȱparticipantsȱ ȱȱ 126 ““Ifȱ thereȱwasȱaȱ safeȱplaceȱ toȱ smokeȱyourȱdrugsȱ (ventilatedȱ inhalationȱ room),ȱ closeȱ toȱ whereȱyouȱbuyȱorȱuse,ȱwouldȱyouȱuseȱit?””ȱȱ Variablesȱofȱinterestȱforȱourȱsecondȱanalysisȱwereȱalsoȱselectedȱaȱprioriȱbasedȱonȱ factorsȱweȱ hypothesizedȱmightȱ beȱ associatedȱwithȱ willingnessȱ toȱ useȱ anȱ inhalationȱ room.ȱ Theseȱ included:ȱ ageȱ (perȱ yearȱ older);ȱ genderȱ (femaleȱ vs.ȱ male);ȱ Aboriginalȱ Ancestryȱ (yesȱvs.ȱno);ȱ limitedȱ accessȱ toȱprivateȱ space,ȱ asȱdefinedȱ above,ȱ (yesȱvs.ȱno);ȱ drugȱ sceneȱexposure,ȱdefinedȱasȱ spendingȱanȱaverageȱofȱ sevenȱorȱmoreȱhoursȱonȱ theȱ streetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicentreȱinȱtheȱpreviousȱsixȱmonths247ȱ(yesȱvs.ȱ no);ȱmostȱdrugȱuseȱinȱpublicȱareas,ȱdefinedȱbasedȱonȱreportsȱthatȱpublicȱlocationsȱwereȱ whereȱ theyȱmostȱ frequentlyȱusedȱdrugsȱ (yesȱvs.ȱno);ȱdailyȱcrackȱcocaineȱsmokingȱ (yesȱ vs.ȱno);ȱriskyȱpipeȱsharing,ȱdefinedȱasȱreportingȱsharingȱaȱcrackȱpipeȱorȱmouthpieceȱinȱ theȱ sameȱ sixȱmonthȱ periodȱ asȱ havingȱ burnsȱ orȱ soresȱ onȱ theirȱmouthȱ (yesȱ vs.ȱ no);ȱ encountersȱwithȱpoliceȱinȱtheȱlastȱmonthȱ(yesȱvs.ȱno);ȱandȱbeingȱaȱvictimȱofȱviolenceȱ(yesȱ vs.ȱno).ȱAsȱabove,ȱunlessȱotherwiseȱstated,ȱallȱdrugȱuseȱandȱbehaviouralȱvariablesȱreferȱ toȱtheȱpreviousȱsixȱmonthȱperiod.ȱȱ Forȱbothȱofȱourȱ firstȱandȱsecondȱanalyses,ȱweȱusedȱunivariateȱandȱmultivariateȱ statisticsȱ toȱdetermineȱ factorsȱ associatedȱwithȱ ourȱ outcomesȱ ofȱ interest.ȱ Inȱunivariateȱ analysisȱcategoricalȱexplanatoryȱvariablesȱwereȱanalyzedȱusingȱPearson’’sȱchiȬsquareȱtestȱ andȱ continuousȱ variablesȱwereȱ analyzedȱ usingȱ theȱWilcoxonȱ rankȱ sumȱ test.ȱ Fisher’’sȱ exactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱwasȱlessȱthanȱorȱequalȱtoȱfive.ȱ ȱȱ 127 Toȱevaluateȱfactorsȱindependentlyȱassociatedȱwithȱourȱoutcomesȱofȱinterest,ȱallȱvariablesȱ thatȱwereȱpȱ<ȱ0.05ȱ inȱunivariateȱanalysesȱwereȱenteredȱ intoȱ theȱrespectiveȱmultivariateȱ regressionȱmodels.ȱAllȱstatisticalȱanalysesȱwereȱperformedȱusingȱSASȱsoftwareȱversionȱ 9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ 7.3 Resultsȱ Duringȱ theȱ studyȱperiodȱ 623ȱparticipantsȱwereȱ seenȱ forȱ studyȱ followȬupȱvisitsȱ andȱ reportedȱsmokingȱcrackȱcocaineȱ inȱ theȱ lastȱsixȱmonths.ȱTheseȱ includedȱ249ȱ (40%)ȱ womenȱandȱ231ȱ(37%)ȱpersonsȱwhoȱidentifiedȱasȱAboriginal.ȱAmongȱourȱsampleȱofȱ623ȱ crackȱcocaineȱsmokers,ȱaȱtotalȱofȱ382ȱ(61%)ȱreportedȱusingȱinȱpublicȱareasȱinȱtheȱlastȱsixȱ months.ȱ ȱ Theȱ characteristicsȱ ofȱ theȱ studyȱ sampleȱ stratifiedȱ byȱ publicȱ drugȱ useȱ areȱ presentedȱ inȱ Tableȱ 7.1,ȱ andȱ theȱ univariateȱ analysesȱ ofȱ behaviouralȱ andȱ socioȬ demographicȱvariablesȱassociatedȱwithȱpublicȱdrugȱuseȱamongȱcrackȱcocaineȱsmokersȱ areȱpresentedȱinȱTableȱ7.2.ȱTheȱresultsȱofȱtheȱmultivariateȱlogisticȱregressionȱforȱfactorsȱ associatedȱwithȱpublicȱdrugȱuseȱamongȱcrackȱcocaineȱsmokersȱareȱalsoȱshownȱinȱTableȱ 7.2.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ included:ȱdailyȱheroinȱ injectionȱ (adjustedȱ oddsȱ ratioȱ [AOR]ȱ =ȱ 1.95,ȱ 95%CI:ȱ 1.17Ȭ3.27),ȱ dailyȱ crackȱ cocaineȱ smokingȱ (AORȱ =ȱ 2.17,ȱ 95%CI:ȱ 1.49Ȭ3.14),ȱ encountersȱwithȱ policeȱ (AORȱ=ȱ1.69,ȱ95%CI:ȱ1.07Ȭ2.68)ȱandȱdrugȱdealingȱ(AORȱ=ȱ1.61,ȱ95%CI:ȱ1.06Ȭ2.47).ȱ Forȱ ourȱ secondȱ analysis,ȱ theȱ demographicȱ andȱ behaviouralȱ characteristicsȱ ofȱ publicȱ crackȱ cocaineȱ smokersȱ stratifiedȱbyȱwillingnessȱ toȱuseȱ aȱ supervisedȱ inhalationȱ ȱȱ 128 roomȱ areȱpresentedȱ inȱTableȱ 7.3ȱ andȱ theȱunivariateȱ resultsȱofȱ factorsȱ associatedȱwithȱ willingnessȱtoȱuseȱaȱsupervisedȱinhalationȱroomȱareȱpresentedȱinȱTableȱ7.4.ȱTheȱresultsȱ ofȱ theȱmultivariateȱ logisticȱ regressionȱ forȱ factorsȱassociatedȱwithȱwillingnessȱ toȱuseȱaȱ supervisedȱ inhalationȱ roomȱ areȱ alsoȱ shownȱ inȱ Tableȱ 7.4.ȱ Factorsȱ thatȱ remainedȱ independentlyȱassociatedȱwithȱwillingnessȱ included:ȱ femaleȱgenderȱ (AORȱ=ȱ2.11,ȱ95%ȱ CI:ȱ1.26Ȭ3.55),ȱriskyȱpipeȱsharingȱ(AORȱ=ȱ5.50,ȱ95%ȱCI:ȱ1.63Ȭ18.56)ȱandȱrecentȱencountersȱ withȱpoliceȱ(AORȱ=ȱ2.09,ȱ95%ȱCI:ȱ1.20Ȭ3.65).ȱ 7.4 Discussionȱ Weȱ foundȱ thatȱ theȱmajorityȱ ofȱ crackȱ cocaineȱ smokersȱ inȱ ourȱ studyȱ reportedȱ havingȱusedȱdrugsȱinȱpublicȱareasȱatȱsomeȱpointȱinȱtheȱlastȱsixȱmonths.ȱThisȱgroupȱwasȱ moreȱlikelyȱtoȱbeȱhigherȬintensityȱdrugȱusersȱwithȱrespectȱtoȱheroinȱinjectionȱandȱcrackȱ cocaineȱsmoking,ȱhaveȱencountersȱwithȱtheȱpoliceȱandȱbeȱinvolvedȱinȱdrugȱdealing.ȱOfȱ theseȱ publicȱ crackȱ cocaineȱ smokers,ȱ 71%ȱ reportedȱ beingȱwillingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ roomȱ ifȱ oneȱwasȱ available.ȱ Individualsȱwhoȱ reportedȱ beingȱwillingȱwereȱ moreȱ likelyȱ toȱbeȱ female,ȱengageȱ inȱ riskyȱpipeȱ sharingȱandȱhaveȱencountersȱwithȱ theȱ police.ȱ TheȱprofileȱofȱpublicȱcrackȱcocaineȱsmokersȱasȱhigherȬintensityȱdrugȱusersȱwhoȱ haveȱ interactionsȱwithȱ theȱ criminalȱ justiceȱ systemȱ isȱ reflectiveȱ ofȱ previousȱ findingsȱ describingȱpublicȱinjectionȱdrugȱuserȱpopulations.5,ȱ 6,ȱ290ȱOurȱfindingȱthatȱ71%ȱofȱpublicȱ crackȱ cocaineȱ smokersȱareȱwillingȱ toȱuseȱanȱ inhalationȱ facilityȱalsoȱ supportsȱpreviousȱ ȱȱ 129 willingnessȱ estimatesȱ conductedȱ amongȱ theȱ generalȱ populationȱ ofȱ VancouverȬbasedȱ illicitȱdrugȱusersȱandȱsuggestsȱ thatȱanȱ interventionȱofȱ thisȱnatureȱwillȱ likelyȱ reachȱ theȱ targetȱpopulation.288ȱTheȱhighȱdegreeȱofȱwillingnessȱthatȱthisȱstudyȱfoundȱamongȱpublicȱ crackȱ cocaineȱ smokersȱ toȱ useȱ anȱ inhalationȱ facilityȱ suggestsȱ that,ȱ likeȱ supervisedȱ injectionȱ facilities,ȱ theseȱ interventionsȱareȱ likelyȱ toȱsuccessfullyȱencourageȱpublicȱdrugȱ usersȱtoȱrelocateȱtoȱindoorȱvenues.ȱȱ Interestingly,ȱ oneȱ ofȱ theȱ commonȱ featuresȱ amongȱ bothȱ publicȱ crackȱ cocaineȱ smokersȱ andȱ thoseȱ whoȱ areȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ isȱ theirȱ elevatedȱlikelihoodȱofȱrecentlyȱhavingȱencountersȱwithȱlawȱenforcement.ȱThisȱsuggestsȱ thatȱpublicȱcrackȱcocaineȱsmokersȱwhoȱareȱtheȱsubjectȱofȱlawȱenforcementȱattentionȱareȱ veryȱwillingȱ toȱ relocateȱ toȱ alternativeȱ offȬstreetȱ andȱ healthȬfocussedȱ environmentsȱ ifȱ theyȱwereȱmadeȱavailable.ȱ Indeed,ȱourȱdataȱ indicateȱ thatȱ81%ȱofȱpublicȱcrackȱcocaineȱ smokersȱwhoȱhaveȱhadȱaȱrecentȱencounterȱwithȱpoliceȱareȱwillingȱ toȱuseȱaȱsupervisedȱ inhalationȱfacility.ȱȱ Aȱkeyȱimplicationȱofȱtheseȱfindingsȱisȱthatȱthereȱisȱaȱlargeȱdemandȱforȱsupervisedȱ inhalationȱ roomsȱ amongȱ individualsȱ thatȱ areȱ potentiallyȱ keyȱ contributorsȱ toȱ drugȬ relatedȱ streetȱ disorder.ȱ Theȱ associationȱ betweenȱ publicȱ crackȱ cocaineȱ smokingȱ andȱ encountersȱwithȱpoliceȱsuggestsȱ thatȱ interventionsȱofȱ thisȱnatureȱareȱ likelyȱ toȱ targetȱaȱ criticalȱ subȬpopulationȱ ofȱ drugȱ usersȱ andȱ couldȱ beȱ aȱ valuableȱ toolȱ forȱ policeȱ inȱ theȱ managementȱ ofȱ streetȱ disorder.ȱ ȱ Previousȱ studiesȱ haveȱ foundȱ thatȱVancouverȱ policeȱ ȱȱ 130 regularlyȱ referȱpublicȱ injectionȱdrugȱusersȱ toȱ theȱ localȱ supervisedȱ injectionȱ facility.291ȱ Sinceȱ ourȱ analysisȱ indicatesȱ thatȱ localȱ policeȱ areȱ alreadyȱ frequentlyȱ interactingȱwithȱ publicȱcrackȱcocaineȱsmokers,ȱtheȱestablishmentȱofȱaȱsupervisedȱinhalationȱfacilityȱcouldȱ provideȱ aȱ uniqueȱ opportunityȱ forȱ policeȱ toȱ directȱ thisȱ vulnerableȱ groupȱ toȱ aȱ lowȬ thresholdȱ serviceȱwhereȱ theyȱwillȱ haveȱ opportunitiesȱ toȱ beȱ linkedȱwithȱ appropriateȱ healthȱandȱsocialȱservices.ȱȱ Thisȱstudyȱhasȱaȱnumberȱofȱlimitations.ȱFirstly,ȱVIDUSȱisȱaȱcommunityȱrecruitedȱ nonȬrandomizedȱsampleȱandȱ thereforeȱourȱ findingsȱmayȱnotȱbeȱgeneralizableȱ toȱotherȱ settings.ȱ Ifȱ supervisedȱ inhalationȱ facilitiesȱ areȱ beingȱ consideredȱ inȱ otherȱ settings,ȱ willingnessȱstudiesȱshouldȱbeȱconductedȱamongȱtheȱlocalȱtargetȱpopulationsȱandȱshouldȱ notȱrelyȱonȱtheȱfindingsȱemergingȱfromȱourȱsetting.ȱTheȱgeneralizabilityȱofȱourȱfindingsȱ isȱalsoȱlimitedȱbyȱourȱstudyȱsampleȱwhichȱwasȱrestrictedȱtoȱindividualsȱwithȱaȱhistoryȱofȱ injectionȱdrugȱuse.ȱCrackȱcocaineȱsmokersȱwhoȱdidȱnotȱhaveȱaȱhistoryȱofȱinjectionȱdrugȱ useȱwereȱnotȱeligibleȱforȱourȱstudy.ȱGivenȱtheȱharmsȱassociatedȱwithȱinjectionȱdrugȱuseȱ weȱ anticipateȱ thatȱ ifȱ aȱ selectionȱ effectȱwereȱ presentȱ itȱwouldȱ likelyȱ biasȱ ourȱ sampleȱ towardsȱhighȱriskȱdrugȱusers,ȱsuggestingȱthatȱthisȱgroupȱwouldȱbeȱanȱappropriateȱtargetȱ populationȱforȱpublicȱhealthȱ intervention.ȱ ȱWeȱshouldȱalsoȱnoteȱthatȱamongȱourȱstudyȱ sampleȱ dailyȱ crackȱ cocaineȱ smokingȱ wasȱ significantlyȱ moreȱ commonȱ thanȱ dailyȱ injecting,ȱsuggestingȱ thatȱdespiteȱ theȱrequirementȱofȱaȱhistoryȱofȱ injecting,ȱourȱsampleȱ representsȱ aȱ primarilyȱ crackȱ cocaineȱ smokingȱ population.ȱ Secondly,ȱ someȱ ofȱ ourȱ measuresȱreliedȱonȱselfȬreportȱandȱcouldȱbeȱvulnerableȱ toȱsociallyȱdesirableȱreporting.ȱ ȱȱ 131 Thisȱwouldȱ haveȱ likelyȱ beenȱ ofȱmostȱ relevanceȱ toȱ ourȱmeasureȱ ofȱwillingness,ȱ sinceȱ respondentsȱmightȱ perceiveȱ aȱ pressureȱ toȱ reportȱ beingȱwillingȱ toȱ engageȱwithȱ lowȬ thresholdȱservicesȱofȱthisȱnatureȱgivenȱtheȱwidespreadȱactivismȱamongȱlocalȱdrugȱusersȱ inȱourȱstudyȱsettingȱtoȱimplementȱsupervisedȱdrugȱconsumptionȱfacilities.284ȱWhileȱitȱisȱ possibleȱ thatȱ someȱ respondentsȱ mayȱ overȬreportȱ willingness,ȱ aȱ previousȱ studyȱ comparingȱmeasuresȱofȱwillingnessȱ toȱuseȱaȱsupervisedȱ injectionȱ facilityȱbeforeȱ itȱwasȱ establishedȱ withȱ laterȱ reportsȱ ofȱ actualȱ attendanceȱ afterȱ anȱ injectionȱ facilityȱ wasȱ establishedȱsuggestsȱ thatȱwillingnessȱmeasuresȱareȱgoodȱpredictorsȱofȱ laterȱbehaviourȱ amongȱ thisȱ population.263ȱ Lastly,ȱ sociallyȱ desirableȱ reportingȱ couldȱ haveȱ influencedȱ reportsȱ ofȱ stigmatizedȱ behaviour,ȱ suchȱ asȱ publicȱ drugȱ use,ȱ leadingȱ toȱ anȱ underestimationȱofȱpublicȱcrackȱcocaineȱsmoking.ȱIfȱsocialȱdesirabilityȱwasȱanȱ issueȱ inȱ ourȱstudyȱweȱsuspectȱourȱfindingȱwouldȱbeȱaȱconservativeȱindicationȱofȱtheȱprevalenceȱ ofȱandȱharmsȱassociatedȱwithȱpublicȱdrugȱuseȱamongȱcrackȱcocaineȱsmokers.ȱȱȱ Inȱ summary,ȱ ourȱ studyȱ foundȱ thatȱ locally,ȱ publicȱ crackȱ cocaineȱ smokingȱ isȱ aȱ commonȱpracticeȱ thatȱ isȱalsoȱassociatedȱwithȱrecentȱencountersȱwithȱpolice.ȱWeȱ foundȱ thatȱ theȱmajorityȱ ofȱ publicȱ crackȱ cocaineȱ smokersȱwereȱwillingȱ toȱ useȱ anȱ inhalationȱ facilityȱ ifȱ oneȱ wereȱ available.ȱ Furthermore,ȱ publicȱ crackȱ cocaineȱ smokersȱ whoȱ hadȱ recentȱencountersȱwithȱpoliceȱwereȱevenȱmoreȱlikelyȱtoȱbeȱwillingȱtoȱuseȱanȱinhalationȱ room,ȱsuggestingȱthatȱsupervisedȱinhalationȱfacilitiesȱmayȱofferȱuniqueȱopportunitiesȱtoȱ decreaseȱoneȱcomponentȱofȱdrugȬrelatedȱstreetȱdisorderȱandȱreduceȱtheȱburdenȱonȱlocalȱ lawȱenforcementȱagencies.ȱȱ ȱTableȱ7.1ȱCharacteristicsȱofȱ crackȱ cocaineȱ smokersȱ stratifiedȱ byȱpublicȱdrugȱuseȱ(n=623)ȱ ȱ Publicȱdrugȱuseȱaȱ Characteristicȱ Yesȱn=ȱ382,ȱnȱ(%)ȱ Noȱn=ȱ241,ȱnȱ(%)ȱ Ageȱpreȱyearȱolderȱȱ ȱ ȱ (Median,ȱIQR)ȱcȱ 43ȱ(37Ȭ49)ȱ 46ȱ(40Ȭ50)ȱ FemaleȱGenderȱȱ Yesȱ 145ȱ(38)ȱ 104ȱ(43)ȱ Noȱ 237ȱ(62)ȱ 137ȱ(57)ȱ AboriginalȱAncestryȱȱ Yesȱ 137ȱ(36)ȱ 94ȱ(39)ȱ Noȱ 245ȱ(64)ȱ 147ȱ(61)ȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱdȱ Yesȱ 316ȱ(83)ȱ 169ȱ(70)ȱ Noȱ 66ȱ(17)ȱ 72ȱ(30)ȱ DailyȱCocaineȱInjectionȱdȱ Yesȱ 39ȱ(10)ȱ 9ȱ(4)ȱ Noȱ 343ȱ(90)ȱ 232ȱ(96)ȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ 107(28)ȱ 25ȱ(10)ȱ Noȱ 275ȱ(72)ȱ 216ȱ(90)ȱ DailyȱCrackȱSmokingȱdȱ Yesȱ 220ȱ(58)ȱ 72ȱ(30)ȱȱȱȱ Noȱ 162ȱ(42)ȱ 169ȱ(70)ȱ Overdoseȱ(nonȬfatal)dȱ Yesȱ 18ȱ(5)ȱ 3ȱ(1)ȱ Noȱ 364ȱ(95)ȱ 238ȱ(99)ȱ Encountersȱwithȱpoliceȱeȱ Yesȱ 114ȱ(30)ȱ 35ȱ(15)ȱ Noȱ 268ȱ(70)ȱ 206ȱ(85)ȱ VictimȱofȱViolenceȱdȱ Yesȱ 77ȱ(20)ȱ 30ȱ(12)ȱ Noȱ 305ȱ(80)ȱ 211ȱ(88)ȱ SexȱTradeȱdȱ Yesȱ 60ȱ(16)ȱ 19ȱ(8)ȱ Noȱ 322ȱ(84)ȱ 222ȱ(92)ȱ DrugȱDealingȱdȱ Yesȱ 150ȱ(39)ȱ 46ȱ(19)ȱ Noȱ 232ȱ(61)ȱ 195ȱ(81)ȱ Note:ȱaȱPublicȱlocationsȱinclude:ȱcityȱstreets,ȱparks,ȱpublicȱwashrooms,ȱ parkingȱlots,ȱclubsȱorȱbars,ȱandȱabandonȱbuildings;ȱcȱIQR=ȱInterȱQuartileȱ Range;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱe Denotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱȱmonth.ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ 132 ȱ  ȱTableȱ7.2ȱUnivariateȱandȱmultivariateȱanalysesȱofȱ factorsȱassociatedȱwithȱpublicȱ drugȱuseȱamongȱcrackȱcocaineȱsmokersȱaȱȱ(n=623)ȱ ȱ Univariateȱȱ ȱȱȱ Multivariateȱ Characteristicȱ ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ AORȱ(95%ȱCI)ȱ pȬvalueȱ OlderȱAgeȱȱ ȱ ȱ ȱ ȱ Perȱyearȱolderȱ 0.96ȱȱ(0.94ȱ––ȱ0.98)ȱ <0.001ȱ 0.98ȱȱ(0.96ȱ––ȱ1.00)ȱ 0.065ȱ Genderȱȱ Femaleȱvs.ȱMaleȱ 0.81ȱȱ(0.58ȱ––ȱ1.12)ȱ 0.197ȱ AboriginalȱAncestryȱȱ Yesȱvs.ȱNoȱ 0.87ȱȱ(0.63ȱ––ȱ1.22)ȱ 0.429ȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱeȱ Yesȱvs.ȱNoȱ 2.04ȱȱ(1.39ȱ––ȱ2.99)ȱ <0.001ȱ 1.49ȱ(0.99ȱ––ȱ2.26)ȱ 0.058ȱ DailyȱCocaineȱInjectionȱeȱ Yesȱvs.ȱNoȱ 2.93ȱȱ(1.39ȱ––ȱ6.17)ȱ 0.003ȱ 1.70ȱ(0.77ȱ––ȱ3.75)ȱ 0.190ȱ DailyȱHeroinȱInjectionȱeȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 3.36ȱȱ(2.10ȱ––ȱ5.38)ȱ <ȱ0.001ȱ 1.95ȱ(1.17ȱ––ȱ3.27)ȱ 0.011ȱ DailyȱCrackȱCocaineȱSmokingȱeȱ ȱ ȱ Yesȱvs.ȱNoȱ 3.19ȱȱ(2.26ȱ––ȱ4.49)ȱ <ȱ0.001ȱ 2.17ȱ(1.49ȱ––ȱ3.14)ȱ <.001ȱ Overdoseȱ(nonȬfatal)*ȱeȱ ȱ ȱ Yesȱvs.ȱNoȱ 3.92ȱȱ(1.13ȱ––ȱ20.98)ȱ 0.020ȱ 2.04ȱ(0.55ȱ––ȱ7.61)ȱ 0.288ȱ EncountersȱwithȱPoliceȱdȱ ȱ ȱ Yesȱvs.ȱNoȱ 2.50ȱȱ(1.64ȱ––ȱ3.81)ȱ <0.001ȱ 1.69ȱ(1.07ȱ––ȱ2.68)ȱ 0.025ȱ VictimȱofȱViolenceȱeȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.78ȱȱ(1.12ȱ––ȱ2.80)ȱ 0.013ȱ 1.52ȱ(0.92ȱ––ȱ2.51)ȱ 0.100ȱ SexȱTradeȱeȱȱ ȱ ȱ Yesȱvs.ȱNoȱ 2.18ȱȱ(1.26ȱ––ȱ3.75)ȱ 0.004ȱ 1.30ȱ(0.72ȱ––ȱ2.38)ȱ 0.386ȱ DrugȱDealingȱeȱ ȱ ȱ Yesȱvs.ȱNoȱ 2.74ȱȱ(1.87ȱ––ȱ4.01)ȱ <0.001ȱ 1.61ȱ(1.06ȱ––ȱ2.47)ȱ 0.027ȱ Note:ȱaȱPublicȱareasȱincluded:ȱcityȱstreets,ȱparks,ȱpublicȱwashrooms,ȱparkingȱlots,ȱclubsȱorȱbars,ȱandȱ abandonȱbuildings;ȱbORȱ=ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱAORȱ=ȱAdjustedȱOddsȱRatio;ȱ eDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱ referringȱtoȱpreviousȱmonth.ȱȱ *pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱlessȱthanȱ 5.ȱ ȱ   ȱ ȱ ȱ 133 ȱTableȱ7.3ȱCharacteristicsȱofȱcrackȱcocaineȱsmokersȱwhoȱuseȱdrugsȱinȱ publicȱstratifiedȱbyȱwillingnessȱtoȱuseȱaȱsupervisedȱinhalationȱroomȱ (n=382)ȱ ȱ WillingȱtoȱuseȱSIRȱaȱ Characteristicȱ Yesȱn=ȱ271,ȱnȱ(%)ȱ Noȱn=ȱ111,ȱnȱ(%)ȱ Ageȱpreȱyearȱolderȱȱ ȱ ȱ (Median,ȱIQR)ȱcȱ 43ȱ(37Ȭ49)ȱ 44ȱ(37Ȭ48)ȱ FemaleȱGenderȱȱ Yesȱ 117ȱ(43)ȱ 28ȱ(25)ȱ Noȱ 154ȱ(57)ȱ 83ȱ(75)ȱ AboriginalȱAncestryȱȱ Yesȱ 108ȱ(40)ȱ 29ȱ(26)ȱ Noȱ 163ȱ(60)ȱ 82ȱ(74)ȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱeȱ Yesȱ 230ȱ(85)ȱ 86ȱ(77)ȱ Noȱ 41ȱ(15)ȱ 25ȱ(23)ȱ DrugȱSceneȱExposureȱe,ȱfȱ Yesȱ 157ȱ(58)ȱ 49ȱ(44)ȱ Noȱ 114ȱ(42)ȱ 62ȱ(56)ȱ MostȱDrugȱUseȱinȱPublicȱAreasȱeȱ Yesȱ 140ȱ(52)ȱ 43ȱ(39)ȱ Noȱ 131ȱ(48)ȱ 68ȱ(61)ȱ DailyȱCrackȱCocaineȱSmokingȱeȱ Yesȱ 164ȱ(61)ȱ 56ȱ(50)ȱȱȱȱ Noȱ 107ȱ(39)ȱ 55ȱ(50)ȱ RiskyȱPipeȱSharingȱeȱ Yesȱ 38ȱ(14)ȱ 3ȱ(3)ȱ Noȱ 233ȱ(86)ȱ 108ȱ(97)ȱ EncountersȱwithȱPoliceȱdȱ Yesȱ 92ȱ(34)ȱ 22ȱ(20)ȱ Noȱ 179ȱ(66)ȱ 89ȱ(80)ȱ VictimȱofȱViolenceȱeȱ Yesȱ 53ȱ(20)ȱ 24ȱ(22)ȱ Noȱ 218ȱ(80)ȱ 87ȱ(78)ȱ Note:ȱcȱIQR=ȱInterȱQuartileȱRange;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱ toȱpreviousȱ6ȱmonths;ȱeȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱȱ month;ȱfȱDrugȱsceneȱexposureȱwasȱdefinedȱasȱspendingȱanȱaverageȱofȱ7ȱorȱ moreȱhoursȱonȱtheȱstreetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicenterȱinȱtheȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ   ȱ 134 ȱTableȱ7.4ȱUnivariateȱandȱmultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱ toȱuseȱaȱsupervisedȱinhalationȱroomȱamongȱparticipantsȱthatȱsmokeȱcrackȱcocaineȱandȱ useȱdrugsȱinȱpublicȱlocationsȱaȱȱ(n=382)ȱ ȱ Univariateȱȱ ȱȱȱ Multivariateȱ Characteristicȱ ORaȱȱ(95%ȱCI)ȱ pȬvalueȱ AORbȱ(95%ȱCI)ȱ pȬvalueȱ OlderȱAgeȱȱ ȱ ȱ ȱ ȱ Perȱyearȱolderȱ 1.01ȱȱ(0.98ȱ––ȱ1.04)ȱ 0.446ȱ Genderȱȱ Femaleȱvs.ȱMaleȱ 2.25ȱȱ(1.38ȱ––ȱ3.68)ȱ 0.001ȱ 2.11ȱȱ(1.26ȱ––ȱ3.55)ȱ 0.005ȱ AboriginalȱAncestryȱȱ Yesȱvs.ȱNoȱ 1.87ȱȱ(1.15ȱ––ȱ3.05)ȱ 0.011ȱ 1.61ȱȱ(0.96ȱ––ȱ2.72)ȱ 0.072ȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱeȱ Yesȱvs.ȱNoȱ 1.63ȱȱ(0.94ȱ––ȱ2.84)ȱ 0.083ȱ ȱ ȱ DrugȱSceneȱExposureȱeȱ Yesȱvs.ȱNoȱ 1.74ȱ(1.12ȱ––ȱ2.72)ȱ 0.014ȱ 1.40ȱ(0.86ȱ––ȱ2.28)ȱ 0.181ȱ MostȱDrugȱUseȱinȱPublicȱAreasȱeȱ Yesȱvs.ȱNoȱ 1.69ȱȱ(1.08ȱ––ȱ2.65)ȱ 0.022ȱ 1.39ȱȱ(0.85ȱ––ȱ2.28)ȱ 0.187ȱ DailyȱCrackȱCocaineȱSmokingȱeȱ Yesȱvs.ȱNoȱ 1.51ȱȱ(0.96ȱ––ȱ2.35)ȱ 0.071ȱ BingeȱDrugȱUseȱeȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱ ȱ ȱ ȱ ȱ RiskyȱPipeȱSharing*ȱeȱ Yesȱvs.ȱNoȱ 5.87ȱ(1.79ȱ––ȱ30.29)ȱ <ȱ0.001ȱ 5.50ȱ(1.63ȱ––ȱ18.56)ȱ 0.006ȱ EncountersȱwithȱPoliceȱdȱ Yesȱvs.ȱNoȱ 2.08ȱȱ(1.22ȱ––ȱ3.53)ȱ 0.006ȱ 2.09ȱȱ(1.20ȱ––ȱ3.65)ȱ 0.010ȱ VictimȱofȱViolenceȱeȱ Yesȱvs.ȱNoȱ 0.88ȱȱ(0.51ȱ––ȱ1.52)ȱ 0.648ȱ Note:ȱaORȱ=ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱbAORȱ=ȱAdjustedȱOddsȱRatio;ȱeDenotesȱactivitiesȱ orȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ month.ȱ*pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱ lessȱthanȱ5.ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱȱ ȱ 135 ȱȱ 136 CHAPTER 8: ȱ CONCLUSIONSȱ 8.1 Summaryȱofȱfindingsȱ ThisȱthesisȱbeganȱwithȱanȱoverviewȱofȱtheȱproblemsȱassociatedȱwithȱdrugȬrelatedȱ streetȱdisorderȱandȱaȱ reviewȱofȱ literatureȱonȱ theȱ impactsȱofȱcurrentȱpolicyȬapproachesȱ thatȱhaveȱbeenȱ implementedȱ toȱaddressȱ thisȱ issue.ȱTheȱresultsȱofȱ theȱ literatureȱreviewȱ suggestȱ thatȱ lawȱenforcementȱbasedȱapproachesȱwhichȱaimȱ toȱaddressȱ streetȱdisorderȱ areȱ associatedȱwithȱmanyȱunintendedȱharmfulȱ consequencesȱ andȱ areȱ limitedȱ inȱ theirȱ effectivenessȱtoȱsustainablyȱreduceȱstreetȱdisorder.ȱTheȱreviewȱalsoȱsuggestedȱthatȱthereȱ areȱ aȱ numberȱ ofȱ interventionsȱ withȱ promisingȱ signsȱ ofȱ effectivenessȱ inȱ reducingȱ engagementȱ inȱdrugȬrelatedȱstreetȱdisorder.ȱTheseȱ includeȱ lowȬthresholdȱemploymentȱ programs,ȱsupervisedȱinjectionȱfacilitiesȱandȱaddictionȱtreatmentȱprograms.ȱInȱaddition,ȱ theȱ reviewȱhighlightedȱpromisingȱunderexploredȱ interventionsȱ suchȱasȱ lowȬthresholdȱ supportiveȱhousingȱandȱsupervisedȱinhalationȱfacilitiesȱforȱpeopleȱwhoȱsmokeȱdrugs.ȱItȱ concludedȱ thatȱ furtherȱ researchȱ shouldȱ beȱ directedȱ towardsȱ identifyingȱ innovativeȱ interventionsȱ toȱ addressȱ streetȱ disorderȱ asȱ wellȱ asȱ assessingȱ theȱ impactȱ thatȱ underexploredȱpublicȱhealthȱbasedȱ interventionsȱmightȱhaveȱonȱreducingȱengagementȱ inȱstreetȱdisorder.ȱ Theȱ centralȱaimsȱofȱ thisȱ thesisȱwereȱ toȱ identifyȱ factorsȱ thatȱ contributeȱ toȱdrugȬ relatedȱ streetȱdisorder,ȱ exploreȱ theȱ impactsȱofȱdrugȬrelatedȱ streetȱdisorderȱandȱassessȱ ȱȱ 137 potentialȱ policyȱ responsesȱ toȱ thisȱ problem.ȱ Theȱ firstȱ dataȬdrivenȱ chapter,ȱChapterȱ 3,ȱ describedȱtheȱhealthȱandȱsocialȱimpactsȱofȱexposureȱtoȱdrugȬrelatedȱstreetȱdisorderȱandȱ assessedȱwhetherȱexposureȱposedȱpublicȱhealthȱrisks.ȱItȱfoundȱthatȱdrugȱsceneȱexposureȱ wasȱassociatedȱ inȱaȱdoseȬdependentȱ fashionȱwithȱmultipleȱmarkersȱofȱvulnerabilityȱ toȱ harmȱandȱadverseȱhealthȱoutcomes,ȱincludingȱbeingȱunstablyȱhoused,ȱbeingȱaȱvictimȱofȱ violence,ȱhavingȱencountersȱwithȱpoliceȱandȱparticipatingȱ inȱdrugȱdealing.ȱDrugȱsceneȱ exposureȱ wasȱ alsoȱ associatedȱ withȱ higherȬintensityȱ drugȱ use,ȱ specifically,ȱ greaterȱ likelihoodȱofȱ injectingȱcocaineȱandȱheroinȱonȱaȱdailyȱbasisȱandȱsmokingȱcrackȱcocaineȱ daily.ȱ Theȱ analysisȱ furtherȱ foundȱ thatȱ employmentȱ andȱ addictionȱ treatmentȱ wereȱ associatedȱ withȱ decreasedȱ drugȱ sceneȱ exposure.ȱ Theseȱ findingsȱ supportedȱ theȱ explorationȱofȱpolicyȱinterventionsȱinȱtheȱareasȱofȱhousingȱandȱemployment.ȱ Toȱ provideȱ aȱ basisȱ forȱ exploringȱ theȱ potentialȱ impactsȱ ofȱ differentȱ policyȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder,ȱ Chapterȱ 4ȱ soughtȱ toȱ assessȱ whetherȱ willingnessȱ measuresȱ couldȱ beȱ effectiveȱ toolsȱ forȱ planningȱ publicȱ healthȱ interventionsȱ forȱ injectionȱdrugȱuserȱpopulations.ȱAfterȱcomparingȱpriorȱmeasuresȱ forȱ willingnessȱ toȱ useȱ aȱ supervisedȱ injectionȱ facilityȱwithȱ laterȱ attendanceȱ atȱ theȱ facilityȱ onceȱ itȱwasȱ established,ȱ thisȱ analysisȱ foundȱ thatȱ initialȱwillingnessȱ toȱ useȱ aȱ SIFȱwasȱ independentlyȱ associatedȱwithȱ subsequentȱ attendanceȱ atȱVancouver’’sȱ SIF,ȱ evenȱ afterȱ adjustingȱforȱotherȱdeterminantsȱofȱwillingness.ȱThisȱsuggestsȱthatȱwillingnessȱmeasuresȱ areȱ reasonablyȱ validȱ toolsȱ forȱ predictingȱ engagementȱ withȱ publicȱ healthȱ programsȱ amongȱlocalȱIDU.ȱȱ ȱȱ 138 Afterȱestablishingȱ thatȱwillingnessȱmeasuresȱwereȱappropriateȱ toolsȱ toȱassessȱaȱ population’’sȱ potentialȱ engagementȱ withȱ specificȱ publicȱ healthȱ interventions,ȱ theȱ relationshipȱbetweenȱaccessȱtoȱprivateȱspaceȱandȱtimeȱspentȱsocializingȱinȱtheȱopenȱdrugȱ sceneȱwasȱ thenȱexamined.ȱThisȱwasȱ theȱ firstȱanalysisȱ toȱconsiderȱwhetherȱaȱparticularȱ interventionȱ (increasingȱ accessȱ toȱ privateȱ space)ȱ mightȱ haveȱ anȱ influenceȱ onȱ streetȱ disorder.ȱItȱalsoȱsoughtȱtoȱidentifyȱfactorsȱthatȱmightȱcontributeȱtoȱstreetȱdisorder.ȱThisȱ studyȱ foundȱ thatȱ havingȱ limitedȱ privateȱ spaceȱ wasȱ significantlyȱ associatedȱ withȱ spendingȱanȱaverageȱofȱthreeȱorȱmoreȱhoursȱperȱdayȱsocializingȱinȱtheȱopenȱdrugȱsceneȱ amongȱ localȱ IDU.ȱThisȱassociationȱpersistedȱ afterȱ adjustmentȱ forȱaȱ rangeȱofȱpotentialȱ confoundingȱ factors,ȱ suggestingȱ thatȱ limitedȱ accessȱ toȱ privateȱ spaceȱ mayȱ beȱ contributingȱ toȱoneȱaspectȱofȱdrugȬrelatedȱstreetȱdisorder.ȱ ȱTheȱmajority,ȱ65%ȱofȱ thoseȱ whoȱhadȱ limitedȱaccessȱ toȱprivateȱ spaceȱandȱ spendȱ significantȱ timeȱ socializingȱ inȱ theȱ openȱdrugȱscene,ȱreportedȱ thatȱ theyȱwouldȱbeȱwillingȱ toȱrelocateȱawayȱ fromȱ theȱopenȱ drugȱsceneȱifȱtheyȱwereȱprovidedȱwithȱprivateȱspaceȱforȱsocializing.ȱWhenȱcomparedȱtoȱ IDUȱwhoȱlivedȱinȱstableȱhousing,ȱstudyȱparticipantsȱwhoȱlivedȱinȱSROs,ȱsheltersȱorȱhadȱ noȱfixedȱaddressȱwereȱsignificantlyȱmoreȱlikelyȱtoȱsocializeȱinȱtheȱopenȱdrugȱsceneȱandȱ wereȱsignificantlyȱmoreȱlikelyȱtoȱbeȱwillingȱtoȱrelocate.ȱȱ Followingȱ theȱ analysisȱ ofȱwillingnessȱ toȱ relocateȱ socializing,ȱ theȱ nextȱ areaȱ ofȱ studyȱassessedȱengagementȱinȱstreetȬbasedȱdisorderlyȱincomeȱgenerationȱactivitiesȱandȱ examinedȱtheȱrelationshipȱbetweenȱprovidingȱlowȬthresholdȱemploymentȱopportunitiesȱ andȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivities.ȱThisȱstudyȱfoundȱthatȱ48%ȱofȱ ȱȱ 139 localȱ IDUȱ reportedȱengagingȱ inȱaȱdisorderlyȱ incomeȱgenerationȱactivityȱ inȱ theȱ lastȱsixȱ months.ȱTheȱmostȱcommonȱactivitiesȱreportedȱwereȱdrugȱdealingȱandȱrecyclingȱ(whichȱ includedȱsalvagingȱandȱunsanctionedȱstreetȱvending).ȱInȱaȱmultivariateȱanalysisȱpeopleȱ whoȱreportedȱengagingȱ inȱdisorderlyȱ incomeȱgenerationȱactivitiesȱwereȱmoreȱ likelyȱ toȱ smokeȱcrackȱcocaineȱonȱaȱdailyȱbasisȱandȱinjectȱcocaineȱonȱaȱdailyȱbasis.ȱThisȱpopulationȱ wasȱ alsoȱmoreȱ likelyȱ toȱ engageȱ inȱbingeȱdrugȱuse,ȱhaveȱ encountersȱwithȱpolice,ȱbeȱaȱ victimȱ ofȱ violence,ȱ shareȱusedȱ syringesȱ andȱ injectȱdrugsȱ inȱpublicȱ areas.ȱConversely,ȱ individualsȱwithȱregularȱemploymentȱwereȱsignificantlyȱ lessȱ likelyȱ toȱreportȱengagingȱ inȱdisorderlyȱincomeȱgenerationȱactivities.ȱTheȱstudyȱalsoȱfoundȱthatȱamongȱindividualsȱ whoȱengagedȱinȱdisorderlyȱincomeȱgenerationȱactivities,ȱ47%ȱreportedȱthatȱtheyȱwouldȱ beȱwillingȱ toȱstopȱengagingȱ inȱ theseȱactivitiesȱ ifȱ theyȱwereȱofferedȱotherȱopportunitiesȱ forȱ lowȬthresholdȱemployment.ȱ Individualsȱengagedȱ inȱsexȱwork,ȱdrugȱdealing,ȱbingeȱ drugȱ use,ȱ orȱwhoȱwereȱ recentlyȱ incarceratedȱwereȱmostȱ interestedȱ inȱ ceasingȱ theirȱ engagementȱinȱdisorderlyȱincomeȱgenerationȱactivities.ȱȱ Theȱnextȱandȱfinalȱanalysisȱsoughtȱtoȱcharacterizeȱpublicȱcrackȱcocaineȱsmokingȱ andȱ assessȱ whetherȱ aȱ supervisedȱ inhalationȱ facilityȱ hadȱ potentialȱ toȱ addressȱ streetȱ disorderȱ byȱ reducingȱ theȱ prevalenceȱ ofȱ thisȱ behaviour.ȱ Itȱ foundȱ thatȱ theȱmajorityȱ ofȱ crackȱcocaineȱsmokersȱreportedȱhavingȱsmokedȱdrugsȱinȱpublicȱareasȱatȱsomeȱpointȱinȱ theȱlastȱsixȱmonths.ȱThisȱgroupȱwasȱmoreȱlikelyȱtoȱincludeȱhigherȱintensityȱdrugȱusersȱ withȱ respectȱ toȱheroinȱ injectionȱandȱcrackȱcocaineȱsmoking,ȱhaveȱencountersȱwithȱ theȱ policeȱandȱbeȱinvolvedȱinȱdrugȱdealing.ȱAmongȱtheseȱpublicȱcrackȱcocaineȱsmokers,ȱ71%ȱ ȱȱ 140 reportedȱ beingȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ roomȱ ifȱ oneȱ wasȱ available.ȱ Individualsȱwhoȱreportedȱbeingȱwillingȱwereȱmoreȱlikelyȱtoȱbeȱfemale,ȱengageȱinȱriskyȱ pipeȱsharingȱandȱhaveȱencountersȱwithȱtheȱpolice.ȱ 8.2 UniqueȱContributionsȱȱ Thisȱ thesisȱmakesȱaȱnumberȱofȱuniqueȱ contributionsȱ thatȱhaveȱ implicationsȱ forȱ framingȱ andȱ respondingȱ toȱdrugȬrelatedȱ streetȱdisorder.ȱTheȱ literatureȱ reviewȱ ofȱ theȱ impactsȱofȱpolicyȱresponsesȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorderȱisȱtheȱfirstȱofȱitsȱkindȱ toȱ summarizeȱ theȱ impactsȱofȱpoliciesȱ inȱ thisȱarea.ȱByȱ identifyingȱ theȱ lackȱofȱ scientificȱ evidenceȱ inȱsupportȱofȱcurrentȱapproachesȱ toȱdrugȬrelatedȱstreetȱdisorder,ȱ thisȱreviewȱ underscoresȱtheȱneedȱtoȱidentifyȱalternativeȱpolicyȱinterventionsȱandȱguidedȱtheȱcurrentȱ thesisȱstudies.ȱȱȱȱȱ Anotherȱuniqueȱcontributionȱofȱthisȱthesisȱisȱtheȱdemonstrationȱthatȱexposureȱtoȱ drugȬrelatedȱ streetȱ disorderȱ isȱ associatedȱ inȱ aȱ doseȬdependentȱ fashionȱwithȱ higherȬ intensityȱaddictionȱandȱmarkersȱofȱvulnerabilityȱtoȱadverseȱhealthȱoutcomes.ȱAlthoughȱ previousȱ studiesȱ haveȱ assessedȱ harmsȱ associatedȱwithȱ activitiesȱ thatȱ generateȱ streetȱ disorder,4,ȱ7,ȱ10,ȱ57,ȱ61ȱthisȱisȱtheȱfirstȱtoȱsuggestȱthatȱexposureȱindependentȱofȱengagementȱinȱ specificȱactivitiesȱisȱaȱsourceȱofȱharmȱforȱstreetȬbasedȱdrugȱusers.ȱTheseȱfindingȱprovideȱ evidenceȱthatȱdrugȬrelatedȱstreetȱdisorderȱisȱnotȱjustȱaȱpublicȱorderȱconcernȱbutȱshouldȱ beȱconsideredȱaȱpublicȱhealthȱthreatȱandȱaddressedȱasȱsuch.ȱȱȱ ȱȱ 141 Theȱ thirdȱ uniqueȱ contributionȱ ofȱ thisȱ thesisȱ isȱ theȱ findingȱ thatȱ willingnessȱ measuresȱ areȱ reasonablyȱ goodȱ toolsȱ forȱ predictingȱ engagementȱ withȱ publicȱ healthȱ interventionsȱ amongȱ localȱ IDUȱ populations.ȱDespiteȱ theȱ commonȱ useȱ ofȱwillingnessȱ measuresȱ toȱ assessȱ theȱ feasibilityȱ ofȱ publicȱ healthȱ interventionsȱ amongȱ drugȱ usingȱ populations,193,ȱ 222,ȱ 225Ȭ230ȱ itȱ appearsȱ thatȱ noȱ studyȱ hasȱ assessedȱwhetherȱ theyȱ areȱ validȱ measurementȱ tools.ȱThisȱ studyȱmakesȱaȱcriticalȱcontributionȱ toȱ theȱoverallȱ thesisȱasȱ itȱ providesȱ aȱ justificationȱ forȱ theȱ useȱ ofȱ willingnessȱ measuresȱ toȱ exploreȱ potentialȱ interventionsȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorder.ȱȱ Whenȱtakenȱtogether,ȱtheȱstudiesȱinȱthisȱthesisȱrepresentȱaȱuniqueȱexplorationȱofȱ theȱ factorsȱ thatȱcontributeȱ toȱdrugȬrelatedȱstreetȱdisorder,ȱdangersȱassociatedȱwithȱ theȱ phenomenonȱandȱpotentialȱpolicyȱresponses.ȱByȱprovidingȱanȱ inȬdepthȱunderstandingȱ ofȱ theȱ experiencesȱ ofȱ streetȬinvolvedȱ drugȱ usersȱ andȱ tailoringȱ potentialȱ policyȱ interventionsȱtoȱconsiderȱandȱaddressȱtheȱmotivationsȱandȱcurrentȱcircumstancesȱofȱthisȱ population,ȱ theȱpolicyȱdevelopmentȱapproachȱ inȱ thisȱ thesisȱ isȱdistinctȱandȱ somethingȱ that,ȱtoȱdate,ȱhasȱnotȱbeenȱwidelyȱemployed.ȱȱMoreȱspecifically,ȱthisȱthesisȱisȱtheȱfirstȱofȱ itsȱkindȱtoȱconsiderȱandȱfindȱanȱassociationȱbetweenȱlimitedȱaccessȱtoȱprivateȱspaceȱandȱ socializingȱinȱtheȱopenȱdrugȱscene,ȱandȱitȱisȱalsoȱtheȱfirstȱstudyȱtoȱdemonstrateȱthatȱthereȱ isȱaȱhighȱ levelȱofȱwillingnessȱamongȱ localȱ IDUȱ toȱ relocateȱ toȱ indoorȱ locationsȱ ifȱ theyȱ wereȱ givenȱ accessȱ toȱmoreȱ privateȱ indoorȱ space.ȱ Increasingȱ assessȱ toȱ privateȱ indoorȱ spaceȱ throughȱ theȱprovisionȱofȱ lowȬthresholdȱ supportiveȱhousingȱwithȱ safeguardsȱ toȱ ȱȱ 142 manageȱbehavioursȱassociatedȱwithȱactiveȱdrugȱuseȱ isȱaȱnovelȱapproachȱ toȱpotentiallyȱ reduceȱengagementȱinȱactivitiesȱthatȱgenerateȱstreetȱdisorder.ȱȱ Similarly,ȱthisȱthesisȱmakesȱaȱuniqueȱcontributionȱbyȱassessingȱdemandȱforȱlowȬ thresholdȱ employmentȱ asȱ aȱmeansȱ toȱ reduceȱ engagementȱ inȱ streetȬbasedȱ disorderlyȱ incomeȱ generationȱ activities.ȱGivenȱ thatȱ roughlyȱ halfȱ ofȱ theȱ sampleȱwhoȱ engagedȱ inȱ disorderlyȱ incomeȱgenerationȱwereȱwillingȱ toȱ ceaseȱ ifȱgivenȱ otherȱ incomeȱgenerationȱ opportunities,ȱ thisȱ workȱ demonstratesȱ thatȱ thereȱ isȱ considerableȱ demandȱ forȱ lowȬ thresholdȱ employmentȱ andȱ increasingȱ theseȱ opportunitiesȱ hasȱ potentialȱ toȱ reduceȱ engagementȱinȱdrugȬrelatedȱstreetȱdisorder.ȱȱ Lastly,ȱthisȱthesisȱisȱtheȱfirstȱknownȱstudyȱtoȱexamineȱtheȱspecificȱrisksȱassociatedȱ withȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areasȱ andȱ toȱ assessȱ willingnessȱ toȱ useȱ anȱ inhalationȱfacilityȱamongȱpublicȱcrackȱcocaineȱsmokersȱexclusively.ȱNotably,ȱoneȱofȱtheȱ commonȱ featuresȱ thisȱ studyȱ identifiedȱamongȱbothȱpublicȱ crackȱ cocaineȱ smokersȱandȱ thoseȱ whoȱ wereȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ wasȱ theirȱ elevatedȱ likelihoodȱofȱrecentlyȱhavingȱencountersȱwithȱ lawȱenforcement.ȱThisȱ findingȱ indicatesȱ thatȱ aȱ supervisedȱ inhalationȱ facilityȱ mayȱ beȱ anȱ importantȱ toolȱ forȱ policeȱ inȱ theȱ managementȱofȱstreetȱdisorder.ȱȱȱ 8.3 RecommendationsȱandȱImplicationsȱ Theȱ findingsȱ ofȱ thisȱ thesisȱ highlightȱ thatȱ social,ȱ structuralȱ andȱ environmentalȱ factorsȱplayȱaȱcentralȱroleȱinȱshapingȱtheȱbehaviourȱofȱpeopleȱwhoȱuseȱillicitȱdrugsȱandȱ ȱȱ 143 areȱpotentiallyȱcriticalȱleversȱforȱpolicyȱinterventions.ȱThisȱreinforcesȱtheȱviewȱthatȱstreetȱ disorderȱ shouldȱ beȱ seenȱ inȱ theȱ contextȱ ofȱ currentȱ political,ȱ economicȱ andȱ socialȱ conditionsȱ andȱ shouldȱ notȱ beȱ solelyȱ constructedȱ asȱ theȱ productȱ ofȱ theȱ individualȱ behaviourȱ ofȱ streetȬinvolvedȱ people.ȱ Currentȱ policyȱ approachesȱ thatȱ placeȱ primaryȱ responsibilityȱonȱ individualȬlevelȱfactorsȱwithoutȱconsideringȱtheȱ influenceȱthatȱsocial,ȱ structuralȱandȱenvironmentalȱfactorsȱhaveȱinȱgeneratingȱstreetȱdisorderȱwillȱcontinueȱtoȱ beȱ inadequateȱ responsesȱ thatȱ failȱ toȱmeetȱ theirȱpolicyȱobjectivesȱ andȱwillȱ continueȱ toȱ simultaneouslyȱundermineȱtheȱhealthȱofȱvulnerableȱpopulations.ȱConversely,ȱthisȱthesisȱ contributesȱtoȱaȱgrowingȱbodyȱofȱresearchȱwhichȱindicatesȱthatȱ interventionsȱthatȱalterȱ theȱ structureȱ ofȱ streetȬbasedȱ drugȱ scenesȱ haveȱ concreteȱ potentialȱ toȱ reduceȱ riskȱ behaviours.ȱThisȱhasȱbothȱmicroȱandȱmacroȱlevelȱimplications.ȱ 8.3.1 MicroȱLevelȱRecommendationsȱandȱImplicationsȱ Theȱ studiesȱ presentedȱ inȱ thisȱ thesisȱ illustrateȱ thatȱ structuralȱ factors,ȱ includingȱ havingȱ limitedȱaccessȱ toȱprivateȱspaceȱandȱaȱ lackȱofȱ incomeȱgenerationȱopportunities,ȱ areȱ closelyȱ connectedȱwithȱ streetȱ disorder.ȱ Byȱ addressingȱ aspectsȱ ofȱ theseȱ structuralȱ conditions,ȱ thisȱ thesisȱ hasȱ identifiedȱ threeȱ interventionsȱ thatȱ haveȱ potentialȱ toȱ successfullyȱ engageȱ aȱ largeȱ proportionȱ ofȱ streetȬbasedȱ drugȱ usersȱ andȱ createȱ environmentsȱthatȱenableȱthemȱtoȱreduceȱtheirȱengagementȱinȱbehavioursȱthatȱgenerateȱ drugȬrelatedȱ streetȱdisorder.ȱSpecifically,ȱ studyȱ findingsȱprovideȱ compellingȱevidenceȱ thatȱinvestingȱin:ȱa)ȱlowȬthresholdȱsupportiveȱhousing,ȱb)ȱtheȱcreationȱofȱlowȬthresholdȱ employmentȱopportunities,ȱandȱc)ȱtheȱestablishmentȱofȱmedicallyȱsupervisedȱinhalationȱ ȱȱ 144 facilitiesȱcanȱinfluenceȱtheȱstructureȱofȱstreetȬbasedȱdrugȱscenesȱandȱsupportȱindividualsȱ toȱ modifyȱ theirȱ behaviourȱ inȱ waysȱ thatȱ reduceȱ engagementȱ inȱ streetȱ disorder.ȱ Supportingȱandȱpursuingȱ theseȱpolicyȱ interventionsȱrepresentsȱaȱsignificantȱparadigmȱ changeȱ forȱpolicyȬmakersȱ inȱ thisȱ areaȱ asȱ itȱ involvesȱmovingȱ awayȱ fromȱpunitiveȱ lawȱ enforcementȱbasedȱapproachesȱ thatȱattributeȱchiefȱ responsibilityȱ forȱ streetȱdisorderȱ toȱ individuals.ȱ Itȱisȱimportantȱtoȱnoteȱthatȱtheȱbenefitsȱofȱtheȱinterventionsȱexploredȱinȱthisȱthesisȱ areȱnotȱrestrictedȱtoȱtheȱsimpleȱreductionȱofȱdrugȬrelatedȱstreetȱdisorderȱbutȱalsoȱincludeȱ importantȱhealthȱbenefitsȱforȱvulnerableȱdrugȱuserȱpopulations.ȱThereȱisȱaȱvastȱscientificȱ literatureȱdocumentingȱtheȱmanyȱadvantagesȱthatȱsupportiveȱhousingȱoffersȱvulnerableȱ populations.251,ȱ252,ȱ254,ȱ261,ȱ262ȱEmploymentȱisȱsimilarlyȱlinkedȱwithȱaȱbroadȱrangeȱofȱsocialȱ andȱ healthȱ benefits,170,ȱ 172,ȱ 173ȱ andȱ theȱ opportunitiesȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ createȱ forȱ healthȱ careȱ providersȱ toȱ engageȱ withȱ highȱ riskȱ drugȱ usingȱ populationsȱandȱ linkȱthemȱwithȱhealthȱandȱsocialȱservicesȱareȱalsoȱwellȱdocumented.21ȱ Basedȱonȱtheȱfindingsȱofȱthisȱthesisȱandȱexistingȱpublicȱhealthȱresearch,ȱitȱisȱevidentȱthatȱ theȱ foundationȱ ofȱ ourȱ approachȱ toȱ drugȬrelatedȱ streetȱ disorderȱ shouldȱ involveȱ implementingȱ interventionsȱ thatȱbothȱpromoteȱpublicȱhealthȱobjectivesȱandȱ supportȱaȱ reductionȱ inȱdrugȬrelatedȱ streetȱdisorderȱ byȱ alteringȱ structuralȱ factorsȱ thatȱ shapeȱ theȱ behaviourȱofȱstreetȬbasedȱdrugȱusers.ȱȱ ȱȱ 145 8.3.2 MacroȱLevelȱRecommendationsȱandȱImplicationsȱ Atȱ theȱmacroȱ level,ȱ thisȱ thesisȱ isȱconsistentȱwithȱ theȱgrowingȱrecognitionȱofȱ theȱ needȱforȱaȱparadigmȱshiftȱinȱallȱareasȱofȱillicitȱdrugȱpolicy.292Ȭ296ȱTheȱevidenceȱlinkingȱtheȱ criminalizationȱofȱ illicitȱdrugȱusersȱwithȱ theȱHIVȱepidemicȱandȱaȱwideȱ rangeȱofȱotherȱ devastatingȱhealthȱandȱsocialȱharmsȱisȱnowȱexpansive.71,ȱ113,ȱ292,ȱ296,ȱ297ȱRecognizingȱthatȱlawȱ enforcementȱapproachesȱhaveȱfailedȱtoȱcontrolȱproblematicȱdrugȱuseȱandȱareȱcurrentlyȱ resultingȱinȱsubstantialȱharms,ȱleadingȱscientistsȱinȱtheȱareasȱofȱpublicȱhealthȱandȱpublicȱ policyȱ haveȱ comeȱ togetherȱ andȱ formedȱ aȱ consensusȱ statementȱ onȱ theȱ needȱ toȱmoveȱ awayȱfromȱtheȱcriminalizationȱofȱillicitȱdrugȱusers.293ȱThisȱpositionȱisȱarticulatedȱinȱtheȱ ViennaȱDeclaration,ȱwhichȱwasȱtheȱofficialȱdeclarationȱofȱtheȱInternationalȱAIDSȱSocietyȱ Conferenceȱ inȱ 2010,ȱ andȱ supportsȱ aȱ policyȱ refocusȱ towardsȱ theȱ adoptionȱ ofȱ scienceȬ basedȱdrugȱpoliciesȱthatȱdoȱnotȱundermineȱpublicȱhealth.298ȱThisȱpolicyȱreorientationȱisȱ analogousȱ toȱ whatȱ willȱ beȱ requiredȱ toȱ successfullyȱ respondȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱȱ Aȱ policyȱ reorientationȱ towardsȱ evidenceȬbasedȱ interventions,ȱ whetherȱ itȱ beȱ specificȱ toȱ drugȬrelatedȱ streetȱ disorderȱ orȱ drugȱ policyȱmoreȱ generally,ȱ willȱ requireȱ extensiveȱpolicyȱmonitoringȱandȱevaluationȱandȱsignificantȱchangesȱinȱtheȱallocationȱofȱ drugȱpolicyȱ funding.ȱDrugȱpolicyȱ fundingȱmustȱ beȱdirectedȱ towardsȱ evidenceȬbasedȱ policiesȱwhileȱinterventionsȱthatȱhaveȱbeenȱshownȱtoȱbeȱharmfulȱandȱineffectiveȱshouldȱ noȱlongerȱreceiveȱpublicȱsupport.ȱȱMoreȱspecifically,ȱconsiderationȱmustȱbeȱgivenȱtoȱtheȱ individual,ȱ communityȱ andȱ globalȬlevelȱ impactsȱ ofȱ policyȱ interventions,ȱ andȱ theȱ ȱȱ 146 potentialȱharmsȱandȱunintendedȱ consequencesȱofȱpolicyȱdecisionsȱmustȱbeȱ integratedȱ intoȱ theȱ evaluationȱ ofȱ policiesȱ andȱ centralȱ inȱ fundingȱ allocationȱ decisions.ȱMakingȱ publicȱhealthȱ aȱ cornerstoneȱ ofȱdrugȱpolicyȱdevelopmentȱ andȱ evaluationȱmayȱhelpȱ toȱ ensureȱthatȱseriousȱnegativeȱpublicȱhealthȱimpactsȱareȱnotȱoverlooked.ȱȱ 8.4 FutureȱResearchȱ Theȱ managementȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ willȱ benefitȱ fromȱ furtherȱ researchȱ inȱ aȱ numberȱ ofȱ areas.ȱ Firstly,ȱ althoughȱ thisȱ thesisȱ providesȱ compellingȱ evidenceȱtoȱpursueȱthreeȱtypesȱofȱpolicyȱinterventions,ȱestablishingȱanȱevidenceȬbaseȱforȱ otherȱunderexploredȱ innovativeȱ interventionsȱ thatȱmeetȱbothȱpublicȱhealthȱandȱpublicȱ orderȱ objectivesȱwouldȱ beȱ beneficial.ȱ Theȱ riskȱ environmentȱ frameworkȱ suggestsȱ thatȱ thereȱareȱpolicyȱleversȱinȱtheȱphysical,ȱsocial,ȱeconomicȱandȱpolicyȱenvironmentsȱatȱbothȱ theȱmicroȱandȱmacroȱlevel.ȱIdentifyingȱandȱevaluatingȱtheȱimpactȱofȱinterventionsȱinȱallȱ theseȱ areasȱ onȱ drugȬrelatedȱ streetȱ disorderȱwouldȱ increaseȱ theȱ potentialȱ policyȱ toolsȱ availableȱ toȱ respondȱ toȱ streetȱ disorderȱ andȱ improveȱ outcomesȱ inȱ thisȱ area.ȱ Atȱ theȱ physicalȱ microȬenvironmentalȱ level,ȱ randomizedȱ controlȱ trialsȱ offerȱ importantȱ opportunitiesȱ toȱ evaluateȱ theȱ impactsȱ ofȱ novelȱ housingȱ interventions,ȱ asȱ doȱ observationalȱ studiesȱ ofȱ theȱ impactȱ ofȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ onȱ aȱ rangeȱ ofȱ outcomes,ȱ includingȱ drugȬrelatedȱ streetȱ disorder.ȱ Atȱ theȱ socialȱ microȬ environmentalȱlevelȱthereȱareȱopportunitiesȱtoȱimplementȱandȱevaluateȱtheȱpotentialȱforȱ peerȬbasedȱ interventionsȱ toȱ supportȱ reductionsȱ inȱ engagementȱ inȱ drugȬrelatedȱ streetȱ ȱȱ 147 disorder.ȱ Creatingȱ trainingȱ programsȱ forȱ policeȱ toȱ educateȱ themȱ aboutȱ theȱ harmfulȱ impactsȱ associatedȱwithȱ lawȱ enforcementȱ basedȱ approachesȱ isȱ anotherȱ typeȱ ofȱ socialȱ microȬenvironmentalȱ interventionȱ thatȱmightȱ haveȱ anȱ impactȱ onȱ drugȬrelatedȱ streetȱ disorderȱandȱshouldȱbeȱ theȱsubjectȱofȱ furtherȱprocessȱandȱoutcomeȱevaluation.ȱAtȱ theȱ macroȱlevel,ȱsocialȱinterventionsȱthatȱwarrantȱexplorationȱincludeȱusingȱtheȱmediaȱandȱ socialȱmarketingȱ toȱ educateȱ theȱ publicȱ aboutȱ factorsȱ thatȱ contributeȱ toȱ drugȬrelatedȱ streetȱdisorderȱandȱtheȱimportanceȱofȱimplementedȱresponsesȱthatȱaddressȱbothȱpublicȱ healthȱandȱpublicȱorderȱobjectives.ȱȱ Furtherȱstudiesȱcouldȱalsoȱbeȱconductedȱtoȱevaluateȱtheȱpotentialȱforȱpolicyȱlevelȱ macroȬenvironmentalȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder.ȱ Inȱ particular,ȱ studyingȱ howȱ reformingȱ lawsȱ andȱ policiesȱ thatȱ governȱ drugȱ useȱ mightȱ impactȱdrugȬrelatedȱstreetȱdisorderȱandȱassociatedȱharmsȱappearsȱ toȱbeȱaȱparticularlyȱ importantȱareaȱforȱfurtherȱresearch.ȱSimilarly,ȱecologicalȱstudiesȱexaminingȱassociationsȱ betweenȱdrugȱpolicyȱfundingȱallocationȱandȱdrugȱpolicyȱoutcomesȱwouldȱcontributeȱtoȱ ourȱunderstandingȱofȱhowȱweȱmightȱbetterȱmanageȱdrugȬrelatedȱstreetȱdisorder.ȱ Anotherȱ importantȱ areaȱ ofȱ furtherȱ researchȱ isȱ toȱ identifyȱ complementaryȱ interventionsȱandȱ theȱpotentialȱ forȱsynergiesȱamongȱmultipleȱ interventionsȱ toȱaddressȱ streetȱ disorder.ȱ Forȱ instance,ȱ integratingȱ microȱ andȱ macroȱ levelȱ interventionsȱ orȱ combiningȱmultipleȱ interventionsȱ inȱanyȱoneȱ levelȱorȱareaȱmayȱcreateȱaȱmultiplicativeȱ effectȱ thatȱ couldȱ maximizeȱ theȱ impactsȱ ofȱ policyȱ responses.ȱ Itȱ wouldȱ beȱ equallyȱ ȱȱ 148 importantȱ toȱdetermineȱ ifȱ certainȱ conditionsȱ areȱ requiredȱ inȱ orderȱ forȱ someȱ typesȱ ofȱ interventionsȱ toȱ beȱ effective.ȱ Forȱ instance,ȱ initiatingȱ policeȱ andȱ publicȱ healthȱ partnershipsȱ thatȱeducateȱpoliceȱaboutȱ theȱdynamicsȱofȱstreetȱdisorderȱandȱ theȱhealthȱ harmsȱresultingȱfromȱpolicingȱpracticesȱinȱthisȱareaȱmayȱcreateȱaȱdesireȱamongȱpoliceȱtoȱ changeȱhowȱtheyȱrespondȱtoȱindividualsȱwhoȱareȱgeneratingȱstreetȱdisorder.ȱHowever,ȱ ifȱ alternativeȱ mechanismsȱ toȱ manageȱ streetȱ disorderȱ areȱ notȱ simultaneouslyȱ implementedȱpoliceȱmayȱbeȱunableȱ toȱmodifyȱ theirȱpractices.ȱSimilarly,ȱestablishingȱaȱ supervisedȱ inhalationȱ facilityȱmayȱprovideȱ alternativeȱ locationsȱ forȱ streetȬbasedȱdrugȱ usersȱtoȱconsumeȱdrugs;ȱhowever,ȱifȱlocalȱpoliceȱareȱnotȱsupportiveȱofȱtheȱintervention,ȱ streetȬbasedȱdrugȱusersȱmayȱnotȱfeelȱsafeȱvisitingȱtheȱfacilityȱandȱtheȱpotentialȱbenefitsȱ ofȱ theȱ interventionȱ couldȱ beȱ lost.ȱConversely,ȱ ifȱ aȱ supervisedȱ inhalationȱ facilityȱwasȱ implementedȱinȱconjunctionȱwithȱeffortsȱtoȱbuildȱpoliceȱandȱpublicȱhealthȱpartnerships,ȱ theȱ twoȱ interventionsȱ couldȱ complementȱandȱ supportȱ eachȱotherȱandȱ theirȱ combinedȱ benefitsȱ couldȱ beȱ largerȱ thanȱ theirȱ individualȱ contributions.ȱ Identifyingȱwhereȱ theseȱ complementaryȱrelationshipsȱbetweenȱ interventionsȱexistȱandȱfactorsȱthatȱareȱrequiredȱ toȱsupportȱpotentialȱinterventionsȱisȱaȱkeyȱareaȱforȱfutureȱresearchȱ ȱInȱ addition,ȱ onceȱ additionalȱ interventionsȱ areȱ identified,ȱ furtherȱ researchȱ toȱ developȱ andȱ evaluateȱ theȱ impactsȱ ofȱ differentȱ interventionȱmodelsȱ onȱ specificȱ subȬ populationsȱofȱillicitȱdrugȱusersȱ(e.g.,ȱfemaleȱdrugȱusersȱandȱAboriginalȱpeopleȱwhoȱuseȱ drugs)ȱ couldȱ helpȱ tailorȱ interventionsȱ toȱ meetȱ theȱ needsȱ ofȱ particularlyȱ vulnerableȱ streetȬinvolvedȱdrugȱusersȱandȱshouldȱbeȱanotherȱareaȱforȱfutureȱresearch.ȱȱȱ ȱȱ 149 8.5 Conclusionsȱ Thisȱ thesisȱ hasȱ shownȱ thatȱ drugȬrelatedȱ streetȱ disorderȱ isȱ aȱ seriousȱ policyȱ problemȱwithȱpublicȱhealthȱ implicationsȱ forȱstreetȬbasedȱdrugȱusers.ȱResearchȱ toȱdateȱ indicatesȱ thatȱcurrentȱpolicyȱresponsesȱ toȱstreetȱdisorderȱhaveȱbeenȱdominatedȱbyȱ lawȱ enforcementȱbasedȱapproachesȱthatȱareȱassociatedȱwithȱaȱrangeȱofȱnegativeȱunintendedȱ consequences.270ȱTheȱevidenceȱemergingȱ fromȱ thisȱ thesisȱ suggestsȱ thatȱ thereȱ isȱaȱhighȱ degreeȱ ofȱwillingnessȱ amongȱ localȱ IDUȱ toȱ reduceȱ engagementȱ inȱ drugȬrelatedȱ streetȱ disorderȱ ifȱ givenȱ otherȱ optionsȱ inȱ theȱ areasȱ ofȱ housing,ȱ employmentȱ andȱ drugȱ consumptionȱlocations.ȱSpecifically,ȱ65%ȱofȱparticipantsȱthatȱreportedȱsocializingȱinȱtheȱ openȱdrugȱsceneȱwereȱwillingȱtoȱrelocateȱifȱgivenȱaccessȱtoȱmoreȱprivateȱspace;ȱ47%ȱofȱ participantsȱwhoȱ engagedȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱwereȱwillingȱ toȱ forgoȱthoseȱincomeȱsourcesȱifȱgivenȱlowȬthresholdȱemployment;ȱandȱ71%ȱofȱparticipantsȱ whoȱreportedȱsmokingȱcrackȱcocaineȱ inȱpublicȱareasȱwereȱwillingȱ toȱuseȱaȱsupervisedȱ inhalationȱ facility.ȱ Togetherȱ theseȱ findingsȱ provideȱ strongȱ evidenceȱ toȱ suggestȱ thatȱ structuralȱ andȱ environmentalȱ interventions,ȱ consistentȱ withȱ theȱ riskȱ environmentȱ framework,ȱ couldȱhaveȱaȱ significantȱpositiveȱ impactȱonȱ theȱ reductionȱofȱdrugȬrelatedȱ streetȱdisorder.ȱȱȱ Inȱsum,ȱstreetȱdisorderȱremainsȱaȱsignificantȱandȱunderȬaddressedȱproblemȱwithȱ farȬreachingȱ implicationsȱ forȱ publicȱ healthȱ andȱ publicȱ order.ȱ However,ȱ theȱ dataȱ presentedȱhereinȱrevealȱthatȱnovelȱsolutionsȱthatȱsimultaneouslyȱaddressȱpublicȱhealthȱ andȱpublicȱorderȱ challengesȱ arisingȱ fromȱ streetȱdisorderȱ areȱwithinȱ reach.ȱ Ifȱdecisiveȱ ȱȱ 150 effortsȱ areȱmadeȱbyȱpolicyȬmakersȱ toȱ shiftȱ theȱ focusȱofȱourȱ approachȱ toȱdrugȬrelatedȱ streetȱ disorderȱ towardsȱ theseȱ evidenceȬbasedȱ interventionsȱ weȱ canȱ expectȱ toȱ seeȱ significantȱ improvementsȱ inȱ theȱ healthȱ andȱ socialȱ conditionsȱ ofȱ streetȬinvolvedȱ drugȱ users,ȱasȱwellȱasȱmeaningfulȱandȱlastingȱreductionsȱinȱdrugȬrelatedȱstreetȱdisorder.ȱ .ȱ ȱREFERENCESȱ ȱ 1.ȱSampsonȱRJ,ȱRaudenbushȱSW.ȱSystematicȱsocialȱobservationȱofȱpublicȱspaces:ȱAȱnewȱ lookȱatȱdisorderȱinȱurbanȱneighborhoods.ȱAm.ȱJ.ȱSociol.ȱ1999;105:603Ȭ651.ȱȱ 2.ȱScottȱMS.ȱPanhandling.ȱUSȱDept.ȱofȱ 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