UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Policing and public health : experiences of people who inject drugs in Bangkok, Thailand Hayashi, Kanna 2013

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
24-ubc_2013_fall_hayashi_kanna.pdf [ 1.8MB ]
Metadata
JSON: 24-1.0074103.json
JSON-LD: 24-1.0074103-ld.json
RDF/XML (Pretty): 24-1.0074103-rdf.xml
RDF/JSON: 24-1.0074103-rdf.json
Turtle: 24-1.0074103-turtle.txt
N-Triples: 24-1.0074103-rdf-ntriples.txt
Original Record: 24-1.0074103-source.json
Full Text
24-1.0074103-fulltext.txt
Citation
24-1.0074103.ris

Full Text

 POLICING ?AND ?PUBLIC ?HEALTH: ?EXPERIENCES ?OF ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ? ? by ? ?KANNA ?HAYASHI ?B.A., ?Tokyo ?University ?of ?Foreign ?Studies, ?2002 ?M.P.H., ?Columbia ?University, ?2009 ?M.I.A., ?Columbia ?University, ?2009 ? ?  ?A ?THESIS ?SUBMITTED ?IN ?PARTIAL ?FULFILLMENT ?OF ?THE ?REQUIREMENTS ?FOR ?THE ?DEGREE ?OF ?DOCTOR ?OF ?PHILOSOPHY ?in ?THE ?FACULTY ?OF ?GRADUATE ?STUDIES ?(Interdisciplinary ?Studies) ? ?THE ?UNIVERSITY ?OF ?BRITISH ?COLUMBIA ?(Vancouver) ? ?August ?2013 ?? ?Kanna ?Hayashi, ?2013 ? ?  ? ? ii ?ABSTRACT ? ?Background: ? In ?recent ?years, ?Thailand ?has ? intensified ?policing ?efforts ?as ?a ?strategy ?to ? address ? a ? continuing ? epidemic ? of ? illicit ? drug ? use. ? Thailand?s ?war on drugs? campaign of 2003 received international criticism due to extensive human rights violations. However, ? few ? studies ? have ? since ? investigated ? the ? impacts ? of ? drug ?policing ? on ? people ? who ? inject ? drugs ? (IDU) ? in ? this ? setting. ? Drawing ? on ? the ? Risk ?Environment ? Framework, ? this ? dissertation ? sought ? to: ? explore ? IDUs? ? lived ?experiences ? with ? police; ? identify ? the ? prevalence ? and ? correlates ? of ? experiencing ?beatings ?and ?drug ?testing ?by ?police; ?examine ?the ?relationship ?between ?exposures ?to ?policing ?and ?syringe ? sharing; ?and ?assess ? changes ? in ? the ?availability ?of ? illicit ?drugs ?among ?IDU ?in ?Bangkok, ?Thailand. ?Methods: ?Between ?June ?2009 ?and ?June ?2012, ?a ?community-???recruited ?sample ?of ?IDU ?in ? Bangkok ? participated ? in ? a ? serial ? cross-???sectional ? mixed-???methods ? study ? and ?completed ? interviewer-???administered ? questionnaires ? and ? semi-???structured ? in-???depth ?interviews. ? Audio-???recorded ? interviews ? were ? transcribed ? verbatim ? and ? a ? thematic ?analysis ?was ?conducted ?to ?document ?the ?character ?of ?IDUs? ?encounters ?with ?police. ?A ?variety ?of ?multivariate ?regression ?techniques ?were ?used ?to ?estimate ?independent ?relationships ?between ?exposures ?to ?specific ?policing ?tactics ?and ?indicators ?of ?drug-???related ?harm, ?as ?well ? as ? to ? examine ?a ? temporal ? trend ?of ? street-???level ? availability ?of ?illicit ?drugs. ? ?Results: ?Respondents? ? narratives ? indicated ? that ? drug ? policing ? involved ? numerous ?forms ? of ? human ? rights ? infringements ? and ? negatively ? influenced ? healthcare ? access ?among ? IDU ? in ? Bangkok. ? Reports ? of ? beatings ? and ? drug ? testing ? by ? police ? were ?common ? (38% ? and ? 67%, ? respectively) ? and ? were ? independently ? associated ? with ?various ? indicators ?of ?drug-???related ?harm, ? including ? syringe ? sharing ?and ?barriers ? to ? ? iii ?healthcare. ? Street-???level ? availability ? of ? illicit ? drugs ? increased ? significantly ? between ?2009 ?and ?2011. ?Conclusions: ? The ? findings ? indicate ? that ? the ? over-???reliance ? on ? repressive ? drug ?policing ? is ? not ? suppressing ? the ? illegal ? drug ?market ? and ? is ? instead ? contributing ? to ?police-???perpetrated ? abuses, ? the ? perpetuation ? of ? risky ? injection ? behaviour, ? and ? an ?impediment ? to ? healthcare ? among ? IDU ? in ? Bangkok. ? These ? findings ? raise ? concern ?about ? the ? ongoing ? policing ? practices ? and ? point ? to ? the ? need ? for ? providing ? greater ?police ?oversight, ?as ?well ?as ?a ?shift ?toward ?more ?balanced ?approaches ?to ?drug ?control ?in ?this ?setting. ? ?  ? ? ? ? ?  ? ? iv ?PREFACE ?This ? statement ? certifies ? that ? all ? of ? the ? work ? presented ? henceforth ? was ?conceived, ? undertaken, ? and ? written ? by ? the ? author, ? Kanna ? Hayashi ? (KH). ? All ?empirical ? research ? conducted ? for ? this ? dissertation ? was ? approved ? by ? the ? research ?ethics ? boards ? at ? Chulalongkorn ? University ? (certificate ? COA ? 085/2009 ? and ? COA ?093/2011) ?and ?the ?University ?of ?British ?Columbia/Providence ?Health ?Care ?(certificate ?H08-???00702 ? and ? H11-???00581). ? The ? co-???authors ? of ? the ? manuscripts, ? including ? Dr. ?Thomas ?Kerr ?(TK), ?Dr. ?Jane ?Buxton ?(JB), ?Dr. ?Joanne ?Csete ?(JC), ?Dr. ?Evan ?Wood ?(EW), ?Ms. ?Karyn ?Kaplan ?(KK), ?Mr. ?Paisan ?Suwannawong ?(PS), ?Ms. ?Lianping ?Ti ? (LT), ?Dr. ?Bohdan ? Nosyk ? (BN), ? Dr. ? Will ? Small ? (WS), ? and ? Ms. ? Sattara ? Hattirat ? (SH) ? made ?contributions ?only ?as ?is ?commensurate ?with ?supervisory ?committee, ?collegial, ?or ?co-???investigator ?duties. ? The ?principal ? investigator ? (TK) ? of ? the ?Mitsampan ?Community ?Research ?Project, ?from ?which ?all ?empirical ?analyses ?were ?derived, ?has ?access ?to ?all ?of ?the ?data ?and ?as ?corresponding ?author ?takes ?full ?responsibility ?for ?the ?integrity ?of ?the ?results ? and ? the ? accuracy ? of ? the ? analyses. ? Relative ? contributions ? of ? the ? author, ?collaborators, ?and ?co-???authors ?are ?described ?in ?detail ?below. ?Chapters ? 1, ? 2, ? and ? 8 ? are ? original, ? unpublished ? intellectual ? products ? of ? the ?author. ?With ?substantive ?guidance ?and ?input ?from ?co-???supervisors ?(TK ?and ?JB) ?and ?a ?supervisory ?committee ?member ?(JC), ?KH ?searched ?and ?reviewed ?all ?of ?the ?literature ?presented, ?designed ?the ?research, ?and ?synthesized ?the ?findings ?of ?all ?chapters. ?A ? version ? of ? Chapter ? 3 ? is ? currently ? under ? review ? for ? peer-???reviewed ?publication: ?Hayashi ?K, ?Small ?W, ?Csete ?J, ?Hattirat ?S, ?Kerr ?T. ??Help ?with ?the ?nation?: ?a ? qualitative ? study ? of ? experiences ? with ? drug ? policing ? among ? people ? who ? inject ?drugs ?in ?Bangkok, ?Thailand. ?WS, ?TK, ?and ?KH ?designed ?the ?study ?and ?trained ?two ?interviewers. ? KH ? oversaw ? the ? data ? collection ? process, ? managed ? the ? data, ? took ? a ?primary ?role ? in ?analyzing ? the ?data, ?and ?prepared ? the ? first ?draft ?of ? the ?manuscript. ? ? ? v ?WS, ?TK, ?JC, ?and ?SH ?provided ?input ?to ?the ?draft ?and ?contributed ?to ?the ?revision ?of ?the ?manuscript. ? ? ? ?A ?version ?of ?Chapter ?4 ?has ?been ?published: ?Hayashi ?K, ?Ti ?L, ?Csete ?J, ?Kaplan ?K, ?Suwannawong ?P, ?Wood ?E, ?Kerr ?T. ?Reports ?of ?police ?beating ?and ?associated ?harms ?among ?people ?who ?inject ?drugs ?in ?Bangkok, ?Thailand: ?a ?serial ?cross-???sectional ?study. ?BMC ? Public ? Health. ? 2013;13(1):733. ? TK ? and ? KH ? designed ? the ? study. ? KH ? trained ?interviewers, ?oversaw ?the ?data ?collection ?process, ?managed ?the ?data, ?conducted ?the ?statistical ?analyses, ?and ?prepared ? the ? first ?draft ?of ? the ?manuscript. ?LT, ? JC, ?KK, ?PS, ?EW, ? and ? TK ? provided ? input ? to ? the ? draft ? and ? contributed ? to ? the ? revision ? of ? the ?manuscript. ? ?A ? version ? of ? Chapter ? 5 ? is ? currently ? under ? review ? for ? peer-???reviewed ?publication: ?Hayashi ?K, ?Ti ?L, ?Buxton ?J, ?Kaplan ?K, ?Suwannawong ?P, ?Wood ?E, ?Kerr ?T. ?Experienced ?with ? urine ? drug ? testing ? by ? police ? among ?people ?who ? inject ? drugs ? in ?Bangkok, ? Thailand. ? TK ? and ? KH ? designed ? the ? study. ? KH ? trained ? interviewers, ?oversaw ? the ? data ? collection ? process, ? managed ? the ? data, ? conducted ? the ? statistical ?analyses, ?and ?prepared ?the ?first ?draft ?of ?the ?manuscript. ?LT, ?JB, ?KK, ?PS, ?EW, ?and ?TK ?provided ?input ?to ?the ?draft ?and ?contributed ?to ?the ?revision ?of ?the ?manuscript. ?A ? version ? of ? Chapter ? 6 ? has ? been ? published ? and ? is ? reused ? here ? with ? kind ?permission ? from ?Springer ?Science ?and ?Business ?Media: ?Hayashi ?K, ?Ti ?L, ?Buxton ? J, ?Kaplan ?K, ?Suwannawong ?P, ?Kerr ?T. ?The ?effect ?of ?exposures ? to ?policing ?on ?syringe ?sharing ? among ?people ?who ? inject ?drugs ? in ?Bangkok, ?Thailand. ?AIDS ?and ?Behavior, ?2013 ? Jun ? 25. ? [Epub ? ahead ? of ? print]. ? TK ? and ? KH ? designed ? the ? study. ? KH ? trained ?interviewers, ?oversaw ?the ?data ?collection ?process, ?managed ?the ?data, ?conducted ?the ?statistical ? analyses, ? and ?prepared ? the ? first ?draft ?of ? the ?manuscript. ?LT, ? JB, ?KK, ?PS, ?and ? TK ? provided ? input ? to ? the ? draft ? and ? contributed ? to ? the ? revision ? of ? the ?manuscript. ? ? vi ?A ? version ? of ? Chapter ? 7 ? has ? been ? published ? and ? is ? reused ? here ? with ? kind ?permission ? from ?Elsevier: ?Hayashi ?K, ?Nosyk ?B, ? Ti ? L, ? Suwannawong ?P, ?Kaplan ?K, ?Wood ? E, ? Kerr ? T. ? Increasing ? availability ? of ? illicit ? drugs ? among ? people ? who ? inject ?drugs ?in ?Bangkok, ?Thailand. ?Drug ?and ?Alcohol ?Dependence. ?2013;132(1-???2):251-???256. ?BN, ?TK, ? and ? KH ? designed ? the ? study. ? KH ? trained ? interviewers, ? oversaw ? the ? data ?collection ? process, ? managed ? the ? data, ? conducted ? the ? statistical ? analyses, ? and ?prepared ? the ? first ?draft ?of ? the ?manuscript. ?BN, ?LT, ?PS, ?KK, ?EW, ?and ?TK ?provided ?input ? to ? the ?draft ? and ? contributed ? to ? the ? revision ?of ? the ?manuscript. ? The ?material ?presented ? in ? this ?dissertation ?was ?prepared ?by ?KH, ? following ? comments ? from ? the ?journal ?editor ?and ?external ?peer ?reviewers. ? ? ?  ? ? vii ?Table ?of ?Contents ?ABSTRACT ?............................................................................................................................ ?ii	 ?PREFACE ?............................................................................................................................... ?iv	 ?TABLE ?OF ?CONTENTS ?................................................................................................... ?vii	 ?LIST ?OF ?TABLES ?.................................................................................................................. ?x	 ?LIST ?OF ?FIGURES ?............................................................................................................... ?xi	 ?LIST ?OF ?ABBREVIATIONS ?............................................................................................. ?xii	 ?ACKNOWLEDGEMENTS ?.............................................................................................. ?xiii	 ?CHAPTER ?1: ?INTRODUCTION ?........................................................................................ ?1	 ?1.1 ?Global ?Response ?to ?Illicit ?Drug ?Use ?....................................................................... ?1	 ?1.2 ?Study ?Setting ?............................................................................................................... ?2	 ?1.3 ?Study ?Justification ?...................................................................................................... ?6	 ?1.4 ?Conceptual ?Framework ?.............................................................................................. ?7	 ?1.5 ?Study ?Objectives ?......................................................................................................... ?9	 ?1.6 ?Study ?Design ?............................................................................................................. ?12	 ?1.6.1 ?Mitsampan ?Community ?Research ?Project ?....................................................... ?12	 ?1.6.2 ?Quantitative ?data ?collection ?.............................................................................. ?14	 ?1.6.3 ?Qualitative ?data ?collection ?................................................................................. ?15	 ?1.7 ?Summary ?..................................................................................................................... ?16	 ?CHAPTER ?2: ?LITERATURE ?REVIEW: ?THE ?IMPACTS ?OF ?DRUG ?POLICING ?ON ?RISK ?ENVIRONMENTS ?AND ?HEALTH-???RELATED ?HARM ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?...................................................................................................... ?19	 ?2.1 ?Introduction ?............................................................................................................... ?19	 ?2.2 ?Methods ?...................................................................................................................... ?20	 ?2.3 ?Results ?......................................................................................................................... ?21	 ?2.3.1 ?Street-???level ?drug ?policing ?.................................................................................. ?21	 ?2.3.2 ?Individual-???level ?impacts ?of ?direct ?encounters ?with ?police ?........................... ?22	 ?2.3.3 ?Impacts ?through ?the ?micro-???level ?social ?and ?physical ?environment ?............ ?24	 ?2.3.4 ?Impacts ?through ?the ?meso-???level ?social ?and ?physical ?environment ?............. ?27	 ?2.3.5 ?Impacts ?through ?macro-???level ?structures ?......................................................... ?30	 ?2.3.6 ?Interventions ?to ?mitigate ?the ?adverse ?impacts ?of ?drug ?policing ?.................. ?31	 ?2.4 ?Discussion ?.................................................................................................................. ?35	 ?CHAPTER ?3: ??HELP ?WITH ?THE ?NATION?: ?EXPERIENCES ?WITH ?DRUG ?POLICING ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?......................................................................................................................... ?39	 ? ? viii ?3.1 ?Introduction ?............................................................................................................... ?39	 ?3.2 ?Methods ?...................................................................................................................... ?40	 ?3.3 ?Results ?......................................................................................................................... ?43	 ?3.3.1 ?Circumstances ?of ?police ?confrontations ?.......................................................... ?44	 ?3.3.2 ?Police ?violence ?and ?misconduct ?........................................................................ ?49	 ?3.3.3 ?IDUs? ?reactions ?to ?drug ?policing ?practices ?...................................................... ?51	 ?3.4 ?Discussion ?.................................................................................................................. ?55	 ?CHAPTER ?4: ?REPORTS ?OF ?POLICE ?BEATING ?AND ?ASSOCIATED ?HARMS ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?.............. ?64	 ?4.1 ?Introduction ?............................................................................................................... ?64	 ?4.2 ?Methods ?...................................................................................................................... ?65	 ?4.3 ?Results ?......................................................................................................................... ?67	 ?4.4 ?Discussion ?.................................................................................................................. ?68	 ?CHAPTER ?5: ?EXPERIENCES ?WITH ?URINE ?DRUG ?TESTING ?BY ?POLICE ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?.............. ?76	 ?5.1 ?Introduction ?............................................................................................................... ?76	 ?5.2 ?Methods ?...................................................................................................................... ?76	 ?5.3 ?Results ?......................................................................................................................... ?78	 ?5.4 ?Discussion ?.................................................................................................................. ?79	 ?CHAPTER ?6: ?THE ?RELATIONSHIP ?BETWEEN ?EXPOSURES ?TO ?POLICING ?AND ?SYRINGE ?SHARING ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?.................................................................................................. ?86	 ?6.1 ?Introduction ?............................................................................................................... ?86	 ?6.2 ?Methods ?...................................................................................................................... ?87	 ?6.3 ?Results ?......................................................................................................................... ?90	 ?6.4 ?Discussion ?.................................................................................................................. ?92	 ?CHAPTER ?7: ?INCREASING ?AVAILABILITY ?OF ?ILLICIT ?DRUGS ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?.............................. ?101	 ?7.1 ?Introduction ?............................................................................................................. ?101	 ?7.2 ?Methods ?.................................................................................................................... ?102	 ?7.3 ?Results ?....................................................................................................................... ?105	 ?7.3.1 ?Summary ?statistics ?............................................................................................ ?105	 ?7.3.2 ?Univariate ?trends ?in ?availability ?..................................................................... ?106	 ?7.3.3 ?Multivariate ?analyses ?....................................................................................... ?106	 ?7.3.4 ?Sub-???analysis ?....................................................................................................... ?107	 ?7.4 ?Discussion ?................................................................................................................ ?108	 ?CHAPTER ?8: ?CONCLUSION ?......................................................................................... ?118	 ?8.1 ?Summary ?of ?Findings ?............................................................................................. ?118	 ? ? ix ?8.2 ?Human ?Rights ?Implications ?................................................................................. ?122	 ?8.3 ?Study ?Strengths ?and ?Unique ?Contributions ?..................................................... ?125	 ?8.4 ?Limitations ?............................................................................................................... ?128	 ?8.5 ?Recommendations ?.................................................................................................. ?129	 ?8.6 ?Future ?Research ?....................................................................................................... ?132	 ?8.7 ?Conclusion ?............................................................................................................... ?133	 ?REFERENCES ?.................................................................................................................... ?135	 ? ? ?  ? ? x ?LIST ?OF ?TABLES ?Table ?1: ?Characteristics ?of ?42 ?IDU ?in ?Bangkok, ?Thailand, ?participating ?in ?the ?qualitative ?arm ?of ?the ?Mitsampan ?Community ?Research ?Project ?between ?July ?2011 ?and ?June ?2012 ?....................................................................................................... ?63	 ?Table ?2: ?Bivariate ?analyses ?of ?factors ?associated ?with ?reports ?of ?police ?beatings ?among ?639 ?IDU ?in ?Bangkok, ?Thailand ?..................................................................... ?73	 ?Table ?3: ?Multivariate ?log-???binomial ?regression ?analysis ?of ?factors ?associated ?with ?reports ?of ?police ?beatings ?among ?639 ?IDU ?in ?Bangkok, ?Thailand ?........................ ?75	 ?Table ?4: ?Bivariate ?analyses ?of ?factors ?associated ?with ?experiencing ?drug ?testing ?by ?police ?among ?438 ?IDU ?in ?Bangkok, ?Thailand ?.......................................................... ?83	 ?Table ?5: ?Multivariate ?Poisson ?regression ?analysis ?of ?factors ?associated ?with ?experiencing ?drug ?testing ?by ?police ?among ?438 ?IDU ?in ?Bangkok, ?Thailand ?...... ?85	 ?Table ?6: ?Bivariate ?analyses ?of ?factors ?associated ?with ?syringe ?sharing ?in ?the ?past ?6 ?months ?among ?435 ?IDU ?in ?Bangkok, ?Thailand ?....................................................... ?97	 ?Table ?7: ?Multivariate ?log-???binomial ?regression ?analysis ?of ?factors ?associated ?with ?syringe ?sharing ?in ?the ?past ?6 ?months ?among ?435 ?IDU ?in ?Bangkok, ?Thailand ?.... ?99	 ?Table ?8: ?Characteristics ?of ?718 ?of ?IDU ?in ?Bangkok, ?Thailand, ?participating ?in ?the ?Mitsampan ?Community ?Research ?Project ?in ?2009 ?and ?2011 ?............................... ?113	 ?Table ?9: ?Multivariate ?analyses ?of ?factors ?associated ?with ?the ?availability ?of ?drugs ?among ?a ?community-???recruited ?sample ?of ?IDUs ?in ?Bangkok, ?Thailand ?............. ?114	 ?Table ?10: ?Modal ?retail ?price ?and ?unit ?of ?five ?substances ?reported ?by ?a ?community-???recruited ?sample ?of ?IDU ?in ?Bangkok, ?Thailand ?.................................................... ?116	 ? ?  ? ? xi ?LIST ?OF ?FIGURES ?Figure ?1: ?Conceptual ?framework ?....................................................................................... ?18	 ?Figure ?2: ?Adjusted ?prevalence ?ratios ?for ?syringe ?sharing ?in ?the ?past ?6 ?months ?by ?types ?of ?exposures ?to ?policing ?among ?435 ?IDU ?in ?Bangkok, ?Thailand ?.............. ?100	 ?Figure ?3: ?Distributions ?of ?immediate, ?moderate ?and ?delayed ?availability ?of ?five ?substances ?reported ?by ?IDU ?in ?Bangkok, ?Thailand ?.............................................. ?117	 ? ? ?  ? ? xii ?LIST ?OF ?ABBREVIATIONS ?AIC ? Akaike ?Information ?Criterion ?ART ? Antiretroviral ?therapy ?ASEAN ? The ?Association ?of ?Southeast ?Asian ?Nations ?ATS ? Amphetamine-???type ?stimulants ?CAT ? Convention ?against ?Torture ?and ?Other ?Cruel, ?Inhuman ?or ?Degrading ?Treatment ?or ?Punishment ?CESCR ? The ?Committee ?on ?Economic, ?Social ?and ?Cultural ?Rights ?GFATM ? Global ?Fund ?to ?Fight ?AIDS, ?Tuberculosis ?and ?Malaria ?HIV ? Human ?immunodeficiency ?virus ?  ?HCV ? Hepatitis ?C ?virus ?ICCPR ? International ?Covenant ?on ?Civil ?and ?Political ?Rights ?  ?ICESCR ? International ?Covenant ?on ?Economic, ?Social ?and ?Cultural ?Rights ?IDU ? People ?who ?inject ?drugs ?NSPs ? Needle ?and ?syringe ?programs ?ONCB ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand ?UDHR ? Universal ?Declaration ?of ?Human ?Rights ?UN ? The ?United ?Nations ?UNODC ? United ?Nations ?Office ?on ?Drugs ?and ?Crime ?WHO ? World ?Health ?Organization ? ? ?	 	  ?  ? ? xiii ?ACKNOWLEDGEMENTS ?I ? express ?my ?sincere ?gratitude ? to ?my ?co-???supervisors, ?Drs. ?Thomas ?Kerr ?and ?Jane ?Buxton, ?and ?to ?my ?supervisory ?committee ?member, ?Dr. ?Joanne ?Csete, ?for ?their ?constant ? support, ? guidance, ? and ? encouragement ? throughout ?my ?doctoral ? training. ?Their ? constructive ? comments ? and ? suggestions ? on ? the ? earlier ? versions ? of ? the ?dissertation ?were ?most ?helpful. ?In ?particular, ?I ?owe ?a ?great ?deal ?to ?Dr. ?Kerr, ?who ?has ?generously ? supported ? my ? involvement ? in ? the ? Mitsampan ? Community ? Research ?Project ?since ?before ?I ?commenced ?the ?doctoral ?program. ?His ?exceptional ?mentorship ?support ?has ?earned ?him ?my ?eternal ?gratitude. ?I ?am ?also ?deeply ?grateful ?to ?Dr. ?Evan ?Wood ?for ?the ?strong ?support ?and ?guidance ?that ?he ?has ?offered ?to ?me. ? ?I ?would ?like ?to ?extend ?my ?special ?appreciation ?to ?Mr. ?Paisan ?Suwannawong ?and ?Ms. ?Karyn ?Kaplan, ?who ?have ?been ?extraordinarily ?instrumental ?in ?the ?progress ?I ?have ?made ? in ?my ?work ?to ?date. ?They ?gave ?me ?countless ?moments ?of ? inspiration, ?which ?have ?been ?woven ?into ?much ?of ?my ?work. ?I ?would ?also ?like ?to ?acknowledge ?Dr. ?Niyada ? Kiatying-???Angsulee ? of ? the ? Social ? Research ? Institute, ? Chulalongkorn ?University ?for ?her ?assistance ?with ?developing ?this ?project. ?Particular ?thanks ?also ?go ?to ? two ? fabulous ? fellow ? research ? team ? members, ? Dr. ? Nadia ? Fairbairn ? and ? Ms. ?Lianping ? Ti. ? I ? would ? not ? have ? been ? able ? to ? complete ? the ? work ? without ? their ?intellectual, ?physical, ?and ?mental ?support. ?None ? of ? the ?work ? contained ? in ? this ? dissertation ?would ? have ? been ? possible ?without ? the ?contributions ?made ?by ? the ?people ?who ?participated ? in ? the ?Mitsampan ?Community ?Research ?Project. ?I ?extend ?a ?special ?acknowledgement ?and ?thanks ?to ?all ?who ?were ? courageous ?enough ? to ? share ? their ? experiences ?with ?me. ? I ?hope ? that ?our ?work ?will ?contribute ?to ?the ?development ?of ?evidence-???informed, ?human ?rights-???based ?drug ?policy ?in ?Thailand. ?In ?addition, ?I ?gratefully ?acknowledge ?a ?number ?of ?staff ?at ?the ? BC ? Centre ? for ? Excellence ? in ? HIV/AIDS, ? Mitsampan ? Harm ? Reduction ? Center, ? ? xiv ?Thai ? AIDS ? Treatment ?Action ?Group, ? and ?O-???Zone ?House ? for ? their ? assistance ?with ?data ? collection ? and ? management, ? especially ? Duangchai ? Amornkul, ? Arphatsaporn ?Chaimongkon, ? Amnat ? Chamchern, ? Wiwat ? Chotichatmala, ? Tricia ? Collingham, ?Khemaluck ?Deeprawat, ?Cameron ?Dilworth, ?Deborah ?Graham, ?Sabrina ?K. ?Gyorvary, ?Sattara ?Hattirat, ?Caitlin ? Johnston, ?Daniel ?Miles ?Kane, ?Orntima ?Kularb, ?Calvin ?Lai, ?Somkiat ?Meetham, ?Prempreeda ?Pramoj ?Na ?Ayutthaya, ?Puripakorn ?Pakdirat, ?Christy ?Power, ? Anusorn ? Quamman, ? Jirasak ? Sripramong, ? Vipawan ? Suwannawong, ? Pascal ?Tanguay, ?Kamon ?Uppakaew, ?and ?Peter ?Vann, ?as ?well ?as ?many ?peer ?researchers ?of ?the ?Mitsampan ?Community ?Research ?Project. ?I ? feel ? very ? lucky ? to ? have ? been ? able ? to ? work ? with ? an ? exceptional ? group ? of ?scientists, ? colleagues, ? and ? fellow ? graduate ? students ? at ? the ? University ? of ? British ?Columbia ?and ?the ?BC ?Centre ?for ?Excellence ?in ?HIV/AIDS. ?I ?would ?like ?to ?thank ?for ?the ? enduring ? support, ? advice, ? and ? encouragement ? they ? offered ? to ?me ? during ?my ?doctoral ?training: ?Mr. ?Cody ?Callon, ?Dr. ?Kora ?DeBeck, ?Ms. ?Danya ?Fast, ?Ms. ?Andrea ?Kru ?si, ? Dr. ? Brandon ? Marshall, ? Mr. ? Ryan ? McNeil, ? Dr. ? M-???J ? Milloy, ? Ms. ? Michaela ?Montaner, ?Dr. ?Bohdan ?Nosyk, ?Dr. ?Lindsey ?Richardson, ?Ms. ?Annick ?Simo, ?Dr. ?Will ?Small, ?Mr. ?Daniel ?Werb, ?and ?Ms. ?Wendy ?Zhang. ? ?Funding ? to ? support ? my ? doctoral ? training ? and ? dissertation ? research ? was ?generously ?provided ?by ?the ?University ?of ?British ?Columbia ?Doctoral ?Fellowship ?and ?the ? Ryoichi ? Sasakawa ? Young ? Leaders ? Fellowship ? Fund ? Research ? Abroad. ? I ? also ?thank ? the ? Urban ? Health ? Research ? Initiative ? at ? the ? BC ? Centre ? for ? Excellence ? in ?HIV/AIDS ?for ?providing ?salary ?support ?during ?my ?doctoral ?activities. ?Last ?but ?not ? least, ? I ?express ?my ?heartfelt ?gratitude ?to ?my ?family ?and ?friends ?for ?their ?unstinting ?support ?throughout ?the ?years. ? ? ?	  ? 1 ?CHAPTER ?1: ?INTRODUCTION ?1.1 ?Global ?Response ?to ?Illicit ?Drug ?Use ?Illicit ?drug ?use, ?particularly ?injection ?drug ?use, ?is ?associated ?with ?an ?array ?of ?health ? and ? social ? harm ? for ? individuals ? and ? communities. ? In ? 2010, ? the ? United ?Nations ? Office ? on ? Drugs ? and ? Crime ? (UNODC) ? estimated ? that ? globally, ? 153?300 ?million ?people ?(3.4?6.6% ?of ?the ?population ?aged ?15?64 ?years) ?had ?used ?illicit ?drugs ?at ? least ?once ? in ?the ?previous ?year, ?and ?that ?approximately ?one ? in ?every ?100 ?deaths ?among ?adults ?was ?attributed ? to ? illicit ?drug ?use.1 ? In ?2008, ?globally, ?an ?estimated ?16 ?million ? people ? injected ? drugs, ? and ? 3 ?million ? (19%) ? of ? them ?were ? estimated ? to ? be ?living ?with ?human ? immunodeficiency ?virus ? (HIV).2 ?Around ? the ?world, ?millions ?of ?people ?who ?inject ?drugs ?(IDU)i ?suffer ?from ?high ?rates ?of ?preventable ?morbidity ?and ?mortality, ? which ? are ? largely ? attributable ? to ? HIV ? and ? hepatitis ? C ? virus ? (HCV) ?infections, ?and ?overdoses.2-???4 ?In ?addition ?to ?epidemics ?of ?infectious ?disease, ?untreated ?drug ? addiction ? also ? inflicts ? a ? great ? deal ? of ? economic ? and ? social ? harm ? on ?communities, ?including ?productivity ?loss ?and ?excessive ?healthcare ?costs.5,6 ? ?Traditionally, ?the ?dominant ?societal ?response ?to ?illicit ?drug ?use ?has ?been ?the ?enforcement ? of ? repressive ? drug ? laws.7 ? This ? tendency ? results ? from ? the ? fact ? that ?strategies ? to ? address ? illicit ? drug ? use ? are ? largely ? governed ? by ? three ? international ?treaties ?which ?most ?nations ?have ? ratified: ? the ? 1961 ? Single ?Convention ?on ?Narcotic ?Drugs, ? the ?1971 ?Convention ?on ?Psychotropic ?Substances, ?and ?the ?1988 ?Convention ?against ?Illicit ?Traffic ?in ?Narcotic ?Drugs ?and ?Psychotropic ?Substances. ?These ?treaties ?emphasize ? the ? use ? of ? criminal ? sanctions ? for ? reducing ? the ? illicit ? use ? and ? supply ? of ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?  ? ? ? ? ? ? ? ?i ?Throughout this dissertation, I use the acronym ?IDU? when referring to ?people who inject drugs.? The term ?IDU? is widely used in academic publications to refer to ?injection drug users.? However, as this term fails to affirm the personhood of this group of people, I employ the term ?people who inject drugs,? as used by the United Nations and others, while retaining the acronym ?IDU.? ? ? 2 ?controlled ?substances.7,8 ?In ?theory, ?the ?treaties ?are ?flexible ?enough ?to ?accommodate ?a ?range ?of ?public ?health ?responses ?to ?problematic ?drug ?use ?(e.g., ?providing ?addiction ?treatment ? services) ? instead ? of ? punishment; ? however, ? the ? international ? entities ?charged ?with ?interpreting ?the ?conventions ?have ?tended ?to ?direct ?the ?state ?parties ?to ?respond ?to ?illicit ?drug ?use ?by ?enforcing ?criminal ?laws.9,10 ? ?In ? recent ? years, ? there ? has ? been ? growing ? concern ? among ? public ? health ?practitioners, ? scientists, ? and ? policy ? makers ? worldwide ? that ? the ? overreliance ? on ?criminal ? law ? enforcement ? has ? not ? reduced ? drug ? use ? and ? has ? instead ? produced ?unintended ?consequences, ? including ? the ?marginalization ?of ?people ?who ?use ?drugs ?and ? widespread ? epidemics ? of ? infectious ? disease ? among ? IDU.6,11,12 ? Unfortunately, ?aggressive ? drug ? prohibition ? approaches ? continue ? to ? be ? emphasized ? in ? settings ?hardest ? hit ? by ? HIV ? epidemics ? among ? IDU,7 ? despite ? the ? fact ? that ? international ?guidelines ?issued ?by ?the ?World ?Health ?Organization ?(WHO) ?and ?the ?United ?Nations ?(UN) ? recommend ? taking ? a ? public ? health ? approach ? to ? this ? problem ? (e.g., ? harm ?reduction).13 ? ?1.2 ?Study ?Setting ?Thailand, ? located ? along ? some ? of ? the ? world?s ? major ? export ? routes ? for ? illicit ?drugs, ?is ?home ?to ?a ?population ?that ?is ?particularly ?vulnerable ?to ?drug-???related ?harm. ?During ? the ? 1970s, ? the ? country ? became ? the ? world?s ? largest ? opium ? refining ? and ?distribution ?site, ?and ?heroin ?use ?became ?a ?major ?driver ?of ?drug-???related ?harm ?in ?this ?setting.14,15 ? Since ? the ? late ? 1990s, ? there ? has ? been ? a ? dramatic ? increase ? in ? the ? use ? of ?methamphetamine, ?which ?is ?now ?the ?most ?widely ?used ?illicit ?drug ?in ?the ?country.16 ?The ?most ?recent ?national ?household ?survey ?estimated ?that ?in ?2007, ?more ?than ?5% ?of ?the ? population ? (approximately ? 2.5 ? million ? people) ? had ? used ? illicit ? drugs ? at ? some ?point ?in ?their ?lives, ?and ?more ?than ?575,000 ?did ?so ?during ?the ?past ?12 ?months.17 ?While ?estimates ? of ? IDU ? population ? in ? Thailand ? vary ? widely, ? with ? studies ? indicating ? ? 3 ?numbers ?ranging ?from ?48,00018 ?to ?270,000,19 ?recent ?reports, ?including ?one ?by ?the ?2007 ?Reference ?Group ?to ?the ?UN ?on ?HIV ?and ?Injecting ?Drug ?Use,2 ?referred ?to ?160,000 ?as ?an ?estimated ?number ?of ?Thai ?IDU.20,21 ? ?In ?response, ?the ?Thai ?government ?has ?relied ?on ?criminal ?law ?enforcement ?to ?address ? illicit ?drug ?use.22 ? In ?1975, ?Thailand ? ratified ? the ?1961 ?Single ?Convention ?on ?Narcotic ? Drugs23 ? and ? the ? 1971 ? Convention ? of ? Psychotropic ? Substances.24 ? In ? 2002, ?Thailand ? became ? a ? signatory ? to ? the ? 1988 ? Convention ? against ? Illicit ? Traffic ? in ?Narcotic ?Drugs ?and ?Psychotropic ?Substances.25 ?The ?1975 ?Psychotropic ?Substances ?Act ?B.E. ?2518 ?and ?the ?1979 ?Narcotics ?Act ?B.E. ?2522 ?impose ?criminal ?sanctions ?against ?the ?unauthorized ? production, ? distribution, ? sale, ? possession, ? and ? consumption ? of ?controlled ? substances.26 ? According ? to ? the ? terms ? of ? these ? drug ? statutes, ? those ?involved ? in ? trafficking ? of ? certain ? controlled ? substances ? (e.g., ? heroin ? and ?amphetamine ? type ? substances) ?may ?be ? sentenced ? to ? capital ?punishment.26 ? In ?1976, ?the ? Narcotics ? Control ? Act ? B.E. ? 2519 ? was ? enacted, ? and ? the ? Office ? of ? the ? Narcotics ?Control ?Board ?(ONCB) ?was ?established ?to ?coordinate ?national ?drug ?control ?efforts.26 ? ? ?Although ? Thailand ? enacted ? the ?Narcotic ? Addict ? Rehabilitation ? Act ? B.E. ? 2545, ?which ? reclassified ? people ? who ? use ? drugs ? as ? ?patients? ? instead ? of ? ?criminals,? ? in ?2002, ? possession ? and ? consumption ? of ? illicit ? drugs ? remain ? criminal ? offenses.26 ?Furthermore, ? the ? new ? legislation ? created ? a ? system ? of ? compulsory ? drug ? detention ?centres ? (referred ? to ? as ? bangkap ? bambat ? or ? ?forced ? treatment?). ? Under ? this ? system, ?those ? charged ? with ? illicit ? drug ? use ? are ? sent ? to ? pre-???trial ? detention ? facilities ? while ?waiting ? for ? the ? eligibility ? assessment ? for ? compulsory ? drug ? detention ? centres ? that ?supposedly ?provide ?drug ??treatment? ?for ?the ?duration ?of ?a ?few ?months.27 ?However, ?past ? reports ? have ? indicated ? that ? the ? majority ? of ? these ? centres ? were ? run ? by ? the ?military, ? and ? that ? so-???called ? ?treatment ?programs? ? consisted ?primarily ? of ? intensive ?physical ? exercise ? and ? therapeutic ? community ? programming ? and ? offer ? little ? in ? the ? ? 4 ?way ? of ? scientifically ? sound ? addiction ? treatment.27,28 ? In ? March ? 2012, ? twelve ? UN ?agencies ? released ? a ? joint ? statement ? stating ? that ? such ? compulsory ? drug ? detention ?centres ?violated ?international ?human ?rights ?law ?and ?calling ?on ?governments ?to ?close ?down ? the ? centres.29 ?However, ? the ? compulsory ?drug ?detention ? system ?continues ? to ?proliferate ?to ?this ?day. ?With ? this ? legislative ? framework ? in ? place, ? Thailand ? has ? traditionally ?maintained ? strict ?drug ?prohibition ?policies ? in ?an ?effort ? to ?make ? the ? country ??drug ?free.?30,31 ?While ?the ?country?s ?national ?drug ?policy ?has ?been ?revised ?every ?2-???3 ?years ?over ? the ? past ? decade, ? principal ?measures ? of ? drug ? control ? remain ? unchanged ? and ?consist ? of ? supply ? reduction, ? demand ? reduction, ? potential ? demand ? reduction ? (i.e., ?drug ?use ?prevention), ?and ?integrative ?management ?(i.e., ?effective ?coordination ?of ?the ?other ?three ?principal ?measures).31-???40 ?All ?policy ?documents ?during ?this ?period ?refer ?to ?a ? core ?principle, ?which ? is ? that ? ?addicts ? are ?patients ?who ?are ? in ?need ?of ? treatment, ?while ? traffickers ? are ? those ? who ? must ? be ? punished ? under ? the ? rule ? of ? law.?31-???40 ?However, ? this ? principle ? does ? not ? exclude ? people ? who ? use ? drugs ? from ? repressive ?policing. ? According ? to ? the ? ONCB, ? ?drug ? addicts ? must ? enter ? treatment ? and ?rehabilitation ? programs? ? through ? one ? of ? the ? three ? schemes: ? voluntary ? drug ?treatment ? programs, ? compulsory ? drug ? detention ? centres, ? and ? prison-???based ?treatment ? programs.40 ? Although ? the ? policy, ? in ? theory, ? prioritizes ? efforts ? for ?encouraging ? enrolment ? in ? voluntary ? drug ? treatment, ? in ? practice, ? the ? Thai ?government ?has ? implemented ?a ? series ?of ?police ? crackdowns ? to ?detain ?people ?who ?use ? drugs ? in ? compulsory ? drug ? detention ? centres ? and ? prison-???based ? treatment ?programs. ?Between ?2008 ?and ?2011, ?Thai ?authorities ?increased ?the ?number ?of ?people ?who ? use ? drugs ? targeted ? to ? enter ? rehabilitation ? programs ? from ? 60,000 ? in ? 2008 ? to ?400,000 ? in ? 2011.41-???44 ? During ? this ? period, ? the ? number ? of ? people ? enrolled ? in ? drug ?treatment ?increased ?as ?well, ?from ?89,999 ?in ?2008 ?to ?170,485 ?in ?2011, ?while ?more ?than ? ? 5 ?60% ? of ? these ? ?patients? ? were ? placed ? in ? compulsory ? drug ? detention ? centres ? and ?approximately ? 15% ? were ? in ? prison-???based ? treatment ? programs ? each ? year.31,39,40 ? In ?particular, ?a ?renewed ?policy ?initiative ?in ?2011 ?has ?led ?to ?a ?record ?number ?of ?people ?being ? detained ? in ? compulsory ? drug ? detention.45 ? The ? statistics ? illustrate ? that ?Thailand?s ? demand ? reduction ? measures ? are ? driven ? by ? an ? ideology ? of ? abstinence ?from ?illicit ?drug ?use ?and ?have ?relied ?heavily ?on ?repressive ?policing ?to ?coerce ?people ?who ?use ?drugs ?into ?drug ??treatment.? ?The ? over-???reliance ? on ? police ? force ? raises ? concerns ? about ? potential ? human ?rights ? abuses ? being ? committed ? against ? arrestees ? and ? detainees. ? Human ? rights ?organization ?have ?noted ?that ?Thai ?police ?have ?long ?been ?alleged ?to ?have ?committed ?human ? rights ? violations, ? including ? through ? excessive ? use ? of ? force, ? ill-???treatment ? at ?the ? time ? of ? arrest ? and ? during ? police ? custody, ? and ?widespread ? use ? of ? torture ? and ?cruel, ?inhuman, ?and ?degrading ?treatment ?of ?detainees.46,47 ?Most ?notably, ?aggressive ?policing ? practices ? under ? the ? ?war ? on ? drugs? ? campaign ? of ? 2003 ? resulted ? in ? the ?extrajudicial ?killing ?of ?more ?than ?2,800 ?alleged ?drug ?dealers ?and ?users.22,48 ?However, ?impartial ? and ? prompt ? investigations ? into ? alleged ? cases ? of ? grave ? abuses ? by ? police ?have ? seldom ? been ? conducted.46,49 ? Even ? when ? they ? were, ? few ? investigations ? have ?resulted ? in ? prosecutions, ? and ? even ? fewer ? in ? convictions.46,49 ? In ? addition, ? previous ?reports ? have ? suggested ? that ? corruption ? is ? deeply ? entrenched ? in ? public ? sectors ? in ?Thailand, ?and ?the ?police ? force ?was ? listed ?as ?one ?of ? the ?most ?corrupt ? institutions ? in ?2010.50,51 ? These ? known ? features ? of ? the ? Thai ? police ? raise ? concerns ? about ? ongoing ?policing ? practices ? pertaining ? to ? drug ? control ? (hereinafter ? referred ? to ? as ? drug ?policing). ?As ? the ??war ?on ?drugs? ?continues ?unabated, ? the ?available ?evidence ?suggests ?that ? Thai ? IDU ? continue ? to ? suffer ? from ? alarmingly ? high ? rates ? of ? mortality ? and ?morbidity. ?A ? study ? showed ? that ?mortality ? rates ? among ? IDU ? in ?northern ?Thailand ? ? 6 ?were ? 5.8 ? times ? higher ? than ? those ? in ? the ? general ? population, ? and ? the ? excessive ?mortality ? was ? associated ? with ? HIV-???seropositivity, ? benzodiazepine ? use, ? and ?excessive ? alcohol ? consumption.52 ? Furthermore, ? since ? the ? 1990s, ? there ? has ? been ? a ?dramatic ?increase ?in ?incarceration ?rates ?for ?drug-???related ?offenders.53 ?As ?of ?May ?2012, ?64% ? of ? all ? incarceration ? events ? in ? Thailand ? were ? attributable ? to ? drug-???related ?charges.54 ?Incarceration ?carries ?well-???documented ?risks ?of ?drug-???related ?harm ?among ?IDU, ?including ?transmission ?of ?blood-???borne ?pathogens ?and ?overdose.53,55-???59 ? ?Indeed, ?Thailand ? is ? listed ?among ? the ? top ? ten ?countries ?where ? IDU ?are ?most ?severely ? affected ? by ? the ? dual ? epidemics ? of ? HIV ? and ? HCV, ? with ? an ? estimated ?prevalence ?of ?30?50% ?and ?more ?than ?90%, ?respectively.60-???62 ?Despite ?these ?problems, ?needle ?and ?syringe ?programs ?(NSPs), ?which ?are ?recommended ?by ?WHO ?and ?other ?UN ?agencies ?as ?essential ?HIV ?prevention ?services ?for ?IDU,13 ?remain ?controversial ?in ?Thailand ? until ? today. ? While ? public ? health ? authorities ? endorsed ? NSPs, ? legal ?authorities ? regard ? them ? as ? illegal.63,64 ? In ? this ? context, ? less ? than ? 1% ? of ? Thai ? IDU ?reportedly ?have ?access ?to ?NSPs.65 ?Collectively, ?these ?reports ?illustrate ?that ?Thai ?IDU ?are ?facing ?grave ?threats ?to ?their ?health. ? ?1.3 ?Study ?Justification ?In ?the ?wake ?of ?the ?renewed ?and ?intensified ?crackdowns ?on ?illicit ?drug ?use ?in ?Thailand45 ? and ? the ? persistent ? HIV ? epidemic ? among ? Thai ? IDU,61 ? there ? is ? concern ?among ?human ?rights ?advocates ?and ?public ?health ?researchers ?and ?practitioners ?that ?the ?Thai ?government?s ?extensive ?use ?of ?its ?police ?force ?to ?search ?and ?arrest ?IDU ?may ?be ? rendering ? IDU ?populations ? susceptible ? to ? human ? rights ? abuses, ?HIV ? infection, ?and ?other ?health ?concerns.66,67 ?While ?the ?most ?common ?form ?of ?drug ?use ?is ?smoking ?crushed ? methamphetamine ? tablets,16,17,68 ? IDU ? represent ? a ? particularly ? vulnerable ?population ?in ?this ?setting ?due ?to ?the ?high ?rates ?of ?morbidity ?and ?mortality.52, ?60-???62 ? In ?Thailand, ? it ? is ? well ? known ? that ? aggressive ? policing ? practices ? under ? the ? ?war ? on ? ? 7 ?drugs? ?campaign ?of ?2003 ?resulted ? in ?grave ?human ?rights ?violations.22,48 ?Since ? then, ?however, ?few ?studies ?have ?been ?undertaken ?to ?characterize ?the ?harms ?that ?may ?be ?associated ?with ?policing ?practices ?under ? the ?subsequent ?drug ?policy ? initiatives. ?As ?well, ? the ? impact ? of ? intensified ?drug ? suppression ? efforts ? on ?Thailand?s ? illegal ?drug ?market ?has ?not ?been ?evaluated. ?Therefore, ? there ? is ?an ?urgent ?need ?for ?a ?systematic ?investigation ?of ?ongoing ? repressive ?drug ?policing ?and ? the ? impact ?on ?public ?health ?and ?human ?rights ?concerns ?in ?Thailand. ?Previous ? research ? has ? indicated ? that ? repressive ? policing ? of ? drug ? users ? can ?harm ? IDU ? directly ? through ? various ? forms ? of ? police ? violence69-???71 ? and ? indirectly ?through ?multiple ?pathways; ?to ?date, ?a ?number ?of ?studies ?have ?collectively ?identified ?various ?ways ? in ?which ?policing ?activities ?may ? increase ? IDUs? ?vulnerability ? to ?HIV ?infection ?and ?other ?poor ?health ?outcomes.72-???75 ?However, ?these ?studies ?have ?tended ?to ?focus ?on ?the ?aggregate ?effects ?and ?consequences ?of ?police ?crackdowns ?rather ?than ?on ?specific ? policing ? tactics. ? While ? a ? smaller ? number ? of ? studies ? have ? described ? the ?impact ? of ? certain ? police ? actions ? on ? IDU ? (e.g., ? syringe ? confiscation ? by ? police),76-???78 ?other ? tactics ? that ? police ? may ? commonly ? employ, ? such ? as ? urine ? testing ? of ? alleged ?drug ? users, ? have ? not ? been ? fully ? explored. ? Examining ? specific ? policing ? tactics ?will ?advance ?the ?knowledge ?in ?this ?field ?and ?produce ?important ?evidence ?and ?practical ?recommendations ?regarding ?ongoing ?policing ?practices. ? ? ?1.4 ?Conceptual ?Framework ?This ? research ? draws ? on ? a ? modified ? version ? of ? Rhodes? ? Risk ? Environment ?Framework.79,80 ? Central ? to ? this ? framework ? is ? the ? notion ? that ? a ? variety ? of ?environmental ? factors ? exogenous ? to ? the ? individual ? interact ? with ? each ? other ? to ?increase ?or ?reduce ?vulnerability ?to ?poor ?health ?outcomes. ?The ?framework ?delineates ?types ? of ? environment ? (structural, ? social, ? and ? physical), ? levels ? of ? environmental ?influence ? (micro, ? meso, ? and ? macro) ? and ? mechanisms ? of ? environmental ? influence ? ? 8 ?(intermediate ? pathways ? to ? increase ? susceptibility ? and ? vulnerability ? to ? poor ? health ?outcomes) ?that ?help ?unpack ?the ?key ?dimensions ?of ?a ?given ?risk ?environment. ?In ?the ?past ?decade, ?this ?framework ?has ?been ?extensively ?applied ?to ?examinations ?of ?police ?crackdowns ?on ?the ?health ?of ?IDU.81,82 ? ?Policing ? activities ? are ? conceptualized ? as ? key ? features ? of ? the ?micro-???level ? risk ?environment, ?which ? is ?shaped ?primarily ?by ?macro-???level ?structures ? (e.g., ?drug ? laws ?and ? policies) ? and ? meso-???level ? social ? and ? physical ? environments ? (e.g., ? resources ?available ? for ? policing).83 ? This ? research ? also ? recognizes ? the ? existence ? of ? a ? policy ?process ?through ?which ?drug ?policy ?may ?not ?fully ?translate ?into ?street-???level ?policing ?activities ?due ?to ?internal ?organizational ?factors ?within ?the ?police ?as ?well ?as ?external ?factors ?(e.g., ?stigma ?attached ?to ?IDU) ?that ?may ?influence ?police ?officers? ?interactions ?with ?IDU.83,84 ?Based ?on ?previous ?studies ?examining ?the ?impact ?of ?repressive ?policing ?on ?IDU,69,70,72-???77,82,85-???87 ?a ?conceptual ?framework ?was ?developed ?to ?guide ?the ?research, ?as ?shown ?in ?Figure ?1. ?While ?many ?factors ?in ?the ?diagram ?may ?be ?interrelated ?with ?each ?other, ?regression ?analyses ?in ?this ?dissertation ?seek ?to ?tease ?out ?the ?complex ?web ?of ?causation ?and ?identify ?factors ?independently ?associated ?with ?policing ?practices. ?This ?will ?help ?develop ?types ?of ?interventions ?needed ?for ?improving ?the ?health ?of ?IDU. ?In ? addition, ? this ? research ? will ? assess ? the ? human ? rights ? implications ? of ? the ?drug ?policing ?practices ?in ?question. ?The ?added ?value ?of ?using ?human ?rights ?norms ?and ? principles ? for ? this ? research ? includes ? that ? they ? can ? set ? ethical ? standards ? for ?evaluating ? policing ? practices ? and ? drug ? policies, ? offer ? a ? powerful ? and ? common ?vocabulary ? for ? describing ? the ? vulnerability ? of ? the ? study ? population, ? and ? provide ?mechanisms ?to ?demand ?accountability ?for ?rights ?violations ?to ?national ?governments ?and ?human ?rights ? institutions ?within ? the ?UN.88-???90 ?As ?highlighted ? in ?a ?statement ?by ?the ?UNODC,91 ? there ? is ? a ? growing ? recognition ? that ? drug ? control ? efforts ? need ? to ? be ?better ? synchronized ? with ? human ? rights ? guidelines ? and ? standards, ? and ? tools ? for ? ? 9 ?assessing ?the ?potential ?human ?rights ?impacts ?of ?drug ?control ?efforts ?are ?needed. ?This ?research ?seeks ? to ?respond ?to ? that ?call ?by ?generating ?empirical ?evidence ?about ?how ?this ?situation ?stands ?in ?Thailand. ?1.5 ?Study ?Objectives ?The ? central ? aim ? of ? this ? dissertation ? is ? to ? examine ? the ? relationship ? between ?drug ?policing ? and ? the ? health ? of ? IDU ? in ? Bangkok, ? Thailand ? and ? the ? availability ? of ?drugs ? in ? this ? setting. ? Analyses ? involve ? characterizing ? the ? nature ? and ? context ? of ?policing ? practices, ? and ? examining ? the ? relationships ? between ? certain ? policing ?practices ? (i.e., ?police-???perpetrated ?physical ?violence ?and ?drug ? testing) ?and ?HIV ?risk ?behaviour ?and ?other ?health-???related ?outcomes ?among ?a ?community-???recruited ?sample ?of ?IDU ?in ?Bangkok. ?As ?well, ?in ?an ?effort ?to ?estimate ?the ?impact ?of ?drug ?policing ?on ?the ?illegal ?drug ?market, ?additional ?analyses ?seek ?to ?assess ?changes ?in ?the ?street-???level ?availability ?of ? illicit ?drugs ?between ?two ?time ?points ? in ?Bangkok. ? In ?addition, ?using ?internationally ? recognized ?human ?rights ?principles, ? this ? research ?aims ? to ?elucidate ?human ? rights ? abuses ? related ? to ? the ? pursuit ? and ? arrest ? of ? IDU ? in ? Bangkok. ?Specifically, ?the ?research ?focuses ?on ?the ?following ?objectives ?and ?hypotheses: ?1. To ? characterize ? factors ? leading ? to ? interactions ?with ?police ? officers ? among ?IDU ?in ?Bangkok, ?and ?to ?analyze ?specific ?policing ?tactics ?employed ?during ?these ? interactions ? and ? IDUs? ? reactions ? to ? the ? policing ? practices. ? Using ?qualitative ? data ? collected ? through ? semi-???structured ? interviews, ? Chapter ? 3 ?analyzes ?how ?social ?and ?structural ? factors ? shape ? the ?encounters ?with ?police ?among ? IDU ? in ? Bangkok ? and ? identifies ? specific ? policing ? tactics ? that ? violate ?human ? rights. ? This ? chapter ? also ? explores ? IDUs? ? perceptions ? of ? social ? and ?structural ?barriers ?to ?seeking ?justice ?for ?police ?misconduct ?and ?their ?strategies ?for ? avoiding ? future ? encounters ? with ? police ? officers, ? as ? well ? as ? how ? these ? ? 10 ?experiences ?shape ?healthcare ?access ?and ?drug-???using ?behaviour ?among ?IDU ?in ?Bangkok. ? ?2. To ? identify ? the ? prevalence ? and ? correlates ? of ? experiencing ?police ? beatings ?among ? IDU ? in ? Bangkok. ? In ? order ? to ? investigate ? the ? relationship ? between ?police-???perpetrated ? physical ? violence ? and ? the ? health ? of ? IDU ? in ? Bangkok, ?Chapter ? 4 ? uses ? log-???binomial ? regression ? to ? identify ? factors ? associated ? with ?reported ?police ?beatings. ?While ?police-???perpetrated ?physical ?violence ?can ?take ?various ? forms, ? including ? police ? leaving ? people ? to ? suffer ? from ? extended ?withdrawal ?and ?detaining ?people ?in ?unhygienic ?facilities, ?police ?beating ?was ?chosen ? for ? the ? present ? analysis. ? Given ? the ? widespread ? reports ? of ? police ?beating ? alleged ? drug ? dealers ? and ? users ? during ? the ? 2003 ? ?war ? on ? drugs? ?campaign,22 ? there ? was ? a ? possibility ? that ? this ? form ? of ? police ? violence ? had ?persisted ?through ?the ?subsequent ?police ?crackdowns. ?It ?is ?hypothesized ?that ?a ?high ?proportion ?(more ?than ?30%) ?of ?a ?community-???recruited ?sample ?of ?IDU ?in ?Bangkok ? have ? been ? beaten ? by ? police. ? Based ? on ? the ? conceptual ? framework ?(Figure ? 1), ? it ? is ? hypothesized ? that ? having ? been ? beaten ? by ? police ? is ?independently ? associated ? with: ? a ? history ? of ? incarceration, ? a ? history ? of ?compulsory ? drug ? detention, ? injection-???related ? risk ? behaviour ? (i.e., ? syringe ?sharing), ?and ?reporting ?barriers ?to ?accessing ?healthcare. ? ?3. To ?identify ?the ?prevalence ?and ?correlates ?of ?experiencing ?urine ?drug ?testing ?by ?police ?among ?IDU ?in ?Bangkok. ?To ?investigate ?the ?implications ?of ?another ?specific ? policing ? tactic ? for ? the ? health ? of ? IDU ? in ? Bangkok, ? Chapter ? 5 ? uses ?Poisson ?regression ?to ?identify ?factors ?associated ?with ?experiencing ?urine ?drug ?testing ?by ?police. ?Drug ? testing ?was ? chosen ?as ? a ?policing ? tactic ?of ? interest ? in ?light ? of ? anecdotal ? reports ? about ? its ? pervasive ? use ? among ? IDU ? in ? Bangkok. ?While ?drug ?testing ?is ?believed ?to ?be ?one ?of ?the ?common ?tactics ?employed ?by ? ? 11 ?police ?in ?Bangkok, ?little ?is ?known ?about ?its ?effects ?on ?the ?health ?of ?IDU. ?It ?is ?hypothesized ? that ? a ? high ? proportion ? (more ? than ? 50%) ? of ? a ? community-???recruited ?sample ?of ? IDU ?in ?Bangkok ?have ?been ?subjected ?to ?drug ?testing ?by ?police. ? Guided ? by ? the ? conceptual ? framework ? (Figure ? 1), ? it ? is ? hypothesized ?that ?exposures ?to ?drug ?testing ?by ?police ?are ?independently ?associated ?with: ?a ?history ?of ?incarceration, ?a ?history ?of ?compulsory ?drug ?detention, ?internalized ?stigma ? (i.e., ? feeling ? ashamed ? about ? being ? a ? drug ? user), ? and ? reporting ?avoidance ?of ?healthcare. ?4. To ?examine ?the ?relationship ?between ?direct ?exposures ?to ?policing ?practices ?and ? syringe ? sharing ? among ? IDU ? in ? Bangkok. ? Building ? on ? the ? previous ?chapters, ?Chapter ?6 ?uses ?log-???binomial ?regression ?to ?examine ?the ?relationship ?between ? syringe ? sharing ? and ? exposures ? to ? two ? types ? of ? policing ? practices: ?having ?ever ?been ?beaten ?by ?police ?and ?having ?been ?tested ?for ?illicit ?drugs ?by ?police ? in ? the ? past ? six ? months. ? It ? is ? hypothesized ? that ? both ? experiences ? of ?severe ?police ?violence ?(regardless ?of ?the ?timing) ?and ?recent ?direct ?encounters ?with ? police ? (operationalized ? as ? having ? been ? subjected ? to ? drug ? testing ? by ?police) ?would ? increase ? fear ? of ? police ? and ? in ? turn, ? increase ? the ? likelihood ?of ?IDU ?sharing ?syringes. ?5. To ?estimate ? the ? impact ?of ?drug ?policing ?on ? the ? street-???level ? availability ?of ?illicit ? drugs ? among ? IDU ? in ? Bangkok. ? Motivated ? by ? the ? lack ? of ? research ?evaluating ? the ? impact ? of ? drug ? policing ? efforts ? on ? the ? illegal ? drug ? market, ?Chapter ? 7 ? uses ? serial ? cross-???sectional ? data ? collected ? before ? and ? after ? 2011, ?when ?the ?Thai ?government ?intensified ?the ?police ?crackdown ?on ?illicit ?drugs,45 ?and ? assesses ? changes ? in ? the ? availability ? of ? five ? substances ? commonly ? used ?among ? IDU ? in ? Bangkok ? between ? 2009 ? and ? 2011. ? This ? study ? also ? seeks ? to ?examine ? social, ? structural, ? and ? individual ? factors ? influencing ? drug ? ? 12 ?availability. ?It ?is ?hypothesized ?that ?street-???level ?availability ?of ?illicit ?drugs ?will ?have ?remained ?constant ?throughout ?this ?two-???year ?period. ?Given ?some ?recent ?government ? and ?media ? reports ? indicating ?a ? large-???scale ?drug ?dealing ?within ?prisons, ? a ? history ? of ? incarceration ? and ? compulsory ? drug ? detention ? are ? also ?hypothesized ?to ?increase ?the ?availability ?of ?illicit ?drug. ? ?1.6 ?Study ?Design ?1.6.1 ?Mitsampan ?Community ?Research ?Project ? ? This ?research ?was ?undertaken ?through ?the ?Mitsampan ?Community ?Research ?Project, ? a ? collaborative ? research ? effort ? involving ? the ?Mitsampan ? Harm ? Reduction ?Center ? (MSHRC; ?Bangkok, ?Thailand), ?Thai ?AIDS ?Treatment ?Action ?Group ? (TTAG; ?Bangkok, ?Thailand), ?Chulalongkorn ?University ?(Bangkok, ?Thailand), ?and ?the ?Urban ?Health ?Research ?Initiative ? (UHRI) ?of ? the ?British ?Columbia ?Center ? for ?Excellence ? in ?HIV/AIDS ?/ ?University ?of ?British ?Columbia ?(Vancouver, ?Canada). ?The ?MSHRC ?is ?a ?drug ?user-???run ?drop-???in ?centre ?that ?opened ?in ?2004 ?in ?a ?part ?of ?central ?Bangkok ?where ?many ? people ? who ? use ? drugs ? reside. ? The ? MSHRC ? operates ? independently ? of ?government-???sponsored ?treatment ?programs ?and ?provides ?a ?broad ?range ?of ?peer-???led ?harm ?reduction ?services. ? Launched ? in ? 2008, ? the ? Mitsampan ? Community ? Research ? Project ? is ? a ? serial ?cross-???sectional ?mixed-???methods ?study ?that ?aims ?to ?investigate ?drug-???using ?behaviour, ?barriers ?to ?healthcare ?access, ?and ?other ?drug-???related ?harm ?among ?IDU ?in ?Bangkok. ?This ? project ? employs ? a ? community-???based ? research ? approach.92,93 ? The ? overarching ?aims ?of ?the ?study ?were ?developed ?based ?on ?the ?needs ?expressed ?by ?the ?TTAG ?and ?MSHRC ? representatives, ? which ? were ? to ? increase ? the ? uptake ? of ? the ? MSHRC?s ?programs ? and ? to ? collect ? local ? evidence ? for ? national ? policy ? advocacy ? that ?demonstrated ?the ?situation ?facing ?local ?IDU, ?and ?described ?their ?immediate ?health-???related ?challenges.94 ?A ?group ?of ?peer ?researchers ?(i.e., ?active ?or ?former ?drug ?users ?at ? ? 13 ?the ?MSHRC) ?were ?hired ?and ?trained ?in ?research ?ethics, ?outreach, ?and ?interviewing ?techniques ?for ?this ?study. ?They ?were ?involved ?in ?all ?stages ?of ?the ?research, ?including ?the ?development ?of ?the ?research ?questions ?and ?study ?design.94 ?For ?example, ?a ?survey ?instrument ?was ?designed ?in ?consultation ?with ?the ?peer ?researchers ?in ?several ?phases. ?The ? first ? phase ? involved ? brainstorming ? about ? key ? issues ? in ? the ? community. ? The ?academic ?researchers ?then ?drafted ?a ?survey ?questionnaire ?to ?reflect ?these ?concerns. ?Follow-???up ?discussions ?involved ?fine-???tuning ?the ?data ?collection ?instrument ?to ?ensure ?a ? proper ? scope ? of ? question ? topics ? and ? adjusting ? language ? discrepancies ? between ?English ?and ?Thai ?versions ?with ? the ?assistance ?of ?bilingual ?staff ?persons ?at ?TTAG.94 ?This ? participatory ? process ? helped ? ensure ? that ? the ? research ? efforts ? addressed ?concerns ?immediately ?relevant ?to ?the ?local ?IDU ?community. ?Respondent ?recruitment ?strategies ?were ?carefully ?planned ?with ?consideration ?for ?the ?needs ?and ?assets ?of ?the ?MSHRC. ?To ?date, ?32 ?peer ?researchers ?have ?been ?trained ?and ?involved ?in ?the ?project. ?Between ?2008 ?and ?2011, ?the ?research ?team ?completed ?three ?cycles ?of ?surveying ?and ?reached ?an ?accumulated ?total ?of ?1,009 ?IDU ?(778 ?unique ?individuals) ?in ?Bangkok. ?In ?2011, ?a ?qualitative ?arm ?was ?added ? to ? the ?project, ?and ?48 ? in-???depth ? interviews ?were ?conducted ?in ?conjunction ?with ?the ?surveys. ?The ?qualitative ?study ?sought ?to ?explore ?IDUs? ? experiences ? with ? drug ? policing, ? compulsory ? drug ? detention, ? and ? access ? to ?HIV ? testing ? and ? care. ? A ? detailed ? description ? of ? the ? data ? collection ? procedures ? is ?provided ? in ? sections ? 1.6.2 ? and ? 1.6.3. ? Qualitative ? and ? quantitative ? data ? are ?concurrently ? but ? separately ? analyzed.95 ? Chapter ? 8 ? brings ? the ? separate ? results ?together ?in ?the ?interpretation. ? ? ?As ?a ?coordinator ?for ?the ?Mitsampan ?Community ?Research ?Project, ?the ?author ?has ? been ? actively ? involved ? in ? the ? project ? since ? 2008 ? and ? spent ? over ? 1,500 ? hours ?conducting ?fieldwork ?in ?Bangkok.94 ?With ?support ?and ?guidance ?from ?the ?principal ?investigator, ?other ?investigators, ?and ?local ?community ?research ?partners, ?the ?author ? ? 14 ?took ? a ? lead ? role ? in ? all ? research ? stages, ? including ? the ? development ? of ? the ? data ?collection ? instruments, ? training ? of ? peer ? researchers ? and ? local ? research ? assistants, ?data ? collection, ? management ? and ? analysis, ? manuscript ? development, ? and ?dissemination ?of ?the ?findings. ? ?1.6.2 ?Quantitative ?data ?collection ?The ?core ?procedures ?for ?quantitative ?data ?collection ?remained ?the ?same ?over ?the ?three ?survey ?cycles ?in ?2008, ?2009, ?and ?2011. ?The ?respondent ?recruitment ?criteria ?included: ? being ? 18 ?years ? of ? age ?or ? older; ? living ? in ?Bangkok ?or ? adjacent ?provinces; ?being ?able ?to ?understand ?and ?speak ?Thai; ?and ?having ?injected ?drug(s) ?during ?the ?six ?months ?prior ?to ?the ?interview. ?Individuals ?who ?were ?under ?the ?influence ?of ?alcohol ?or ?drugs, ?unable ?to ?have ?a ?conversation ?in ?Thai, ?unable ?to ?understand ?and ?agree ?to ?the ? study ? procedures ? (i.e., ? provide ? informed ? consent); ? or ? needed ? a ? parent ? or ?guardian?s ?consent ?to ?participate ?in ?the ?study ?(i.e., ?being ?less ?than ?18 ?years ?old) ?were ?excluded ? from ? participation. ? Potential ? respondents ? were ? contacted ? through ? peer ?outreach ? and ?word-???of-???mouth ? and ? invited ? to ? the ?MSHRC ? to ? learn ?more ? about ? the ?study. ? After ? providing ? verbal ? informed ? consent, ? a ? respondent ? completed ? an ?interviewer-???administered ? questionnaire ? covering ? a ? range ? of ? topics ? such ? as ?demographic ? data, ? information ? on ? drug ? use ? patterns, ? HIV ? risk ? behaviour, ? health ?problems, ?access ?to ?healthcare, ?and ?experiences ?with ?the ?criminal ?justice ?system. ?The ?respondents ? received ? an ?honorarium ?of ? 250 ?Thai ? baht ? (in ? 2008, ? approximately ?US ?$8.60) ?or ?350 ?Thai ?baht ?(in ?2009 ?and ?2011, ?approximately ?US ?$12) ?for ?each ?completed ?questionnaire ?for ?their ?time ?and ?travel ?expenses. ?The ?amount ?changed ?between ?2008 ?and ?2009 ?because ?of ?the ?increases ?in ?the ?size ?of ?the ?questionnaire. ?In ? order ? to ? increase ? the ? sample ? size, ? additional ? data ? collection ? was ?undertaken ? at ? another ? drop-???in ? centre ? in ? Bangkok ? called ? O-???Zone ? House ? in ? 2011. ?Founded ? in ? 2005, ? O-???Zone ? House ? is ? run ? by ? an ? international ? non-???governmental ? ? 15 ?organization, ? Population ? Services ? International. ? Like ? the ?MSHRC, ? O-???Zone ? House ?provides ?a ?range ?of ?harm ?reduction ?services ?to ?local ?IDU. ?During ?the ?data ?collection ?period, ?peer ?researchers ?from ?the ?MSHRC ?traveled ?to ?the ?O-???Zone ?House, ?recruited ?respondents, ?and ?administered ?surveys ?in ?the ?same ?way ?they ?did ?at ?the ?MSHRC. ?In ?August ? 2008, ? 252 ? IDU ?participated ? in ? the ? study; ? 317 ? between ? June ? and ? July ? 2009, ?and ? 440 ? between ? July ? and ?October ? 2011. ? Some ? individuals ? participated ? in ? two ? or ?three ? waves ? of ? surveys. ? However, ? as ? respondents ? did ? not ? keep ? the ? same ?participation ?codes ?over ?the ?years, ?repeat ?respondents ?were ?identified ?by ?their ?self-???reports: ?reporting ??Yes? ?to ?questions ?in ?the ?2009 ?and ?2011 ?questionnaires: ??Did ?you ?participate ?in ?our ?survey ?in ?2008 ?and/or ?2009?? ? ? ?1.6.3 ?Qualitative ?data ?collection ?Between ?July ?2011 ?and ?June ?2012, ?respondents ?for ?the ?qualitative ?arm ?of ?the ?study ?were ? recruited ? from ? the ?440 ? respondents ? in ? the ?quantitative ?arm, ?as ?well ? as ?via ?peer ?outreach ?and ?word-???of-???mouth. ?Two ?bilingual ?Thai ?research ?assistants ?were ?trained ?to ?conduct ?in-???depth ?interviews ?in ?Thai ?based ?on ?a ?semi-???structured ?interview ?guide ? that ? the ? author ? developed ? with ? guidance ? from ? supervisors ? and ? research ?partners. ? Topics ? for ? in-???depth ? interviews ? included ? current ? drug ? use ? patterns, ?encounters ?with ?police, ?experiences ?with ?compulsory ?and ?voluntary ?drug ?treatment, ?access ? to ? HIV ? testing ? and ? treatment, ? and ? access ? to ? general ? healthcare. ? After ?obtaining ? verbal ? informed ? consent ? from ? potential ? interviewees, ? the ? research ?assistants ? conducted ? interviews ? at ? the ?MSHRC ?and ?O-???Zone ?House. ?Each ? in-???depth ?interview ? was ? audio-???recorded, ? transcribed ? verbatim, ? and ? translated ? into ? English. ?Research ?assistants ?and ?translators ?who ?had ?developed ?familiarity ?with ?terms ?used ?among ? local ? IDU ? reviewed ? the ? translated ? transcripts ? for ? language ? accuracy. ?Furthermore, ? a ? native ?English-???speaking ?proof-???reader ?with ? an ? excellent ? knowledge ?of ? the ? idiomatic ? correlates ? between ? Thai ? and ? English ? also ? verified ? English ? ? 16 ?transcripts ? for ? grammatical ? accuracy ? and ? nuance ? by ? comparing ? the ? English ?transcripts ? with ? Thai ? transcripts ? and ? audio-???files. ? The ?methods ? of ? conducting ? and ?transcribing ? in-???depth ? interviews ? in ? Thai ? and ? subsequently ? translating ? transcripts ?into ? English ? were ? successfully ? used ? in ? a ? previous ? qualitative ? study ? examining ?sexual ? behaviour ? among ?methamphetamine ? users ? in ? Thailand.96 ? The ? interviewees ?received ?an ?honorarium ?of ?450 ?Thai ?baht ?(approximately ?US ?$15) ?for ?their ?time ?and ?travel ?expenses ? for ?each ?completed ? in-???depth ? interview. ? In ? total, ?48 ? IDU ?completed ?in-???depth ?interviews. ?A ?more ?detailed ?description ?of ?the ?qualitative ?research ?methods ?used ?in ?this ?dissertation ?is ?noted ?in ?section ?3.2. ? ?1.7 ?Summary ? ? This ? dissertation ? consists ? of ? eight ? chapters. ? Chapter ? 2 ? is ? a ? review ? of ? the ?literature ? focused ?on ? the ?adverse ? impacts ?of ?drug ?policing ?on ? the ?health ?of ?people ?who ? use ? drugs. ? Drawing ? on ? the ? Risk ? Environment ? Framework, ? the ? author ?delineates ?how ?policing ?practices ?produce ?drug-???related ?harm, ?as ?well ?as ?how ?these ?practices ? intersect ? with ? distinct ? types ? of ? environments ? and ? increase ? IDUs? ?vulnerability ? to ? drug-???related ? harm. ? The ? qualitative ? analysis ? in ? Chapter ? 3 ? sets ? the ?scene ? for ? drug ? policing ? activities ? in ? Bangkok ? by ? characterizing ? the ? circumstances ?and ? situational ? factors ? leading ? to ? interactions ? with ? police ? officers, ? as ? well ? as ?analyzing ?specific ?policing ? tactics ?employed ?during ? these ? interactions ?with ? respect ?to ?international ?human ?rights ?norms. ?The ?epidemiological ?analyses ?in ?Chapters ?4?6 ?explore ?harms ?associated ?with ?specific ?policing ?tactics ?commonly ?used ?against ?IDU. ?Specifically, ? the ? author ? identifies ? the ? prevalence ? and ? correlates ? of ? police ? beatings ?(Chapter ?4) ?and ?police-???conducted ?drug ?testing ?(Chapter ?5). ?Chapter ?6 ?examines ?the ?relationship ? between ? syringe ? sharing ? and ? exposures ? to ? police ? beatings ? and ? drug ?testing. ?Chapter ?7 ?seeks ?to ?estimate ?the ?impact ?of ?drug ?policing ?efforts ?on ?the ?illegal ?drug ?market ?in ?Bangkok. ?Finally, ?Chapter ?8 ?synthesizes ?the ?key ?study ?findings ?and ? ? 17 ?assesses ? the ?human ?rights ? implications ?of ? the ? findings. ? It ?also ?presents ? limitations, ?recommendations, ?and ?directions ?for ?future ?research. ? ? ? 18 ?Figure 1: Conceptual framework  ?Intermediate*Pathways*?? !Risky&drug&use&(e.g.,&binge)&?? !Difficulty&accessing&harm&reduc:on/healthcare&resources&?? "Healthcare&service&u:liza:on&?? !Police&violence&(e.g.,&bea:ng) ?? !Incarcera:on&?? !Internalized&s:gma&Macro3structural*Environment*?? Interna:onal&trea:es& &guidelines&concerning&illicit&drug&use&and&human&rights&?? Drug&laws&?? Drug&control&policies/campaigns&?? Prolifera:on&of&compulsory&drug&deten:on&centres&?? Availability&of&harm&reduc:on/healthcare&services&Individual*Factors*?? Gender&?? Age&?? Drugs&injected&?? Income&from&illegal&sources&(e.g.,&drug&dealing)&Meso3social/physical*Environment&?? Intensity&of&drug&law&enforcement&?? Penal&ins:tu:on&environments&?? S:gma&aJached&to& &social&pressure&on&IDU&Micro3social/physical*Environment&?? Police&encounters,&drug&tes:ng&by&police&?? Physical&features&of&drug&use&scenes&?? Discrimina:on&against&IDU&Intermediate*Outcomes*?? Sharing&injec:on&equipment&Health*Outcomes*?? HIV&infec:on&?? HCV&infec:on&?? Overdose&Individual*factors*interact*with*the*macro3structural,*meso3*and*micro3social/physical*environments*to*facilitate*pathways*to*intermediate*and*health*outcomes.*Adapted*from*the*Risk*Environment*Framework*(Rhodes,*2002,*2009).* ? 19 ?CHAPTER ?2: ?LITERATURE ?REVIEW: ?THE ?IMPACTS ?OF ?DRUG ?POLICING ?ON ?RISK ?ENVIRONMENTS ?AND ?HEALTH-???RELATED ?HARM ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?2.1 ?Introduction ?Many ?countries ?continue ?to ?rely ?heavily ?on ?drug ?prohibition ?approaches ?and ?repressive ?policing ? to ?address ?problems ?related ? to ? illicit ?drug ?use.7,8 ?This ? tendency ?reflects ? features ? of ? the ? international ? system ?of ?drug ? control. ?Over ? the ?past ? several ?decades, ? the ? system ? has ? been ? established ? through ? three ? international ? drug ?conventions?the ?1961 ?Single ?Convention ?on ?Narcotic ?Drugs, ? the ?1971 ?Convention ?on ? Psychotropic ? Substances, ? and ? the ? 1988 ? Convention ? against ? Illicit ? Traffic ? in ?Narcotic ?Drugs ? and ?Psychotropic ? Substances?and ?has ? emphasized ? strict ? criminal ?law ? enforcement ? against ? illegal ? production, ? distribution, ? and ? consumption ? of ? the ?controlled ?psychoactive ?drugs.97 ?As ?virtually ?every ?nation ?in ?the ?world ?has ?ratified ?at ? least ? one ? of ? these ? conventions, ? the ? international ? drug ? prohibition ? scheme ? has ?exerted ?a ?tremendous ?influence ?on ?domestic ?drug ?legislation.97 ? ?To ?date, ?several ?reviews ?have ?been ?conducted ?to ?describe ?the ?adverse ?impacts ?of ? intensive ? drug ? policing ? on ? the ? health ? of ? IDU ? internationally. ? A ? peer-???reviewed ?literature ? review ? conducted ? by ?Kerr ? et ? al.82 ? described ?mechanisms ? through ?which ?policing ? practices ? in ? the ? drug ? market ? may ? produce ? negative ? impacts ? on ? public ?health. ? Strathdee ? et ? al.81 ? systematically ? reviewed ? epidemiological ? studies ? on ? the ?determinants ?of ?HIV ?infections ?in ?IDU. ?They ?identified ?several ?studies ?showing ?that ?aggressive ?police ?practices ?were ?associated ?with ?HIV ?seroconversion. ?J?rgens ?et ?al.98 ?reviewed ?more ?than ?900 ?published ?reports ?to ?examine ?links ?between ?human ?rights ?abuses ?experienced ?by ?people ?who ?use ?drugs ?and ?vulnerability ?to ?HIV ?infection ?and ?access ? to ? health ? services. ? They ? found ? many ? aspects ? of ? drug ? laws, ? policies ? and ?practices ?that ?violated ?human ?rights ?and ?increased ?vulnerability ?to ?HIV/AIDS. ?These ? ? 20 ?reviews ?collectively ?provided ?a ?rich ?description ?of ?health-???related ?harm ?attributable ?to ?punitive ?drug ?laws ?and ?policing ?practices ?among ?people ?who ?use ?drugs. ?Although ? these ? previous ? reviews ? referred ? to ? the ? Risk ? Environment ?Framework,79,80 ? the ? impacts ? of ? drug ? policing ? have ? seldom ? been ? analyzed ? by ? type ?and ? level ? of ? the ? risk ? environment. ? As ? the ? framework ? has ? become ? extensively ?utilized ?in ?research ?on ?the ?health ?of ?IDU ?over ?the ?past ?decade,81 ?it ?is ?useful ?for ?future ?research ?in ?this ?field ?to ?delineate ?how ?drug ?policing ?practices ?are ?situated ?in ?a ?given ?risk ?environment. ?Furthermore, ? as ? the ? literature ? in ? this ? field ?has ? rapidly ?grown ? in ?recent ?years, ? there ? is ?a ?need ?to ? identify ?remaining ?knowledge ?gaps. ?Therefore, ? this ?literature ? review ? sought ? to ?describe ? the ? evidence ?pertaining ? to ? the ? effects ? of ? drug ?policing ?on ?the ?health ?of ?IDU, ?using ?the ?Risk ?Environment ?framework, ?and ?identify ?remaining ?research ?gaps ?in ?this ?field. ? ? ?2.2 ?Methods ?This ?review ?identified ?English-???language ?literature ?through ?online ?searches ?of ?Medline, ?Web ? of ? Science, ? and ?Google ? Scholar. ?Various ? search ? terms ?were ?used ? in ?combination, ? including ? ?law ? enforcement,? ? ?police,? ? ?crackdown,? ? ?substance ?abuse,? ??injection ?drug ?use,? ??drug-???related ?harm,? ?and ??HIV.? ?Additional ?literature ?was ? identified ? in ? the ? bibliographies ? of ? earlier ? reviews.81,82,98-???100 ? The ? literature ? used ?included ?peer-???reviewed ? scientific ? studies ? (i.e., ? quantitative ? studies, ?qualitative ?and ?ethnographic ? studies, ? and ? review ? studies) ? and ? research ? reports ? published ? by ? civil ?society ?organizations. ?While ?the ?primary ?focus ?was ?on ?the ?health ?of ?IDU, ?the ?review ?included ?literature ?describing ?the ?impacts ?of ?drug ?policing ?on ?the ?health ?of ?people ?who ?use ?drugs ?in ?general, ?when ?the ?impacts ?were ?applicable ?to ?IDU. ?As ?a ?first ?step, ?this ?review ?summarized ?examples ?of ?policing ?practices ?that ?have ?direct ?relevance ?to ?IDU. ? Policing ? practices ? that ? primarily ? target ? drug ? dealers ? and ? traffickers ? were ?excluded ? from ? this ? review. ? Then, ? the ? impacts ? of ? drug ? policing ? were ? described ? ? 21 ?according ? to ? the ? Risk ? Environment ? Framework.79,80 ? Directions ? for ? future ? scientific ?research ?were ?then ?identified ?in ?section ?2.4. ?2.3 ?Results ?2.3.1 ?Street-???level ?drug ?policing ? ? Street-???level ?drug ?policing ?is ?largely ?shaped ?by ?drug ?laws ?and ?policies ?(which ?are ? features ? of ? the ? macro-???level ? structure), ? among ? other ? factors.83 ? Such ? laws ? and ?policies ? include ? drug ? and ? drug ? paraphernalia ? laws,83,101 ? drug ? user ? registration ?systems,102 ?compulsory ?drug ?detention ?systems,27,103 ?and ?policies ?on ?harm ?reduction ?programs.104,105 ? Although ? drug ? laws ? and ? policies ? differ ? across ? jurisdictions, ? police ?officers ? typically ?serve ?several ?aims. ? In ?settings ?where ?drug ?policies ? focus ?on ?strict ?drug ?prohibition ?and ?pursue ?complete ?eradication ?of ?illicit ?drugs, ?police ?intervene ?in ?drug ? markets ? by ? removing ? drug ? dealers ? and ? users ? through ? criminal ? justice ?measures, ?such ?as ?incarceration.106 ?As ?part ?of ?demand ?reduction ?strategies, ?police ?are ?also ?expected ?to ?deter ?people ?who ?use ?drugs ?from ?sustaining ?drug-???using ?habits ?by ?disrupting ? illegal ? drug ? markets ? and ? by ? fuelling ? fear ? regarding ? the ? adverse ?consequences ? of ? arrest.82,107 ? These ? goals ? may ? be ? central ? to ? police ? officers ? who ?specialize ? in ?drug ?control, ?although ? for ?other ?police ?officers, ? the ?goals ?are ?situated ?under ? a ? broader ? mandate ? of ? policing ? to ? maintain ? public ? order ? and ? enforce ? drug ?laws.108 ?There ?can ?be ?heterogeneity ?in ?the ?extent ?of ?drug ?policing, ?due ?to ?differences ?in ? management ? policies, ? procedures, ? and ? training ? within ? police, ? as ? well ? as ? the ?discretionary ?power ?given ?to ?police ?officers ?and ?social ?milieus ?that ?may ?affect ?police ?behaviours.83,108 ? ? Policing ? approaches ? (which ? are ? a ? feature ? of ? the ? meso-???level ? structure) ? also ?affect ? street-???level ? drug ? policing. ? Weisburd ? and ? Eck109 ? conceptualized ? modern ?policing ?approaches ?according ?to ?the ?levels ?of ?focus, ?as ?well ?as ?the ?diversity ?of ?actors ?and ? interventions. ?Based ?on ? their ?work, ?Mazzerolle ?et ?al.110 ? classified ? four ?policing ? ? 22 ?approaches: ?(1) ??hot ?spot? ?policing, ?which ?focuses ?on ?small ?geographical ?areas ?with ?high ?concentrations ?of ? crime ? (i.e., ? ?hot ? spots?) ?and ?relies ?on ? intensive ?policing; ? (2) ?problem-???oriented ? policing, ? which ? focuses ? on ? specific ? geographical ? areas ? or ?problems ?and ?involves ?multi-???agency ?collaborations ?(e.g., ?public ?health ?agencies) ?and, ?consequently, ?multiple ? interventions; ? (3) ? community ? policing, ?which ? aims ? to ? deal ?with ? a ? range ? of ? problems ? in ? a ? larger ? area ? through ? partnerships ? with ? community ?stakeholders ? and ? diverse ? interventions; ? and ? (4) ? standard ? policing, ? which ? is ?unfocused ?in ?terms ?of ?geographical ?area ?or ?type ?of ?problem ?addressed, ?and ?relies ?on ?traditional ?policing ?strategies ?such ?as ?patrols. ? ?One ?widely ?documented ?policing ?strategy ?that ?is ?often ?employed ?in ?hot ?spot ?policing ? and ? is ? directly ? relevant ? to ? people ? who ? use ? drugs ? is ? called ? ?sweeps? ? or ??crackdowns,? ? which ? Cooper ? et ? al.85 ? defined ? as ? ?centrally ? organized, ? rapidly ?initiated, ?sustained ?police ?efforts ?crafted ?to ?reduce ?the ?possession ?and ?sale ?of ? illicit ?drugs ? through ? heightened ? surveillance ? and ? arrest ? of ? drugs ? users ? and ? street-???level ?dealers? ?(p.674). ?Other ?similar ?but ?different ?strategies ?include ?high ?visibility ?policing ?and ? saturation ? policing, ? in ? which ? substantial ? numbers ? of ? police ? officers ? are ?deployed ? to ? a ? specific ? area, ? in ? order ? to ? deter ? people ? from ? committing ? a ? crime. ? In ?these ? strategies, ? however, ? the ? emphasis ? may ? not ? necessarily ? be ? on ? drug-???related ?offenses ? but ? on ? other ? offenses ?more ? broadly.107 ? Police ? search-???and-???arrest ? tactics ? are ?diverse ?and ? include ? surveillance ?via ? closed-???circuit ? television,111 ? raids ?on ? the ? street, ?night ? clubs, ? and ? other ? places,87,102 ? information ? gathering ? through ? police ?informants107,112 ? and ? drug ? user ? registries,102 ? buy-???bust ? operations,82 ? drug ? detection ?dogs,113 ?and ?rapid ?urine ?toxicology ?screening.114 ? ?2.3.2 ?Individual-???level ?impacts ?of ?direct ?encounters ?with ?police ? ? One ?of ?the ?most ?direct ?adverse ?impacts ?of ?drug ?policing ?is ?police-???perpetrated ?violence ? against ? people ? who ? use ? drugs. ? A ? number ? of ? human ? rights ? reports ? and ? ? 23 ?qualitative ? studies ? from ? the ? Americas, ? Eastern ? Europe, ? Australia, ? and ? Asia ?documented ? police ? violence ? against ? people ? who ? use ? drugs, ? including ? physical ?violence, ? such ? as ? beatings ? and ? using ? forced ? drug ? withdrawal ? to ? coerce ?confession,22,69-???71,87,112,115-???118 ?sexual ?violence,69,70,117,118 ?psychological ?violence ?(e.g., ?undue ?threats ?and ?harassment),69,70,74,87,111,112,115,117,119 ?and ?neglect.70 ?The ?most ?extreme ?example ?was ?found ?in ?Thailand, ?where ?more ?than ?2,800 ?alleged ?drug ?dealers ?and ?users ?were ?killed ?extrajudicially ?during ?the ?government-???initiated ?three-???month ??war ?on ?drugs? ?campaign ? in ? 2003.22 ? Additionally, ? police ? may ? abuse ? IDU ? through ? arbitrary ?arrests22,69,115,117,119 ?and ?extortion.22,69,78,111,112,115-???118 ?In ?many ?settings, ?it ?was ?reported ?that ?IDU ?were ?often ?arrested ?for ?carrying ?sterile ?or ?used ?syringes, ?even ?in ?settings ?where ?the ? possession ? of ? syringes ? was ? not ? illegal.22,69,74,76,117 ? Arrests ? for ? having ? needle-???marks,118 ?as ?well ?as ?confiscation ?of ?drugs, ?syringes, ?and ?antiretroviral ?drugs,74,111,112,120 ?were ? also ? documented. ? These ? abuses ? of ? police ? power ? have ? been ? termed ? ?lethal? ?human ? rights ? violations ? by ? Csete ? and ? Cohen.121 ? Moreover, ? police ? violence ? and ?misconduct ?likely ?also ?produce ?other ?harms ?by ?creating ?a ?climate ?of ?fear ?among ?IDU, ?which ?is ?described ?in ?detail ?in ?the ?following ?section ?1.3.3. ? ? ? A ?smaller ?number ?of ?quantitative ?studies ?have ?examined ?the ?prevalence ?and ?associated ?harm ?of ?police ?misconduct ?and ?abuse ?of ?power ?among ?IDU. ?In ?Bangkok, ?Thailand, ?48% ?of ?a ?community-???recruited ?sample ?of ?IDU ?reported ?having ?had ?drugs ?planted ? on ? them ? by ? the ? police, ?which ?was ? independently ? associated ?with ? syringe ?lending ? and ? a ? history ? of ? compulsory ? drug ? detention.78 ? In ?Odessa, ?Ukraine, ? police ?beatings ?were ?shown ?to ?elevate ?the ?likelihood ?of ?syringe ?sharing ?among ?IDU, ?and ?a ?mathematical ? model ? estimated ? that ? the ? elimination ? of ? this ? police ? practice ? would ?avert ? 4?19% ? of ? new ? HIV ? infections ? among ? IDU ? by ? 2015.81,122 ? Two ? cross-???sectional ?studies ? of ? IDU ? in ? Mexico-???US ? border ? cities ? found ? that ? about ? half ? of ? the ? study ?participants ? experienced ? unlawful ? police ? actions: ? having ? syringes ? confiscated ? by ? ? 24 ?police123 ? or ? having ? been ? arrested ? for ? carrying ? an ? unused ? syringe.76 ? Experiences ? of ?syringe ?confiscation ?were ?associated ?with ?HIV ?seropositivity,123 ?and ?experiences ?of ?arrests ? for ? possessing ? both ? unused ? and ? used ? syringes ? were ? found ? to ? be ?independently ?associated ?with ?recent ?receptive ?syringe ?sharing ?(i.e., ?using ?a ?syringe ?used ? by ? others) ? and ? injecting ? in ? shooting ? galleries, ? after ? adjusting ? for ? potential ?confounders.76 ?Arrests ? for ? carrying ? needles ?were ? also ? found ? to ? be ? associated ?with ?suicidal ? ideation ? among ? male ? IDU ? in ? Delhi, ? India.124 ? These ? findings ? suggest ? that ?police ? violence ? and ? misconduct ? may ? be ? fuelling ? fear ? of ? police ? among ? IDU ? and ?prompting ?them ?to ?engage ?in ?risky ?injection ?behaviours. ? ?In ?Tijuana, ?Mexico, ? frequent ?arrests ? for ?having ?needle-???marks ?were ? found ? to ?be ?an ?independent ?risk ?factor ?for ?HIV ?seroconversion ?among ?IDU, ?while ?a ?history ?of ?incarceration ? was ? not ? associated ? with ? HIV ? infection.125 ? Taken ? together ? with ? a ?previous ? qualitative ? study ? conducted ? in ? this ? setting,118 ? this ? longitudinal ? study ?indicates ? that ? this ? policing ? practice ?may ? be ? increasing ? IDUs? ? vulnerability ? to ?HIV ?infection ? by ? pressuring ? them ? to ? engage ? in ? rushed ? injections ? or ? inject ? in ? shooting ?galleries, ?both ?of ?which ?are ?known ?to ?increase ?the ?risk ?of ?syringe ?sharing.126,127 ? ?  ?2.3.3 ?Impacts ?through ?the ?micro-???level ?social ?and ?physical ?environment ? ? In ?the ?Risk ?Environment ?Framework, ?drug ?policing ?is ?considered ?to ?be ?a ?key ?feature ? of ? the ?micro-???level ? social ? environment.79 ? Policing ? activities ? can ? produce ? an ?array ?of ?drug-???related ?harms ?by ?fuelling ?fear ?of ?police ?among ?IDU ?and ?by ?disrupting ?established ?drug ?markets ?and ?social ?networks ?of ? IDU ?(impacts ? through ? the ?micro-???level ? social ? environment). ? They ? can ? also ? interact ? with ? the ? micro-???level ? physical ?environment ?and ?result ?in ?interfering ?with ?harm ?reduction ?and ?health ?services ?and ?displacing ?locations ?for ?injection ?drug ?use. ? ?As ? Sarang ? et ? al.69 ? described, ? policing ? practices, ? particularly ? extrajudicial ?practices, ?can ?generate ?fear ?of ?police ?among ?IDU, ?even ?in ?the ?absence ?of ?crackdowns. ? ? 25 ?Fear ? of ? police ? has ? been ? shown ? to ? shape ? IDUs? ? drug-???injecting ? behaviours. ? It ? can ?discourage ? IDU ? from ? carrying ? sterile ? syringes,69,73,108,117,118,128,129 ? prompt ? rushed ?injections ?and ?other ?risky ? injection ?behaviours ? (e.g., ?syringe ?sharing), ?and ?result ? in ?unsafe ?disposal ?of ?used ?syringes.69,72,73,108,126,129,130 ?Fear ?of ?police ?also ?can ?also ?result ?in ?displacement ?of ?IDU ?into ?more ?hidden ?locations, ?where ?safer ?injection ?practices ?are ?often ?difficult ?to ?maintain ?and ?medical ?emergencies ?are ?hard ?to ?address.69,72,73,108,118 ? ?All ?of ?these ?behaviours ?have ?the ?potential ?to ?exacerbate ?to ?harm ?individuals ?and ?communities. ?For ?example, ?rushed ?injections ?are ?known ?to ?increase ?the ?risk ?of ?overdose, ?cutaneous ?infections, ?and ?vascular ?and ?nerve ?damage ?by ?undermining ?the ?important ? steps ? needed ? to ? ensure ? a ? safe ? injection.131,132 ? In ? the ? United ? States ? and ?Mexico, ? fear ? of ? arrest ? was ? shown ? to ? prompt ? IDU ? to ? use ? shooting ? galleries?a ?physical ?environment ?known ?to ?increase ?the ?risk ?of ?HIV ?and ?HCV ?transmission ?due ?to ?the ?sharing ?of ?injection ?equipment.118,133-???135 ?An ?ethnographic ?study ?from ?Australia ?reported ? another ? dangerous ? consequence ? of ? fear ? of ? police: ? nasal ? and ? oral ? drug ?storage, ?which ? can ? lead ? to ? the ? transmission ?of ? tuberculosis ? and ?other ?blood-???borne ?viruses ?by ? risking ? exposure ? to ?blood ?and ?bodily ? fluids, ? as ?well ? as ? overdose ?when ?drugs ?are ?accidentally ?swallowed.108 ? ?Several ? studies ? have ? shown ? that ? increased ? police ? presence ? in ? one ?neighbourhood ? can ? serve ? to ? displace ? people ? who ? use ? drugs ? to ? different ?neighbourhoods.72,73,75,87,108,136 ? In ? Vancouver, ? ethnographic ? and ? human ? rights ?investigations ?documented ?the ?displacement ?of ?a ? large ?population ?of ? IDU ?from ?an ?area ?subjected ?to ?a ?police ?crackdown ?into ?adjacent ?areas ?of ?the ?city.73,87 ?This ?finding ?was ? corroborated ? by ? a ? quantitative ? study ? showing ? that ? the ? intensity ? of ? injection ?drug ? use ? among ? IDU ? did ? not ? change ? as ? a ? result ? of ? the ? crackdown, ? although ? the ?number ? of ? used ? syringes ? disposed ? of ? on ? the ? streets ? increased ? significantly ? in ? the ?adjacent ?areas.75 ? ? ? 26 ?Fear ? of ? police ? has ? also ? been ? shown ? to ? discourage ? IDU ? from ? seeking ?healthcare, ?including ?emergency ?medical ?services.137,138 ?In ?an ?investigation ?of ?heroin ?overdose ?experiences ?among ?IDU ?in ?South ?Australia, ?McGregor ?et ?al.137 ? found ?that ?fear ?of ?police ?was ? the ?primary ? reason ? for ?delaying ?or ? stopping ?attempts ? to ?obtain ?help ?in ?the ?event ?of ?an ?overdose. ?This ?finding ?was ?consistent ?with ?a ?report ?from ?St. ?Petersburg, ?Russia.138 ?Police ?presence ?and ?harassment ?near ?clinics, ?pharmacies, ?and ?harm ? reduction ? service ? points ? have ? been ? documented ? in ? many ? reports ? and ? are ?shown ? to ? impede ? drug ? users? ? access ? to ? sterile ? syringes, ? other ? health ? and ? social ?services, ?as ?well ?as ?the ?outreach ?efforts ?of ?these ?programs ?and ?services.73,86,87,108,115,117,139 ?In ? a ? study ? of ? substance-???using ? women ? engaged ? in ? street-???based ? sex ? work ? in ?Vancouver, ?Canada, ? Shannon ? et ? al.136 ? vividly ? illustrated ? this ? point ? by ?using ? social ?mapping ? techniques. ? They ? found ? that ? women ? who ? were ? displaced ? by ? policing ?tended ? to ?move ? away ? from ? areas ? where ? harm ? reduction ? services ? were ? provided. ?Another ? quantitative ? study ? from ? Vancouver ? demonstrated ? that ? the ? number ? of ?syringes ? reaching ? IDU ? from ? a ? night-???time ? syringe ? exchange ? program ? declined ? by ?more ?than ?26% ?during ?a ?police ?crackdown.140 ? ?Drug ?policing ?activities ?are ?designed ?to ?disrupt ?drug ?markets. ?However, ?past ?reviews ? of ? research ?have ? suggested ? that ? the ? impacts ? of ? such ? activities ? are ?modest ?and ? temporary ? at ? best.82,107 ? Despite ? mixed ? reports ? on ? the ? relationship ? between ?policing ?activities ?in ?a ?drug ?market ?and ?subsequent ?increases ?in ?the ?price ?of ?drugs, ?a ?strong ?consensus ?exists ?on ?the ?remarkable ?resilience ?of ?drug ?markets ?in ?response ?to ?policing ?efforts?they ?became ?increasingly ?sophisticated ?by ?transitioning ?from ?open ?markets ? to ? closed ? ones, ? increasing ? the ? complexity ? in ? distribution ? structures, ? and ?using ?new ?information ?technologies.82,107 ?The ?sophistication ?of ?drug ?markets ?has ?also ?made ? street-???level ? drug ? dealing ? more ? volatile ? and ? elusive.108 ? In ? fact, ? a ? recent ?systematic ? review ? found ? a ? positive ? association ? between ? aggressive ? drug ? policing ? ? 27 ?and ? drug ?market ? violence, ? suggesting ? that ? gun ? violence ? and ? high ? homicide ? rates ?were ? likely ? the ? inevitable ? consequences ? of ? increasing ? policing ? efforts ?within ? drug ?markets.141 ? ?In ?instances ?where ?a ?drug ?market ?was ?temporarily ?disrupted, ?it ?was ?reported ?that ?people ?who ?use ?drugs ?simply ?changed ?the ?types ?of ?drugs ?they ?consumed ?(e.g., ?diverted ? prescription ? medicines) ? or ? their ? routes ? of ? administration,108,142,143 ? which ?sometimes ?resulted ?in ?an ?increased ?risk ?of ?drug-???related ?harm. ?For ?example, ?in ?2001, ?New ? South ? Wales, ? Australia ? experienced ? a ? sudden ? and ? substantial ? reduction ? in ?heroin ? availability.144 ? A ? longitudinal ? study ? of ? IDU ? in ? this ? setting ? found ? that ? a ?reduction ? in ? heroin ? injection ?was ? coupled ?with ? a ? concomitant ? increase ? in ? cocaine ?injection ? among ? the ? study ? sample, ? and ? cocaine ? injection ? was ? shown ? to ? be ? an ?independent ?risk ?factor ?of ?HCV ?infection.143 ?The ?transition ?from ?smoking ?to ?injecting ?heroin ?has ?also ?been ?observed ?in ?many ?settings ?and ?has ?had ?serious ?implications ?for ?public ?health, ?due ?to ?an ?increased ?risk ?of ?blood-???borne ?disease ?transmission.14,108 ?Several ? ethnographic ? studies ? have ? suggested ? that ? intensive ? drug ? policing ?during ? crackdowns ? disrupts ? established ? social ? networks ? among ? drug ? dealers ? and ?users. ?This ?likely ?leads ?to ?increased ?threats ?or ?acts ?of ?violence ?used ?to ?obtain ?drugs ?and ? the ? sale ? of ? fake ? or ? low-???quality ? drugs.72,74,130 ? The ?disruption ? of ? stable ? networks ?may ?also ? result ? in ? the ? reconstitution ?of ?HIV ? sero-???mixed ?networks, ?which ? facilitate ?the ?spread ?of ?HIV ?among ?IDU.83,145 ?In ?addition, ?Blankenship ?and ?Koester130 ?suggest ?that ?the ?police ?use ?of ?IDU ?as ?informants ?may ?have ?created ?mistrust ?and ?discouraged ?social ?cohesion ?among ?IDU ?and ?consequently ?undermined ?the ?effectiveness ?of ?peer-???based ?harm ?reduction ?services. ? ?2.3.4 ?Impacts ?through ?the ?meso-???level ?social ?and ?physical ?environment ?Drug ?policing ?activities ?also ?intersect ?with ?certain ?meso-???level ?environmental ?factors ?and ?shape ?IDUs? ?vulnerability ?to ?poor ?health. ?These ?factors ?include ?detention ? ? 28 ?in ? state ? custody ? (the ?meso-???level ? physical ? environment), ? as ?well ? as ? accessibility ? of ?health ? and ? social ? services ? and ? stigma ? attached ? to ? IDU ? (the ? meso-???level ? social ?environment). ? ? Intensive ? policing ? practices ? can ? subsequently ? have ? serious ? impacts ? on ? the ?meso-???level ?physical ?environment, ? including ?the ?overcrowding ?of ?penal ? institutions ?due ? to ? increased ? drug-???related ? arrests.53,106,146 ? In ? most ? settings, ? prison ? systems ? lack ?sufficient ? resources ? to ? effectively ?deal ?with ? growing ? incarcerated ?populations. ? For ?example, ? in ?Thailand, ? drug ?users ? are ? routinely ?detained ? in ?prisons ? for ? 45 ?days ? or ?longer ? to ? undergo ? an ? eligibility ? assessment ? for ? compulsory ? drug ? detention, ? even ?though ?the ? law ?indicates ? that ?an ?assessment ?should ?generally ? take ?place ?within ?15 ?days.27 ?The ?prolonged ?assessment ?period ?was ?reportedly ?due ?to ?the ?limited ?human ?resources.27 ? Penal ? institutions, ? including ? pre-???trial ? detention ? facilities, ? are ?environments ? where ? infectious ? diseases ? are ? known ? to ? spread, ? and ? where ? other ?health ? and ? human ? rights ? concerns, ? such ? as ? torture ? and ? physical ? abuses, ? sexual ?violence, ?and ?inadequate ?basic ?living ?conditions, ?remain ?major ?challenges.58,147,148 ? ?In ?addition, ? in ? the ?United ?States, ? those ?who ?were ? convicted ?of ?drug-???related ?felonies ? generally ? lose ? eligibility ? for ? welfare ? services ? and ? public ? housing, ? cannot ?receive ?home ?and ?student ?loans, ?grants ?for ?higher ?education, ?and ?in ?some ?states ?lose ?the ? right ? to ? vote.126,130,149 ? Sentencing ? and ? incarceration ? have ? also ? been ? shown ? to ?reduce ? chances ? of ? access ? to ? and ? success ? in ? the ? labour ? market.150 ? These ? are ? distal ?effects ? of ? drug ? policing ? on ? the ? health ? and ? well-???being ? of ? IDU ? that ? are ? produced ?through ? the ? intersection ? of ? other ? elements ? in ? the ? meso-??? ? and ? macro-???level ?environment. ? ?In ? some ? Asian ? countries ? where ? compulsory ? drug ? detention ? centres ? are ?instituted, ?IDU ?who ?are ?arrested ?by ?police ?can ?be ?subjected ?to ?detention ?without ?due ?process, ?physical ?and ?sexual ?violence, ?forced ?labour, ?substandard ?living ?conditions, ? ? 29 ?and ? so-???called ? ?treatment? ? programs ? not ? based ? on ? medical ? evidence ? and ? fail ? to ?adhere ? to ?best ?practices ? in ?addiction ? treatment.27,28,103,116,151-???153 ? In ?March ?2012, ? twelve ?UN ? agencies ? issued ? a ? joint ? statement ? urging ? governments ? to ? close ? down ? these ?detention ?centres, ?due ?to ?human ?rights ?and ?health ?concerns.29 ?This ?call ?was ?echoed ?by ? the ?UN ?Special ?Rapporteur ?on ? torture ? in ?March ?2013.154 ?However, ? it ? remains ? a ?serious ?concern ?that ?this ?type ?of ?cruel ?and ?inhumane ?treatment ?has ?continued.27,28 ? ? ? ?Intensive ? policing ? practices ? can ? also ? penetrate ? healthcare ? settings, ? in ?which ?police ? officers ? obtain ? information ? on ? suspected ? drug ? users ? from ? healthcare ?providers ? and ? search ? and ? arrest ? the ? suspects. ? This ? practice ? has ? been ? shown ? to ?reduce ?the ?accessibility ?of ?healthcare ?services ?for ?IDU. ?Where ?drug ?user ?registration ?laws ?are ?in ?place,102,155 ?the ?patients? ?right ?to ?confidentiality ?of ?medical ?information ?is ?violated, ?and ?information ?sharing ?between ?police ?and ?healthcare ?providers ?increases ?vulnerability ? to ? police ? abuse ? and ? extortion ? and ? constitutes ? a ? barrier ? to ? seeking ?medical ?attention.102,120,129,156 ?In ?Thailand, ?even ?though ?drug ?user ?registration ?laws ?are ?not ? in ? place, ? a ? human ? rights ? investigation ? revealed ? that ? information ? sharing ?between ? police ? and ? public ? hospitals ? occurred ? as ? a ?matter ? of ? practice, ? and ? fear ? of ?police ? has ? prompted ? drug ? users ? to ? avoid ? accessing ? public ? hospitals ? in ? favour ? of ?private ? clinics ? that ? are ? too ? expensive ? for ?many ? IDU.157 ? Thus, ? the ? accessibility ? and ?affordability ?of ?healthcare ?services ?were ?significantly ?undermined.157 ? ? ? At ? the ? meso-???level, ? policing ? practices ? can ? also ? exacerbate ? the ? ongoing ?stigmatization ? and ? marginalization ? of ? IDU, ? as ? well ? as ? other ? inequalities, ? such ? as ?those ?based ?on ?gender, ?ethnicity, ?and ?social ?class. ?According ?to ?Link ?and ?Phelan,158 ??stigma ? is ?entirely ?dependent ?on ?social, ?economic, ?and ?political ?power? ? (p.375). ? In ?this ? regard, ? drug ? policing ? can ? constitute ? a ? powerful ? social ? force ? that ? promotes ?ongoing ? stigmatization. ? For ? example, ? an ? ethnographic ? study ? in ? Sydney, ?Australia ?showed ?that ?policing ?practices ?within ?ethnic ?minority ?communities ?intersected ?with ? ? 30 ?racism ? and ? aggravated ? social ? exclusion.111 ? Stigma ?produces ? harmful ? consequences ?on ? health.159 ? Among ? people ? who ? use ? drugs, ? it ? has ? been ? associated ? with ? poorer ?mental ? and ? physical ? health.160 ? One ? pathway ? through ? which ? drug ? policing ? and ?stigma ?affect ?the ?health ?and ?well-???being ?of ?IDU ?was ?shown ?in ?a ?qualitative ?study ?in ?Russia, ?which ? indicated ? that ? aggressive ? policing ?practices ? have ? contributed ? to ? the ?reproduction ? and ? experience ? of ? stigma ? among ? IDU ?who, ? in ? turn, ? internalized ? the ?stigma ?as ?self-???blame, ?lack ?of ?self-???worth, ?and ?fatalism ?regarding ?risk, ?and ?engaged ?in ?drug ?use ?to ?cope ?with ?excess ?stress.69 ? ?2.3.5 ?Impacts ?through ?macro-???level ?structures ? ?  ?As ?policing ?activities ?are ?largely ?shaped ?by ?macro-???level ?structures ?(e.g., ?drug ?laws), ?many ? of ? the ? adverse ? impacts ? of ? drug ? policing ? described ? in ? this ? review ? are ?arguably ?attributable ?to ?the ?drug ?laws ?that ?criminalize ?illicit ?drug ?use, ?among ?other ?factors. ?This ?review ?has ?also ?identified ?several ?features ?of ?macro-???level ?structures ?that ?serve ?to ?augment ?the ?production ?of ?drug-???related ?harm ?through ?street-???level ?policing. ?Other ?macro-???level ?factors ?affecting ?the ?health ?of ?IDU ?include ?the ?death ?penalty ?for ?drug-???related ?offenses, ?drug ?paraphernalia ?laws ?that ?prohibit ?the ?sale, ?purchase, ?and ?possession ? of ? injection ? equipment, ? and ? laws ? and ? policies ? that ? undermine ? harm ?reduction ?programs ?in ?communities ?or ?correctional ?facilities. ? ? Some ?countries ?impose ?the ?death ?penalty ?for ?drug-???related ?offenses, ?including ?simple ?possession ?of ?illicit ?drugs.161 ?Although ?Article ?6 ?of ?the ?International ?Covenant ?on ?Civil ? and ? Political ? Rights ? (ICCPR) ? states ? that ? capital ? punishment ?may ? only ? be ?applied ? to ? the ? ?most ? serious ? crimes,? ? an ? international ? review ? of ? drug ? legislation ?revealed ?substantial ?arbitrariness ?and ?inconsistency ?in ?the ?definition ?of ?capital ?drug ?offenses ? around ? the ?world, ? raising ? concern ? regarding ? the ? justifiability ? of ? such ? an ?approach.162 ? Moreover, ? the ? number ? of ? countries ? that ? apply ? the ? death ? penalty ? for ?drug-???related ?offenses ?has ? increased ?over ? the ?past ? two ?decades.162 ?Although ?capital ? ? 31 ?punishment ? for ? drug-???related ? offenses ? is ? not ? applied ? in ? most ? countries, ? the ? death ?penalty ?may ?be ?the ?ultimate ?consequence ?of ?drug ?policing ?for ?IDU. ? ? ? ? ? The ? harmful ? effect ? of ? drug ? paraphernalia ? laws ? has ? been ? extensively ?investigated ? in ? the ?United ?States.86,126,130,163 ? In ?many ?US ?states, ?NSPs ?are ?outlawed.86 ?Such ? laws ? also ? manifest ? themselves ? in ? police ? actions ? and ? have ? limited ? the ?availability ?of ?tools ?to ?prevent ?the ?spread ?of ?blood-???borne ?diseases ?among ?IDU. ?For ?example, ? Bluthenthal ? et ? al.126 ? found ? that ? IDU ? who ? reported ? fear ? of ? arrest ? while ?carrying ? drug ? paraphernalia ? were ? more ? likely ? than ? others ? to ? share ? syringes. ? An ?ecological ? study ? also ? found ? higher ? prevalence ? and ? incidence ? of ? HIV ? in ? US ?metropolitan ?areas ?where ?laws ?prohibit ?over-???the-???counter ?syringe ?sales.163 ? ? ? Lastly, ?laws ?and ?policies ?that ?limit ?or ?prohibit ?harm ?reduction ?programs ?also ?exacerbate ? the ? adverse ? effects ? of ? repressive ? policing. ? In ? Russia, ? where ? opioid ?substitution ? therapies ? are ? banned, ? treatment ? options ? for ? opioid-???using ? IDU ? are ?extremely ?limited; ?therefore, ?IDU ?will ?likely ?continue ?to ?use ?illicit ?drugs, ?at ?the ?risk ?of ?being ?subjected ?to ?police ?surveillance ?as ?well ?as ?overdose ?and ?other ?harms.69,155,156 ?Furthermore, ?despite ?the ?well-???known ?risk ?of ?HIV ?and ?HCV ?infection ?in ?prisons, ?few ?countries ?provide ?harm ?reduction ?services ?(e.g., ?NSPs) ?in ?detention ?settings.148,164 ?As ?detention ? of ? IDU ? is ? a ? frequent ? consequence ? of ? aggressive ? drug ? policing ? in ?many ?countries, ? the ? lack ? of ? harm ? reduction ? programs ? in ? detention ? settings ?worsens ? the ?harm ?associated ?with ?policing. ? ?2.3.6 ?Interventions ?to ?mitigate ?the ?adverse ?impacts ?of ?drug ?policing ?Globally, ?there ?has ?been ?a ?range ?of ?efforts ?and ?recommendations ?to ?mitigate ?the ?adverse ?impacts ?of ?drug ?policing ?on ?the ?health ?of ?IDU. ?Since ?some ?of ?the ?harm ?that ? IDU ? experience ? through ? policing ? activities?such ? as ? arbitrary ? arrests?constitute ?violations ?of ?due ?process, ?the ?provision ?of ?legal ?services ?to ?this ?population ?can ? help ? victims ? of ? police ? abuse ? obtain ? redress. ? In ? addition, ? Csete ? and ? Cohen165 ? ? 32 ?listed ?various ?kinds ?of ? legal ?services ?that ?could ?promote ?health ?among ?IDU. ?These ?services ? include: ? facilitating ? access ? to ? housing, ? healthcare, ? and ? social ? services; ?training ? non-???lawyers ? as ? paralegals ? and ? ?accompaniers? ? who ? accompany ? IDU ? to ?court ? or ? other ? places; ? training ? IDU ? to ? know ? and ? assert ? their ? rights; ? documenting ?human ?rights ?abuses ?against ?IDU ?and ?conducting ?related ?advocacy; ?and ?convening ?workshops ? for ? police ? and ? prosecutors ? on ? the ? legality ? of ? health ? services ? for ? drug ?users. ? Such ? legal ? interventions ?may ? help ? facilitate ? reforms ? of ? police ? practices. ? To ?date, ? however, ? few ? public ? health ? researchers ? have ? investigated ? the ? effects ? of ?providing ?legal ?services ?on ?drug-???related ?harm.165 ?In ? some ? countries, ? including ? Britain, ? Ireland, ? Australia, ? and ? Russia, ? drug ?referral ?schemes ?have ?been ?developed ?in ?an ?effort ?to ?assist ?arrestees ?who ?use ?drugs ?in ? entering ? drug ? treatment ? services.166,167 ? Under ? such ? schemes, ? trained ? counsellors ?work ? within ? police ? stations ? and ? provide ? arrestees ? with ? advice, ? information, ?assessment, ?and ?referral ?to ?drug ?treatment ?services. ?A ?central ?aim ?of ?such ?programs ?is ? to ? reduce ? rates ? of ? recidivism ? by ? increasing ? uptake ? of ? drug ? treatment, ? although ?they ?do ?not ?offer ?an ?alternative ?to ?prosecution. ?Evaluations ?in ?Britain ?showed ?that ?a ?significant ?number ?of ?opiate ?and ?cocaine ?users ?were ?enrolled ?in ?addiction ?treatment ?through ? such ? a ? program.166,167 ? However, ? the ? evaluations ? also ? highlighted ? some ?difficulties ? in ? delivering ? referral ? services ? in ? a ? police ? environment, ? including ?difficulties ?in ?establishing ?the ?credibility ?of ?the ?services ?among ?drug-???using ?arrestees ?and ?resolving ?tensions ?between ?police ?and ?drug ?referral ?workers.166,167 ? ?In ? recent ? years, ? efforts ? to ? cultivate ? police ? support ? for ? harm ? reduction ?programs ?have ?emerged ?in ?many ?countries ?where ?harm ?reduction ?was ?endorsed ?as ?a ?matter ?of ?policy ?or ?practice.166 ?Examples ?of ?these ?efforts ?include ?establishing ?formal ?partnerships ? between ? police ? and ? health ? agencies,168,169 ? instructing ? police ? to ? not ?interfere ?with ?health ?and ?harm ?reduction ?services,104,170 ?training ?police ?to ?understand ? ? 33 ?and ?support ?harm ?reduction ?programs,169,171,172 ?and ?allowing ?police ?officers ?to ?utilize ?their ? powers ? of ? discretion ? to ? support ?NSPs.166 ? Some ? of ? these ? interventions ? can ? be ?viewed ? as ? changing ? policing ? approaches ? from ? ?hot ? spot ? policing,? ? which ? relies ?solely ?on ?policing ?measures, ?to ??problem-???oriented ?policing,? ?which ?seeks ?to ?address ?problems ? in ? a ? given ? community ? through ? multi-???sector ? collaborations.110,168 ? In ? the ?United ?States, ?it ?was ?reported ?that ?police ?officers ?were ?generally ?misinformed ?about ?the ? legality ? of ? syringe ? purchasing ? and ? possession ? and ? were ? concerned ? about ?accidental ?needle ?sticks ? for ? themselves ?when ?arresting ? IDU.173 ? In ? response, ?a ?harm ?reduction ? training ? curriculum ? that ? addressed ? occupational ? safety ? issues ? was ?developed. ?The ?training ?was ?shown ?to ?significantly ?improve ?police ?attitudes ?toward ?syringe ?access.171,172 ?These ? reports ? suggest ? that ? exploring ?police ?officers? ?views ?and ?concerns ? about ?harm ? reduction ? interventions ? and ? tailoring ? training ? to ? address ? the ?identified ?barriers ? are ? important ? for ? changing ?policing ?practices ?on ? the ?ground. ?A ?positive ? result ? of ? such ? police-???public ? health ? cooperation ? was ? documented ? in ?Vancouver ?where ?the ?police ?facilitated ?the ?use ?of ?a ?supervised ?injection ?facility ?for ?IDU.105 ? This ? study ? indicates ? that ? increasing ? the ?modalities ? and ? coverage ? of ? health ?and ?harm ?reduction ?services ? in ?community ?settings ? is ?not ?only ? important ? in ? itself, ?but ?also ?for ?supporting ?effective ?police-???public ?health ?cooperation. ? ?Although ? the ? aforementioned ? police ? interventions ? have ? not ? always ? been ?evaluated, ? available ? data ? have ? pointed ? out ? various ? barriers ? to ? implementation, ?including ?staff ?turnover, ?inconsistent ?dissemination ?of ?harm ?reduction ?policy ?within ?the ?police ? force, ? variations ? in ?public ?perception ?of ? the ? role ? of ?police, ? and ?ongoing ?police ? corruption.82,166,168,174,175 ? In ? particular, ? reports ? from ?Vietnam ?documented ? that ?police ? officers ? perceived ? conflicting ? responsibilities ? as ? they ? were ? instructed ? to ?support ?harm ?reduction ?services ?and ?encourage ?drug ?users ?to ?access ?voluntary ?drug ?treatment ? while ? also ? being ? pressured ? to ? meet ? quotas ? for ? compulsory ? drug ? ? 34 ?detention.174,175 ?Observations ?from ?a ?cross-???border ?area ?of ?Vietnam ?and ?China ?where ?governments ?occasionally ?implement ?crackdowns ?on ?drug ?users ?indicated ?that ?fear ?of ?police ?was ?deeply ?entrenched ?in ?IDU ?and ?impeded ?IDUs? ?access ?to ?NSPs ?during ?crackdowns, ? even ? when ? the ? local ? police ? did ? not ? interfere ? with ? NSPs.170 ? These ?findings ?indicate ?that ?police ?training ?that ?attempts ?to ?align ?drug ?policing ?and ?public ?health ?goals ?may ?not ?be ? sufficient ? for ? reducing ? IDUs? ?vulnerability ? to ?poor ?health ?without ? broader ? structural ? changes, ? including ? abolishing ? compulsory ? drug ?detention. ?A ? number ? of ? countries ? are ? experimenting ? with ? alternative ? regulatory ?frameworks ? for ? illicit ? drugs, ? including ? decriminalization ? of ? personal ? drug ? use.101 ?While ? forms ? of ? decriminalization ? vary ? across ? jurisdictions,101 ? some ? schemes ? may ?remove ?criminal ?sanctions ?from ?personal ?drug ?use ?and ?create ?a ?legal ?framework ?for ?treating ?drug ?use ?as ?a ?public ?health ?problem, ?not ?a ?criminal ?one.176 ?Although ?not ?all ?forms ?of ?decriminalization ?schemes ?have ?been ?evaluated,101 ?emerging ?evidence ?from ?Portugal?where ? the ?possession ? of ? small ? quantities ? of ? drugs ? for ? personal ? use ? and ?the ? consumption ? of ? drugs ? has ? been ? considered ? an ? administrative ? offence, ? not ? a ?criminal ? offence, ? since ? 2001?suggests ? that ? this ? form ? of ? decriminalization ? of ?personal ? drug ? use ? has ? produced ? some ? positive ? results, ? including ? reductions ? in ?problematic ? drug ? use ? and ? increases ? in ? voluntary ? enrolment ? in ? drug ? treatment.177 ?Calls ? for ?decriminalization ?have ?also ?been ?put ? forward ?by ? the ?Global ?Commission ?on ? Drug ? Policy11?which ? includes ? former ? heads ? of ? state?and ? the ? UN ? Special ?Rapporteur ?on ?the ?right ? to ?health.178 ?As ?changes ? in ? the ??law ?on ?the ?books? ?are ?not ?necessarily ? followed ? by ? changes ? in ? the ? ?law ? on ? the ? street,?83 ? further ? research ? is ?needed ? to ? investigate ? how ? decriminalization ? has ? influenced ? drug ? policing ? and ? a ?given ?risk ?environment ?surrounding ?IDU. ?However, ?this ?type ?of ?broader ?structural ?change ?will ? likely ?serve ? to ?reduce ? the ?harm ?associated ?with ? incarceration ?and ?pre-??? ? 35 ?trial ? detention ? of ? IDU ? and ? may ? help ? promote ? evidence-???based ? drug ? treatment ?services ?and ?reduce ?stigma ?attached ?to ?illicit ?drug ?use. ? ? ?2.4 ?Discussion ? ? This ?review ?found ?that ?repressive ?drug ?policing ?can ?harm ?IDU ?directly ?and ?indirectly ? through ? multiple ? pathways. ? Within ? the ? Risk ? Environment ? Framework, ?street-???level ? drug ? policing ? is ? considered ? a ? key ? feature ? of ? the ? micro-???level ? social ?environment. ?This ? review ? identified ?a ?number ?of ? other ?micro-???, ?meso-???, ? and ?macro-???level ? risk ? environment ? factors ? that ? intersect ? with ? drug ? policing ? activities ? and ?produce ?harm ?to ?IDU. ?At ?the ?micro-???level, ?policing ?activities ?re-???shape ?drug ?markets ?and ? social ? and ? injecting ? networks ? of ? IDU ? (the ? social ? environment) ? and ? exert ?influence ?on ?locations ?where ?harm ?reduction ?and ?health ?services ?are ?provided ?and ?where ? individuals ? inject ? drugs ? (the ? physical ? environment). ? The ? meso-???level ?environmental ? factors ? that ? intersect ? with ? drug ? policing ? and ? increase ? IDUs? ?vulnerability ? to ? poor ? health ? include ? correctional ? facilities ? where ? IDU ? will ? be ?relocated ? as ? a ? result ? of ? policing ? activities ? (the ? physical ? environment), ? as ? well ? as ?accessibility ?of ?health ?and ?social ?services ?and ?the ?stigma ?attached ?to ?IDU ?(the ?social ?environment). ? The ? macro-???level ? structures ? that ? augment ? the ? production ? of ? drug-???related ?harm ?through ?drug ?policing ?include ?drug ?registration ?systems, ?compulsory ?drug ?detention ?systems, ?laws ?that ?deny ?welfare ?benefits ?to ?those ?convicted ?of ?drug ?offenses, ? laws ? that ? impose ? the ? death ? penalty ? for ? drug-???related ? offenses, ? drug ?paraphernalia ? laws ? that ? prohibit ? the ? sale, ? purchase, ? and ? possession ? of ? injection ?equipment, ? and ? laws ? and ? policies ? that ? undermine ? harm ? reduction ? programs ? in ?communities ?or ?correctional ?facilities. ?The ?health-???related ?harm ?that ?IDU ?experience ?as ? a ? result ? of ? repressive ? drug ? policing ? is ? diverse ? and ? includes ? physical ? and ?psychological ? injuries, ?perpetuation ?of ?drug ?use, ? acquisition ?of ? infectious ?diseases, ? ? 36 ?overdose, ? and ? deaths. ? These ? consequences ? also ? have ? harmful ? implications ? for ? the ?communities ?in ?which ?IDU ?live. ? ? ? While ?there ?is ?a ?large ?body ?of ?international ?literature ?on ?this ?topic, ?this ?review ?identified ? some ? gaps ? in ? knowledge. ? First, ? the ? majority ? of ? the ? reviewed ? studies ?tended ? to ? focus ? on ? the ? aggregate ? effects ? and ? consequences ? of ? police ? crackdowns ?rather ? than ? on ? specific ? policing ? tactics. ? Although ? some ? qualitative ? studies ? and ?human ? rights ? investigations ?have ? shed ? light ?on ? specific ?police ?actions ? that ? are ?not ?only ? unlawful ? but ? may ? also ? contribute ? to ? other ? drug-???related ? harm,69,112,117,118,129 ? a ?smaller ?number ?of ?quantitative ?studies ?examined ?the ?prevalence ?and ?effects ?of ?these ?police ?actions, ?including ?arrests ?for ?having ?syringes76 ?or ?needle ?marks125 ?and ?syringe ?confiscation ?by ?police.123 ?Other ? tactics ? that ?police ?may ?commonly ?employ ?were ?not ?fully ?evaluated. ?Examining ?the ?effects ?of ?specific ?police ?actions?and ?discerning ?the ?effects ? of ? lawful ? and ? unlawful ? police ? actions ? in ? particular?will ? be ? useful ? for ?identifying ?types ?of ?interventions ?required ?to ?mitigate ?the ?adverse ?impacts ?of ?drug ?policing ?on ?the ?health ?of ?IDU. ?In ?particular, ? if ?a ?lawful ?police ?action ?is ?found ?to ?be ?associated ? with ? IDUs? ? vulnerability ? to ? poor ? health, ? reforms ? of ? relevant ? laws ? and ?policies ?need ?to ?be ?discussed. ? ?Second, ?this ?review ?also ?suggests ?that ?combining ?scientific ?empirical ?research ?evidence ?with ?human ?rights ?norms ?and ?principles ?would ?enrich ?the ?literature ?in ?this ?field ?and ?render ? it ?more ?useful ? for ? informing ? the ?development ?of ?drug ?policy ?and ?programming.98,179 ? In ? recent ? years, ? there ? have ? been ? several ? statements ? at ? the ?international ? level ? that ? the ? protection ? and ? promotion ? of ? human ? rights ? need ? to ? be ?mainstreamed ? in ? both ? national ? and ? international ? drug ? policy.10,11 ?Accordingly, ? the ?UNODC ?has ?begun ?to ?develop ?a ?guide ?to ?integrate ?human ?rights ?principles ?in ?their ?work.91,180 ?However, ?public ?health ?researchers ?rarely ?consider ?human ?rights ?in ?their ?empirical ? research. ?The ?value ?of ?using ? internationally ?agreed ?human ? rights ?norms ? ? 37 ?includes: ? linking ? health ? issues ? directly ? with ? principles ? of ? equity ? and ? non-???discrimination; ? setting ? ethical ? standards ? for ? evaluating ? policing ? practices; ? and ?providing ? mechanisms ? to ? demand ? accountability ? for ? rights ? violations ? to ? national ?governments ?and ?human ?rights ?institutions ?within ?the ?UN.88-???90 ?While ?it ?is ?not ?to ?say ?that ? all ? public ? health ? researchers ? should ? incorporate ? human ? rights ? in ? their ? work, ?attention ?to ?human ?rights ?concerns ?gives ?an ?opportunity ?for ?researchers ?to ?generate ?empirical ? evidence ? that ?has ?both ?pragmatic ? and ?principled ? implications ? for ?policy ?and ?programming.98,179 ? ?Lastly, ?the ?findings ?of ?this ?review ?also ?indicates ?that ?more ?research ?is ?needed ?to ? evaluate ? the ? public ? health ? impacts ? of ? ongoing ? and ? emerging ? interventions ? that ?seek ? to ? align ? drug ? policing ? and ? public ? health ? goals. ? Likewise, ? the ? impacts ? of ? a ?broader ? structural ? change ? (e.g., ? decriminalization ? of ? personal ? drug ? use) ? on ? drug ?policing ?and ?public ?health ?need ?to ?be ?scrutinized. ?As ?some ?scholars ?have ?noted,181,182 ?evaluations ?of ?drug ?policing ?often ?focus ?on ??process? ?measures, ?such ?as ?numbers ?of ?arrests ? and ? seizure ? statistics, ? and ? not ? ?outcomes.? ? Although ? some ? measures ? to ?assess ?outcomes ?exist, ?they ?tend ?to ?focus ?on ?reductions ?in ?supply ?of ?illicit ?drugs ?(e.g., ?the ?UNODC ?Illicit ?Drug ?Index) ?or ?are ?meant ?to ?calculate ?the ?monetary ?value ?of ?harm ?that ?could ?be ?averted ?through ?seizing ?illicit ?drugs ?(e.g., ?the ?Australian ?Federal ?Police ?Drug ? Harm ? Index).183,184 ? Given ? the ? findings ? of ? this ? review ? showing ? multiple ?pathways ? through ?which ? drug ? policing ?may ? increase ? IDUs? ? vulnerability ? to ? poor ?health, ? evaluations ? of ? police ? interventions ? should ? also ? assess ? the ? reduction ? of ?vulnerability ?to ?drug-???related ?harm. ? ?In ? summary, ? this ? review ? identified ?numerous ?ways ? in ?which ?drug ?policing ?produces ?health-???related ?harm ?among ?IDU. ?Although ?a ?vast ?amount ?of ?international ?literature ?exists ?in ?this ?field, ?future ?research ?should ?examine ?the ?impacts ?of ?specific ?policing ?tactics ?on ?the ?health ?of ?IDU, ?generate ?more ?empirical ?evidence ?elucidating ? ? 38 ?the ? link ? between ? human ? rights ? concerns ? and ? health ? outcomes, ? and ? evaluate ?emerging ?efforts ?to ?align ?drug ?policing ?and ?public ?health ?goals. ? ? ? ? ? ? ? ? ? ? ? ? ? ?  ? ? 39 ?CHAPTER ?3: ??HELP ?WITH ?THE ?NATION?: ?EXPERIENCES ?WITH ?DRUG ?POLICING ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?3.1 ?Introduction ?As ?described ?in ?section ?1.2, ?Thailand ?has ?been ?contending ?with ?longstanding ?dual ? epidemics ? of ? illicit ? drug ? use17 ? and ? HIV/AIDS ? among ? IDU.61 ? The ? Thai ?government ?has ? regarded ? the ?widespread ?use ?of ? illicit ?drugs ?as ?a ??national ? crisis? ?and ?called ?upon ?all ? sectors ?of ? society ? to ?unite ?as ?a ??national ? force? ? to ? combat ? this ?crisis.44 ? Although ? the ? 2002 ? Narcotic ? Addict ? Rehabilitation ? Act ? B.E. ? 2545 ? reclassified ?people ? who ? use ? drugs ? as ? ?patients? ? instead ? of ? ?criminals,? ? possession ? and ?consumption ?of ?illicit ?drugs ?remain ?criminal ?offenses.26 ?Further, ?the ?new ?legislation ?created ? a ? system ? of ? compulsory ? drug ? detention ? centres ? (referred ? to ? as ? bangkap ?bambat ?or ??forced ?treatment?) ?where ?those ?charged ?with ?illicit ?drug ?use ?are ?confined ?and ?said ?to ?undergo ??rehabilitation?. ?However, ?the ?majority ?of ?these ?centres ?are ?run ?by ? the ? military ? and ? lack ? evidence-???based ? addiction ? treatment ? services.27 ? Recently, ?these ? centres ? have ? attracted ? strong ? criticism, ? as ? twelve ? UN ? agencies ? urged ?governments ?around ?the ?world ?to ?close ?down ?such ?centres.29	 Since ? the ? launch ? of ? the ? compulsory ? drug ? detention ? system, ? the ? Thai ?government ?has ? implemented ?a ?series ?of ?police ?crackdowns ?focused ?on ?illicit ?drug ?use ?and ?expanded ?this ?system.27 ?Most ?notably, ?in ?2003, ?a ?three-???month ??war ?on ?drugs? ?campaign ?was ?launched ?to ?supress ?drug ?trafficking ?and ?to ?enrol ?300,000 ?drug ?users ?into ?treatment, ?mostly ?through ?compulsory ?drug ?detention. ?Being ?pressured ?to ?meet ?mandatory ?arrest ?quotas ?and ?encouraged ?to ?use ??harsh? ?means ?during ?arrests, ? the ?police ? reportedly ? engaged ? in ? abusive ? practices, ? including ? more ? than ? 2,800 ?extrajudicial ?killings ?of ?suspected ?drug ?dealers ?and ?users.22,48 ?Between ?2008 ?and ?2011, ?the ?national ?drug ?policy ?was ?revised ?several ?times, ?and ?the ?number ?of ?people ?who ? ? 40 ?use ?drugs ?targeted ?to ?undergo ?rehabilitation ?programs ?increased ?from ?60,000 ?in ?2008 ?to ? 400,000 ? in ? 2011.41-???44 ? Although ? the ? policy ? emphasizes ? voluntary ? access ? to ? drug ?treatment, ?compulsory ?drug ?detention ?centres ?remain ?the ?principal ?means ? to ?enrol ?people ?who ?use ?drugs ? in ? treatment. ? In ? 2010, ? over ? 60% ?of ? those ? in ?drug ? treatment ?were ? placed ? in ? such ? centres.39 ? Between ? September ? 2011 ? and ? August ? 2012, ? the ?number ? of ? drug-???related ? arrests ? increased ? by ? 14% ? compared ? to ? the ? previous ? year, ?and ?more ?than ?330,000 ?persons ?were ?arrested.45 ? ?Despite ? concern ? that ? recent ? drug ? policy ? developments ?may ? have ?marked ? a ?return ?to ?the ?old ?drug ?war,67,185 ?few ?studies ?have ?investigated ? ?current ?drug ?policing ?practices ?in ?Thailand. ?In ?addition, ?although ?a ?considerable ?number ?of ?public ?health ?evaluations ? of ? aggressive ? drug ? policing ? have ? been ? undertaken ? in ? other ?countries,69,73,74,85,118 ? it ? is ? unknown ? to ? what ? extent ? these ? findings ? are ? applicable ? to ?Thailand, ?given ?that ?the ?legal, ?structural, ?and ?social ?environment ?surrounding ?drug ?use ?differs ? considerably ?across ? settings. ?Therefore, ? this ?qualitative ? study ?sought ? to ?examine ? IDUs? ? recent ? experiences ? with ? drug ? policing ? in ? Bangkok, ? Thailand. ? Our ?specific ? study ? objectives ? were ? to ? characterize ? the ? circumstances ? and ? social ? and ?structural ? factors ? leading ? to ? encounters ? of ? IDU ? with ? the ? police, ? and ? to ? identify ?policing ? tactics ?employed ?during ? these ?encounters ?as ?well ?as ? the ?associated ?health ?consequences. ?3.2 ?Methods ?A ? qualitative ? descriptive ? approach186 ? was ? the ? methodological ? orientation ?underlying ? the ? study. ? Acknowledging ? that ? qualitative ? descriptive ? designs ? are ?typically ? an ? eclectic ? combination ? of ? various ? methods,186 ? this ? study ? employed ? a ?constant ? comparison ? analysis ? that ? is ? central ? to ? grounded ? theory187 ? to ? generate ?knowledge ?about ?common ?patterns ?and ?themes ?within ?respondents? ?experiences. ? ? 41 ?Qualitative ?data ? for ? this ? study ?were ?generated ? through ? in-???depth ? interviews ?with ?IDU ?participating ?in ?the ?Mitsampan ?Community ?Research ?Project, ?as ?described ?in ? detail ? in ? section ? 1.6. ? In ? brief, ? this ? study ? was ? conducted ? as ? part ? of ? the ? larger ?qualitative ? study ? that ? sought ? to ? explore ? IDUs? ? experiences ? with ? drug ? policing, ?compulsory ? drug ? detention ? centres, ? and ? access ? to ?HIV ? testing ? and ? care. ? Between ?July ?2011 ?and ?June ?2012, ?potential ?respondents ?were ?recruited ?from ?the ?concurrent ?quantitative ?arm ?of ?the ?project188 ?as ?well ?as ?through ?peer-???based ?outreach ?efforts ?and ?word-???of-???mouth, ?and ?were ?invited ?to ?attend ?the ?MSHRC ?or ?O-???Zone ?House ?in ?order ?to ?participate ?in ?the ?study. ?Adults ?residing ?in ?Bangkok ?or ?in ?adjacent ?provinces ?who ?had ?injected ?drug(s) ?in ?the ?past ?six ?months ?were ?eligible ?for ?participation. ?Sampling ?methods ?were ?purposive, ? and ? efforts ?were ?made ? to ? attain ? balance ? in ? age, ? gender, ?and ?HIV ?seropositivity ?and ?to ?recruit ?individuals ?who ?had ?encounters ?with ?police ?in ?the ? past ? three ? years ? and/or ? those ? who ? had ? been ? in ? compulsory ? drug ? detention ?centres ?in ?the ?past ?five ?years. ?As ?described ?in ?section ?1.6.3, ?two ?bilingual ?Thai ?research ?assistants ?(including ?the ?study?s ?fourth ?author, ?SH) ?were ?trained ?by ?the ?study?s ?first ?and ?last ?authors ?(KH ?and ? TK) ? to ? conduct ? in-???depth ? interviews ? in ? Thai ? based ? on ? a ? semi-???structured ?interview ?guide ?that ?the ?first ?author ?developed ?with ?guidance ?from ?her ?supervisors ?and ? research ?partners. ?With ? regard ? to ? encounters ?with ?police, ? the ? interview ?guide ?sought ? to ? elicit ? discussions ? about: ? under ? what ? circumstances ? police ? approached ?respondents; ? police?s ? search-???and-???arrest ? procedures ? during ? the ? most ? recent ?encounters ?with ?police; ?any ?negative ?and ?positive ?experiences ?with ?police; ?how ?the ?police ?identify ?and ?detain ?drug ?users ?in ?general; ?respondents? ?reactions ?to ?any ?police ?misconduct ? and ? abuse; ? the ? impacts ? of ? drug ? policing ? on ? respondents? ? drug ? use ?patterns, ? healthcare ? access, ? and ? daily ? lives. ? All ? respondents ? provided ? informed ? ? 42 ?consent ?and ?were ?interviewed ?by ?two ?Thai ?interviewers. ?Interviews ?lasted ?between ?40 ?and ?90 ?minutes ?and ?were ?audio-???recorded. ?The ?data ?collection ?and ?analysis ?followed ?an ?iterative ?process: ?throughout ?the ?data ?collection ?process, ?the ?research ?team ?discussed ?the ?content ?of ?interview ?data ?as ?well ? as ? the ? focus ? and ? direction ? of ? subsequent ? interviews. ? Data ? collection ? was ?continued ? until ? data ? reached ? a ? point ? of ? data ? saturation ? (i.e., ? new ? respondents? ?narratives ?kept ?reiterating ?the ?same ?points). ? ?All ? audio-???recorded ? interviews ? were ? transcribed ? verbatim ? in ? Thai ? and ?translated ?into ?English. ?The ?bilingual ? interviewers ?who ?have ?developed ?familiarity ?with ?terms ?used ?among ?local ?IDU ?reviewed ?the ?translated ?transcripts ?for ?accuracy. ?Further, ?a ?native ?English-???speaking ?proof-???reader ?with ?an ?excellent ?knowledge ?of ?both ?Thai ?and ?English ?also ?verified ?the ?English ?transcripts ?for ?grammatical ?accuracy ?and ?nuance ?by ?comparing ?the ?English ?transcripts ?with ?Thai ?transcripts ?and ?audio-???files. ? ?In-???depth ? interview ? data ? were ? analysed ? to ? identify ? the ? circumstances ? and ?situational ? factors ? surrounding ? and ? leading ? to ? police ? encounters ? as ? well ? as ? to ?identify ? and ? analyse ? policing ? tactics ? employed ? during ? these ? interactions, ?particularly ?with ?respect ?to ?international ?human ?rights ?norms ?for ?policing. ?We ?also ?analysed ?respondents? ?actions ?and ?behaviours ?after ? the ?police ?encounters, ?and ?any ?subsequent ? health ? consequences. ? All ? data ?were ? entered ? into ?Atlas.ti ? (version ? 6.2), ?software ?designed ?to ?assist ?qualitative ?data ?management ?and ?analyses. ?Data ?analysis ?was ?informed ?by ?the ?Risk ?Environment ?Framework,79,80 ?which ?posits ?that ?a ?range ?of ?social, ? political, ? economic, ? and ? physical ? environmental ? factors ? interact ? each ? other ?and ?shape ?the ?production ?of ?drug-???related ?harm. ?Given ?that ?the ?past ??war ?on ?drugs? ?campaign ? resulted ? in ? numerous ? human ? rights ? abuses ? in ? this ? setting, ? the ? analysis ?was ?also ?informed ?by ?the ?work ?of ?J?rgens ?et ?al.,98 ?which ?asserts ?that ?rights ?violations ?also ?constitute ?core ?features ?of ?risk ?environments ?surrounding ?drug ?use. ? ? ? 43 ?Data ? analysis ? was ? conducted ? inductively, ? employing ? a ?multi-???step ? thematic ?analysis. ?On ? the ? first ? pass, ? the ? primary ? author ? created ? an ? initial ? set ? of ? codes. ? The ?initial ? codes ? included ? the ? time ?and ?place ?of ?one?s ? encounters ?with ?police, ?ways ? in ?which ? police ? officers ? approached ? respondents, ? the ? nature ? of ? the ? police ? actions, ?reporting ?of ?police ?misconduct ?to ?local ?authorities, ?and ?changes ?in ?the ?respondent?s ?behaviour ?due ? to ?police ?activities. ?Subsequent ?reviews ? involved ?refining ? the ?codes ?and ? assigning ? data ? segments ? to ? categories ? with ? substantive ? input ? from ? other ? co-???authors. ? The ? analysis ? considered ? the ? range ? and ? diversity ? of ? respondents? ?experiences, ?as ?well ?as ?negative ?evidence ?in ?each ?category ?of ?experience. ?According ?to ? the ?modified ? Risk ? Environment ? Framework ? described ? in ? section ? 1.4, ? the ? codes ?indicating ?factors ?surrounding ?and ?leading ?to ?police ?confrontations ?and ?influencing ?respondents? ? behaviour ?were ? categorized ? as ? individual ? characteristics, ?micro-??? ? and ?meso-???level ? social ? and ? environmental ? factors, ? and ? macro-???level ? structures. ? Police ?actions ? were ? labelled ? as ? lawful ? or ? unlawful ? and ? analysed ? with ? respect ? to ?international ?human ?rights ?norms ?for ?policing. ?Finally, ?the ?data ?were ?grouped ?into ?three ? parts ? in ? chronological ? order: ? circumstances ? of ? police ? confrontations, ? police ?violence ?and ?misconduct, ?and ?IDUs? ?reactions ?to ?drug ?policing ?practices. ?3.3 ?Results ?In ?total, ?42 ?IDU ?were ?interviewed ?for ?this ?study, ?including ?17 ?(40.5%) ?women. ?The ? median ? age ? was ? 35.5 ? years ? (range: ? 23 ? ? ? 52 ? years). ? Table ? 1 ? summarizes ? the ?respondents? ?demographic ? characteristics, ?drug-???using ?behaviour, ?and ?self-???reported ?HIV ?status. ?All ?respondents ?reported ?interactions ?with ?police ?during ?the ?three ?years ?before ?the ?interviews. ? ?As ? presented ? in ? sections ? 3.3.1?3, ? various ? factors ? surrounding ? and ? leading ? to ?police ? confrontations ? have ? been ? identified ? from ? respondents? ? accounts. ? In ? brief, ?macro-???structural ? factors ? that ? appeared ? to ? shape ?police ? activities ? included ? the ? 2011 ? ? 44 ?state-???sponsored, ? large-???scale ? police ? crackdown; ? changes ? in ? drug ? laws ? that ? enabled ?police ?officers ?to ?use ?rapid ?urine ?drug ?testing; ?the ?deployment ?of ?civil ?volunteers ?in ?drug ?policing; ?and ?the ?focus ?on ?young ?people, ?as ?stated ?in ?drug ?policy ?documents. ?The ?meso-???level ?social ?and ?environmental ?factors ?that ?characterized ?the ?respondents? ?experiences ?with ?police ? included ?police ? corruption, ? financial ? incentives ?within ? the ?police, ?and ?strategic ?police ?surveillance ?(e.g., ?focusing ?on ??red ?zones?). ?Other ?meso-???level ?social ?factors ?were ?identified ?as ?significant ?barriers ?to ?seeking ?justice, ?including ?a ? lack ?of ? confidence ? in ? the ? rule ? of ? law ?and ?poor ? availability ? of ? legal ? services. ?The ?micro-???level ? social ? and ? environmental ? factors ? included ? intense ? police ? surveillance ?near ?methadone ?clinics, ?as ?well ?as ?by ?civil ?volunteers. ?Respondents ?perceived ?some ?individual ?characteristics?including ?being ?young ?and ?having ?criminal ?records?as ?increasing ?one?s ?chance ?of ?being ?approached ?by ?the ?police. ?Respondents? ?narratives ?indicated ?that ?many ?of ?these ?factors ?interacted ?with ?each ?other ?and ?often ?resulted ?in ?severe ?human ?rights ?abuses. ?Respondents? ?reactions ?to ?policing ?were ?also ?shaped ?by ?the ? multiple ? levels ? of ? social, ? structural ? and ? environmental ? factors, ? and ? they ?increased ?vulnerability ?to ?poor ?health ?through ?various ?pathways. ? ? ? ? ?3.3.1 ?Circumstances ?of ?police ?confrontations ? ? Respondents ? noted ? that ? drug ? policing ? during ? the ? past ? three ? years ? was ?experienced ? as ? recurrent ? waves ? of ? crackdowns ? on ? people ? who ? use ? drugs. ? It ? was ?reported ? that ? policing ? activities ? had ? noticeably ? intensified ? since ? rapid ? urine ?toxicology ?screening ?became ?widely ?available ?to ?police. ? ?R: ? ?[The ?police] ?have ?become ?more ?repressive ?these ?days. ?Now ?they ? insist ?on ?urine ? testing! ? In ? the ?past, ?all ? they ?did ?was ? to ?check ? our ? arms ? to ? see ? if ?we ? had ? needle ?marks. ?Okay, ? that?s ?like ?red-???handed. ?But ?now ?they ?can ?arrest ?us ?for ?having ?drugs ?in ? our ? body. ? Is ?my ?urine ? illegal ? now? ? Isn?t ? this ? too ?much? ?(Respondent ?#27, ?female, ?age ?32) ? ? ? 45 ?Respondents ? also ? perceived ? greater ? police ? pressure ? since ? the ? government ?initiated ? a ? large-???scale ? crackdown ? on ? drug ? users ? in ? 2011.189 ? In ? particular, ? the ? local ?police ?appeared ? to ?be ?pressured ? to ?make ?arrests ? towards ? the ?end ?of ? the ?year ?2011 ?when ?they ?needed ?to ?submit ?the ?arrest ?records ?to ?the ?authority. ?	 R: ?Towards ? the ? end ? of ? the ? year ? [2011], ? the ? police ? needed ? to ?submit ?records ?to ?higher-???ups, ?right? ?So, ?they ?wanted ?to ?look ?impressive. ?This ?police ?officer ?knew ?us ?for ?long ?time. ?He ?came ?to ?us ?and ?said, ??Hey! ?You ?come ?help ?with ?the ?nation!? ?Then, ?he ?put ?us ?in ?a ?jail ?for ?nothing ?for ?a ?week. ?He ?said ?it ?was ?for ?the ?nation. ?(Respondent ?#35, ?female, ?age ?50) ? ? ? During ?the ?2003 ??war ?on ?drugs? ?campaign, ?the ?police ?had ?to ?fill ?arrest ?quotas ?and ?were ?rewarded ?for ?making ?drug-???related ?arrests.22 ?Although ?it ?is ?unknown ?from ?publicly ?available ? information ?whether ?mandatory ?arrest ?quotas ?were ?still ? in ?place ?under ? the ? subsequent ? drug ? policies, ? according ? to ? the ? ONCB ? (Sirisabphaya ? A, ?written ?communication, ?April ?2013), ?a ?cash ?reward ?system ?does ?remain ?in ?place ?for ?confiscation ? of ? drugs. ? Respondents ? suggested ? that ? financial ? incentives ? stimulated ?the ?police ?to ?make ?drug-???related ?arrests. ? ?R: ?There ? is ? a ? price ? on ? each ? person?s ? head. ? It?s ? like ? a ? quota ?coming ? down ? to ? each ? police ? station. ? And ? they ? get ? money ?when ?they ?make ?an ?arrest ?? ?It?s ?their ?system. ?I ?really ?don?t ?think ? it?s ? right. ? It?s ? just ? for ? the ?money. ?  ? (Respondent ? #16, ?male, ?age ?35) ? ? ? Respondents ? described ? various ? overt ? and ? covert ? surveillance ? methods ?employed ?by ?police ?officers ?to ?identify ?drug ?users. ?Many ?police ?officers ?reportedly ?wore ? plain ? clothes ? at ? work. ? Some ? respondents ? also ? reported ? that ? ONCB ? officials ?engaged ? in ? arresting ? drug ? dealers. ?Although ? the ?majority ? of ? respondents ? claimed ?they ?could ?immediately ?identify ?a ?plain-???clothes ?officer ?by ?his/her ?appearance, ?some ?respondents ? reported ? confusion ? because ? these ? plain-???clothes ? officers ? sometimes ? ? 46 ?demanded ?a ?search ?without ?identifying ?themselves ?as ?police, ?and ?at ?the ?same ?time ?would ?not ?show ?identification ?when ?asked. ? ?One ?account ?noted ?that ?in ?this ?situation ?an ?unscrupulous ?person ?could ?pretend ?to ?be ?a ?policeman ?and ?position ?himself ?to ?rob ?an ?IDU. ? R: ?When ?I ?was ?at ?a ?methadone ?clinic, ?three ?young ?guys ?came ?to ?me ? and ? said, ? ?Won?t ? you ? sit ? down ? and ? talk ? to ? the ? police?? ?They ? were ? actually ? new ? police ? officers ? that ? I?d ? never ? seen ?before. ?So, ?I ?asked, ??Sit ?down ?for ?what? ?Can ?I ?see ?your ?ID?? ?Then, ? they ? said, ? ?Hah! ? Are ? you ? a ? smart ? ass?? ? I?d ? met ?someone ?who ?pretended ?to ?be ?a ?police ?officer ?and ?robbed ?me ?of ?some ? stuff. ? That?s ?why ? I ? asked ? for ? ID. ? But ? he ? said ? I ?was ? a ?smart ?ass! ? ?(Respondent ?#24, ?male, ?age ?46) ? ? ? One ? of ? the ?most ? frequently ? cited ?police ? surveillance ?methods ?was ? roadside ?checkpoints. ?These ?checkpoints ?were ?set ?up ?in ?diverse ?locations ?at ?various ?times ?but ?were ?most ? common ? at ? night ? and ? in ? ?red ? zones,? ?which ? denote ? districts ? in ?which ?many ? drug ? dealers ? and ? users ? are ? believed ? to ? congregate, ? including ? ?slum-???like ?neighbourhoods? ?(respondent ?#1, ?male, ?age ?37). ?R: ? ?These ?days ?the ?police ?have ?increased ?their ?efforts ?to ?find ?and ?arrest ? us. ?My ?place ? is ? in ? a ? red ? zone. ? It?s ? a ? dangerous ? zone. ?They ? put ? up ? campaign ? signs ? and ? often ? set ? up ? checkpoints. ?(Respondent ?#15, ?male, ?age ?43) ? ? Police ? surveillance ? was ? also ? reported ? to ? be ? common ? around ? methadone ?clinics, ?presumably ?to ?take ?advantage ?of ?the ?volume ?of ?drug ?users ?coming ?and ?going ?from ?these ?venues. ?Several ?patients ?in ?methadone ?treatment ?reported ?that ?the ?police ?threatened ?to ?send ?them ?to ?compulsory ?drug ?detention ?centres: ?R: ? ?After ? taking ?methadone, ? I ?was ? sitting ? in ? front ? of ? the ? clinic ?with ?my ?friends. ?Then, ?3-???4 ?police ?officers ?came, ?saying ??Hey, ?you! ?Come ?over ?here! ?If ?we ?find ?drugs ?in ?your ?urine, ?what ?do ?you ? want ? us ? to ? do?? ? I ? said, ? ?Sir, ? you ? can?t ? find ? anything ?because ?we ?don?t ?use ?yaba ?or ?ice ?[i.e., ?methamphetamines]. ? ? 47 ?We?re ?patients ?taking ?methadone ?everyday.? ?Then, ?they ?said, ??If ?your ?urine ?comes ?out ?positive, ?you?ll ?be ?sent ?to ??treatment? ?[i.e., ?compulsory ?drug ?detention ?centres] ?right ?away!? ?So, ?I ?said, ??Such ??treatment? ?can?t ?treat ?drug ?users.? ?Then, ?they ?said, ??Bastard! ?You ?think ?you?re ?a ?smart ?ass?? ?(Respondent ?#25, ?male, ?age ?41) ? ? Respondents ?perceived ?that ?several ? individual ?factors ?made ?them ??look ?like ?drug ?users? ?or ?otherwise ?increased ?the ?chance ?of ?being ?subjected ?to ?stop-???and-???search ?procedures ?by ?the ?police. ?These ?factors ?included ?being ?known ?to ?the ?local ?police ?as ?a ?drug ?user ?(e.g., ?those ?with ?criminal ?records), ?being ?young, ?having ?visible ?tattoos ?or ?needle ?marks, ?and ? looking ?nervous. ?Many ?respondents ?shared ?a ?belief ? that ? tattoos ?signified ? that ? a ? person ? had ? been ? in ? prison ? and ? were ? indicative ? of ? being ? a ? drug ?offender. ? ? I: ? Why ? do ? you ? think ? the ? police ? stopped ? you ? three ? times ? in ? a ?month? ?R: ?I ?have ? lots ?of ? tattoos. ?The ?police ? like ? to ?keep ?an ?eye ?on ?guys ?with ? tattoos. ? ?People ? think ? we?ve ? been ? in ? prison. ? Good ?people ? don?t ? have ? tattoos. ? Only ? ex-???cons ? do! ? (Respondent ?#13, ?male, ?age ?36) ? ? In ? addition ? to ? roadside ? stop-???and-???search ? surveillance, ? police ? often ? relied ? on ?information ?supplied ?by ?drug ?users ?or ?local ?residents ?to ?identify ?potential ?offenders. ?For ? example, ? some ? respondents ? were ? forced ? by ? police ? to ? identify ? known ? drug ?dealers ? (?to ? be ? a ? finger ? for ? the ? police?). ? However, ? all ? of ? them ? reported ? that ? they ?refused ?to ??be ?a ?finger? ?out ?of ?fear ?of ?retaliation ?and ?distrust ?from ?drug ?dealers ?and ?other ?drug ?users. ? ?R: ?[The ?police ?officer] ?also ?wanted ?me ?to ?be ?a ??finger? ?for ?him. ?If ?I ?did ?that, ?he ?would ?let ?me ?go. ?It ?was ?like ?an ?exchange. ?So, ?I ?said ? that ? I?d ?give ?him ? information ?on ?where ? the ?drug ?dealer ?lived. ?But ?I ?didn?t ?give ?him ?real ?information. ?I ?just ?randomly ? ? 48 ?picked ? a ? house ? in ? the ? neighbourhood. ? (Respondent ? #35, ?female, ?age ?50) ? ?As ?the ?Thai ?drug ?authorities ?have ?ordered ?local ?authorities ?to ?engage ?civilians ?in ? identifying ?people ?who ?use ?drugs,31,35,39,44 ? respondents? ? narratives ? indicated ? that ?anyone ? in ? the ? neighbourhood ? could ? be ? ?a ? finger ? for ? the ? police.? ? Also, ? it ? was ?reported ?that ?during ?crackdowns, ?local ?residents ?volunteered ?to ?assist ?police ?officers ?with ?finding ?drug ?offenders. ? ?R: ? ?I ? was ? standing ? on ? a ? street, ? waiting ? for ? the ? stuff ? [drugs]. ?Then, ? a ? big ? bus ? drove ? by. ? There ? were ? about ? 10 ? police ?volunteers ? in ? there. ? They ? said, ? ?Stay ? still! ? Don?t ? move!? ?Then, ?they ?took ?me ?to ?a ?police ?station ?to ?do ?a ?urine ?test. ?I: ? But ?they ?weren?t ?police ?officers, ?were ?they? ?Why ?did ?you ?feel ?that ?you ?had ?to ?follow ?them? ? ?R: ?They ? were ? locals ? and ? called ? themselves ? volunteers. ? And ? it ?was ? a ? crackdown. ? I ? already ? knew ? how ? it ? would ? go. ?(Respondent ?#30, ?female, ?age ?33) ? ?One ?consequence ?of ?being ?identified ?by ?the ?local ?police ?as ?a ?drug ?user ?was ?a ?police ?raid ?on ?one?s ?home, ?sometimes ?after ?midnight. ?Respondents ?who ?were ?raided ?in ?their ?homes ?tended ?to ?experience ?it ?more ?than ?once. ?R: ??They ?know ?where ?I ? live! ?They ?know ?they ?will ?get ?me. ?So, ?they ? keep ? coming? ? I?m ? scared. ? I ? was ? sent ? to ? prison ? eight ?times! ?I ?don?t ?wanna ?go ?there ?again. ?I?ve ?never ?been ?arrested ?outside ?my ?house. ?They ?always ?get ?me ?at ?my ?house. ? ?I: ? Why ?do ?the ?police ?come ?to ?your ?house ?so ?often? ?R: ?It ?could ?be ?because ?some ?people ?reported ?on ?me. ?I ?don?t ?know. ?But ?when ?they ?come, ?they ?say, ??People ?reported ?on ?you. ?So, ?we ?are ?here ?to ?arrest ?you!? ??Some ?people ?in ?my ?community ?love ?me, ? but ? others ? hate ?me. ? (Respondent ? #17, ?male, ? age ?23) ? ? ?R: ??5-???6 ?undercover ?police ? officers. ?They ? came ? at ?night. ? I ?was ?going ?to ?bed ?at ?that ?time. ?They ?break ?in ?whenever ?they ?want! ?They ?even ?climbed ?over ?the ?wall! ? ? 49 ?I: ? They ? weren?t ? wearing ? a ? uniform, ? right? ? Weren?t ? you ?surprised ?at ?having ?5-???6 ?strangers ?climbing ?into ?your ?house? ?Didn?t ?you ?think ?that ?they ?were ?thieves? ?R: ?Thieves ?wouldn?t ?climb ?into ?my ?house. ?But ?the ?police ?would ?do. ?So, ?I ?knew ?they ?had ?to ?be ?the ?police. ?I: ? When ?they ?came ?in, ?what ?did ?they ?say? ?R: ?They ?just ?told ?me ?to ?put ?on ?my ?clothes ?and ?come ?with ?them ?to ? the ? police ? station ? to ? do ? a ? urine ? test. ?  ? (Respondent ? #18, ?male, ?age ?29) ? 3.3.2 ?Police ?violence ?and ?misconduct ?Respondents ?described ?various ? forms ?of ?police ?violence ?and ?misconduct ? that ?they ? experienced ? first-???hand. ? Some ? respondents ? known ? to ? local ? police ? officers ? as ?drug ?users ?reported ?that ?they ?were ?coerced ?into ??helping? ?the ?country ?by ?admitting ?guilt ?to ?false ?charges. ? ?R: ?They ? said, ? ?Help ? with ? the ? nation ? with ? some ? work! ? What ?charge ?do ?you ?want?? ?I: ? Did ?they ?find ?any ?drugs ?on ?you ?when ?they ?said ?that? ?R: ?No! ?But ?I ?knew ?what ?charge ?I ?should ?go ?for. ?So, ?I ?picked ?the ?one ?with ?the ?minimum ?sentence. ? ?I: ? Did ?they ?let ?you ?pick ?a ?light ?charge? ?R: ?Mostly ?they ?do, ?because ?that ?way, ?they ?can ?arrest ?you ?again ?after ?you?ve ?been ?released. ?(Respondent ?#26, ?male, ?age ?36) ? ?Many ? respondents ? reported ? that ? police ? would ? immediately ? search ? their ?bodies ? or ? belongings, ? often ? in ? degrading ?ways. ? Possession ? of ? drug ? paraphernalia ?was ? experienced ?by ? some ? respondents ? as ? grounds ? for ? arrest, ? despite ? the ?National ?Police ?Office?s ?memorandum ?instructing ?that ?it ?should ?not ?be ?done.157 ?In ?the ?absence ?of ? illicit ? drugs ? or ? drug ? paraphernalia, ? respondents ? were ? often ? forced ? to ? undergo ?urine ?toxicology ?testing. ?Stop-???and-???search ?and ?drug ?testing ?procedures ?typically ?took ?place ?in ?public ?places, ?which ?some ?respondents ?felt ?caused ?unnecessary ?humiliation: ? ? ? 50 ?R: ? ?There ?were ?people ?walking ?around. ?They ?wanted ?me ?to ?pee ?in ?a ? corner. ? There ? was ? nowhere ? to ? hide. ? Isn?t ? that ? nasty? ? It?s ?not ?at ?all ?proper. ?They ?could ?have ?let ?me ?find ?a ?more ?discreet ?place. ?Passers-???by ? looked ? at ?me ? and ? knew ?what ? I ?was ? doing. ?Women ?giggled. ?(Respondent ?#10, ?male, ?age ?35) ? ?R: ?First, ? [two ? male ? police ? officers] ? searched ? inside ? my ? bag. ?There ?was ?nothing ?in ?it. ?Then, ?they ?told ?me ?to ?take ?off ?my ?bra, ?right ? in ? front ? of ? the ? Soi ? [i.e., ? street]! ? (Respondent ? #29, ?female, ?age ?23) ? ?A ? number ? of ? respondents ? reported ? that ? police ? attempted ? to ? extort ? money ?from ? them, ? particularly ? when ? the ? results ? of ? drug ? testing ? were ? positive. ? In ? many ?cases, ? the ?respondents ?were ?presented ?with ?an ?opportunity ?to ?provide ?a ?bribe ?and ?negotiate ? with ? police ? for ? lighter ? charges ? or ? avoid ? the ? charge ? altogether. ? The ?negotiation ?was ?initiated ?by ?either ?the ?person ?detained ?or ?the ?police, ?who ?may ?cite ?a ?specific ?monetary ?value ?or ?goods ?(e.g., ?a ?bottle ?of ?whiskey) ?in ?return ?for ?a ?bribe. ? ?R: ?They ?asked, ??How ?much ?money ?do ?you ?have?? ?I ?asked, ??Will ?a ?thousand ?do?? ?They ?said, ??Two ?thousand.? ?So ?I ?gave ?them ?2,000 ?baht ?[i.e., ?approximately ?US$ ?66]. ?Then ?they ?told ?me ?to ?fill ?out ?a ?form ?saying ?that ?I ?was ?arrested ?for ?not ?carrying ?my ? driver?s ? licence. ? Because ? they ? brought ? me ? to ? the ? police ?station, ?they ?had ?to ?charge ?me ?with ?something. ?(Respondent ?#21, ?male, ?age ?30) ? ?R: ?If ?your ?urine ?turns ?purple, ?but ?you ?have ?money ?and ?want ?to ?negotiate ?with ?them, ?the ?urine ?is ?magically ?no ?longer ?purple. ?This ?is ?what ?happens ?in ?most ?cases. ?(Respondent ?#1, ?male, ?age ?37) ? ? When ? the ? results ? of ? drug ? testing ?were ? negative, ? several ? respondents ? stated ?that ? they ?were ? falsely ? accused, ? had ? evidence ? planted ? on ? them ? by ? police, ? or ?were ?coerced ? into ? confessing ? to ? a ? crime ? that ? they ? did ? not ? commit ? (e.g., ? theft). ? Some ? ? 51 ?respondents ?reported ?that ?they ?were ?compelled ?to ?sign ?a ?blank ?sheet ?and ?were ?not ?informed ?of ?the ?charges ?they ?faced ?until ?at ?a ?later ?stage. ? ?R: ? He ? just ? handed ? me ? a ? letter ? to ? sign. ? I ? thought ? it ? was ?paperwork ? for ?a ?urine ?test. ?Then ?he ?said, ??Here! ?The ?charge ?has ? been ? changed ? from ?drug ?use ? to ? stealing. ?Otherwise ? you ?would ? have ? been ? sent ? away ? for ? a ? long ? time ? this ? time. ? You ?wouldn?t ?have ?the ?money ?to ?bail ?yourself ?out. ?Just ?think ?of ?it ?as ? a ? favour. ? Or ? do ? you ? want ? me ? to ? charge ? you ? with ?something ?heavier?? ?(Respondent ?#27, ?female, ?age ?32) ? ?Excessive ? use ? of ? force ? was ? also ? reported ? as ? another ? means ? frequently ?employed ?by ?police ? to ? extract ? a ? confession ? from ?a ?detainee. ?Respondents ? asserted ?that ?these ?confessions ?were ?often ?false. ?The ?methods ?used ?by ?police ?included ?beating ?or ?kicking ?suspects, ?sometimes ?combined ?with ?a ?physical ?restraint ?(e.g., ?handcuffs), ?electric ?shock, ?and ?being ?soaked ?in ?ice ?water. ?R: ?When ?we ?arrived ?at ?the ?precinct, ?they ?gave ?us ?a ?blank ?sheet ?of ?paper ?to ?sign. ?We ?had ?the ??blank ?paper ?treatment? ?before. ?So ?we ?knew! ?I ?told ?them, ??Sir, ?we ?can?t ?sign ?on ?a ?blank ?sheet ?of ?paper. ?If ?you ?don?t ?let ?us ?read ?it ?first, ?we ?won?t ?sign.? ?Then, ?six ? or ? seven ? officers ? took ? me ? into ? a ? small ? room. ? It ? was ? a ?sound-???proof ?glass ?room...Then, ?they ?kicked ?me. ?Thud! ?Thud! ?Then, ? they ? wrapped ? me ? with ? a ? blanket ? and ? blasted ? the ? air ?conditioner. ?They ? soaked ?me ?with ? icy ?water? ?I ?was ? shaken ?up ? so ? badly. ? They ? did ? that ? to ? me ? for ? three ? hours. ?(Respondent ?#25, ?male, ?age ?41) ? ?3.3.3 ?IDUs? ?reactions ?to ?drug ?policing ?practices ? ? Despite ? having ? experienced ? police ? abuse, ? the ? majority ? of ? respondents ?reported ? that ? they ?were ? reluctant ? to ? report ? these ? experiences ? to ? the ? authorities ? or ?seek ?justice. ?Many ?respondents ?reported ?feeling ?powerless ?in ?relation ?to ?police, ?and ?felt ?discouraged ?and ?intimidated ?by ?the ?police ?officers? ?disregard ?for ?their ?rights: ? ? 52 ? R: ?The ?police ?don?t ?give ?you ?any ?respect. ?If ?you ?talk ?about ?your ?rights, ?you?ll ?just ?end ?up ?getting ?hurt. ?Even ?though ?the ?law ?supports ?your ?rights, ? the ?police ?will ? think ?you?re ?a ?know-???it-???all. ?They ?may ?have ?it ?out ? for ?you. ? (Respondent ?#34, ?male, ?age ?35) ? ? Other ?respondents ?reported ?police ?corruption ?and ?fear ?of ?retaliation ?from ?the ?police ?as ?being ?important ?barriers ?to ?obtaining ?redress. ?R: ?In ? my ? district, ? people ? from ? this ? political ? party ? abuse ? the ?power. ?If ?they ?don?t ?like ?anyone, ?they ?would ?tell ?the ?police ?to ?take ?care ?of ?the ?person. ?And ?the ?police ?would ?do ?anything ?to ?put ?this ?person ?in ?a ?jail. ?They ?can ?do ?it ?even ?when ?this ?person ?hasn?t ? committed ? any ? crime. ?They ? are ?much ?more ? powerful ?than ?we ?are. ?To ?make ? it ? simple, ? they ?have ?money. ?How ?can ?we ? fight ? against ? them? ? Do ? we ? have ? money? ? No. ?(Respondent ?#35, ?female, ?age ?50) ? ? R: ? I ? wanted ? to ? report ? it ? [that ? her ? partner ? was ? beaten ? by ?police ? during ? the ? interrogation] ? to ? the ? Chief ? Inspector. ?But ?my ?boyfriend ?and ?his ?mom ?told ?me ?to ?just ?let ?it ?go. ?They ?were ? afraid ? that ? it ?wouldn?t ? end ?well ? if ? I ? reported ? it ? to ? the ?police. ?I: ? What ?do ?you ?mean? ?R: ?They ?were ?afraid ?that ?the ?police ?might ?think ?that ?we ?brought ?too ? much ? trouble. ? The ? police ? might ? do ? something ? to ? us. ?(Respondent ?#36, ?female, ?age ?37) ? ? In ?addition, ?respondents ?reported ?barriers ?related ?to ?the ? judicial ?system ?and ?processes, ? including ? limited ? knowledge ? about ? or ? access ? to ? legal ? services, ? slow ?judicial ?proceedings, ?and ?fear ?of ?detention ?while ?awaiting ?a ? trial. ?  ?One ?respondent ?recounted ? a ? three-???year-???long ? court ? fight ? against ? a ? false ? accusation. ? Furthermore, ?respondents ?believed ?that ?a ?previous ?drug ?conviction ?meant ?that ?they ?could ?not ?win ?a ? court ? case ? over ? police ? misconduct ? or ? prove ? their ? innocence. ? One ? respondent ?reported ? that ?a ? court-???appointed ? lawyer ?even ?advised ? that ?he ?accept ?a ? false ? charge ?rather ?than ?fight ?it: ? ? ? 53 ?R: ? The ? court-???appointed ? lawyer ? said ? that ? a ? confession ? would ?make ?things ?easier, ?but ?if ?I ?chose ?to ?fight, ?it ?would ?be ?a ?long ?fight. ? He ? didn?t ? have ? any ? other ? suggestions ? for ? me. ? He ?probably ? thought ? I ? wasn?t ? in ? a ? position ? to ? fight ? this ? false ?charge ? because ? I ? had ? a ? previous ? record ? [drug-???related ?charges]. ?So, ?I ?was ?doomed ?to ?lose. ?(Respondent ?#9, ?male, ?age ?34) ? ? ? As ?a ? result ?of ?numerous ?and ?repeated ?negative ? interactions ?with ? the ?police, ?the ? majority ? of ? respondents ? employed ? strategies ? to ? avoid ? the ? police. ? Common ?strategies ?included ?retreating ?to ?one?s ?house ?or ?a ?new ?location ?outside ??red ?zones? ?and ?making ?changes ?to ?drug ?use ?behaviours. ?Many ?of ?these ?tactics ?appeared ?to ?have ?negative ?impacts ?on ?respondents? ?health ?and ?well-???being. ? ?The ?simplest ? strategy ? for ?avoiding ?police ?was ? to ? refrain ? from ?going ?outside ?where ? one ? could ? be ? subjected ? to ? police ? scrutiny. ? This ? strategy ? often ? impeded ?respondents? ?access ?to ?healthcare, ?including ?methadone ?clinics. ? ? ?I: ? Are ?there ?any ?other ?reasons ?that ?make ?you ?feel ?like ?you ?don?t ?want ?to ?go ?to ?the ?doctor? ?R: ?Yes, ? I?m ?scared ?of ? the ?police ?checkpoints ? in ?the ?area. ? I ?could ?go ?during ?rush ?hour. ?But ?if ?it?s ?a ?little ?later, ?I ?don?t ?want ?to ?go. ?(Respondent ?#21, ?male, ?age ?30) ? ? R: ?When ?they ?[the ?police] ?were ?campaigning ?against ?drug ?use, ?we ? couldn?t ? even ? get ? into ? the ?methadone ? clinic. ?We ? had ? to ?wait. ?And ?we ?couldn?t ?hang ?around ?there ?and ?let ?them ?see ?us ?either. ?They ?would ?often ?wait ?for ?us ?along ?the ?routes ?we ?use. ?I?ve ? run ? into ? trouble ? with ? them ? two ? or ? three ? times. ?(Respondent ?#5, ?male, ?age ?50) ? ? Some ? respondents ? also ? reported ? that ? they ? changed ? the ? venues ? where ? they ?used ? drugs, ? resorting ? to ? injecting ? drugs ? alone ? in ? more ? discreet ? locations, ? while ?others ?engaged ?in ?hurried ?injections ?out ?of ?fear ?of ?being ?detected ?by ?the ?police. ? ? ? 54 ?R: ? I ? inject ? drugs ?mostly ? at ? gas ? stations. ? I ? hurry ? in ? and ?hurry ?out ?because ? it?s ?dangerous. ?Sometimes ?the ?police ?check ?these ?places, ?and ? if ? the ?staff ?at ? the ?gas ?station ?sees ?me ?go ? in ?there ?[to ?the ?bathroom] ?for ?a ?long ?time, ?they ?may ?call ?the ?police. ?So, ?I ?have ?to ?do ?it ?fast. ?(Respondent ?#15, ?male, ?age ?43) ? ?Respondents ?noted ?that ?police ?actions ?also ?sometimes ?led ?them ?to ?change ?the ?types ? of ? drugs ? they ? consumed. ? Many ? respondents ? believed ? that ? the ? rapid ? urine ?screening ?kits ?used ?by ?the ?police ?detected ?the ?presence ?of ?methamphetamines ?only, ?so ? they ? stopped ? using ? methamphetamines ? and ? shifted ? to ? other ? drugs, ? including ?midazolam, ?a ?short-???acting ?benzodiazepine ?that ?can ?be ?obtained ?from ?private ?clinics. ? ?R: ? I?ve ? definitely ? stopped ? using ? ice ? [crystal ?methamphetamine] ? and ? meth. ? Urine ? tests ? only ? test ? for ?meth. ? So ? now ? I ? only ? inject ? heroin ? and ? Dormicum ?[midazolam]. ?(Respondent ?#14, ?male, ?age ?32) ? ?Finally, ? some ? respondents ? did ? not ? report ? any ? strategies ? to ? avoid ? police ?confrontations ?but ?felt ?concerned ?and ?anxious ?about ?the ?intensive ?and ?endless ?police ?pressure. ? These ? individuals ? reported ? either ? becoming ? fatalistic ? about ? the ? risk ? of ?police ?encounters ?and ?the ?associated ?harms ?or ?engaging ?in ?drug ?use ?to ?cope ?with ?the ?excessive ?stress. ? ? ?R: ?I?m ?paranoid ?about ?the ?police. ?Every ?day ?when ?I?m ?at ?home, ?I ?don?t ?feel ?like ?going ?to ?bed? ?The ??puyai? ?[i.e., ?elders] ?in ?my ?neighbourhood ?all ?know ?whether ?I ?have ?drugs ?or ?not, ?and ?the ?police ?will ? come ?and ? take ?me. ??But ? I ?have ? to ? just ? let ? it ?go. ?Whatever ? happens ? happens. ? (Respondent ? #18, ? male, ? age ?29) ? ?R: ? [The ? police] ? stress ? me ? out. ? They ? make ? me ? feel ? like ? using ?[drugs] ? so ? that ? I ? can ? forget ? about ? them! ? It?s ? as ? simple ? as ?that! ?(Respondent ?#22, ?female, ?age ?47) ? ? ? 55 ?3.4 ?Discussion ? ? This ?study ?of ?IDUs? ?lived ?experiences ?suggests ?that ?drug ?policing ?in ?Bangkok ?is ? characterized ? by ? severe ? injustices, ? grave ? human ? rights ? abuses, ? and ? entrenched ?corruption. ? Consistent ? with ? a ? large ? body ? of ? literature ? from ? several ? settings,82,108 ?aggressive ?policing ?practices ?in ?Bangkok ?appear ?to ?have ?compromised ?the ?health ?of ?respondents ?in ?many ?ways. ?Human ?rights ?abuses ?included ?violations ?of ?due ?process ?and ? discriminatory ? practices. ? Respondents? ? narratives ? indicated ? the ? targeting ? of ?former ? drug ? users ? for ? arrest ? in ? the ? absence ? of ? evidence ? of ? new ? offenses. ? Such ?practices ? directly ? undermine ? the ? credibility ? of ? the ? criminal ? justice ? system ? and ?people?s ?confidence ?in ?the ?rule ?of ?law. ?In ?the ?face ?of ?such ?abuse, ?it ?is ?not ?surprising ?that ?respondents ?were ?reluctant ?to ?seek ?justice ?or ?redress ?from ?the ?same ?system ?that ?generated ?such ?injustices. ? ?A ?notable ?finding ?of ?this ?study ?is ?evidence ?of ?harm ?related ?to ?the ?use ?of ?rapid ?urine ?testing ?by ?police. ?In ?Thailand, ?the ?2000 ?amendment ?of ?the ?Narcotics ?Control ?Act ?(Section ? 14) ? and ? the ? 2003 ? amendment ? of ? the ?Narcotics ?Act ? (Section ? 58/1)26 ? allowed ?law ?enforcement ?officers ?to ?perform ?drug ?testing ?on ?anyone ?based ?upon ??reasonable ?suspicion.? ?According ?to ?the ?ONCB ?(Sirisabphaya ?A, ?written ?communication, ?April ?2013), ? the ? police ? use ? two ? kinds ? of ? rapid ? urine ? screening ? kits ? (one ? screening ?methamphetamines ?only ? and ? the ?other ? screening ?multiple ?drugs). ?Use ?of ? this ? tool ?empowered ?police ?to ?identify ?drug ?offenders ?even ?when ?they ?were ?not ?in ?possession ?of ?illicit ?drugs ?or ?in ?the ?act ?of ?using ?drugs. ?The ?experiences ?recounted ?here ?indicate ?abusive ? use ? of ? this ? tool: ? people ? were ? forced ? to ? urinate ? in ? public ? places, ? and ? the ?police ? used ? positive ? test ? results ? as ? a ? means ? of ? extortion. ? Furthermore, ? many ?respondents ?believed ?that ?police ?tested ?only ?for ?methamphetamine, ?leading ?some ?to ?transition ? from ? methamphetamines ? to ? midazolam ? use. ? Midazolam ? injection ? is ?associated ?with ?elevated ?risk ?of ?severe ?injection-???related ?complications, ?such ?as ?nerve ? ? 56 ?and ? vascular ? injuries.188,190 ? Echoing ? earlier ? results ? from ? other ? police ? practices ? in ?Sydney, ?Australia,74 ?these ?findings ?suggest ?that ?potential ?gains ?from ?disrupting ?the ?use ?of ?certain ?illicit ?drugs ?may ?be ?offset ?by ?the ?harm ?associated ?with ?the ?misuse ?of ?other ?drugs, ?as ?policing ?forces ?changes ?in ?drug-???using ?behaviours. ? ?Our ? findings ? shed ? light ? on ? a ? number ? of ? social ? and ? structural ? factors ?contributing ? to ? the ? observed ? rights ? violations. ? Respondents ? perceived ? increasing ?police ?pressure ?in ?2011 ?when ?the ?Thai ?government ?substantially ?increased ?numerical ?targets ? for ? drug ? treatment ? enrolment.43,44 ? The ? police ? take ? the ? number ? of ? new ?admissions ?to ?drug ?treatment ?as ?an ?indicator ?of ?success ?of ?the ?drug ?policy,45 ?where ?drug ? ?treatment? ? primarily ? means ? being ? sentenced ? to ? compulsory ? drug ?detention.27,39 ? Drug ? police ? in ? Thailand ? were ? also ? given ? financial ? incentives ? to ? fill ?arrest ?quotas ?during ?the ?2003 ?drug ?war.22 ?Our ?respondents? ?accounts ?and ?available ?information,47 ? including ? that ? from ? the ? ONCB ? (Sirisabphaya ? A, ? written ?communication, ?April ?2013), ?indicate ?that ?a ?cash ?reward ?system ?has ?persisted. ?Given ?the ?low ?salaries ?of ?police ?officers ? in ?Thailand,50 ? these ?incentives ?appear ?to ?promote ?aggressive ?and ?corrupt ?policing ?practices. ?These ?features ?of ?Thai ?drug ?policing ?may ?help ?explain ?why ?some ?individuals ?who ?were ?known ?to ?the ?police ?had ?their ?homes ?raided ?many ? times, ? why ? some ?methadone ? patients ? were ? harassed ? by ? police ? near ?methadone ?clinics, ?and ?why ?some ?had ?drugs ?planted ?on ?them ?and ?were ?coerced ?to ?confess ?to ?crimes ?they ?did ?not ?commit. ?As ?suggested ?by ?some ?respondents, ? it ?may ?also ?be ?that ?the ?police ?intentionally ?charged ?people ?with ?lesser ?offenses ?so ?that ?they ?would ? be ? released ? and ? available ? for ? re-???arrest ? to ? help ? inflate ? arrest ? figures. ? Our ?findings ? illustrate ? how ? macro-???structures ? (e.g., ? state-???sponsored, ? large-???scale ? police ?crackdowns) ? are ? translated ? into ?meso-???level ? social ? and ? environmental ? factors ? (e.g., ?financial ? incentives ?within ? the ? police) ? and ? shape ? police ? activities, ? as ?well ? as ? how ?police ?activities ?interact ?with ?other ?meso-???level ?social ?and ?environmental ?factors ?(e.g., ? ? 57 ?police ?corruption), ?micro-???level ?social ?and ?environmental ?factors ?(e.g., ?intense ?police ?surveillance ? near ? methadone ? clinics) ? and ? individual ? characteristics ? (e.g., ? having ?criminal ? records ? and ?being ? known ? to ? the ? local ? police) ? and ? result ? in ? human ? rights ?abuses ?of ?IDU ?in ?Bangkok. ? ?Respondents? ? narratives ? indicate ? that ? drug ? policing ? in ? Bangkok ? involves ?severe ? human ? rights ? abuses. ? Evidence ? planting ? and ? false ? accusations ? represent ? a ?violation ?of ?the ?right ?to ?freedom ?from ?arbitrary ?arrest ?and ?detention ?under ?Article ?9 ?of ?the ?ICCPR, ?which ?Thailand ?ratified ?in ?1996. ?In ?some ?cases, ?respondents ?reported ?that ?police ?used ?physical ? force ? to ?coerce ?confessions. ?This ?practice ? is ?a ?violation ?of ?the ?rights ?to ?security ?of ?the ?person ?(Article ?9) ?and ?to ?freedom ?from ?torture ?and ?cruel, ?inhuman, ?and ?degrading ?treatment ?(Article ?7) ?under ?the ?ICCPR, ?as ?well ?as ?under ?the ?Convention ?against ?Torture ?and ?Other ?Cruel, ?Inhuman ?or ?Degrading ?Treatment ?or ?Punishment ?(CAT), ?to ?which ?Thailand ?became ?a ?party ?in ?2007. ?These ?rights ?are ?also ?enshrined ?in ?the ?2007 ?Constitution ?of ?the ?Kingdom ?of ?Thailand ?B.E. ?2550 ?(Section ?32).191 ?Consistent ? with ? studies ? from ? other ? countries,73 ? our ? findings ? suggest ? that ? police ?presence ?and ?harassment ?near ?methadone ?clinics ?deterred ?methadone ?patients ?from ?accessing ?treatment. ?This ?type ?of ?targeted ?police ?interference ?with ?access ?to ?essential ?health ?services ?is ?a ?violation ?of ?the ?right ?to ?the ?highest ?attainable ?standard ?of ?health ?enshrined ? in ? the ? International ? Covenant ? on ? Economic, ? Social ? and ?Cultural ? Rights ?(ICESCR, ?Article ?12),192 ?to ?which ?Thailand ?became ?a ?party ?in ?1999. ? ?In ? addition, ? the ? findings ? indicate ? that ? police ? corruption ? and ? other ? police ?misconduct ? further ? contributed ? to ? IDUs? ? vulnerability ? to ? drug-???related ? harm. ? The ?majority ?of ?respondents ?experienced ?extortion ?of ?money ?by ?police. ?This ?is ?consistent ?with ? a ? previous ? study ? from ? this ? setting ? reporting ? that ? half ? of ? IDU ?who ? reported ?having ?drugs ?planted ?on ?them ?paid ?police ?a ?bribe ?to ?avoid ?arrest.78 ?Respondents ?also ?reported ? arrests ? for ? syringe ? possession ? and ? needle ?marks; ? such ? arrests ? have ? been ? ? 58 ?found ?in ?several ?settings ?to ?facilitate ?risky ?injection ?behaviour ?and ?impede ?access ?to ?healthcare.76,118,125 ? Respondents? ? accounts ? that ? plain-???clothes ? police ? did ? not ? always ?identify ? themselves ? as ? police ? were ? concerning, ? not ? only ? because ? this ? practice ? is ?unlawful ?under ? the ?Narcotics ?Act ? (Section ?49),26 ?but ?also ?because ?respondents ?were ?reluctant ? to ? exercise ? their ? right ? to ? ask ? for ? identification. ? In ? addition, ? our ? findings ?highlight ? possible ? abuse ? associated ? with ? ?deputizing? ? local ? residents ? to ? help ? the ?police ? identify ?alleged ?drug ?offenders. ?Particularly ?where ?police ?are ?not ?always ? in ?uniform, ? deputized ? civilians ? may ? be ? mistaken ? for ? police ? or ? may ? overstep ? their ?authority, ?leading ?IDU ?to ?flee, ?hide ?or ?otherwise ?respond ?in ?ways ?that ?may ?be ?risky ?to ?them ?and ?those ?around ?them. ?Mobilization ?of ?civilians ?of ?this ?kind ?has ?also ?been ?reported ? in ? Laos ? and ? Vietnam, ? where ? many ? civilians ? (e.g., ? heads ? of ? villages) ? are ?compelled ?by ?local ?authorities ?to ?help ?achieve ??drug-???free? ?environments ?and ?submit ?drug ?users ?to ?the ?police ?or ?compulsory ?drug ?detention ?centres.153,193 ? ?Our ?findings ?also ?suggest ? that ?policing ?practices ?disproportionately ?affected ?some ? persons, ? particularly ? former ? drug ? offenders. ? Even ? though ? there ? is ? no ? drug ?user ? registration ? system ? in ? Thailand, ? as ? there ? is ? in ? many ? eastern ? European ?countries,102 ?in ?practice ?the ?Thai ?police ?reportedly ?maintain ??blacklists? ?of ?suspected ?or ? formerly ? convicted ? drug ? dealers ? and ? users.22,157,189 ? These ? lists ? seem ? to ? serve ?effectively ?as ?a ?registration ?system ?and ?similarly ?increase ?the ?vulnerability ?of ?those ?listed ?to ?police ?abuse ?and ?extortion.102 ?In ?addition, ?police ?target ?people ?with ?tattoos, ?which ?are ?taken ?as ?markers ?of ?former ?incarceration. ?This ?practice ?likely ?violates ?the ?principle ?of ?non-???discrimination ?under ?Article ?26 ?of ?the ?ICCPR ?and ?Section ?30 ?of ?the ?Thai ?constitution.191 ? ? ? ? ?  ?It ? is ?particularly ?concerning ?that ?many ?respondents ?who ?experienced ?police ?abuse ?were ? forced ? to ?bear ? this ? abuse ? in ? silence ? for ?various ? reasons. ? In ? accordance ?with ?its ?international ?human ?rights ?obligations, ?Thailand ?has ?a ?legal ?framework ?that ? ? 59 ?prohibits ? state ?corruption, ?prohibits ? the ?use ? in ?court ?of ?evidence ?obtained ? through ?unlawful ? means, ? and ? grants ? victims ? of ? torture ? the ? right ? to ? seek ? redress ? and ?compensation.51,194 ? However, ? investigations ? of ? police ? abuses ? committed ? under ? the ?2003 ? drug ?war ? have ? not ? been ? completed,47 ? indicating ? a ? political ? unwillingness ? to ?bring ?the ?perpetrators ?of ?these ?heinous ?abuses ?to ?account. ?This ?is ?likely ?contributing ?to ?respondents? ?reluctance ?to ?seek ?justice. ?Our ?findings ?underscore ?repeated ?calls ?for ?ensuring ? full ? accountability ? for ? police ? abuses.47,49 ? Given ? the ? observed ? lack ? of ?knowledge ? and ? access ? to ? legal ? services ? among ? the ? respondents, ? greater ? efforts ?should ?also ?be ?made ?to ?provide ?legal ?services ?to ?IDU ?in ?Bangkok. ?A ?recent ?review ?highlighted ?that ?legal ?services ?are ?often ?as ?important ?as ?health ?services ?to ?safeguard ?the ?rights ?and ?well-???being ?of ?people ?who ?use ?drugs.165 ?While ?ensuring ?the ?accountability ?for ?police ?abuses ?is ?an ?imperative ?duty ?of ?the ? Thai ? government, ? our ? findings ? also ? suggest ? a ? need ? for ? multilevel ? structural ?changes ? and ? interventions ? to ? mitigate ? the ? harm ? associated ? with ? drug ? policing ? in ?Thailand. ?These ?include ?abolishing ?numerical ?targets ?for ?drug ?treatment ?enrolment ?that ? effectively ? promote ? compulsory ? drug ? detention, ? banning ? financial ? incentives ?and ? blacklists ? to ? reduce ? the ? potential ? for ? abusive ? practices, ? establishing ? binding ?commitments ? from ? the ? police ? not ? to ? interfere ? with ? health ? and ? harm ? reduction ?services,170 ?and ?training ?police ?to ?understand ?harm ?reduction ?activities.169,172 ?Globally, ?the ?latter ?two ?interventions ?have ?been ?applied ?in ?many ?settings ?and ?have ?faced ?such ?challenges ?as ?high ? turnover ?among ?police, ?varied ?public ?perceptions ?of ? the ? role ?of ?police, ? and ?police ? corruption.82,174 ? In ?particular, ? reports ? from ?Vietnam ?documented ?that ? a ? macro-???level ? drug ? policy ? that ? emphasized ? compulsory ? drug ? detention ? as ? a ?means ?to ?address ?illicit ?drug ?use ?has ?pressured ?police ?to ?arrest ?drug ?users ?and ?has ?undermined ? the ? effectiveness ? of ? these ? police ? interventions ? aimed ? at ? supporting ?harm ?reduction ?services.174,175 ? ? ? 60 ?Repressive ? and ? harmful ? drug ? policing ? is ? largely ? attributable ? to ? harsh ?application ?of ?criminal ?penalties ?to ?a ?wide ?range ?of ?drug ?offenses. ?In ?recent ?years, ?a ?number ?of ?countries ?have ?experimented ?with ?alternative ?regulatory ?frameworks ?for ?illicit ?drugs, ? including ?decriminalization ?of ?personal ?drug ?use.101 ?Decriminalization ?has ? a ? number ? of ? potential ? benefits ? to ? public ? health, ? including ? reducing ? harms ?associated ?with ? incarceration ?and ?pre-???trial ?detention ?of ?drug ?users ? and ? facilitating ?the ? scale-???up ? of ? evidence-???based ? drug ? treatment ? services ? for ? those ?who ? need ? them. ?Given ?some ?emerging ?evidence ?of ?positive ?results,11,177 ?these ?alternative ?frameworks ?are ?worth ?exploring ?in ?Thailand. ?Lastly, ? clear ? ethical ? standards ?need ? to ?be ? established ? to ? safeguard ?against ? abusive ?practices ? related ? to ? the ? police?s ? use ? of ? drug ? testing. ?While ? drug ? testing ? is ? used ? in ?many ? settings, ? including ?healthcare ? settings, ?workplaces, ? schools, ? and ? correctional ?facilities,195,196 ? there ? is ? scant ? literature ? to ? inform ? the ? development ? of ? humane ? and ?pragmatic ?guidelines ?for ?drug ?testing ?by ?police, ?which ?are ?sorely ?needed. ?In ?recent ?years, ? following ? the ?model ? of ? roadside ? breathalyzer ? alcohol ? tests, ? some ?European ?countries ?have ?authorized ? roadside ?drug ? testing ? (by ?means ?of ?oral ? fluid, ?urine, ? or ?sweat ?tests) ?to ?identify ?drivers ?under ?the ?influence ?of ?drugs.197 ?Some ?countries ?have ?legal ? provisions ? stipulating ? that ? sanctions ? should ? be ? based ? on ? the ? impairment ? of ?driving ?ability ?by ?substance ?abuse, ?not ?on ?the ?analytical ?detection ?of ?drugs ?in ?body ?fluid.198 ?The ?majority ?of ?the ?countries ?recognize ?that ?any ?roadside ?testing ?procedure ?can ?be ?an ?intrusion ?into ?individual ?rights ?and, ?therefore, ?they ?take ?some ?measures ?to ?respect ? voluntariness ? and ? privacy ? (e.g., ? using ? a ? sanitary ? van ? for ? urine ? tests).197,198 ?These ?experiences, ?particularly ?valuing ?the ?voluntary ?nature ?of ?drug ?testing, ?may ?be ?useful ? to ? inform ? developing ? ethical ? and ? rights-???friendly ? drug ? testing ? practices ? in ?Bangkok. ? ? ? 61 ?This ? study ? has ? several ? strengths ? that ? served ? to ? enhance ? the ? credibility ? of ?results. ?The ?primary ?author ?has ? coordinated ? the ?Mitsampan ?Community ?Research ?Project ? at ? the ? MSHRC ? since ? 2008 ? and ? has ? spent ? over ? 1,500 ? hours ? conducting ?fieldwork.94 ?These ?periods ?of ?time ?provided ?numerous ?opportunities ?to ?observe ?and ?discuss ? issues ? related ? to ? drug ? policing ? at ? the ? MSHRC, ? and ? helped ? the ? author ?develop ?an ?early ?familiarity ?with ?relevant ?issues ?and ?build ?rapport ?with ?local ?IDU. ?Although ?some ?scholars ?have ?noted ?that ?the ?prolonged ?engagement ?in ?the ?field ?may ?lead ?researchers ? to ?develop ?some ?biases,199 ? the ? involvement ?of ?other ?researchers ? in ?the ?data ?analysis ?served ?to ?maintain ?the ?integrity ?of ?the ?analysis. ?Given ?that ?IDUs? ?experiences ? with ? police ? involve ? sensitive ? information, ? extra ? efforts ? were ?made ? to ?assure ?confidentiality ?and ?anonymity ?of ?responses ?and ?to ?encourage ?respondents ?to ?be ? frank. ? For ? example, ? all ? interviews ? were ? conducted ? in ? private ? space, ? any ?personally ?identifiable ?information ?was ?not ?collected ?or ?was ?removed ?from ?the ?data, ?and ? interviewers ? emphasized ? that ? the ? study ? had ? no ? connection ? with ? the ? state ?authorities. ?Further, ?interviewers ?frequently ?used ?probes ?to ?elicit ?detailed ?data ?and ?iterative ? questioning ? to ? verify ? the ? accuracy ? of ? data ? and ?provide ? respondents ?with ?opportunities ?to ?check ?the ?data. ? ? ?However, ? the ? following ? limitations ? should ? be ? noted ?when ? interpreting ? the ?findings. ? First, ? the ? interview ? transcripts ? were ? translated ? into ? English ? and ? then ?analyzed. ? Although ? the ? interviewers ? and ? proof-???readers ? reviewed ? the ? translated ?transcripts ?(and ?SH ?reviewed ?this ?manuscript), ?linguistic ?nuances ?that ?were ?relevant ?to ? the ? study ?may ?have ?been ? lost ? in ? translation. ? Second, ?our ? findings ? are ?based ?on ?interviews ?with ? IDU ?who ?had ?direct ? encounters ?with ?police ? in ? the ?previous ? three ?years. ? Therefore, ? experiences ? and ? views ? of ? non-???IDU ? or ? other ? IDU ? who ? did ? not ?confront ?police ?officers ?were ?not ?included. ?In ?addition, ?those ?who ?came ?forward ?to ?participate ?in ?the ?study ?may ?have ?tended ?to ?have ?negative ?experiences ?with ?police. ? ? 62 ?Although ? efforts ? were ? made ? to ? attain ? a ? balance ? in ? gender ? and ? age ? among ? the ?interviewees, ? we ? could ? not ?meaningfully ? reach ? sub-???populations ? of ? IDU ?who ? also ?belonged ? to ? other ? vulnerable ? populations, ? including ? transgendered ? persons, ?migrants, ?and ?sex ?workers. ?These ?features ?of ?our ?sample ?limit ?the ?transferability ?of ?the ?present ?findings. ? ? ?  ? ? 63 ?Table 1: Characteristics of 42 IDU in Bangkok, Thailand, participating in the qualitative arm of the Mitsampan Community Research Project between July 2011 and June 2012 Characteristic n (%) Female gender 17 (40.5%) Age  ? 30 years 7 (16.7%) 31 ? 40 years 21 (50.0%) > 41 years 14 (33.3%) Drugs most frequently injected*:  Midazolam 30 (71.4%) Heroin 17 (40.5%) Methamphetamine 13 (31.0%) Crystal methamphetamine 10 (23.8%) Methadone 4 (9.5%) Self-reported HIV seropositivity 14 (33.3%) IDU: people who inject drugs. * Refers to the 6 months prior to the interview. Multiple answers were allowed.  ?  ? ? 64 ?CHAPTER ?4: ?REPORTS ?OF ?POLICE ?BEATING ?AND ?ASSOCIATED ?HARMS ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?4.1 ?Introduction ?As ? described ? in ? section ? 1.2, ? in ? 2002 ? Thailand ? enacted ? a ? new ? law ? that ?reclassified ? people ? who ? use ? drugs ? as ? ?patients? ? not ? ?criminals.? ? However, ? the ?criminal ? laws ?governing ?drug ?use ?remain ? in ?effect,26 ?and ?the ?Thai ?government ?has ?continued ?to ?support ?intensive ?police ?crackdowns, ?as ?well ?as ?compulsory ?detention ?and ? incarceration ? of ? people ?who ? use ? drugs.27 ? During ? the ? Thai ? ?war ? on ? drugs? ? in ?2003, ? the ? government?s ? strong ? emphasis ? on ? drug ? suppression ? efforts ? led ? the ? Thai ?police ? to ? commit ? various ? forms ? of ? violence, ? including ? over ? 2,800 ? extrajudicial ?killings ? of ? alleged ? drug ? dealers ? and ? users.22,48 ? Although ? the ? Thai ? government ?promised ?that ?the ?police ?would ?not ?breach ?due ?process ?or ?use ?excessive ?forces ?again ?(according ? to ?a ?media ? report),185 ? recent ? reports ? suggest ? that ?police ?misconduct ?has ?continued ?during ?subsequent ?crackdowns. ?For ?example, ?a ?2008 ?study ?showed ?that ?almost ?half ?of ?a ?sample ?of ?IDU ?in ?Bangkok ?reported ?having ?drugs ?planted ?on ?them ?by ? police.78 ? Further, ? other ? reports ? documented ? police ? misconduct ? and ? fatal ?shootings ?of ?suspects ?during ?drug ?suppression ?operations ?in ?2012.200,201 ?Despite ?ongoing ?concern ?regarding ?the ?renewed ?and ?intensified ?crackdowns ?on ? drug ? use ? in ? Thailand, ? few ? studies ? have ? endeavored ? to ? identify ? the ? extent ? and ?impact ? of ? police ? violence ? among ? IDU ? in ? this ? setting. ? Although ? many ? detailed ?narratives ?on ?police ?violence ?were ?documented ?during ?the ??war ?on ?drugs? ?in ?2003,22 ?few ? studies ? have ? been ? undertaken ? in ? the ? post-???2003 ? period.78,157 ? As ? well, ? while ?international ? literature ? indicates ? that ? aggressive ? drug ? policing ? practices ? increase ?vulnerability ? to ? HIV ? infection ? and ? other ? harms ? among ? IDU,73,74,82,85 ? these ? studies ?have ? tended ? to ? focus ? on ? the ? aggregate ? impact ? of ? police ? crackdowns ? of ? relatively ? ? 65 ?short ? duration, ? and ? the ? impact ? of ? specific ? forms ? of ? police ?misconduct ? has ? seldom ?been ?quantified. ?Therefore, ?we ? sought ? to ? identify ? the ?prevalence ? and ? correlates ? of ?experiencing ? police ? beating ? among ? a ? community-???recruited ? sample ? of ? IDU ? in ?Bangkok, ?Thailand. ? ?4.2 ?Methods ?Quantitative ? data ? for ? this ? study ? were ? derived ? from ? the ? Mitsampan ?Community ?Research ?Project, ?as ?described ?in ?detail ?in ?section ?1.6. ?In ?this ?study, ?we ?included ?respondents ?who ?completed ?the ?interview ?in ?2009 ?or ?2011. ?Given ? that ? some ? individuals ?were ? interviewed ? in ?both ?2009 ?and ?2011, ?we ?included ? all ? respondents ? from ? the ? first ?wave ? and ? only ? new ? respondents ? from ? the ?second ?wave ? in ?order ? to ? ensure ? the ? independence ?of ? the ?observations ?analysed ? in ?the ?present ?study. ?As ?described ?in ?section ?1.6.2, ?this ?was ?the ?only ?way ?to ?eliminate ?repeat ?respondents ?from ?the ?data ?set. ?The ?sample ?of ?each ?survey ?wave ?was ?further ?restricted ? to ? individuals ?who ? had ? complete ? data ? for ? the ? present ? analyses. ? For ? the ?present ?analyses, ?the ?primary ?outcome ?of ?interest ?was ?reporting ?a ?history ?of ?police ?beating, ?defined ?as ?answering ??Yes? ?to ?a ?question: ??Have ?you ?ever ?been ?beaten ?by ?police?? ?In ?addition, ? in ?2011 ?a ?follow-???up ?question ?was ?added ?to ?the ?survey, ?which ?asked ?respondents ?reporting ?episodes ?of ?police ?beating ?about ? the ?circumstances ?of ?police ? beatings ? (e.g., ? where ? and ? when ? they ? occurred). ? Although ? many ? forms ? of ?police ?violence ?exist,70 ?police ?beating ?was ?selected ?as ?the ?primary ?outcome ?of ?interest ?because ?it ?was ?identified ?as ?one ?of ?the ?major ?forms ?of ?police ?violence ?by ?a ?group ?of ?peer ?researchers ?during ?the ?process ?of ?developing ?survey ?instruments, ?and ?yet ?little ?was ? known ? about ? the ? prevalence ? and ? correlates ? of ? experiencing ? police ? beating ?among ?IDU ?in ?Bangkok. ?Informed ? by ? the ? conceptual ? framework ? (Figure ? 1) ? and ? previous ? studies ?exploring ? the ? impacts ? of ? aggressive ? drug ? policing ? on ? IDU,73,74,85 ? explanatory ? ? 66 ?variables ?that ?were ?hypothesized ?to ?be ?potentially ?associated ?with ?the ?outcome ?were ?selected. ?They ?included ?age ?(below ?or ?above ?median ?age: ?< ?37 ?years ?vs. ?? ?37 ?years); ?gender ?(male ?vs. ? female); ?drug-???dealing ?involvement ?in ?the ?past ?six ?months ?(yes ?vs. ?no); ?injection ?of ?each ?of ?the ?four ?kinds ?of ?drugs ?that ?are ?commonly ?used ?among ?IDU ?in ?Bangkok: ?heroin, ?midazolam ?(a ?short-???acting ?benzodiazepine), ?methamphetamine ?(locally ? called ? yaba), ? and ? crystal ? methamphetamine ? (locally ? called ? ice); ? ever ?incarcerated; ? ever ? in ? compulsory ? drug ? detention; ? ever ? accessed ? methadone ?treatment; ? reporting ? barriers ? to ? accessing ? healthcare ? (any ? vs. ? none); ? ever ? shared ?syringes; ? HIV ? serostatus ? (positive ? vs. ? negative ? or ? unknown); ? non-???fatal ? overdose ?ever; ?and ?calendar ?year ?of ?study ?enrolment ?(2011 ?vs. ?2009). ?All ?variables ?were ?coded ?dichotomously ?as ?yes ?vs. ?no, ?unless ?otherwise ?stated. ?All ?variables ?related ?to ?drug-???using ? behaviour ? referred ? to ? any ? time ? in ? the ? past. ? Drug-???dealing ? involvement ? was ?ascertained ?by ?asking ?whether ?drug ?dealing ?(i.e., ?selling ?or ?transporting ?illicit ?drugs) ?constituted ?a ?source ?of ?personal ? income ?for ? the ?respondent ? in ?the ?past ?six ?months. ?As ? in ? our ? previous ? work,202 ? our ? barriers ? to ? accessing ? healthcare ? variable ?incorporated ? a ? range ? of ? potential ? barriers, ? including ? but ? not ? limited ? to: ? fear ? of ?sharing ? information ? of ? drug ? using ? status ?with ? the ? police, ? not ? wanting ? healthcare ?providers ? to ? know ? one ? injects ? or ? uses ? drugs, ? being ? treated ? poorly ? by ? healthcare ?providers, ?and ?transportation ?issues. ?For ? the ?bivariate ?and ?multivariate ?analyses, ? the ?prevalence ?ratio ?rather ? than ?the ?odds ?ratio ?was ?used ?as ?a ?measure ?of ?association, ?as ?the ?frequency ?of ?the ?outcome ?exceeded ?10%.203 ?First, ?we ?used ?a ?simple ?binomial ?regression ?with ?a ?log ?link ?function ?to ? examine ? bivariate ? associations ? between ? reports ? of ? police ? beating ? and ? the ?explanatory ?variables.204 ?Next, ?we ?used ?an ?a ?priori-???defined ?statistical ?protocol ?based ?on ?examination ?of ?the ?Akaike ?Information ?Criterion ?(AIC) ?and ?p-???values ?to ?construct ?an ?explanatory ?multivariate ?log-???binomial ?regression ?model ?using ?the ?COPY ?method ? ? 67 ?in ? SAS ? (SAS ? Institute ? Inc., ? Cary, ? NC, ? USA).205 ? First, ? we ? constructed ? a ? full ? model ?including ? all ? variables ? analysed ? in ? bivariate ? analyses. ?After ? examining ? the ?AIC ?of ?the ?model, ?we ? removed ? the ? variable ?with ? the ? largest ? p-???value ? and ? built ? a ? reduced ?model. ?We ?continued ?this ?iterative ?process ?until ?no ?variables ?remained ?for ?inclusion. ?We ?selected ?the ?multivariate ?model ?with ?the ?lowest ?AIC ?score. ?Because ?age, ?which ?was ?not ? significantly ?associated ?with ? the ?outcome ?at ? the ?p ? < ?0.05 ? level ? in ?bivariate ?analyses, ?became ?significantly ?associated ?with ? the ?outcome ? in ? the ? full ?multivariate ?log-???binomial ? regression ?model, ?we ?assessed ? two-???way ? interactions ?between ?median ?age ? and ? the ? explanatory ? variables ? by ? creating ? interaction ? terms. ? Interaction ? was ?deemed ?as ?present ?if ?the ?interaction ?term ?was ?associated ?with ?the ?outcome ?at ?the ?p ?< ?0.05 ?level. ?All ?p-???values ?were ?two-???sided. ? ?As ? a ? sub-???analysis, ? we ? used ? descriptive ? statistics ? to ? examine ? at ? what ? point ?during ?interactions ?with ?police ?that ?respondents ?experienced ?beatings. ?All ?statistical ?analyses ?were ?performed ?with ?SAS ?version ?9.3. ?4.3 ?Results ?Among ?644 ?unique ?IDU ?recruited ?between ?June ?2009 ?and ?October ?2011, ?639 ?individuals ?(307 ?individuals ?in ?2009 ?and ?332 ?individuals ?in ?2011) ?had ?complete ?data ?and ?were ?eligible ? for ? inclusion ? in ? the ?present ?analyses. ?The ?median ?age ?of ?eligible ?respondents ?was ? 37 ?years ? (interquartile ? range: ? 33?47 ?years), ? and ?153 ? (23.9%) ?were ?female. ?In ?total, ?240 ?respondents ?(37.6%) ?reported ?having ?ever ?been ?beaten ?by ?police, ?and ? 21 ? (3.3%) ? reported ? having ? been ? beaten ? by ? police ? in ? the ? past ? six ?months. ? The ?unadjusted ?prevalence ?of ?experiencing ?police ?beating ?was ?31.3% ?in ?2009 ?and ?43.4% ?in ?2011. ? ?The ? results ? of ? bivariate ? analyses ? are ? shown ? in ? Table ? 2. ? Reports ? of ? police ?beatings ?were ?significantly ?and ?positively ?associated ?with ?male ?gender ?(prevalence ?ratio ?[PR]: ?5.50; ?95% ?confidence ?interval ?[CI]: ?3.24 ?? ?9.33); ?heroin ?injection ?ever ?(PR: ? ? 68 ?2.45; ?95% ?CI: ?1.45 ?? ?4.15); ?midazolam ? injection ?ever ? (PR: ?1.52; ?95% ?CI: ?1.10 ?? ?2.10); ?crystal ?methamphetamine ?injection ?ever ?(PR: ?1.47; ?95% ?CI: ?1.17 ?? ?1.84); ?ever ?shared ?syringes ? (PR: ?1.93; ? 95% ?CI: ? 1.52 ?? ?2.45); ? ever ? incarcerated ? (PR: ?3.00; ? 95% ?CI: ? 1.98 ?? ?4.56); ? ever ? in ? compulsory ? drug ? detention ? (PR: ? 1.33; ? 95% ? CI: ? 1.06 ? ? ? 1.66); ? ever ?accessed ?methadone ? treatment ?enrolment ? (PR: ?1.74; ?95% ?CI: ?1.30 ?? ?2.33); ? reporting ?barriers ? to ? accessing ? healthcare ? (PR: ? 1.55; ? 95% ?CI: ? 1.25 ? ? ? 1.93); ?HIV ? seropositivity ?(PR: ?1.35; ?95% ?CI: ?1.08 ?? ?1.67); ?non-???fatal ?overdose ?ever ?(PR: ?1.60; ?95% ?CI: ?1.32 ?? ?1.95); ?and ?study ?enrolment ?in ?2011 ?(PR: ?1.39; ?95% ?CI: ?1.13 ?? ?1.71). ? ?Table ?3 ?shows ?the ?results ?from ?the ?final ?multivariate ?log-???binomial ?regression ?model. ? As ? shown, ? an ? interaction ? was ? found ? with ? age ? and ? methamphetamine ?injection ? ever. ? Reports ? of ? police ? beatings ? were ? independently ? and ? positively ?associated ? with ? younger ? age ? (< ? 37 ? years) ? among ? those ? who ? never ? injected ?methamphetamine ?(adjusted ?prevalence ?ratio ?[APR]: ?1.69; ?95% ?CI: ?1.17 ?? ?2.43); ?male ?gender ?(APR: ?4.43; ?95% ?CI: ?2.63 ?? ?7.49); ?ever ?shared ?syringes ?(APR: ?1.44; ?95% ?CI: ?1.15 ?? ?1.80); ?ever ?incarcerated ?(APR: ?2.51; ?95% ?CI: ?1.68 ?? ?3.77); ?ever ?in ?compulsory ?drug ?detention ?(APR: ?1.22; ?95% ?CI: ?1.05 ?? ?1.40); ?reporting ?barriers ?to ?accessing ?healthcare ?(APR: ? 1.23; ? 95% ?CI: ? 1.01 ? ? ? 1.49); ? and ? study ?enrolment ? in ? 2011 ? (APR: ? 1.27; ? 95% ?CI: ?1.07 ?? ?1.49). ?In ? sub-???analysis, ? among ? respondents ? completing ? surveys ? in ? 2011 ? (n ? = ? 144), ?68.1% ?reported ?experiencing ?police ?beating ?while ?being ?interrogated, ?43.1% ?reported ?being ?beaten ?during ?their ?arrest, ?22.9% ?were ?beaten ?while ?being ?searched, ?and ?22.9% ?reported ?having ?been ?beaten ?while ?in ?police ?holding ?cells. ? ?4.4 ?Discussion ?We ?found ?that ?over ?one-???third ?of ?a ?sample ?of ?IDU ?in ?Bangkok ?reported ?having ?ever ?been ?beaten ?by ?police. ?Reports ?of ?police ?beating ?were ?independently ?associated ?with ?male ?gender, ?younger ?age ?among ?those ?who ?never ?injected ?methamphetamine, ? ? 69 ?a ? history ? of ? incarceration, ? compulsory ? drug ? detention ? and ? syringe ? sharing, ? and ?reporting ?barriers ?to ?accessing ?healthcare. ?Respondents ?most ?commonly ?experienced ?police ?beating ?during ?the ?interrogation ?process. ? ?To ?our ?knowledge, ?the ?present ?study ?is ?the ?first ?to ?quantitatively ?examine ?the ?prevalence ? and ? correlates ? of ? experiencing ?physical ? violence ? at ? the ?hands ? of ?police ?among ? IDU ? in ? Thailand. ? The ? findings ? that ? the ? overall ? prevalence ? of ? experiencing ?police ?beatings ?in ?the ?past ?was ?37.6% ?in ?2009?2011, ?and ?the ?majority ?of ?the ?victims ?(68.1%) ?experienced ?it ?during ?the ?interrogation ?process ?raise ?serious ?concern ?about ?police-???perpetrated ?abuses ?against ?this ?population. ?Our ?findings ?are ?consistent ?with ?previous ? reports ?during ? the ? 2003 ? ?war ? on ?drugs? ? campaign ? indicating ? that ? police ?beating ? was ? used ? as ? a ? tactic ? to ? extract ? confessions ? of ? drug-???related ? crimes ? from ?suspected ?drug ?users.22 ? ?We ? also ? found ? that ? male ? IDU ? experienced ? police ? beating ? more ? often ? than ?women. ? Thai ? police ? are ? believed ? to ? profile ? IDU ? based ? on ? factors ? such ? as ? needle ?marks.22 ?As ?the ?great ?majority ?of ?Thai ?IDU ?population ?is ?believed ?to ?be ?comprised ?of ?males,206 ?male ? IDU ?may ?be ?more ?susceptible ? to ?police ?profiling ?of ? IDU ?and ?police-???perpetrated ? physical ? violence. ? However, ? it ? is ? also ? important ? to ? note ? that ? women ?may ?have ?been ?susceptible ?to ?other ?forms ?of ?police ?violence, ?such ?as ?sexual ?violence, ?which ?were ? not ? examined ? in ? the ? present ? study. ?We ? also ? found ? that ? younger ? IDU ?who ? never ? injected ? methamphetamine ? were ? more ? likely ? to ? have ? been ? beaten ? by ?police. ?Given ?that ?young ?people ?are ?a ?major ?target ?of ?drug ?demand ?reduction ?efforts ?in ? Thailand,207 ? young ? IDU ? may ? be ? more ? vulnerable ? to ? police ? beating. ? However, ?reasons ? that ? the ? independent ? association ?was ? found ?only ?among ? those ?who ?never ?injected ?methamphetamine ?were ?unknown. ? ? ? ?Of ? particular ? concern ? is ? the ? finding ? that ? reports ? of ? police ? beating ? were ?independently ? associated ? with ? a ? history ? of ? incarceration ? and ? compulsory ? drug ? ? 70 ?detention. ?This ?finding, ?considered ?alongside ?our ?data ?concerning ?the ?circumstances ?of ?police ?beatings, ? suggests ? that ? IDU ? in ? this ? setting ?may ?experience ?police ?beating ?before ? being ? sent ? to ? prison ? or ? compulsory ? drug ? detention. ? This ? is ? concerning ?because ? these ? institutions ? may ? be ? ill ? equipped ? to ? deal ? with ? physical ? and ?psychological ?manifestations ?of ? traumatic ? injuries.27 ?Alternatively, ? the ? finding ?may ?suggest ? that ? individuals ? with ? a ? history ? of ? incarceration ? or ? compulsory ? drug ?detention ? are ? easier ? targets ? for ? police. ? Indeed, ? previous ? reports ? documented ?widespread ?use ?of ??blacklists? ?by ? the ?Thai ?police ?during ? the ?2003 ??war ?on ?drugs? ?campaign, ?on ?which ?individuals ?with ?records ?of ?drug-???related ?arrests ?were ?listed ?as ?suspected ? drug ? users ? or ? traffickers.22 ? More ? recent ? reports ? also ? suggested ? the ?continued ? use ? of ? blacklists ? by ? police,157,189 ? indicating ? that ? the ? latter ? interpretation ?may ?be ?also ?plausible. ? ?Episodes ?of ?police ?beating ?were ?also ? independently ?associated ?with ? syringe ?sharing ?and ?reporting ?barriers ?to ?accessing ?health ?services. ?Consistent ?with ?previous ?studies ? from ? other ? settings ? indicating ? the ? negative ? impact ? of ? aggressive ? drug ?policing ?on ? seeking ?health ? and ?harm ? reduction ? services ? by ? IDU,73,82,85 ? our ? findings ?suggest ? that ?acts ?of ?violence ?by ?police ?may ?create ?environment ? that ?promotes ? fear ?and ?constrains ?Thai ?IDUs? ?access ?to ?healthcare ?and ?ability ?to ?practice ?harm ?reduction ?activities. ?While ?a ?temporal ?ordering ?of ?police ?beating ?and ?syringe ?sharing ?was ?not ?assessed ? in ? the ? present ? study, ? a ? previous ? study ? demonstrated ? an ? independent ?association ? between ? difficulty ? in ? accessing ? sterile ? syringes ? and ? syringe ? borrowing ?among ?IDU ?in ?this ?setting.208 ?Therefore, ?it ?may ?be ?that ?individuals ?who ?experienced ?police ?beating ? retreated ? into ?more ?hidden ? settings ?where ? it ?was ?difficult ? to ?obtain ?sterile ? syringes, ? making ? the ? adoption ? of ? harm ? reduction ? practices ? difficult ? or ?impossible. ? ? 71 ?Our ? findings ? have ? implications ? for ? policies ? and ? programs ? related ? to ? drug ?policing ?in ?Thailand. ?First, ?the ?extent ?of ?police ?beating ?reported ?in ?the ?present ?study ?raises ? concern ? about ? widespread ? violations ? of ? basic ? human ? rights ? of ? IDU ? in ? this ?setting, ?including ?the ?rights ?to ?security ?of ?the ?person ?(Article ?9) ?and ?to ?freedom ?from ?torture ? and ? cruel, ? inhuman, ? and ? degrading ? treatment ? (Article ? 7) ? under ? the ?International ? Covenant ? on ? Civil ? and ? Political ? Rights ? (ICCPR), ? to ? which ? Thailand ?became ?a ?party ?in ?1996. ?Therefore, ?a ?greater ?oversight ?of ?police ?operations ?should ?be ?a ?priority ? for ? the ?Thai ? government. ? Second, ? given ? the ? findings ? that ?police ?beating ?may ? be ? undermining ?HIV ?prevention ? and ? health-???seeking ? practices ? among ? IDU ? in ?this ? setting, ?more ? efforts ? should ? be ?made ? to ?make ?drug ?policing ? respectful ? of ? the ?right ?to ?health ?of ?IDU. ?Some ?examples ?of ?such ?efforts ?proposed ?and ?made ?in ?other ?settings ? include ? encouraging ?police ? officers ? to ? exercise ?discretion ? or ? cautioning ? or ?other ?measures ?instead ?of ?arresting ?street-???level ?drug ?users,108 ?training ?police ?officers ?to ?support ?or ?at ?least ?not ?undermine ?harm ?reduction ?activities,83,169 ?and ?establishing ?multi-???sectoral ? partnerships ? between ? police ? and ? health ? agencies.168,169 ? However, ?evaluations ? of ? these ? efforts ? showed ? some ? mixed ? results, ? pointing ? out ? various ?barriers ? to ? implementation, ? including ? staff ? turnover, ? organizational ? culture ? in ? the ?police, ? variations ? in ? public ? perception ? of ? the ? role ? of ? police, ? and ? ongoing ? police ?corruption.82,168,174 ?There ?is ?clearly ?a ?need ?for ?more ?work ?to ?address ?such ?barriers. ?This ? study ? has ? several ? limitations. ? First, ? due ? to ? the ? cross-???sectional ? study ?design, ?we ?were ?unable ?to ?assess ?temporal ?relationships ?between ?the ?outcome ?and ?explanatory ? variables. ? Second, ? the ? self-???reported ? data ? may ? have ? been ? affected ? by ?socially ?desirable ?responding ?or ?recall ?bias. ?However, ?we ?note ?that ?this ?type ?of ?data ?has ?been ?commonly ?utilized ?in ?observational ?studies ?involving ?IDU ?and ?found ?to ?be ?valid.209,210 ?Third, ?as ?the ?study ?sample ?was ?not ?randomly ?selected, ?our ?findings ?may ?not ?be ?generalizable ?to ?other ?populations ?of ?IDU ?in ?Thailand. ? ? 72 ?In ?sum, ?we ?found ?that ?a ?high ?proportion ?of ?a ?community-???recruited ?sample ?of ?IDU ?in ?Bangkok ?reported ?having ?been ?beaten ?by ?police. ?Experiencing ?police ?beating ?was ? independently ? associated ? with ? indicators ? of ? drug-???related ? harm, ? including ?syringe ?sharing ?and ?barriers ?to ?accessing ?healthcare. ?These ?findings ?suggest ?that ?the ?over-???reliance ? on ? repressive ? drug ? policing ? may ? be ? contributing ? to ? human ? rights ?violations ? at ? the ? hands ? of ? police ? and ? exacerbating ? HIV ? risk ? among ? IDU ? in ? this ?setting. ? Therefore, ? they ? indicate ? the ? need ? for ? greater ? police ? oversight ? and ? a ? shift ?toward ? the ? implementation ?of ?policies ?and ?programs ? that ?are ?shown ? to ?effectively ?address ?HIV/AIDS211 ?and ?respect ?the ?right ?to ?health ?of ?IDU. ? ? ?  ? ? 73 ?Table 2: Bivariate analyses of factors associated with reports of police beatings among 639 IDU in Bangkok, Thailand Characteristic Ever beaten by police Prevalence Ratio (95% CI) p - value Yes 240 (37.6%) No 399 (62.4%) Calendar year of study enrolment    2011 144 (43.4%) 188 (56.6%) 1.39 (1.13 ? 1.71) 0.002 2009 96 (31.3%) 211 (68.7%)   Sociodemographic characteristics    Age     < 37 years old 119 (38.3%) 192 (61.7%) 1.04 (0.85 ? 1.27)  0.720 ? 37 years old 121 (36.9%) 207 (63.1%)   Gender     Male 227 (46.7%) 259 (53.3%) 5.50 (3.24 ? 9.33) <0.001 Female 13 (8.5%) 140 (91.5%)   Income from drug dealing*     Yes 21 (43.8%) 27 (56.3%) 1.18 (0.84 ? 1.65) 0.335 No 219 (37.1%) 372 (62.9%)   Drug use behaviour     Heroin injection ever     Yes 228 (40.3%) 338 (59.7%) 2.45 (1.45 ? 4.15) <0.001 No 12 (16.4%) 61 (83.6%)   Midazolam injection ever     Yes 210 (40.0%) 315 (60.0%) 1.52 (1.10 ? 2.10) 0.011 No 30 (26.3%) 84 (73.7%)   Methamphetamine injection ever    Yes 180 (39.6%) 274 (60.4%) 1.22 (0.96 ? 1.55) 0.097 No 60 (32.4%) 125 (67.6%)   Crystal methamphetamine injection ever   Yes 48 (51.6%) 45 (48.4%) 1.47 (1.17 ? 1.84) <0.001 No 192 (35.2%) 354 (64.8%)   Syringe sharing ever     Yes 175 (47.0%) 197 (53.0%) 1.93 (1.52 ? 2.45) <0.001 No 65 (24.3%) 202 (75.7%)   IDU: people who inject drugs; CI: Confidence Interval. * denotes events/activities in the previous 6 months.  ?  ? ? 74 ?Table 2: Bivariate analyses of factors associated with reports of police beatings among 639 IDU in Bangkok, Thailand (continued) Characteristic Ever beaten by police Prevalence Ratio (95% CI) p - value Yes 240 (37.6%) No 399 (62.4%) Experiences with criminal justice system  Ever in prison     Yes 220 (43.8%) 282 (56.2%) 3.00 (1.98 ? 4.56) <0.001 No 20 (14.6%) 117 (85.4%)   Ever in compulsory drug detention    Yes 56 (47.1%) 63 (52.9%) 1.33 (1.06 ? 1.66) 0.012 No 184 (35.4%) 336 (64.6%)   Healthcare access Ever accessed methadone treatment   Yes 200 (42.2%) 274 (57.8%) 1.74 (1.30 ? 2.33) <0.001    No 40 (24.2%) 125 (75.8%)   Reporting barriers to accessing healthcare   Any 158 (44.6%) 196 (55.4%) 1.55 (1.25 ? 1.93) <0.001 None 82 (28.8%) 203 (71.2%)   Health outcomes     HIV serostatus     Positive 61 (47.3%) 68 (52.7%) 1.35 (1.08 ? 1.67) 0.007 Negative or unknown 179 (35.1%) 331 (64.9%)   Non-fatal overdose ever     Yes 81 (52.6%) 73 (47.4%) 1.60 (1.32 ? 1.95) <0.001 No 159 (32.8%) 326 (67.2%)   IDU: people who inject drugs; CI: Confidence Interval. * denotes events/activities in the previous 6 months.  ? ?  ? ? 75 ? Table 3: Multivariate log-binomial regression analysis of factors associated with reports of police beatings among 639 IDU in Bangkok, Thailand Variable Adjusted PR 95% CI p - value Calendar year of study enrolment    (2011 vs. 2009) 1.27 (1.07 ? 1.49) 0.005 Younger age among those who ever injected methamphetamine  (< 37 years vs. ? 37 years old) 1.18 (0.99 ? 1.41) 0.062 Younger age among those who never injected methamphetamine   (< 37 years vs. ? 37 years old) 1.69 (1.17 ? 2.43) 0.005 Gender    (Male vs. Female) 4.43 (2.63 ? 7.49) <0.001 Syringe sharing ever    (Yes vs. No) 1.44 (1.15 ? 1.80) 0.002 Ever in prison    (Yes vs. No) 2.51 (1.68 ? 3.77) <0.001 Ever in compulsory drug detention    (Yes vs. No) 1.22 (1.05 ? 1.40) 0.008 Reporting barriers to accessing healthcare   (Any vs. None) 1.23 (1.01 ? 1.49) 0.043 Non-fatal overdose ever    (Yes vs. No) 1.14 (0.97 ? 1.34) 0.115 IDU: people who inject drugs; PR: prevalence ratio; CI: Confidence Interval. *denotes events/activities in the previous six months.  ? ?  ? ? 76 ?CHAPTER ?5: ?EXPERIENCES ?WITH ?URINE ?DRUG ?TESTING ?BY ?POLICE ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?5.1 ?Introduction ?In ? the ? past ? decade, ? Rhodes? ? Risk ? Environment ? Framework79,80 ? has ? been ?applied ? extensively ? to ? examine ? the ? effect ? of ? intensive ? police ? crackdowns ? on ? the ?health ? of ? IDU.81,82 ? As ? described ? in ? Chapter ? 2, ? previous ? research ? shows ? that ?aggressive ?policing ?practices, ? such ?as ?physical ?violence, ? can ?directly ?harm ? IDU.69,70 ?They ? can ? also ? intersect ?with ? other ? elements ? of ? the ? risk ? environment ? and ? increase ?IDUs? ? vulnerability ? to ? poor ? health ? outcomes.72-???74 ? For ? example, ? increased ? police ?presence ?may ?displace ?IDU ?into ?remote ?or ?hidden ?locations ?and ?disrupt ?healthcare ?service ? provision ? to ? this ? population.73 ? Despite ? a ? large ? body ? of ? scientific ? literature ?documenting ? the ? adverse ? impacts ? of ? police ? crackdowns ? on ? the ? health ? of ? IDU, ?previous ?studies ?tended ?to ?focus ?on ?the ?aggregate ?effects ?and ?consequences ?of ?police ?crackdowns ?rather ?than ?on ?specific ?policing ?tactics. ? ?Under ?Thailand?s ?Narcotics ?Control ?Act ?(Section ?14) ?and ?Narcotics ?Act ?(Section ?58/1),26 ?drug ?law ?enforcement ?officers ?have ?the ?authority ?to ?perform ?drug ?testing ?on ?anyone ?based ?upon ?reasonable ?suspicion. ?Although ?anecdotal ? reports ? suggest ? that ?the ? Thai ? police ? frequently ? use ? exercise ? this ? power ? and ?use ? rapid ?urine ? toxicology ?screening ? on ? the ? streets ? of ? Bangkok, ?we ? know ? of ? no ? studies ? that ? investigated ? the ?impact ?and ?ethics ?of ? this ?practice. ?Therefore, ?we ? sought ? to ? identify ? the ?prevalence ?and ? correlates ? of ? experiencing ? urine ? drug ? testing ? by ? police ? among ? a ? community-???recruited ?sample ?of ?IDU ?in ?Bangkok, ?Thailand. ?5.2 ?Methods ?Quantitative ? data ? for ? this ? study ? were ? derived ? from ? the ? Mitsampan ?Community ?Research ?Project, ?as ?described ?in ?detail ?in ?section ?1.6. ? ? 77 ?All ?respondents ?who ?completed ?the ?interview ?between ?July ?and ?October ?2011 ?were ? eligible ? for ? inclusion ? in ? this ? study. ? The ? sample ?was ? restricted ? to ? individuals ?who ? provided ? complete ? data ? for ? the ? present ? analyses. ? The ? primary ? outcome ? of ?interest ?in ?this ?study ?was ?experiencing ?urine ?toxicology ?testing ?by ?police, ?defined ?as ?answering ??Yes? ?to ?the ?following ?question: ??Have ?you ?ever ?been ?tested ?for ?drugs ?by ?police?? ? In ? the ? present ? study ? setting, ? ?having ? been ? tested ? for ? drugs ? by ? police? ?referred ?to ?having ?been ?subjected ?to ?urine ?toxicology ?testing ?by ?police. ?Guided ?by ? the ?Risk ?Environment ?Framework,79,80 ?a ?broad ?set ?of ?explanatory ?variables ?were ? hypothesized ? to ? be ? potentially ? associated ?with ? the ? outcome. ? These ?variables ? included: ? age ? (below ? or ? above ? median ? age; ? < ? 38 ? years ? vs. ? ? ? 38 ? years); ?gender ? (male ? vs. ? female); ? heroin ? injection; ? midazolam ? injection ? (a ? short-???acting ?benzodiazepine); ?methamphetamine ? injection ? (i.e., ?methamphetamine ?pills ? [locally ?called ? yaba] ? or ? crystal ? methamphetamine ? powder ? [locally ? called ? ice]); ? syringe ?sharing; ? ever ? incarcerated; ? ever ? in ? compulsory ? drug ? detention; ? ever ? accessed ?voluntary ? drug ? treatment; ? ever ? disclosed ? illicit ? drug ? use ? to ? a ? doctor; ? reporting ?avoidance ? of ? healthcare; ? reporting ? feeling ? ashamed ? about ? being ? a ? drug ?user; ?HIV ?serostatus ?(positive ?vs. ?negative ?or ?unknown); ?and ?non-???fatal ?overdose ?ever. ?As ?in ?a ?previous ?study,55 ?non-???fatal ?overdose ?was ?defined ?as ?a ?period ?of ?loss ?of ?consciousness ?or ?breathing. ?All ?variables ?were ?coded ?dichotomously ?as ?yes ?vs. ?no, ?unless ?otherwise ?stated. ?All ?variables ?related ?to ?drug-???using ?behaviour ?referred ?to ?any ?time ?in ?the ?past. ? ?For ?bivariate ?and ?multivariate ?analyses, ?we ?used ?the ?prevalence ?ratio, ?rather ?than ? the ? odds ? ratio, ? as ? a ? measure ? of ? association ? because ? the ? frequency ? of ? the ?outcome ?exceeded ?10%.203 ?First, ?we ?used ?Poisson ?regression ?with ?the ?robust ?variance ?to ?examine ?bivariate ?associations ?between ?reports ?of ?drug ?testing ?by ?police ?and ?the ?explanatory ? variables, ? which ? gave ? us ? unadjusted ? prevalence ? ratios ? with ?corresponding ? 95% ? confidence ? intervals.204 ? Next, ? we ? used ? an ? a ? priori-???defined ? ? 78 ?statistical ? protocol ? that ? examined ? factors ? associated ?with ? the ? outcome ? by ? fitting ? a ?multivariate ? robust ?Poisson ? regression ?model ? that ? included ?all ?variables ? that ?were ?significantly ?associated ?with ?the ?outcome ?at ?the ?p ?< ?0.05 ?level ?in ?bivariate ?analyses. ?All ? p-???values ? were ? two-???sided. ? All ? statistical ? analyses ? were ? performed ? with ? SAS ?version ?9.3 ?(SAS ?Institute ?Inc., ?Cary, ?NC, ?USA). ?5.3 ?Results ?In ?total, ?438 ?IDU ?participated ?in ?this ?study, ?including ?87 ?(19.9%) ?women. ?The ?median ? age ?was ? 38 ? years ? (interquartile ? range: ? 34 ? ? ? 48 ? years). ? In ? total, ? 293 ? (66.9%) ?individuals ?reported ?having ?ever ?been ?tested ?for ?illicit ?drugs ?by ?police. ? ?Table ? 4 ? shows ? the ? results ? of ? bivariate ? analyses. ? As ? shown, ? reports ? of ? drug ?testing ? by ? police ? were ? significantly ? and ? positively ? associated ? with ? younger ? age ?(prevalence ? ratio ? [PR]: ? 1.32; ? 95% ? confidence ? interval ? [CI]: ? 1.16 ? ? ? 1.51); ?methamphetamine ? injection ? ever ? (PR: ? 1.33; ? 95% ?CI: ? 1.11 ? ? ? 1.60); ? ever ? incarcerated ?(PR: ?1.25; ?95% ?CI: ?1.05 ?? ?1.50); ?ever ?in ?compulsory ?drug ?detention ?(PR: ?1.58; ?95% ?CI: ?1.43 ?? ?1.74); ?ever ?disclosed ?illicit ?drug ?use ?to ?a ?doctor ?(PR: ?1.16; ?95% ?CI: ?1.01 ?? ?1.34); ?avoidance ?of ?healthcare ?(PR: ?1.19; ?95% ?CI: ?1.04 ?? ?1.36); ?and ?HIV ?seropositivity ?(PR: ?1.18; ?95% ?CI: ?1.02 ?? ?1.36). ?Ever ?accessed ?voluntary ?drug ?treatment ?was ?significantly ?and ?negatively ?associated ?with ?the ?outcome ?(PR: ?0.81; ?95% ?CI: ?0.71 ?? ?0.92). ?Table ? 5 ? shows ? the ? results ? from ? the ? final ? multivariate ? Poisson ? regression ?model. ? As ? shown, ? reports ? of ? drug ? testing ? by ? police ? were ? independently ? and ?positively ?associated ?with ?younger ?age ?(adjusted ?prevalence ?ratio ?[APR]: ?1.28; ?95% ?CI: ? 1.12 ? ? ? 1.45); ?methamphetamine ? injection ? ever ? (APR: ? 1.22; ? 95% ?CI: ? 1.03 ? ? ? 1.44); ?ever ?incarcerated ?(APR: ?1.21; ?95% ?CI: ?1.02 ?? ?1.44); ?ever ?in ?compulsory ?drug ?detention ?(APR: ?1.43; ?95% ?CI: ?1.29 ?? ?1.58); ?avoidance ?of ?healthcare ?(APR: ?1.15; ?95% ?CI: ?1.01 ?? ?1.30); ? and ? HIV ? seropositivity ? (APR: ? 1.19; ? 95% ? CI: ? 1.02 ? ? ? 1.38). ? Ever ? accessed ? ? 79 ?voluntary ?drug ? treatment ? (APR: ? 0.82; ? 95% ?CI: ? 0.71 ? ? ? 0.94) ?was ? independently ? and ?negatively ?associated ?with ?the ?outcome. ?5.4 ?Discussion ?We ? found ? that ? two ? thirds ? of ? a ? sample ? of ? IDU ? in ? Bangkok ? reported ? having ?been ? tested ? for ? illicit ? drugs ? by ? police. ? In ? multivariate ? analyses, ? reports ? of ? drug ?testing ?by ?police ?were ? independently ? and ?positively ? associated ?with ? younger ? age, ?methamphetamine ? injection, ? HIV ? seropositivity, ? incarceration, ? compulsory ? drug ?detention, ? and ? avoidance ? of ? healthcare. ? In ? contrast, ? individuals ? who ? had ?experienced ?drug ?testing ?by ?police ?were ?less ?likely ?to ?have ?accessed ?voluntary ?drug ?treatment. ? ?To ? our ? knowledge, ? the ? present ? study ? is ? the ? first ? to ? describe ? the ? prevalence ?and ? correlates ? of ? experiencing ? drug ? testing ? by ? police ? among ? IDU. ?We ? found ? that ?that ? this ? policing ? tactic ? has ? been ?widely ?used ?with ? IDU ? in ?Bangkok. ?The ? findings ?that ?experiencing ?drug ?testing ?by ?police ?was ?independently ?associated ?with ?younger ?age ?and ?methamphetamine ?injection ?may ?reflect ?the ?fact ?that ?Thai ?authorities ?have ?attached ? great ? importance ? to ? a ? widespread ? epidemic ? of ? methamphetamine ? use ?among ? young ? people ? in ? the ? country.39,212 ? Thus, ? young ? people ?may ? be ? easy ? visible ?targets ? for ? police. ? Methamphetamine ? injectors ? may ? have ? exhibited ? some ? overt ?intoxication ? or ? withdrawal ? symptoms ? of ? methamphetamine ? use213 ? when ? police ?approached ?them. ? ?Having ? been ? in ? compulsory ? drug ? detention ? centres ? was ? independently ?associated ?with ?experiencing ?drug ? testing ?by ?police. ?As ?documented ? in ?a ?previous ?report,157 ? police ? may ? have ? obtained ? information ? on ? people ? who ? underwent ?compulsory ?drug ?detention ?centres ?through ?registries ?and ?approached ?these ?people. ?Another ? plausible ? interpretation ? is ? that ? those ? who ? had ? been ? subjected ? to ? drug ?testing ? by ? police ? were ? subsequently ? sent ? to ? compulsory ? drug ? detention ? centres ? ? 80 ?because ?these ?centres ?primarily ?serve ?those ?charged ?with ?illicit ?drug ?consumption.27 ?The ? finding ? that ? reports ? of ? drug ? testing ? by ? police ? were ? also ? independently ?associated ?with ?incarceration ?supports ?this ?interpretation, ?given ?that ?those ?charged ?with ?illicit ?drug ?consumption ?are ?typically ?detained ?in ?prisons ?while ?being ?assessed ?for ? eligibility ? for ? compulsory ?drug ? treatment.27 ?As ?well, ? given ? the ? increases ? in ? the ?number ?of ?drug ?users ?that ?the ?Thai ?government ?has ?targeted ?for ?rehabilitation ?over ?the ?past ?several ?years,41-???44 ?Thai ?police ?may ?have ?been ?pressured ?to ?make ?arrests ?and ?extensively ?employed ?drug ?testing ?to ?help ?identify ?people ?to ?arrest. ?Regardless, ?our ?findings ? indicate ? that ? forcible ? drug ? testing ? by ? police ? may ? be ? linked ? to ? the ?compulsory ?drug ?detention ?and ?prison ?systems. ? ?We ?also ?found ?that ?individuals ?who ?experienced ?drug ?testing ?by ?police ?were ?more ?likely ?to ?be ?HIV-???positive ?and ?to ?have ?been ?in ?prison. ?As ?prisons ?are ?known ?to ?contribute ? significantly ? to ?HIV ? transmission ? among ? Thai ? IDU,53,56 ? it ? is ? concerning ?that ?the ?extensive ?use ?of ?drug ?testing ?by ?police ?may ?result ?in ?the ?incarceration ?of ?a ?large ? number ? of ? IDU ? and ? thereby ? serve ? to ? fuel ? transmission ? of ? HIV ? among ? IDU ?inmates. ? In ? light ? of ? this ? finding, ? it ? is ? important ? to ? note ? that ?WHO ? and ? other ?UN ?agencies ?recommend ?providing ?comprehensive ?HIV ?prevention ?services ?(e.g., ?sterile ?syringe ?distribution) ? in ?prisons ?and ?ensuring ? the ? continuity ?of ?HIV ? treatment ? and ?care ? as ? HIV-???positive ? persons ? transition ? between ? prison ? and ? the ? community.211 ?However, ? Thai ? prisons ? do ? not ? provide ? sterile ? syringes. ? Although ? antiretroviral ?therapy ? (ART) ? is ? available ? free ? of ? charge ? to ? all ? prisoners ? in ? Bangkok, ? a ? previous ?report ?suggested ?that ?inmates ?who ?received ?ART ?in ?prison ?faced ?various ?barriers ?to ?continuing ?it ?upon ?release.157 ?Therefore, ?our ?findings ?underscore ?a ?need ?to ?improve ?HIV ?prevention ?and ?treatment ?efforts ?in ?Thai ?prisons. ?Of ? particular ? concern ? are ? the ? findings ? in ? relation ? to ? healthcare ? access. ?Experiences ? with ? drug ? testing ? by ? police ? were ? independently ? associated ? with ? ? 81 ?avoidance ? of ? healthcare, ? suggesting ? that ? those ? who ? experienced ? drug ? testing ? by ?police ?might ? be ? deterred ? from ? accessing ? healthcare. ? This ? is ? consistent ?with ? a ? vast ?international ? literature ? showing ? that ? repressive ?drug ?policing ?often ? interferes ?with ?health ?service ?delivery ?to ?IDU.73,82 ?Likewise, ?the ?finding ?that ?reports ?of ?drug ?testing ?by ? police ? were ? negatively ? associated ? with ? the ? enrolment ? in ? voluntary ? drug ?treatment ? may ? suggest ? that ? those ? who ? were ? forced ? to ? undergo ? drug ? testing ? by ?police ?may ?have ?retreated ?into ?more ?hidden ?settings ?and ?therefore ?were ?less ?likely ?to ?access ? voluntary ? drug ? treatment ? programs ? afterwards. ? Alternatively, ? it ? is ? also ?possible ?that ?individuals ?who ?accessed ?voluntary ?drug ?treatment ?may ?have ?had ?less ?visible ? signs ? of ? illicit ? drug ? use ? and ?were ? therefore ? less ? likely ? to ? be ? an ? immediate ?target ? for ? police. ?Although ?more ? research ? is ? needed ? to ? explore ? these ? associations, ?our ? findings ? suggest ? that ? the ? widespread ? use ? of ? drug ? testing ? by ? police ? may ? be ?negatively ?affecting ?IDUs? ?health-???seeking ?behaviour ?in ?this ?setting. ?Facilitating ?access ? to ? scientifically ? sound ?addiction ? treatment ? among ?people ?who ?use ?drugs ?is ?a ?key ?means ?of ?responding ?to ?epidemics ?of ?illicit ?drug ?use ?and ?HIV ?infection.214 ? As ? is ? evident ? in ? previous ? reports,27,39 ? the ? compulsory ? drug ? detention ?system ? is ? the ? principal ? strategy ? employed ? by ? the ? Thai ? government ? as ? part ? of ? the ?demand ? reduction ?measures, ? and ?drug ? testing ?by ?police ?may ?be ?playing ? a ? critical ?role ? in ? this ? system. ?However, ?previous ? reports ? indicated ? that ?prior ? to ? compulsory ?drug ?treatment, ?people ?were ?routinely ?detained ? in ?prison ?with ? little ?or ?no ?medical ?assistance ? for ? drug ? withdrawal ? symptoms,215 ? and ? compulsory ? drug ? detention ?centres ?did ?not ?appear ?to ?reduce ?drug ?use ?among ?IDU ?upon ?release.216 ?Furthermore, ?twelve ?UN ?agencies ?have ?recently ?stated ?that ?these ?centres ?threaten ?the ?health ?and ?human ? rights ? of ? detainees ? and ? called ? upon ? the ? government ? to ? close ? down ? the ?centres,29 ? which ? was ? also ? echoed ? by ? the ? UN ? Special ? Rapporteur ? on ? torture.154 ?Considering ? these ? reports ? and ? the ? harms ? found ? to ? be ? associated ? with ? the ? drug ? ? 82 ?testing ? by ? police ? in ? the ? present ? study, ? the ? Thai ? government ? should ? carefully ?reconsider ?the ?purpose, ?as ?well ?as ?potential ?benefits ?and ?harms ?of ?this ?practice. ? ?This ?study ?has ?several ? limitations. ?First, ?we ?cannot ?infer ?causation ?from ?this ?observational ? study. ?While ? it ? is ? plausible ? that ? urine ? toxicology ? testing ? resulted ? in ?individuals ? ending ? up ? in ? compulsory ? drug ? detention, ? due ? to ? the ? cross-???sectional ?study ?design, ?we ?were ?unable ?to ?assess ?temporal ?relationships ?between ?the ?outcome ?and ?explanatory ?variables. ?Second, ?the ?self-???reported ?data ?may ?have ?been ?affected ?by ?socially ?desirable ?responding ?or ?recall ?bias. ?However, ?we ?note ?that ?this ?type ?of ?data ?has ?been ?commonly ?utilized ?in ?observational ?studies ?involving ?IDU ?and ?found ?to ?be ?valid.209,210 ?Third, ?as ?the ?study ?sample ?was ?not ?randomly ?selected, ?our ?findings ?may ?not ?be ?generalizable ?to ?other ?populations ?of ?IDU ?in ?Thailand ?or ?elsewhere. ? ?In ?sum, ?we ?found ?that ?a ?high ?proportion ?of ?a ?community-???recruited ?sample ?of ?IDU ? in ? Bangkok ? reported ? having ? been ? tested ? for ? illicit ? drugs ? by ? police. ? Young ?people ?and ?methamphetamine ? injectors ?appeared ? to ?be ? the ?primary ? targets ?of ? this ?policing ?tactic. ?Our ?findings ?also ?indicated ?that ?urine ?toxicology ?testing ?by ?police ?is ?linked ? to ? the ? compulsory ? drug ? detention ? system ? and ? other ? indicators ? of ? drug-???related ? harm, ? including ? reduced ? access ? to ? healthcare. ? These ? findings ? raise ? serious ?concern ?about ?the ?use ?of ?drug ?testing ?by ?police ?in ?its ?current ?form. ? ? ?  ? ? 83 ?Table 4: Bivariate analyses of factors associated with experiencing drug testing by police among 438 IDU in Bangkok, Thailand Characteristic Ever tested for illicit drugs by police Prevalence Ratio (95%CI) p - value Yes 293 (66.9%) No 145 (33.1%) Demographic characteristics    Age     < 38 years old 159 (54.3%) 48 (33.1%) 1.32 (1.16 ? 1.51)  <0.001 ? 38 years old 134 (45.7%) 97 (66.9%)   Gender     Male 234 (79.9%) 117 (80.7%) 0.98 (0.84 ? 1.16) 0.837 Female 59 (20.1%) 28 (19.3%)   Drug use behaviour     Heroin injection ever     Yes 262 (89.4%) 136 (93.8%) 0.85 (0.71 ? 1.02) 0.078 No 31 (10.6%) 9 (  6.2%)   Midazolam injection ever     Yes 245 (83.6%) 114 (78.6%) 1.12 (0.93 ? 1.36) 0.233 No 48 (16.4%) 31 (21.4%)   Methamphetamine injection ever*  Yes 230 (78.5%) 91 (62.8%) 1.33 (1.11 ? 1.60) 0.002 No 63 (21.5%) 54 (37.2%)   Syringe sharing ever     Yes 190 (64.9%) 86 (59.3%) 1.08 (0.94 ? 1.25) 0.269 No 103 (35.1%) 59 (40.7%)   Experiences with criminal justice system  Ever in prison     Yes 230 (78.5%) 96 (66.2%) 1.25 (1.05 ? 1.50) 0.013 No 63 (21.5%) 49 (33.8%)   Ever in compulsory drug detention    Yes 79 (27.0%) 4 (  2.8%) 1.58 (1.43 ? 1.74) <0.001 No 214 (73.0%) 141 (97.2%)   IDU: people who inject drugs; CI: Confidence Interval. *Methamphetamine includes methamphetamine pills and crystal methamphetamine powder.  ?  ? ? 84 ?Table 4: Bivariate analyses of factors associated with experiencing drug testing by police among 438 IDU in Bangkok, Thailand (continued) Characteristic Ever tested for illicit drugs by police Prevalence Ratio (95%CI) p - value Yes 293 (66.9%) No 145 (33.1%) Healthcare access Ever accessed voluntary drug treatment   Yes 215 (73.4%) 124 (85.5%) 0.81 (0.71 ? 0.92) 0.001    No 78 (26.6%) 21 (14.5%)   Ever disclosed drug use to a doctor   Yes 183 (62.5%) 75 (51.7%) 1.16 (1.01 ? 1.34) 0.037    No 110 (37.5%) 70 (48.3%)   Avoid accessing healthcare   Yes 85 (29.0%) 27 (18.6%) 1.19 (1.04 ? 1.36) 0.010 No 208 (71.0%) 118 (81.4%)   Internalized stigma Feeling ashamed of being a drug user   Yes 215 (73.4%) 104 (71.7%) 1.03 (0.88 ? 1.20) 0.718 No 78 (26.6%) 41 (28.3%)   Health outcomes     HIV serostatus     Positive 61 (20.8%) 19 (13.1%) 1.18 (1.02 ? 1.36) 0.027 Negative or unknown 232 (79.2%) 126 (86.9%)   Non-fatal overdose ever     Yes 83 (28.3%) 36 (24.8%) 1.06 (0.92 ? 1.22) 0.426 No 210 (71.7%) 109 (75.2%)   IDU: people who inject drugs; CI: Confidence Interval. *Methamphetamine includes methamphetamine pills and crystal methamphetamine powder.  ? ?  ? ? 85 ?Table 5: Multivariate Poisson regression analysis of factors associated with experiencing drug testing by police among 438 IDU in Bangkok, Thailand ?Variable Adjusted PR 95% CI p - value Younger age    (< 38 years vs. ? 38 years old) 1.28 (1.12 ? 1.45) <0.001 Methamphetamine injection ever*  (Yes vs. No) 1.22 (1.03 ? 1.44) 0.023 Ever in prison    (Yes vs. No) 1.21 (1.02 ? 1.44) 0.030 Ever in compulsory drug detention    (Yes vs. No) 1.43 (1.29 ? 1.58) <0.001 Ever accessed voluntary drug treatment    (Yes vs. No) 0.82 (0.71 ? 0.94) 0.004 Ever disclosed drug use to a doctor    (Yes vs. No) 1.11 (0.97 ? 1.27) 0.145 Avoid accessing healthcare   (Yes vs. No) 1.15 (1.01 ? 1.30) 0.038 HIV serostatus    (Positive vs. Negative or unknown) 1.19 (1.02 ? 1.38) 0.024 IDU: people who inject drugs; PR: prevalence ratio; CI: Confidence Interval. *Methamphetamine includes methamphetamine pills and crystal methamphetamine powder.  ? ?  ? ? 86 ?CHAPTER ?6: ?THE ?RELATIONSHIP ?BETWEEN ?EXPOSURES ?TO ?POLICING ?AND ?SYRINGE ?SHARING ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?6.1 ?Introduction ?In ?many ?parts ?of ? the ?world, ? injection ?drug ?use ? remains ?a ?primary ?driver ?of ?HIV ?infection.217 ?On ?June ?10, ?2011, ?the ?UN ?General ?Assembly ?High ?Level ?Meeting ?on ?AIDS ? adopted ? the ? Political ?Declaration ? on ?HIV/AIDS ? and ?made ? a ? bold ? pledge ? to ?halve ?HIV ?transmission ?among ?IDU ?by ?2015.218 ?To ?this ?end, ?the ?declaration ?explicitly ?referred ?to ? the ? implementation ?and ?expansion ?of ?harm ?reduction ?programs, ?which ?had ?been ?recommended ?by ?the ?UN ?agencies ?as ?key ?HIV ?prevention ?efforts ?for ?IDU.13 ?These ? programs ? consist ? of ? nine ? evidence-???based ? interventions, ? including ? NSPs.13 ?Although ?the ?number ?of ?countries ?endorsing ?this ?approach ?has ?increased ?in ?recent ?years,219,220 ? the ? availability ? and ? coverage ? of ? the ? programs ? vary ? across ? jurisdictions ?and ?tend ?to ?be ?low.21,65 ? ?As ? described ? in ? Chapter ? 2, ? a ? large ? body ? of ? literature ? has ? suggested ? that ?repressive ?policing ?practices ?represented ?one ?of ?the ?recognized ?determinants ?of ?HIV ?risk ?and ?infection ?among ?IDU ?in ?many ?regions ?of ?the ?world.81,82,98 ?However, ?previous ?studies ? tended ? to ? focus ? on ? the ? aggregate ? effects ? and ? consequences ? of ? police ?crackdowns ?rather ?than ?on ?direct ?encounters ?with ?police ?or ?specific ?policing ?tactics. ?While ?a ?smaller ?number ?of ?studies ?have ?described ?the ?effects ?of ?experiencing ?specific ?forms ? of ? policing ? on ? HIV ? risk ? behaviour ? among ? IDU, ? such ? as ? arrest ? for ? syringe ?possession76,221 ?and ?syringe ?confiscation ?by ?police,123 ?other ?commonly ?used ?policing ?tactics ?have ?not ?been ?explored. ? ? Thailand ?has ?experienced ?a ?longstanding ?epidemic ?of ?HIV ?among ?IDU, ?with ?an ?estimated ?30% ?to ?50% ?of ?IDU ?living ?with ?HIV/AIDS ?over ?the ?past ?two ?decades.61 ?In ? June ? 2012, ? the ?Thai ?government ? announced ?a ?new ?national ?HIV/AIDS ? strategic ? ? 87 ?plan ? 2012-???2016 ? and ? aimed ? to ? reduce ? new ?HIV ? infection ? by ? two-???thirds ? by ? 2016.222 ?However, ?the ?coverage ?of ?HIV ?prevention ?programs ?for ?IDU ?remains ?low.220 ?On ?the ?other ?hand, ?in ?2011, ?the ?Thai ?government ?targeted ?400,000 ?people ?who ?use ?drugs ?to ?undergo ? drug ? rehabilitation ? programs ? and ? intensified ? police ? crackdowns ? on ? this ?population.44,45 ?It ?is ?well ?known ?that ?the ?2003 ??war ?on ?drugs? ?resulted ?in ?widespread ?police ? misconduct ? and ? human ? rights ? abuses.22 ? Although ? more ? recent ? reports ?suggested ? that ? harmful ? policing ? practices ? have ? continued ? into ? the ? post-???2003 ?period,157 ? the ?extent ? to ?which ?ongoing ?policing ?practices ?affect ?HIV ?risk ?behaviour ?among ?IDU ?has ?not ?been ?well ?investigated ?in ?this ?setting. ?In ?addition, ?although ?Thai ?dug ? laws ? allow ?drug ? law ? enforcement ? officers ? to ? drug ? test ? anyone ? on ? reasonable ?suspicion26 ?and ?anecdotal ?reports ?suggest ? that ? the ?Thai ?police ? frequently ?use ?rapid ?urine ? toxicology ? testing ? to ? identify ? drug ? offenders ? in ? Bangkok, ? the ? effect ? of ? this ?policing ?practice ?on ?HIV ?risk ?behaviour ?has ?not ?been ?investigated. ?In ? the ? wake ? of ? the ? renewed ? crackdowns, ? and ? given ? the ? knowledge ? gaps ?regarding ?the ?effect ?of ?direct ?encounters ?with ?police ?on ?HIV ?risk ?of ?IDU, ?we ?sought ?to ? examine ? the ? relationship ? between ? syringe ? sharing ? and ? exposures ? to ? specific ?policing ?tactics ?among ?IDU ?in ?Bangkok, ?Thailand. ?6.2 ?Methods ?Quantitative ? data ? for ? this ? study ? were ? derived ? from ? the ? Mitsampan ?Community ?Research ?Project, ?as ?described ?in ?detail ?in ?section ?1.6. ?For ? this ? study, ? we ? included ? respondents ? who ? completed ? the ? interview ?between ? July ? and ? October ? 2011. ? The ? sample ? was ? restricted ? to ? individuals ? who ?provided ? complete ? data ? for ? the ? purpose ? of ? the ? present ? analyses. ? The ? primary ?outcome ?of ?interest ?in ?this ?study ?was ?syringe ?sharing ?in ?the ?past ?six ?months, ?defined ?as ?having ?borrowed ?or ?lent ?used ?syringes ?from/to ?others ?in ?the ?past ?six ?months ?(i.e., ?a ?combined ?endpoint ?of ?receptive ?and ?distributive ?sharing). ? ? ? 88 ?The ?primary ? explanatory ? variable ? of ? interest ?was ? the ? effect ? of ? exposures ? to ?specific ? policing ? tactics. ? Previous ? quantitative ? studies ? have ? shown ? that ? increased ?contacts ? with ? police ? (measured ? as ? drug-???related ? arrest ? rates, ? for ? instance) ? were ?positively ?correlated ?with ?syringe ?sharing ?and ?HIV ?prevalence ?among ?IDU.223,224 ?On ?the ?other ?hand, ?a ?qualitative ?study ?suggested ?that ?IDU ?might ?be ?engaged ?in ?syringe ?sharing ?out ?of ? fear ? of ?police ? that ?was ? caused ?not ?necessarily ?by ? recent ? encounters ?with ? police ? but ? by ? past ? experiences ? of ? extrajudicial ? policing ? actions ? (e.g., ? police ?beating ?of ?IDU).69 ?Informed ?by ?these ?previous ?studies ?and ?the ?conceptual ?framework ?(Figure ? 1), ? we ? hypothesized ? that ? both ? experiences ? of ? severe ? police ? violence ?(regardless ?of ?timing) ?and ?a ?recent ?direct ?encounter ?with ?police ?would ?increase ?fear ?of ?police ?and ?in ?turn, ?increase ?risk ?of ?syringe ?sharing. ?The ?two ?types ?of ?exposures ?to ?policing ?were ?operationalized ?as ?having ?ever ?been ?beaten ?by ?police ?and ?having ?been ?tested ? for ? illicit ? drugs ? by ? police ? in ? the ? past ? six ? months. ? We ? hypothesized ? that ?experiencing ?both ?beating ?and ?drug ?testing ?by ?police ?would ?yield ?the ?greatest ?effect ?on ? syringe ? sharing. ? Therefore, ? we ? created ? a ? variable ? for ? exposures ? to ? specific ?policing ?tactics ?with ?four ?categories: ?(1) ?having ?experienced ?drug ?testing ?by ?police ?in ?the ? past ? six ? months ? but ? no ? police ? beatings ? any ? time ? in ? the ? past; ? (2) ? having ?experienced ?police ?beatings ?any ?time ?in ?the ?past ?but ?no ?drug ?testing ?in ?the ?past ?six ?months; ? (3) ?having ? experienced ? the ? two ? events ? (i.e., ? having ?been ?beaten ?by ?police ?any ?time ?in ?the ?past ?and ?having ?been ?tested ?for ?illicit ?drugs ?by ?police ?in ?the ?past ?six ?months); ?and ?(4) ?having ?experienced ?neither ?of ?the ?events ?(our ?reference ?category). ? ?Previous ? studies ? of ? IDU ? in ? Bangkok ? found ? that ? syringe ? sharing ? was ?associated ?with ?difficulty ?accessing ?sterile ?syringes, ?injecting ?with ?other ?people ?on ?a ?frequent ? basis, ? and ? frequent ? methamphetamine ? injection.208,225 ? Building ? on ? these ?findings, ?we ? considered ? secondary ? explanatory ?variables ? that ?might ? confound ? the ?relationship ? between ? exposures ? to ? specific ? policing ? tactics ? and ? syringe ? sharing. ? ? 89 ?These ? included ?younger ? age ? (dichotomized ? at ? the ?median ? age: ? < ? 38 ? years ?vs. ? ? ? 38 ?years); ?gender ?(male ?vs. ?female); ?HIV ?serostatus ?(positive ?vs. ?negative ?or ?unknown); ?injecting ? heroin, ? midazolam ? (a ? short-???acting ? benzodiazepine), ? methamphetamine ?(locally ? called ? yaba), ? or ? crystal ? methamphetamine ? (locally ? called ? ice) ? (> ? once ? per ?week ?vs. ?? ?once ?per ?week); ?use ?of ?drugs ?in ?combination ?(yes ?vs. ?no); ?binge ?drug ?use ?(yes ?vs. ? no); ? injecting ?with ? others ? on ? a ? frequent ? basis ? (> ? 75% ?of ? time ?vs. ? ? ? 75% ?of ?time); ? accessing ? voluntary ?drug ? treatment ? (yes ?vs. ? no); ? having ?difficulty ? accessing ?sterile ?syringes ?(yes ?or ?sometimes ?vs. ?no); ?and ?having ?ever ?accessed ?one ?of ?the ?four ?drop-???in ?centers ? for ?drug ?users ? in ?Bangkok ? (yes ?vs. ?no). ?All ?variables ?were ?derived ?from ?self-???reported ?data ?and ?referred ?to ?the ?period ?beginning ?six ?months ?prior ?to ?the ?interview, ?unless ?otherwise ?stated. ? ?For ? the ? bivariate ? and ? multivariate ? analyses, ? we ? used ? the ? prevalence ? ratio, ?rather ?than ?the ?odds ?ratio, ?as ?a ?measure ?of ?association ?because ?the ?frequency ?of ?the ?outcome ?exceeded ?10%.203 ?First, ?we ?used ?simple ?binomial ?regression ?with ?a ?log ?link ?function204 ?to ?examine ?bivariate ?associations ?between ?syringe ?sharing ?in ?the ?past ?six ?months ?and ?the ?explanatory ?variables, ?which ?gave ?us ?unadjusted ?prevalence ?ratios ?with ? corresponding ? 95% ? confidence ? intervals. ? We ? also ? examined ? Pearson?s ?correlation ? coefficient ? to ? estimate ? the ? strength ? of ? correlation ? between ? each ?explanatory ?variable ?and ?the ?outcome. ?To ?obtain ?effect ?estimates ?for ?exposures ?to ?specific ?policing ?tactics ?accounting ?for ?potential ?confounders, ?we ?used ?an ?a ?priori-???defined ?statistical ?protocol ?proposed ?by ?Maldonado ?and ?Greenland226 ?to ?construct ?a ?multivariate ?log-???binomial ?regression ?model. ?We ?used ?a ?conservative ?p-???value ?of ?0.20 ?in ?the ?bivariate ?analyses ?to ?determine ?whether ?a ?secondary ?explanatory ?variable ?was ?considered ?a ?potential ?confounder ?in ?the ? relationship ?between ?exposures ? to ? specific ?policing ? tactics ?and ?syringe ? sharing ?and ? for ? inclusion ? in ? a ? full ? multivariate ? model. ? Maldonado ? and ? Greenland ? ? 90 ?recommends ? using ? the ? conservative ? p-???value ? to ? account ? for ? potential ? important ?confounders ? that ?may ? not ? be ? associated ?with ? the ? outcome ? at ? the ? p ? < ? 0.05 ? level ? in ?bivariate ? analyses.226 ? The ? full ? model ? was ? then ? subjected ? to ? a ? manual ? backward ?selection ?approach ? to ? select ? significant ? confounders. ? Specifically, ?beginning ?with ?a ?full ?model ?with ?all ?covariates ?that ?were ?associated ?with ?syringe ?sharing ?at ?p ?< ?0.20 ?in ?the ?bivariate ?analyses, ?secondary ?explanatory ?variables ?were ?dropped ?one ?at ?a ?time ?using ? the ? relative ? change ? in ? the ? regression ? coefficient ? for ? the ? variable ? related ? to ?exposures ?to ?specific ?policing ?tactics ?as ?criteria, ?until ?the ?smallest ?relative ?change ?in ?the ?coefficient ?for ?any ?category ?of ?exposures ?to ?specific ?policing ?tactics ?from ?the ?full ?model ? exceeded ? 10%. ? We ? then ? fit ? a ? final ? model ? including ? exposures ? to ? specific ?policing ? tactics ? and ? all ? remaining ? covariates ? as ? terms ? in ? the ? regression ? equation. ?Because ? the ? full ?multivariate ? log-???binomial ? regression ?model ? did ?not ? converge, ?we ?used ? the ?COPY ?method ? in ? the ? SAS ? (SAS ? Institute ? Inc., ? Cary, ?NC, ?USA) ? to ? obtain ?approximate ? maximum ? likelihood ? estimates.205 ? All ? p-???values ? were ? two-???sided. ? All ?statistical ?analyses ?were ?performed ?with ?SAS ?version ?9.3. ?6.3 ?Results ?In ? total, ? 435 ? respondents ?were ? included ? in ? the ? present ? study, ? including ? 84 ?(19.3%) ?women. ?The ?median ?age ?was ?38 ?years ?(interquartile ?range: ?34 ?? ?48 ?years). ?A ?total ? of ? 75 ? (17.2%) ? reported ? having ? shared ? syringes ? in ? the ? past ? six ?months. ? Fifty-???seven ? (13.1%) ? individuals ? reported ? having ? experienced ? both ? police ? beatings ? and ?drug ? testing ?by ?police ? in ? the ?past ? six ?months. ? Sixty ? (13.8%) ? reported ? experiencing ?drug ?testing ?by ?police ?in ?the ?past ?six ?months, ?but ?had ?never ?experienced ?a ?beating ?by ?police. ?One ?hundred ?twenty-???three ?(28.3%) ?reported ?having ?been ?beaten ?by ?police ?but ? not ? having ? been ? tested ? for ? illicit ? drugs ? by ? police ? in ? the ? past ? six ?months. ? The ?remaining ?195 ?(44.8%) ?respondents ?reported ?having ?experienced ?neither ?of ?the ?two ?events. ? ? ? 91 ?Table ?6 ?presents ?the ?unadjusted ?prevalence ?ratios ?of ?syringe ?sharing ?for ?each ?primary ? and ? secondary ? explanatory ? variable, ? as ? well ? as ? Pearson?s ? correlation ?coefficient ?of ?each ?association. ?As ?shown, ?all ?correlation ?coefficients ?fell ?under ?0.17. ?All ? three ? categories ? of ? exposures ? to ? specific ? policing ? tactics ? were ? significantly ?associated ?with ? syringe ? sharing ? in ? the ?past ? six ?months. ? In ?particular, ? compared ? to ?the ? reference ? category ? (i.e., ? reporting ? neither ? of ? police ? beatings ? nor ? recent ? drug ?testing ?by ?police), ? reporting ?both ?police ?beatings ?and ?recent ?drug ?testing ?by ?police ?had ?the ?strongest ?association ?with ?syringe ?sharing ?(prevalence ?ratio ?[PR]: ?2.61; ?95% ?confidence ? interval ? [CI]: ?1.46 ?? ?4.65), ? followed ?by ?reports ?of ?recent ?drug ?testing ?by ?police ?only ? (PR: ?2.17; ? 95% ?CI: ? 1.18 ?? ?3.99) ?and ? reports ?of ?police ?beatings ?only ? (PR: ?1.81; ?95% ?CI: ?1.06 ?? ?3.11). ? ?As ? shown ? in ? Table ? 7 ? and ? Figure ? 2, ? this ? relationship ? persisted ? in ? the ? final ?multivariate ?model, ?accounting ?for ?possible ?confounders ?including ?gender, ?frequent ?injection ?with ?others, ?enrolment ?in ?voluntary ?drug ?treatment, ?and ?having ?difficulty ?in ?accessing ?sterile ?syringes. ?In ?multivariate ?analyses, ?individuals ?who ?experienced ?both ?police ?beatings ?and ?recent ?drug ?testing ?by ?police ?were ?2.4 ?times ?more ?likely ?to ?have ?shared ?syringes ?in ?the ?past ?six ?months ?than ?those ?who ?experienced ?neither ?of ?the ?two ?events ?(adjusted ?prevalence ?ratio ?[APR]: ?2.40; ?95% ?CI: ?1.35 ?? ?4.26). ?Similarly, ?those ?who ?reported ?recent ?drug ?testing ?by ?police ?only ?were ?twice ?as ?likely ?to ?have ?shared ? syringes ? in ? the ?past ? six ?months ? (APR: ? 2.00; ? 95% ?CI: ? 1.16 ?? ? 3.45), ? and ? those ?who ?experienced ?police ?beatings ?only ?were ?1.8 ?times ?more ?likely ?(APR: ?1.82; ?95% ?CI: ?1.04 ?? ?3.20) ?to ?have ?done ?so ?than ?those ?who ?experienced ?neither ?of ?the ?two ?events. ?Other ?variables ?that ?were ?significantly ?associated ?with ?the ?outcome ?in ?multivariate ?analyses ?included: ?injected ?with ?others ?on ?a ?frequent ?basis ?(APR: ?1.59; ?95% ?CI: ?1.06 ?? ?2.39), ? access ? to ? voluntary ? drug ? treatment ? (APR: ? 1.60; ? 95% ? CI: ? 1.11 ? ? ? 2.30), ? and ?difficulty ?accessing ?sterile ?syringes ?(APR: ?2.81; ?95% ?CI: ?1.88 ?? ?4.19). ? ? 92 ?6.4 ?Discussion ?We ?found ?that ?about ?nearly ?one-???fifth ?of ?a ?sample ?of ?IDU ?in ?Bangkok ?engaged ?in ? syringe ? sharing ? during ? the ? six ? months ? prior ? to ? the ? study ? enrolment ? in ? 2011. ?Further, ?exposures ?to ?policing ?were ?common, ?with ?41% ?reporting ?having ?ever ?been ?beaten ? by ? police, ? 27% ? reporting ? recent ? drug ? testing ? by ? police, ? and ? 13% ? reporting ?having ? been ? both ? beaten ? and ? recently ? tested ? for ? drugs ? by ? police. ? In ?multivariate ?analyses, ? exposures ? to ? these ? policing ? tactics ? were ? independently ? associated ? with ?syringe ? sharing ? in ? the ? past ? six ? months ? after ? adjustment ? for ? potential ? social, ?demographic, ? and ? behavioural ? confounders. ? Moreover, ? the ? strength ? of ? the ?association ? between ? exposures ? to ? specific ? policing ? tactics ? and ? syringe ? sharing ?increased ? according ? to ? the ? hypothesized ? level ? of ? exposures ? to ? specific ? policing ?tactics. ? In ? particular, ? in ? multivariate ? analyses, ? compared ? to ? those ? IDU ? who ? had ?never ? been ? beaten ? or ? recently ? tested ? for ? drugs ? by ? police, ? those ? who ? experienced ?both ?police ?beatings ?and ?drug ? testing ?were ?2.4 ? times ?more ? likely ? to ? report ? syringe ?sharing, ? while ? those ?who ? reported ? only ? recent ? drug ? testing ? by ? police ?were ? twice ?more ?likely, ?and ?those ?who ?reported ?only ?police ?beatings ?were ?1.8 ?times ?more ?likely ?to ?report ?syringe ?sharing. ?The ?high ?prevalence ?of ?syringe ?sharing ?observed ?in ?this ?study ?is ?concerning ?given ? the ? high ? HIV ? prevalence ? among ? IDU ? in ? Thailand.61 ? While ? the ? potential ?difference ? in ? sample ? characteristics ? makes ? it ? difficult ? to ? compare ? the ? observed ?prevalence ? of ? syringe ? sharing ? (17%) ? with ? that ? from ? other ? sources, ? two ? previous ?studies ? using ? respondent-???driven ? sampling ?methods ? in ? Bangkok ? reported ? that ? the ?prevalence ? of ? syringe ? sharing ? in ? the ? past ? six ? months ? was ? 17% ? among ? 947 ? IDU ?recruited ?in ?2003-???2004227 ?and ?14% ?among ?742 ?IDU ?interviewed ?in ?2009.206 ?Data ?from ?previous ?years ?of ?our ?own ?serial ? cross-???sectional ? study ?of ? IDU ? in ?Bangkok ?showed ?that ?it ?was ?30% ?among ?238 ?IDU ?in ?2008 ?(the ?rate ?refers ?to ?syringe ?borrowing ?only)208 ? ? 93 ?and ?21% ?among ?311 ?IDU ?in ?2009 ?(the ?rate ?refers ?to ?syringe ?sharing).225 ?Although ?we ?are ?unable ? to ? assess ? the ? temporal ? trends ? in ? the ? rates ?of ? syringe ? sharing, ? it ? is ? clear ?that ?Thailand ?needs ?to ?improve ?its ?HIV ?prevention ?efforts ?among ?IDU ?to ?achieve ?the ?goal ?of ?reducing ?new ?HIV ?infections ?by ?two-???thirds ?by ?2016.222 ?The ? independent ? relationship ?between ? exposures ? to ? specific ? policing ? tactics ?and ? syringe ? sharing ? found ? in ? the ? present ? study ? adds ? important ? evidence ? to ? the ?impact ?of ?drug ?policing ?on ?HIV ?risk ?among ?IDU ?and ?contributes ?to ?the ?development ?of ? the ?Risk ?Environment ?Framework. ?Previous ?studies ?showed ?that ? the ?magnitude ?of ?policing ?practices ? at ? the ? ecological ? level ? (measured ? as ?drug-???related ? arrest ? rates, ?for ? instance) ?was ?positively ? correlated ?with ?HIV ?prevalence ?or ? the ? engagement ? in ?syringe ?sharing ?among ?IDU.223,224 ?Building ?on ?these ?previous ?research ?findings, ? the ?present ?study ?demonstrated ?that ?direct ?exposures ?to ?policing ?at ?the ?individual ?level ?was ? also ? independently ? associated ? with ? HIV ? risk ? behaviour. ? Further, ? while ? the ?majority ? of ? past ? literature ? indicated ? that ? perceived ? increases ? in ?police ? presence ? or ??fear ?of ?arrest? ?among ?IDU ?increases ?the ?likelihood ?of ?the ?uptake ?of ?risky ?injecting ?behaviours ? among ? them,82,126 ? the ? present ? study ? identified ? past ? and ? recent ? direct ?exposures ? to ? specific ? policing ? tactics ? that ? are ? likely ? fuelling ? fear ? among ? IDU ? in ?Bangkok. ? ?Our ? findings ? are ? also ? congruent ? with ? previous ? studies ? from ? Ukraine ?reporting ? a ? significant ? association ? between ? police ? beatings ? and ? syringe ? sharing ?among ? IDU ? in ?Odessa.81,122 ?The ? researchers ?projected ? that ? the ?elimination ?of ?police ?beatings ? in ? this ? setting ?could ?avert ? considerable ?portions ?of ?HIV ? infections ?among ?IDU.122 ?Since ?2003, ?Thailand ?has ?received ?substantial ?support ?from ?the ?Global ?Fund ?to ? Fight ? AIDS, ? Tuberculosis ? and ? Malaria ? (GFATM) ? to ? develop ? harm ? reduction ?programs ? for ? IDU, ? including ? NSPs.220,228 ? Given ? that ? difficulty ? in ? accessing ? sterile ?syringes ? has ? been ? previously ? shown ? to ? be ? an ? independent ? predictor ? of ? syringe ? ? 94 ?sharing ?among ?IDU ?in ?this ?setting,208 ?a ?scale-???up ?of ?NSPs ?through ?the ?GFATM ?grants ?should ?have ?positive ?effects ? in ?reducing ?HIV ?risk ?in ?this ?population. ?However, ?the ?present ?study ?found ?that ?exposures ?to ?policing ?were ?also ?a ?significant ?risk ?factor ?of ?syringe ? sharing, ? independent ? of ? difficulty ? in ? accessing ? sterile ? syringes. ? Taken ?together ? with ? the ? finding ? from ? Ukraine,81,122 ? our ? findings ? suggest ? that ? syringe ?sharing ?in ?Bangkok ?may ?not ?be ?averted ?by ?NSPs ?in ?the ?absence ?of ?efforts ?to ?address ?harmful ?policing ?practices. ? ?Another ?notable ?finding ?of ?this ?study ?is ?that ?the ?two ?distinct ?types ?of ?police ?exposures ?were ? independently ? associated ?with ? syringe ? sharing. ?The ? findings ? shed ?light ?on ?the ?adverse ?impacts ?of ?existing ?Thai ?drug ?policy ?and ?laws. ?Drug ?testing ?by ?police ?is ?a ?lawful ?policing ?practice ?that ?is ?allowed ?by ?drug ?statutes ?in ?this ?setting.26 ?Police ? beatings ? of ? IDU ?are ?unlawful ? practices ? but ?may ?be ? regarded ? as ? an ? indirect ?product ? of ? punitive ? drug ? policy ? and ? laws. ? The ? Thai ? constitution ? (Section ? 32)191 ?certainly ? do ? not ? permit ? police ? to ? use ? excessive ? force, ? but ? the ? disconnect ? between ??laws ?on ?the ?books? ?and ??laws ?on ?the ?streets? ?appears ?to ?facilitate ?it.83 ?Policies ?and ?laws ? that ?strictly ?penalize ? illicit ?drug ?use ?may ?have ? interacted ?with ?existing ?police ?norms, ? attitudes, ? and ? behaviours ? toward ? IDU ? and ? resulted ? in ? police-???perpetrated ?physical ? violence ? against ? this ? population.83 ? Considering ? that ? both ? of ? these ? lawful ?and ? unlawful ? policing ? practices ? are ? shaped ? by ? the ? broader ? prohibitionist ? drug ?policy, ? and ? considering ? the ? present ? study ? findings ? that ? both ? practices ? likely ?contribute ? to ? perpetuation ? of ? the ? HIV ? epidemic ? among ? IDU ? in ? Bangkok, ?interventions ? aimed ? at ? sensitizing ? police ? officers ? to ? harm ? reduction ? may ? not ? be ?sufficient ?to ?address ?the ?root ?cause ?of ?the ?problem175 ?and ?meet ?the ?goal ?of ?reducing ?new ?HIV ?infections ?by ?two-???thirds ?by ?2016.222 ?While ?a ?range ?of ?efforts ?are ?needed ?to ?address ?harmful ?police ?actions, ? including ?providing ?more ?accountable ?oversight ?of ?police ? and ? restricting ? the ? police?s ? use ? of ? drug ? testing, ? broader ? structural ? changes, ? ? 95 ?such ?as ?alternative ?regulatory ?frameworks ?for ?illicit ?drugs, ?should ?also ?be ?explored ?in ? this ? setting. ? An ? increasing ? number ? of ? countries ? have ? recently ? adopted ? various ?models ?of ?decriminalization ?for ?the ?use ?and ?possession ?of ? illicit ?drugs ?for ?personal ?use,101 ? and ? evidence ? from ? Portugal, ? for ? example, ? suggests ? some ? positive ? results, ?including ?reductions ?in ?problematic ?drug ?use ?and ?drug-???related ?harm, ?and ?increases ?in ?enrolment ?into ?voluntary ?addiction ?treatment.177 ? ?Finally, ?we ? found ? that ? recent ?experiences ?with ?drug ? testing ?by ?police ?had ?a ?slightly ?stronger ?association ?with ?syringe ?sharing ?than ?experiences ?of ?police ?beating ?in ?the ?past. ?This ?may ?suggest ?that ?individuals ?who ?have ?recently ?experienced ?drug ?testing ? by ? police ? were ? subsequently ? detained ? in ? pre-???trial ? detention ? facilities ? and ?engaged ? in ? syringe ? sharing ?while ? in ? such ? facilities. ? Indeed, ? a ? previous ? study ? has ?documented ?a ?high ?prevalence ?of ?syringe ?sharing ?in ?pre-???trial ?detention ?facilities ? in ?this ?setting.56 ?Unfortunately, ?the ?present ?study ?was ?unable ?to ?adjust ?for ?the ?potential ?effect ?of ?pre-???trial ?detention ?due ?to ?the ?high ?correlation ?with ?experiences ?with ?police. ?Nonetheless, ? heightened ? HIV ? risk ? within ? the ? pre-???trial ? detention ? facilities ? is ? also ?arguably ?a ?negative ?consequence ?of ?repressive ?drug ?policing. ? ?This ?study ?has ?several ? limitations. ?First, ?we ?cannot ?infer ?causation ?from ?this ?observational ? study. ? Due ? to ? the ? cross-???sectional ? study ? design, ? we ? were ? unable ? to ?assess ? temporal ? relationships ? between ? the ? outcome ? and ? the ? primary ? explanatory ?variables. ? Second, ? the ? self-???reported ? data ? may ? have ? been ? affected ? by ? socially ?desirable ?responding ?or ?recall ?bias. ?However, ?we ?note ?that ?this ?type ?of ?data ?has ?been ?commonly ? employed ? in ? observational ? studies ? involving ? IDU ? and ? found ? to ? be ?valid.209,210 ?Although ?it ?could ?be ?argued ?that ?some ?selection ?biases ?may ?be ?operating, ?whereby ?individuals ?who ?use ?drugs ?frequently, ?and ?hence ?are ?more ?likely ?to ?share ?syringes, ? are ? also ?more ? likely ? to ? have ? encounters ? with ? police, ? we ? note ? that ? the ?observed ?associations ?between ?exposures ?to ?policing ?and ?syringe ?sharing ?persisted ? ? 96 ?after ?extensive ?covariate ?adjustment, ?including ?adjustment ?for ?intensity ?of ?drug ?use. ?Likewise, ? if ? we ? had ? recruited ? respondents ? only ? through ? the ? drop-???in ? centres, ? our ?sample ?may ?have ?been ?biased ?in ?that ?they ?may ?have ?been ?more ?visible ?to ?police ?and ?more ?likely ?to ?have ?encounters ?with ?police ?and ?share ?syringes ?than ?those ?who ?never ?used ? the ?drop-???in ? centres. ?However, ? 20% ?of ? our ? sample ? included ? those ?who ?never ?visited ?the ?drop-???in ?centres, ?and ?access ?to ?the ?drop-???in ?centres ?was ?not ?associated ?with ?the ?outcome. Lastly, ? as ? the ? study ?sample ?was ?not ? randomly ?selected, ?our ? findings ?may ?not ?be ?generalizable ?to ?other ?populations ?of ?IDU ?in ?Thailand. ? ?In ? summary, ? we ? found ? that ? a ? substantial ? proportion ? of ? a ? community-???recruited ? sample ? of ? IDU ? in ? Bangkok ? reported ? engaging ? in ? syringe ? sharing, ? and ?exposures ?to ?two ?types ?of ?specific ?policing ?practices ?were ?independently ?associated ?with ? this ? form ? of ? HIV ? risk ? behaviour ? in ? this ? population, ? with ? experiencing ? both ?practices ? showing ? the ? strongest ? association. ? The ? relationship ? between ? repressive ?drug ?policing ?and ?HIV ?risk ?identified ?in ?the ?present ?study ?is ?significant ?in ?view ?of ?the ? need ? to ? achieve ? the ? internationally ? agreed, ? time-???bound ? goal ? of ? halving ? HIV ?transmission ?among ?IDU ?by ?2015 ?as ?well ?as ?the ?domestic ?goal ?of ?reducing ?new ?HIV ?infections ? by ? two-???thirds ? by ? 2016. ? Taken ? in ? sum, ? these ? findings ? highlight ? the ?importance ? of ? addressing ? the ? policy ? and ? social ? environment ? surrounding ? IDU ? in ?ongoing ?HIV ?prevention ?efforts. ? ? ? 97 ?Table 6: Bivariate analyses of factors associated with syringe sharing in the past 6 months among 435 IDU in Bangkok, Thailand Characteristic Total n (%) Syringe sharing in the past 6 months Prevalence Ratio (95%CI) r p - value Yes 75 (17.2%) No 360 (82.8%) Exposures to policing       Ever beaten and recently tested for drugs* by police 57 (13.1%) 16 (21.3%) 41 (11.4%) 2.61 (1.46 ? 4.65)  0.17 0.001 Recently tested for drugs* by police only 60 (13.8%) 14 (18.7%) 46 (12.8%) 2.17 (1.18 ? 3.99)   0.013 Ever beaten by police only 123 (28.3%) 24 (32.0%) 99 (27.5%) 1.81 (1.06 ? 3.11)   0.031 Never beaten or recently tested for drugs* by police (reference) 195 (44.8%) 21 (28.0%) 174 (48.3%)    Age       < 38 years old 205 (27.1%) 37 (49.3%) 168 (46.7%) 1.09 (0.72 ? 1.65)  0.02 0.674 ? 38 years old 230 (52.9%) 38 (50.7%) 192 (53.3%)    Gender       Male 351 (80.7%) 66 (88.0%) 285 (79.2%) 1.76 (0.91 ? 3.38) 0.08 0.092 Female 84 (19.3%) 9 (12.0%) 75 (20.8%)    HIV serostatus       Positive 80 (18.4%) 16 (21.3%) 64 (17.8%) 1.20 (0.73 ? 1.98) 0.03 0.465    Negative or unknown 355 (81.6%) 59 (78.7%) 296 (82.2%)    Heroin injection*       > Weekly 94 (21.6%) 26 (34.7%) 68 (18.9%) 1.92 (1.27 ? 2.92) 0.14 0.002    ? Weekly 341 (78.4%) 49 (65.3%) 292 (81.1%)    Midazolam injection*       > Weekly 238 (54.7%) 51 (68.0%) 187 (51.9%) 1.76 (1.13 ? 2.75) 0.12 0.013 ? Weekly 197 (45.3%) 24 (32.0%) 173 (48.1%)    Methamphetamine injection*       > Weekly 88 (20.2%) 19 (25.3%) 69 (19.2%) 1.34 (0.84 ? 2.13) 0.06 0.220 ? Weekly 347 (79.8%) 56 (74.7%) 291 (80.8%)    IDU: people who inject drugs; CI: Confidence Interval. r: Pearson?s correlation coefficient. *denotes activities/events in the past 6 months.  ? 98 ? ?Table 6: Bivariate analyses of factors associated with syringe sharing in the past 6 months among 435 IDU in Bangkok, Thailand (continued) Characteristic Total n (%) Syringe sharing in the past 6 months Prevalence Ratio (95%CI) r p - value Yes 75 (17.2%) No 360 (82.8%) Crystal methamphetamine injection*      > Weekly 19 (4.4%) 4 (5.3%) 15 (4.2%) 1.23 (0.50 ? 3.02) 0.02 0.646 ? Weekly 416 (95.6%) 71 (94.7%) 345 (95.8%)    Use of drugs in combination*       Yes 248 (57.0%) 48 (64.0%) 200 (55.6%) 1.34 (0.87 ? 2.06) 0.06 0.183 No 187 (43.0%) 27 (36.0%) 160 (44.4%)    Binge drug use*       Yes 130 (29.9%) 29 (38.7%) 101 (28.1%) 1.48 (0.97 ? 2.24) 0.09 0.066 No 305 (70.1%) 46 (61.3%) 259 (71.9%)    Injected with others on a frequent basis*      > 75% of time 168 (38.6%) 37 (49.3%) 131 (36.4%) 1.55 (1.03 ? 2.33) 0.10 0.037 ? 75% of time 267 (61.4%) 38 (50.7%) 229 (63.6%)    Accessed voluntary drug treatment*     Yes 194 (44.6%) 39 (52.0%) 155 (43.1%) 1.35 (0.89 ? 2.03) 0.07 0.157    No 241 (55.4%) 36 (48.0%) 205 (56.9%)    Difficulty accessing sterile syringes*     Yes or sometimes 21 (4.8%) 9 (12.0%) 12 (3.3%) 2.69 (1.56 ? 4.62) 0.15 <0.001    No 414 (95.2%) 66 (88.0%) 348 (96.7%)    Ever accessed drop-in centers for drug users     Yes 349 (80.2%) 58 (77.3%) 291 (80.8%) 0.84 (0.52 ? 1.37) -0.03 0.484    No 86 (19.8%) 17 (22.7%) 69 (19.2%)    IDU: people who inject drugs; CI: Confidence Interval. r: Pearson?s correlation coefficient. *denotes activities/events in the past 6 months.  ? 99 ? ? ? ? ?  ?Table 7: Multivariate log-binomial regression analysis of factors associated with syringe sharing in the past 6 months among 435 IDU in Bangkok, Thailand ?Variable APR 95% CI p - value Exposures to policing    (Ever beaten & drug testing* by police vs. None) 2.40 (1.35 ? 4.26) 0.003 (Drug testing* by police only vs. None) 2.00 (1.16 ? 3.45) 0.012 (Ever beaten by police only vs. None) 1.82 (1.04 ? 3.20) 0.037 Gender  (Male vs. Female) 1.42 (0.72 ? 2.82) 0.310 Injected with others on a frequent basis*   (>75% of time vs. ? 75% of time) 1.59 (1.06 ? 2.39) 0.024 Accessed voluntary drug treatment*  (Yes vs. No) 1.60 (1.11 ? 2.30) 0.011 Difficulty accessing sterile syringes*    (Yes or sometimes vs. No) 2.81 (1.88 ? 4.19) <0.001 IDU: people who inject drugs; APR: adjusted prevalence ratio; CI: Confidence Interval. *denotes activities/events in the past 6 months.  ? 100 ? ?Figure 2: Adjusted prevalence ratios for syringe sharing in the past 6 months by types of exposures to policing among 435 IDU in Bangkok, Thailand  ? ? ?Adjusted(for(gender;(injected(with(others(on(a(frequent(basis*;(enrolment(in(voluntary(drug(treatment*;(and(difficulty(in(accessing(sterile(syringes.*((*denotes(ac=vi=es/events(in(the(past(6(months.(1.82(2.00(2.40(0.00(1.00(2.00(3.00(4.00(5.00(Ever%beaten%by%police%only%Recently*%tested%for%drugs%by%police%only%Ever%beaten%and%recently*%tested%for%drugs%by%police%Adjusted%PRs% ? 101 ?CHAPTER ?7: ?INCREASING ?AVAILABILITY ?OF ?ILLICIT ?DRUGS ?AMONG ?PEOPLE ?WHO ?INJECT ?DRUGS ?IN ?BANGKOK, ?THAILAND ?7.1 ?Introduction ?Situated ?along ?some ?of ?the ?world?s ?major ?drug ?trafficking ?routes,229 ?Thailand ?has ?been ?contending ?with ?a ?longstanding ?epidemic ?of ?illicit ?drug ?use.17 ?In ?response, ?the ?Thai ?government ? initiated ?a ?series ?of ?aggressive ?prohibitionist ?responses. ?Since ?the ?1990s, ?there ?has ?been ?a ?dramatic ?increase ?in ?incarceration ?rates ?for ?drug-???related ?offenders.53 ?In ?2002, ?a ?system ?of ?compulsory ?drug ?detention ?was ?introduced ?and ?has ?been ? rapidly ? expanded ? in ? recent ? years.27 ? In ? 2010, ? the ?ONCB ? reported ? that ? 116,500 ?people ? were ? admitted ? to ? drug ? treatment ? facilities, ? and ? as ? many ? as ? 63% ? of ? these ??patients? ?were ?in ?compulsory ?drug ?detention ?for ??treatment.?39 ? ?Since ?August ?2011, ?Thai ?authorities ?have ? further ? intensified ?repressive ?drug ?policing.44,189 ?Although ?the ?extent ?to ?which ?these ?efforts ?have ?affected ?the ?supply ?of ?and ? demand ? for ? illicit ? drugs ? is ? unknown, ? available ? data ? paint ? an ? unfavorable ?picture. ?Recent ?media ?reports ?indicated ?an ?illicit ?drug ?trade ??boom? ?within ?prisons, ?with ?only ?seven ?of ?143 ?prisons ?in ?the ?country ?being ?free ?of ?drug ?trading.230,231 ?As ?well, ?a ?previous ?study ?suggested ?that ?compulsory ?drug ?detention ?has ?not ?reduced ?drug ?use ?among ?IDU ?in ?Bangkok, ?as ?drug ?use ?typically ?eventually ?resumes ?after ?release ?from ? detention.216 ? Further, ? intensified ? drug ? control ? campaigns ? have ? resulted ? in ?police ?misconduct ? and ? fatal ? shootings ? of ? suspects, ? raising ? concern ? regarding ? how ?drug ?suppression ?operations ?were ?being ?implemented.200,201 ? ?While ?the ?Thai ?government ?continues ?to ?rely ?on ?repressive ?drug ?policing ?as ?a ?means ? of ? suppressing ? the ? trade ? of ? illicit ? drugs, ?we ? know ? of ? no ? studies ? that ? have ?identified ?trends ?in ?street-???level ?availability ?of ?illicit ?drugs ?in ?Thailand. ?The ?existence ?of ? a ? serial ? cross-???sectional ? study ? of ? IDU ? in ? Bangkok ? enabled ? us ? to ? collect ? data ? on ? ? 102 ?street-???level ? drug ? availability ? at ? two ? different ? time ? points, ? the ? latter ? of ? which ?followed ? a ? period ? of ? renewed ? and ? intensified ? crackdowns ? on ? drugs ? in ? 2011. ?Therefore, ?our ?study ?objective ?was ?to ?assess ?changes ?between ?2009 ?and ?2011 ?in ?the ?availability ?of ?five ?substances ?that ?are ?commonly ?used ?among ?IDU ?in ?Bangkok. ?As ?well, ?we ?sought ?to ?examine ?social, ?structural ?and ?individual ?factors ?influencing ?drug ?availability. ?7.2 ?Methods ? ? Quantitative ? data ? for ? this ? study ? were ? derived ? from ? the ? Mitsampan ?Community ?Research ?Project, ?as ?described ?in ?detail ?in ?section ?1.6. ? ? Items ? assessing ? the ? availability ? of ? illicit ? drugs ? were ? included ? in ? the ?questionnaires ?administered ?in ?both ?2009 ?and ?2011. ?The ?availability ?of ?a ?set ?of ?five ?substances ?(i.e., ?heroin, ?methamphetamine ?pills ?[locally ?referred ?to ?as ?yaba], ?crystal ?methamphetamine ? [locally ? referred ? to ? as ? ice], ? midazolam ? tablets ? [short-???acting ?benzodiazepine ? available ? through ? private ? clinics], ? and ? methadone ? for ? illicit ? use) ?were ?assessed ?at ?five ?levels: ?(1) ?available ?within ?10 ?minutes; ?(2) ?available ?within ?90 ?minutes; ?(3) ?available ?within ?a ?day; ?(4) ?available ?in ?more ?than ?a ?day; ?and ?(5) ?do ?not ?know ?the ?availability. ?Respondents ?were ?asked ?to ?indicate ??[h]ow ?difficult ?would ?it ?be ? for ? you ? to ? get ? the ? following ? drugs ? right ? now ? in ? the ? area ?where ? you ? typically ?obtain ? your ? drugs? ? Please ? answer ? even ? if ? you ? don?t ? use ? the ? drugs ? yourself? ? and ?were ?also ?asked ?to ?indicate ?the ?current ?street ?price ?of ?each ?substance. ?This ?question ?item ?has ?been ?used ?to ?assess ?the ?street-???level ?availability ?of ?illicit ?drugs ?in ?a ?previous ?study ?in ?another ?setting.232 ? ?Respondents ?who ?completed ? the ? interview ? in ?2009 ?or ?2011 ?were ?eligible ? for ?inclusion ? in ? the ?study. ?For ? this ?study, ?we ?excluded ? individuals ?who ?did ?not ?know ?the ?availability ?of ?the ?drugs ?in ?question ?or ?those ?with ?incomplete ?data. ?Further, ?the ?sample ?for ?each ?substance ?was ?restricted ?to ?individuals ?who ?reported ?having ?used ? ? 103 ?the ?substance ?in ?question ?in ?the ?past ?six ?months. ?Given ?that ?the ?primary ?purpose ?of ?the ? study ? was ? to ? assess ? changes ? in ? the ? availability ? of ? drugs ? (at ? the ? time ? of ? the ?interview) ?between ?2009 ?and ?2011, ?repeat ?respondents ?were ?included ?in ?each ?year?s ?sample. ? As ? a ? sensitivity ? analysis, ? we ? repeated ? the ? univariate ? and ? multivariate ?analyses ?described ?below ?using ? smaller ? samples ? that ? excluded ? repeat ? respondents ?from ?the ?2011 ?data ?set. ? ?As ? in ? a ? previous ? study,232 ? we ? conceptualized ? the ? availability ? of ? the ? five ?substances ? as ? being ? an ? aspect ? of ? supply, ? rather ? than ? demand ? for ? the ? substances ? in ?question. ? Informed ? by ? the ? modified ? Risk ? Environment ? Framework ? described ? in ?section ? 1.4, ? we ? hypothesized ? that ? both ? social/structural ? factors ? and ? individual ?characteristics ? were ? potentially ? associated ? with ? availability. ? The ? intensified ? drug ?suppression ?campaign ?in ?2011 ?was ?considered ?a ?macro-???structural ?factor ?that ?may ?be ?associated ?with ?availability. ?This ?variable ?was ?operationalized ?as ?the ?calendar ?year ?of ?study ?enrolment ?(2011 ?vs. ?2009). ?The ?meso-???level ?social ?and ?environmental ?factors ?included: ?ever ?in ?prison ?(yes ?vs. ?no) ?and ?ever ?in ?compulsory ?drug ?detention ?(yes ?vs. ?no). ? The ? micro-???level ? social ? and ? environmental ? factors ? included ? drug ? dealing ?involvement ? in ? the ? past ? six ? months ? (yes ? vs. ? no). ? The ? individual ? characteristics ?included ?age ?(? ?35 ?years ?vs. ?36-???45 ?years ?vs. ?? ?46 ?years), ?gender ?(female ?vs. ?male), ?and ?frequent ?use ?of ?each ?drug ?of ? interest ? in ?the ?past ?six ?months ?(> ?once ?per ?week ?vs. ?? ?once ?per ?week). ?Drug ?dealing ?involvement ?was ?ascertained ?by ?asking ?whether ?drug ?dealing ? (i.e., ? selling ?or ? transporting ? illicit ?drugs) ? constituted ?a ? source ?of ? income ? in ?the ? past ? six ? months. ? Dealing ? status ? and ? frequent ? use ? of ? drugs ? were ? considered ?indicative ? of ? stronger ? contact ? with ? a ? given ? drug ? supply ? chain. ? Given ? recent ?government ?and ?media ?reports ?indicating ?large-???scale ?drug ?dealing ?in ?prisons,230,231 ?a ?history ?of ? incarceration ?and ?compulsory ?drug ?detention ?were ?also ?hypothesized ?to ?increase ? the ?ease ?of ? illicit-???drug ?availability ?as ?relationships ?between ?IDU ?and ?drug ? ? 104 ?dealers ?may ?have ?been ?established ?or ?expanded ?while ?in ?detention. ?We ?note ?that ?all ?data ?used ? in ? our ? study ?were ? self-???reported ?data, ?which ?may ? reflect ? some ?potential ?biases. ?As ?a ?first ?step, ?we ?examined ?sample ?characteristics ?using ?descriptive ?statistics. ?We ?also ?examined ?frequencies ?of ?drugs ?used ?more ?than ?twice ?per ?week ?in ?the ?past ?six ?months ?in ?an ?effort ?to ?capture ?primary ?drugs ?used ?among ?the ?sample. ?Then, ?we ?plotted ?univariate ?trends ?of ?the ?availability ?of ?the ?five ?drugs ?between ?2009 ?and ?2011. ?Given ?low ?levels ?of ?responses ?for ?the ?availability ?in ?> ?90 ?minutes ?up ?to ?one ?day ?and ?> ?1 ?day, ?we ?combined ?these ?categories, ?thus ?providing ?us ?with ?a ?three-???level ?ordered ?outcome ? variable: ? immediate ? availability ? (available ? in ? ? ? 10 ? minutes); ? moderate ?availability ? (available ? in ? > ? 10 ? minutes ? to ? ? ? 90 ? minutes); ? and ? delayed ? availability ?(available ? in ? > ? 90 ?minutes). ? To ? examine ? univariate ? associations ? between ? the ? three ?levels ? of ? availability ? for ? each ? drug ? and ? the ? explanatory ? variables, ? we ? used ? the ?Kruskal-???Wallis ?test. ?The ?distributions ?of ?the ?responses ?of ?the ?explanatory ?variables ?over ?the ?three-???level ? outcome ? variables ? indicated ? that ? the ? proportional ? odds ? assumption ? did ? not ?hold. ?Therefore, ?we ?fitted ?separate ?multivariate ?logistic ?regression ?models ?assessing ?the ?adjusted ?odds ?of ?moderate ?availability ?vs. ?delayed ?availability, ? and ? immediate ?availability ? vs. ? delayed ? availability ? for ? each ? drug ? of ? interest. ?We ? used ? an ? a ? priori-???defined ? statistical ? protocol ? based ? on ? examination ? of ? the ? AIC ? and ? p-???values ? to ?construct ? an ? explanatory ? multivariate ? logistic ? regression ? model. ? First, ? we ?constructed ? a ? full ? model ? including ? all ? variables ? analyzed ? in ? univariate ? analyses. ?After ?examining ?the ?AIC ?of ?the ?model, ?we ?removed ?the ?variable ?with ?the ?largest ?p-???value ? and ? built ? a ? reduced ? model ? while ? keeping ? the ? calendar ? year ? of ? study ?involvement ? in ? the ?model. ?We ? continued ? this ? iterative ? process ? until ? no ? variables ? ? 105 ?remained ? for ? inclusion. ?We ? selected ? the ? multivariate ? model ? with ? the ? lowest ? AIC ?score. ?All ?p-???values ?were ?two-???sided. ? ?As ? a ? sub-???analysis, ? we ? examined ? changes ? in ? the ? street ? price ? of ? each ? drug ?between ? 2009 ? and ? 2011. ? Unfortunately, ? items ? assessing ? drug ? purity ? were ? not ?included ?in ?the ?questionnaire, ?and ?therefore ?we ?were ?unable ?to ?adjust ?the ?prices ?for ?drug ?purity, ?which ?may ?have ?changed ?between ?the ?two ?years. ?Because ?the ?reported ?prices ? of ? drugs ? had ? highly ? skewed ? distributions ? and ? there ? was ? heterogeneity ? in ?retail ?units, ?presumably ?due ?to ?the ?unregulated ?nature ?of ?illicit ?drug ?markets,233 ?we ?presented ? the ?modal ?price ?and ?unit ?of ? each ?drug, ? as ?well ? as ? the ?percentage ?of ? the ?study ? sample ? that ? reported ? the ?modal ?price ? and ?unit. ?All ? statistical ? analyses ?were ?performed ?with ?SPSS ?software ?version ?18.0.0 ?(IBM, ?Armonk, ?New ?York, ?USA). ?7.3 ?Results ?7.3.1 ?Summary ?statistics ?Summary ?statistics ?on ?the ?covariates ?included ?in ?the ?analysis ?are ?provided ?in ?Table ? 8. ? As ? shown, ? a ? total ? of ? 718 ? IDU ? (293 ? IDU ? in ? 2009 ? and ? 425 ? IDU ? in ? 2011) ?participated ? in ? this ? study, ? including ? 165 ? (23.0%) ?women. ? The ?median ? age ?was ? 38 ?years ? (interquartile ? range: ? 33 ? ? ? 47 ? years). ? In ? total, ? 7.4% ? of ? the ? sample ? reported ?obtaining ? income ? from ?drug ? dealing ? in ? the ? past ? six ?months. ? The ?most ? commonly ?used ? drug ? in ? the ? past ? six ? months ? among ? the ? sample ? was ? midazolam ? (75.6%), ?followed ? by ? methamphetamine ? (67.3%) ? and ? heroin ? (60.7%). ? The ? prevalence ? of ?crystal ?methamphetamine ?use ?was ? substantially ? higher ? among ? the ? respondents ? in ?2011 ? (32.9%) ? than ? in ? 2009 ? (5.8%), ? while ? the ? prevalence ? of ? use ? of ? other ? drugs ?remained ?relatively ?stable ?over ?the ?two ?calendar ?years. ?The ?majority ?of ?respondents ?(66.4%) ? reported ? using ?multiple ? drugs ? more ? than ? twice ? per ? week ? in ? the ? past ? six ?months. ? ? 106 ?7.3.2 ?Univariate ?trends ?in ?availability ?Trends ?in ?the ?availability ?of ?the ?five ?drugs ?assessed ?are ?plotted ?in ?Figure ?3. ?As ?shown, ? immediate ? availability ? of ? all ? drugs, ? except ? for ? heroin, ? increased ? between ?2009 ? and ? 2011. ? Moderate ? availability ? of ? all ? drugs ? also ? increased, ? while ? delayed ?availability ? of ? all ? drugs ?declined. ?Changes ? in ? the ? immediate ? availability ? of ? crystal ?methamphetamine ? were ? the ? most ? pronounced, ? increasing ? almost ? six-???fold ? (from ?5.9% ? in ? 2009 ? to ? 35.7% ? in ? 2011) ? between ? 2009 ? and ? 2011. ? Although ? immediate ?availability ?of ?heroin ?slightly ?decreased ?from ?8.3% ?in ?2009 ?to ?7.8% ?in ?2011, ?there ?was ?a ?marked ? increase ? in ? the ?moderate ?availability ?of ?heroin, ? increasing ? from ?47.7% ?in ?2009 ?to ?68.3% ?in ?2011. ? ?The ? results ? of ? univariate ? analyses ? showed ? significant ? associations ? between ?the ? calendar ? year ? of ? study ? enrolment ? and ? the ? availability ? of ? all ? drugs, ? except ? for ?methamphetamine ? (all ? p ? < ? 0.01). ? Other ? significant ? findings ? included ? associations ?between: ?the ?availability ?of ?heroin ?and ?a ?history ?of ?compulsory ?drug ?detention ?(p ?< ?0.01); ? the ? availability ? of ? methamphetamine ? and ? female ? gender ? (p ? = ? 0.02); ? the ?availability ?of ?methamphetamine ?and ?a ?history ?of ? incarceration ? (p ?= ?0.02); ? and ? the ?availability ?of ?illicit ?methadone ?and ?age ?(p ?= ?0.02). ?7.3.3 ?Multivariate ?analyses ?Table ? 9 ? shows ? the ? results ? from ? the ? final ? multivariate ? logistic ? regression ?models. ? After ? controlling ? for ? other ? covariates, ? there ? were ? significant ? increases ? in ?moderate ?availability ?of ?all ?drugs ?(compared ?to ?delayed ?availability) ?between ?2009 ?and ?2011, ?with ?adjusted ?odds ?ratios ?ranging ?between ?2.36 ?(for ?illicit ?methadone) ?and ?4.61 ?(for ?crystal ?methamphetamine) ?(all ?p ?< ?0.01). ?Similarly, ?immediate ?availability ?of ?all ?drugs ?but ?heroin ?(compared ?to ?delayed ?availability) ?also ? increased ?significantly ?between ? 2009 ? and ? 2011 ? (all ? p ? < ? 0.01). ? Female ? gender ? was ? independently ? and ?positively ? associated ? with ? immediate ? availability ? of ? methamphetamine, ? while ? ? 107 ?involvement ? in ? drug ? dealing ? was ? independently ? and ? negatively ? associated ? with ?moderate ? availability ? of ?methamphetamine. ? Illicit ?methadone ?was ? generally ?more ?immediately ? available ? to ? younger ? individuals. ? A ? history ? of ? incarceration ? was ?independently ? and ? positively ? associated ? with ? more ? immediate ? availability ? of ?methamphetamine, ?whereas ?a ?history ?of ?compulsory ?drug ?detention ?exposure ?was ?independently ?and ?negatively ?associated ?with ?more ?immediate ?availability ?of ?heroin ?and ?midazolam. ?The ? results ? of ? the ? sensitivity ? analysis ? were ? consistent ? with ? the ? primary ?analysis, ?while ?smaller ?sample ?sizes ?reduced ?the ?statistical ?power ?of ?the ?multivariate ?logistic ?regression ?models. ?In ?brief, ?after ?controlling ?for ?other ?covariates, ?there ?were ?significant ? increases ? in ? moderate ? availability ? of ? all ? drugs ? (compared ? to ? delayed ?availability) ?between ?2009 ?and ?2011, ?with ?adjusted ?odds ?ratios ?ranging ?between ?2.88 ?(for ? midazolam) ? and ? 5.35 ? (for ? crystal ? methamphetamine) ? (all ? p ? < ? 0.05). ? Similarly, ?immediate ? availability ? of ? all ? drugs ? but ? heroin ? (compared ? to ? delayed ? availability) ?also ? increased ? significantly ? between ? 2009 ? and ? 2011 ? (all ? p ? < ? 0.01). ? The ? list ? of ? the ?factors ? independently ? associated ? with ? the ? outcomes ? in ? the ? primary ? analysis ?remained ?the ?same ?(including ?the ?directions) ?in ?the ?sensitivity ?analysis. ? ?7.3.4 ?Sub-???analysis ?The ?modal ?street ?price ?of ?all ?drugs ?reported ?by ?the ?respondents ?remained ?the ?same ?between ?2009 ?and ?2011. ?As ?shown ?in ?Table ?10, ?the ?modal ?price ?of ?heroin ?was ?500 ?Thai ?baht ?(approximately ?US ?$17) ?per ?tua ?(approximately ?50mg ?of ?powder). ?The ?modal ?price ?of ?methamphetamine ?was ?200 ?Thai ?baht ?(approximately ?US ?$7) ?per ?one ?pill. ? The ? modal ? price ? of ? crystal ? methamphetamine ? was ? 2,500 ? Thai ? baht ?(approximately ?US ?$83) ?per ?gee ?(approximately ?1g). ?The ?modal ?price ?of ?midazolam ?was ? 80 ? Thai ? baht ? (approximately ? US ? $3) ? per ? one ? pill. ? The ? modal ? price ? of ? illicit ?methadone ?was ?500 ?Thai ?baht ?(approximately ?US ?$17) ?per ?60ml ?bottle. ? ? 108 ?7.4 ?Discussion ?We ?found, ?among ?community-???recruited ?samples ?of ?IDU ?in ?Bangkok, ?that ?the ?perceived ? availability ? of ? heroin, ? methamphetamine, ? crystal ? methamphetamine, ?midazolam, ? and ? illicit ? methadone ? increased ? significantly ? between ? 2009 ? and ? 2011. ?Although ? the ? self-???reported ? data ? used ? in ? our ? study ? may ? have ? affected ? our ? study ?findings, ? these ? increases ? in ? perceived ? availability ? of ? five ? illicit ? substances ? were ?independent ? of ? observed ? differences ? in ? the ? meso-??? ? and ? micro-???level ? social ? and ?environmental ? factors ? and ? individual ? characteristics ? of ? the ? samples ? recruited ?through ? the ? two ?waves ? of ? the ? study, ? and ? occurred ? during ? a ? period ? in ?which ? the ?retail ? price ? of ? all ? drugs ? analyzed ? appeared ? to ? be ? constant. ? Consistent ? with ? the ?suggestions ? of ? various ? recent ? reports ? in ? Thailand,39,234,235 ? our ? findings ? indicated ? an ?increased ? supply ? of ? illicit ? drugs ? in ? Bangkok ? between ? June-???July ? of ? 2009 ? and ? July-???October ? of ? 2011 ? despite ? the ? intensified ? drug ? suppression ? efforts ? that ? have ? been ?undertaken ?since ?August ?2011. ?The ?largest ?increase ?in ?availability ?was ?found ?with ?crystal ?methamphetamine, ?and ? the ? proportion ? of ? crystal ? methamphetamine ? users ? among ? our ? sample ? also ?increased ? significantly ?between ?2009 ?and ?2011. ?The ?ONCB ?report ?also ? suggests ?an ?expansion ? of ? the ? crystal ? methamphetamine ? market ? in ? Thailand ? in ? recent ? years, ?documenting ?a ?3.5-???fold ?increase ?in ?seizures ?and ?a ?2.5-???fold ?increase ?in ?admissions ?to ?drug ? treatment ? facilities ? related ? to ? crystal ? methamphetamine ? between ? 2009 ? and ?2010.39 ?The ?same ?report ?also ?documented ?almost ?a ? two-???fold ? increase ? in ?seizures ?of ?methamphetamine ?pills ?between ?2009 ?and ?2010. ?Taken ?together ?with ? these ?seizure ?statistics, ?our ?findings ?suggest ?that ?the ?growth ?of ?the ?amphetamine-???type ?stimulants ?(ATS) ? market ? has ? continued ? through ? 2011. ? Interestingly, ? our ? findings ? showed ? a ?simultaneous ?increase ?in ?ease ?of ?accessing ?heroin ?while ?the ?level ?of ?heroin ?seizures ?remained ?almost ?the ?same ?between ?2009 ?and ?2010.39 ?The ?disparity ?may ?be ?likely ?due ? ? 109 ?to ? the ? fact ? that ? seizures ? statistics ? are ? unable ? to ? fully ? capture ? fluctuations ? in ? illicit ?drug ?markets.236 ? ? ? ?Importantly, ? increases ? in ? the ? availability ? of ? methamphetamine ? were ?associated ? with ? exposures ? to ? prison ? environments. ? The ? findings ? are ? of ? particular ?interest ? given ? that ? between ? 2011 ? and ? 2012, ? Thai ? authorities ? implemented ? a ? six-???month ? crackdown ? in ? prisons ? across ? the ? country ? and ? seized ? a ? total ? of ? 58,991 ?methamphetamine ?pills.237 ?Also, ? the ?majority ?of ?drug-???related ?prisoners ? in ?Thailand ?(95%) ? are ? reportedly ? convicted ? for ? drug-???related ? offenses ? involving ?methamphetamine.54 ? In ? light ? of ? these ? reports, ? while ? temporal ? ordering ? was ? not ?observed, ?our ?findings ?may ?indicate ?that ? incarceration ?of ?IDU ?may ?have ?led ?to ?the ?formation ? of ? new ? social ? network ? in ? a ? way ? to ? increase ? the ? ease ? of ? future ? drug ?purchases ? after ? release ? from ?prisons. ?Alternatively, ? it ?may ? be ? that ? those ?who ? had ?closer ? contact ? with ? methamphetamine ? dealers ? were ? more ? likely ? to ? have ? been ?incarcerated ?and ?yet ?incarceration ?did ?not ?disconnect ?them ?from ?drug ?dealers ?upon ?release. ? These ? findings ? raise ? concern ? about ? negative ? consequences ? of ? the ? ongoing ?drug ? policing ? efforts ? in ? Thailand, ?which ? involve ? the ?mass ? incarceration ? of ? people ?who ?use ?drugs. ? ?Our ?findings ?also ?provide ?some ?insights ? into ? illegal ?drug ?market ?operations ?in ? Bangkok. ?While ? previous ? literature ? from ?North ?America ? suggested ? that ? street-???level ?drug ?users ?typically ?engage ?in ?drug ?dealing ?as ?a ?means ?to ?maintain ?their ?drug-???using ? habit,233,238,239 ? the ? proportion ? of ? individuals ? involved ? in ? drug ? dealing ? in ? our ?sample ? was ? low. ? Also, ? drug-???dealing ? status ? had ? somewhat ? unanticipated ?associations ?with ?the ?availability ?of ?illicit ?drugs, ?as ?it ?was ?not ?associated ?with ?easier ?access ? to ? any ? drugs. ?On ? the ? contrary, ? it ?was ? negatively ? associated ?with ?moderate ?availability ? of ? methamphetamine. ? While ? the ? differential ? associations ? between ? the ?involvement ? in ? drug ? dealing ? and ? availability ? of ? each ? drug ? are ? unknown, ? the ? ? 110 ?findings ? may ? indicate ? that ? the ? structure ? of ? illegal ? drug ? markets ? in ? Thailand ? is ?different ? from ? that ? in ? North ? America, ? which ? typically ? involves ? a ? decentralized ?pyramid ?system,233 ?as ?previously ?suggested ?by ?researchers ?in ?northern ?Thailand.240 ? ?We ? also ? found ? that ? female ? IDU ? were ? more ? likely ? to ? report ? immediate ?availability ?of ?methamphetamine. ?A ?possible ?explanation ?for ?this ?association ?may ?be ?that ?female ?IDU ?are ?often ?asked ?by ?their ?male ?partners ?and ?friends ?to ?acquire ?drugs ?because ? they ?believe ? that ?women ?are ? less ? likely ? to ?be ? caught ?by ?police. ?Therefore, ?women ?may ?have ?stronger ?contact ?with ?a ?given ?drug ?supply ?chain. ?Consistent ?with ?this ?explanation, ?our ?previous ?study ?showed ?that ?female ?IDU ?were ?less ?likely ?than ?males ?to ?have ?been ?incarcerated ?in ?this ?setting,241 ?and ?females ?comprise ?only ?15% ?of ?the ? inmate ? population ? in ? the ? country.242 ?However, ? it ? is ? important ? to ? note ? that ? the ?vast ?majority ? of ? female ? inmates ? (82%) ? are ? incarcerated ? as ? a ? result ? of ? drug-???related ?offences.54 ?A ?recent ?media ?report ?also ?suggested ?that ?drug ?market ?involvement ?was ?a ? major ? factor ? contributing ? to ? incarceration ? among ? women.243 ? Nonetheless, ? the ?extent ? to ?which ? female ? inmates ?were ? involved ? in ?drug ?markets, ?or ? the ? reason ? that ?female ?gender ?was ?associated ?with ?the ?availability ?of ?methamphetamine ?only ?in ?the ?present ?study, ?is ?unknown. ? ?Collectively, ? our ? findings ? have ? important ? implications ? for ? drug ? policy ? and ?programming ?in ?Thailand. ?The ?findings ?suggest ?that ?despite ?the ?Thai ?government?s ?longstanding ? and ? significant ? investment ? in ? drug ? suppression ? efforts, ? illicit ? drug ?markets ? continue ? to ? flourish ? in ? the ? country. ?Under ? such ? circumstances, ? and ?given ?the ? fact ? that ? addiction ? is ? a ? chronic, ? relapsing ? disorder, ? it ? is ? important ? to ? address ?treatment ?and ?care ?needs ?of ?those ?who ?continue ?to ?engage ?in ?drug ?use. ?Specifically, ?consistent ?with ?the ?recent ? joint ?statement ?and ?recommendations ?by ?the ?twelve ?UN ?entities,29 ?the ?ongoing ?reliance ?on ?compulsory ?drug ?detention ?as ?a ?means ?of ?linking ?people ?to ?drug ?treatment ?should ?be ?shifted ?toward ?a ?focus ?on ?providing ?voluntary, ? ? 111 ?scientifically ? sound, ? long-???term ? drug ? treatment ? in ? community ? settings ? that ? is ?accessible ? to ? those ? who ? need ? it. ? In ? addition, ? given ? the ? ongoing ? epidemic ? of ? HIV ?among ? Thai ? IDU61 ? and ? continued ? high ? rates ? of ? HIV ? risk ? behaviour ? (i.e., ? syringe ?sharing) ?among ?this ?population,208 ?evidence-???based ?HIV ?prevention ?services ?tailored ?for ? IDU, ? such ? as ? sterile ? syringe ? distribution13 ? and ? peer-???based ? harm ? reduction ?services, ? need ? to ? be ? urgently ? scaled ? up. ? Currently, ? there ? is ? a ? significant ? lack ? of ?investment ? in ? these ? services ? in ? Thailand, ? and ? there ? have ? been ? repeated ? calls ? for ?increasing ?resource ?allocation ?in ?this ?area.164,244 ? ?This ? study ? has ? several ? limitations. ? First, ? as ? the ? study ? sample ? was ? not ?randomly ? selected, ? our ? findings ?may ?not ? be ? generalizable ? to ? other ? populations ? of ?IDU ?in ?Thailand. ?Second, ?the ?self-???reported ?data ?may ?have ?been ?affected ?by ?socially ?desirable ?responding ?or ?recall ?bias. ?However, ?we ?note ?that ?this ?type ?of ?data ?has ?been ?commonly ? utilized ? in ? other ? studies ? pursuing ? similar ? enquiries ? and ? found ? to ? be ?valid.209,210,232 ?Third, ?given ? the ?observational ?nature ?of ? this ? study, ? the ?magnitude ?of ?changes ? in ? the ? availability ? of ? the ? drugs ? assessed ? may ? have ? been ? over-??? ? or ?underestimated ?due ?to ?residual ?confounding. ?In ?particular, ?the ?potentially ?changing ?mix ?of ?respondents ?over ?the ?two ?waves ?of ?surveying ?may ?have ?contributed ?to ?such ?residual ? confounding. ? Also, ? because ? of ? the ? small ? sample ? size, ? there ? were ? wide ?intervals ?around ?some ?of ?the ?estimates ?reported. ?However, ?the ?direction ?of ?changes ?we ?found ?was ?consistent ?with ?other ?reports, ?including ?those ?published ?by ?the ?Thai ?government, ? suggesting ?an ?expansion ?of ? illicit ?drug ?markets ? in ?Thailand ? in ? recent ?years.39,234 ?Lastly, ?we ?were ?unable ?to ?assess ?fluctuations ?in ?drug ?purity, ?which ?may ?in ?part ?explain ?the ?trends ?of ?street-???level ?availability ?and ?price ?observed ?herein. ?Future ?research ?should ?assess ?the ?effect ?of ?drug ?purity ?on ?the ?demand ?and ?supply ?of ?drugs ?analyzed. ? ? ? 112 ?In ? sum, ? we ? found ? that ? despite ? the ? Thai ? government?s ? intensified ? drug ?suppression ?efforts ?in ?recent ?years, ?the ?availability ?of ?illicit ?drugs ?among ?samples ?of ?IDU ?in ?Bangkok ?increased ?significantly ?between ?2009 ?and ?2011. ?The ?street ?price ?of ?all ? drugs ? assessed ? in ? this ? study ? remained ? the ? same ? during ? the ? study ? period. ? The ?increases ?in ?the ?availability ?of ?methamphetamine ?were ?associated ?with ?a ?history ?of ?incarceration. ?These ?findings ?raise ?concern ?about ?the ?Thai ?government?s ?continued ?overreliance ? on ? the ? aggressive ? drug ? policing ? and ? point ? to ? the ? need ? for ? greater ?investment ?in ?scientifically ?sound ?drug ?treatment ?and ?harm ?reduction ?programming. ? ?  ? ? 113 ? ? Table 8: Characteristics of 718 of IDU in Bangkok, Thailand, participating in the Mitsampan Community Research Project in 2009 and 2011 Characteristic Total n (%) Study enrolment 2011 425 (59.2%) n (column%) 2009 293 (40.8%) n (column%) Female gender 165 (23.0%) 81 (19.1%) 84 (28.7%) Age    ? 35 years 304 (42.3%) 167 (39.3%) 137 (46.7%) 36-45 years 213 (29.7%) 136 (32.0%) 77 (26.3%) ? 46 years 201 (28.0%) 122 (28.7%) 79 (27.0%) Drug dealinga 53 (7.4%) 24 (5.6%) 29 (9.9%) Drugs used at least oncea:    Heroin 436 (60.7%) 243 (57.2%) 193 (65.9%) Methamphetamine 483 (67.3%) 263 (61.9%) 220 (75.1%) Crystal methamphetamine 157 (21.9%) 140 (32.9%) 17 (5.8%) Midazolam 543 (75.6%) 316 (74.4%) 227 (77.5%) Illicit methadone 280 (39.0%) 178 (41.9%) 102 (34.8%) Drugs used more than twice per weeka:  Heroin 189 (26.3%) 94 (22.1%) 95 (32.4%) Methamphetamine 287 (40.0%) 136 (32.0%) 151 (51.5%) Crystal methamphetamine 58 (8.1%) 55 (12.9%) 3 (1.0%) Midazolam 424 (59.1%) 233 (54.8%) 191 (44.9%) Illicit methadone 334 (46.5%) 211 (49.6%) 123 (42.0%) Ever in prison 563 (78.4%) 316 (74.4%) 247 (84.3%) Ever in compulsory drug detention 137 (19.1%) 78 (18.4%) 59 (20.1%) IDU: people who inject drugs. adenotes activities during the 6 months prior to the interview.  ? ? 114 ?Table 9: Multivariate analyses of factors associated with the availability of drugs among a community-recruited sample of IDUs in Bangkok, Thailand Characteristic  Heroin Methamphetamine Crystal methamphetamine  (n=436) (n=483) (n=157) AOR (95% CI) AOR (95% CI) AOR (95% CI) Study enrolment     (2011 vs. 2009) Immediate vs. Delayed 1.67 (0.78 ? 3.61) 4.20 (1.96 ? 9.00)** 23.53 (2.66 ? 208.36)**  Moderate vs. Delayed 2.89 (1.85 ? 4.51)** 2.81 (1.41 ? 5.61)** 4.61 (1.46 ? 14.63)** Gender     (Female vs. Male) Immediate vs. Delayed  2.39 (1.05 ? 5.45)*   Moderate vs. Delayed 0.58 (0.31 ? 1.08)   Age     (36-45 vs. ? 46 yrs) Immediate vs. Delayed   0.48 (0.10 ? 2.19)  Moderate vs. Delayed 0.72 (0.41 ? 1.25)   0.31 (0.08 ? 1.28) (? 35 vs. ? 46 yrs) Immediate vs. Delayed   1.31 (0.28 ? 6.15)  Moderate vs. Delayed 1.38 (0.79 ? 2.40)   0.77 (0.18 ? 3.27) Drug dealinga     (Yes vs. No) Immediate vs. Delayed 2.55 (0.88 ? 7.39)    Moderate vs. Delayed  0.32 (0.12 ? 0.85)*  Use of each drug of interesta    (> Weekly vs.  Immediate vs. Delayed  1.90 (0.93 ? 3.90)   ? Weekly) Moderate vs. Delayed 1.74 (1.10 ? 2.74)*   Ever in prison     (Yes vs. No) Immediate vs. Delayed  3.87 (1.72 ? 8.71)**   Moderate vs. Delayed  2.43 (1.19 ? 4.96)*  Ever in compulsory drug detention    (Yes vs. No) Immediate vs. Delayed 0.16 (0.04 ? 0.72)*    Moderate vs. Delayed 0.41 (0.24 ? 0.70)**   IDU: people who inject drugs; AOR: adjusted odds ratio; CI: confidence interval; Immediate: immediately available (within 10 min.); Moderate: moderate availability (available in > 10 min. to ? 90 min.); Delayed: delayed availability (available in > 90 min.). *p<0.05; **p<0.01. adenotes activities during the 6 months prior to the interview. Empty cells reflect variables that had large p-values and were removed from the final multivariate logistic regression models according to the a priori-defined statistical protocol.  ? ?  ? ? 115 ? ?Table 9: Multivariate analyses of factors associated with the availability of drugs among a community-recruited sample of IDUs in Bangkok, Thailand (continued) Characteristic  Midazolam Illicit methadone  (n=543) (n=280) AOR (95% CI) AOR (95% CI) Study enrolment    (2011 vs. 2009) Immediate vs. Delayed 2.84 (1.71 ? 4.73)** 4.42 (2.07 ? 9.46)**  Moderate vs. Delayed 2.42 (1.58 ? 3.72)** 2.36 (1.33 ? 4.19)** Gender    (Female vs. Male) Immediate vs. Delayed    Moderate vs. Delayed   Age    (36-45 vs. ? 46 yrs) Immediate vs. Delayed 1.24 (0.64 ? 2.39) 3.74 (1.44 ? 9.71)**  Moderate vs. Delayed  2.33 (1.12 ? 4.86)* (? 35 vs. ? 46 yrs) Immediate vs. Delayed 1.83 (0.98 ? 3.43) 2.90 (1.22 ? 6.89)*  Moderate vs. Delayed  1.51 (0.78 ? 2.93) Drug dealinga    (Yes vs. No) Immediate vs. Delayed    Moderate vs. Delayed 1.99 (0.83 ? 4.77)  Use of each drug of interesta   (> Weekly vs.  Immediate vs. Delayed  0.35 (0.08 ? 1.50)  ? Weekly) Moderate vs. Delayed 0.46 (0.27 ? 0.79)**  Ever in prison    (Yes vs. No) Immediate vs. Delayed    Moderate vs. Delayed   Ever in compulsory drug detention   (Yes vs. No) Immediate vs. Delayed  2.19 (0.94 ? 5.14)  Moderate vs. Delayed 0.55 (0.33 ? 0.93)*  IDU: people who inject drugs; AOR: adjusted odds ratio; CI: confidence interval; Immediate: immediately available (within 10 min.); Moderate: moderate availability (available in > 10 min. to ? 90 min.); Delayed: delayed availability (available in > 90 min.). *p<0.05; **p<0.01. adenotes activities during the 6 months prior to the interview. Empty cells reflect variables that had large p-values and were removed from the final multivariate logistic regression models according to the a priori-defined statistical protocol.  ? ? 116 ?Table 10: Modal retail price and unit of five substances reported by a community-recruited sample of IDU in Bangkok, Thailand Substance Year Modal price and unit % reporting the modal price and unit Heroin (n=436) 2009 500 Baht (approx. US$17)/approx. 50mg 80.6% 2011 500 Baht (approx. US$17)/approx. 50mg 68.5% Methamphetamine (n=483) 2009 200 Baht (approx. US$7)/pill 55.0% 2011 200 Baht (approx. US$7)/pill 45.2% Crystal methamphetamine (n=157) 2009 2,500 Baht (approx. US$83)/approx. 1g 35.3% 2011 2,500 Baht (approx. US$83)/approx. 1g 23.6% Midazolam (n=543) 2009 80 Baht (approx. US$3)/pill 59.0% 2011 80 Baht (approx. US$3)/pill 34.8% Illicit methadone (n=280) 2009 500 Baht (approx. US$17)/60ml bottle 27.5% 2011 500 Baht (approx. US$17)/60ml bottle 40.4% IDU: people who inject drugs.  ? ?  ? ? 117 ?Figure 3: Distributions of immediate, moderate and delayed availability of five substances reported by IDU in Bangkok, Thailand  ? ? ?  ?Heroin'(n=436)'Methamphetamine'(n=483)'Crystal'methamphetamine'(n=157)'Midazolam'(n=543)'Illicit'methadone'(n=280)'0%' 20%' 40%' 60%' 80%' 100%'2011'2009'2011'2009'2011'2009'2011'2009'2011'2009'Immediate'availability' Moderate'availability' Delayed'availability' ? 118 ?CHAPTER ?8: ?CONCLUSION ?8.1 ?Summary ?of ?Findings ?This ?dissertation ?sought ?to ?examine ?the ?relationship ?between ?repressive ?drug ?policing ? and ? the ? health ? of ? IDU ? in ? Bangkok, ? Thailand. ? Drawing ? on ? a ? modified ?version ?of ?the ?Risk ?Environment ?Framework, ?the ?analyses ?situated ?policing ?practices ?in ?a ?broader ?social, ?structural ?and ?physical ?environment ?and ?sought ?to ?understand ?various ? pathways ? through ?which ? policing ? practices ?may ? increase ? vulnerability ? to ?poor ?health ?among ?IDU ?in ?Bangkok. ? ? ?The ? literature ? review ? in ?Chapter ? 2 ?described ?how ? repressive ?drug ?policing ?operates ? within ? the ? broader ? risk ? environment ? surrounding ? illicit ? drug ? use ? and ?increases ?IDUs? ?vulnerability ?to ?poor ?health ?in ?settings ?throughout ?the ?world. ?It ?also ?listed ?some ?recommendations ? for ?mitigating ? the ?adverse ? impacts ?of ?drug ?policing, ?as ? well ? as ? the ? challenges ? associated ? with ? such ? efforts. ? The ? results ? indicated ? that ?aggressive ?drug ?policing ?could ?harm ?IDU ?directly ?through ?various ?forms ?of ?police ?violence ?and ?indirectly ?through ?multiple ?pathways. ?While ?a ?large ?body ?of ?literature ?exists ?on ?this ? topic, ?previous ?studies ?have ?tended ?to ? focus ?on ?the ?aggregate ?effects ?and ?consequences ?of ?police ?crackdowns ?rather ?than ?on ?specific ?policing ?tactics. ?The ?review ? also ? highlighted ? that ?most ? of ? the ? interventions ? that ? sought ? to ? align ? police ?actions ? with ? public ? health ? goals ? (e.g., ? police ? training ? on ? harm ? reduction) ? lacked ?rigorous ?evaluation. ?Using ? in-???depth, ? qualitative ? interview ? data ? obtained ? from ? a ? community-???recruited ? sample ? of ? IDU ? in ? Bangkok, ? Chapter ? 3 ? sought ? to ? characterize ? the ?circumstances ? and ? situational ? factors ? surrounding ? encounters ?with ?police, ? analyze ?specific ? policing ? tactics ? employed ? during ? these ? encounters, ? and ? explore ? IDUs? ?reactions ? to ? these ? encounters. ? Respondents ? indicated ? that ? drug ? policing ? had ? ? 119 ?intensified ? since ? rapid ? urine ? toxicology ? testing ? became ?widely ? available ? to ? police. ?They ? reported ? various ? forms ? of ? police ? misconduct, ? including ? false ? accusations, ?coercion ? of ? confessions, ? excessive ?use ? of ? force, ? and ? extortion ? of ?money. ?However, ?respondents ?were ?reluctant ?to ?report ?police ?misconduct ?to ?the ?authorities ?in ?the ?face ?of ?social ?and ?structural ?barriers ?to ?seeking ?justice. ?Respondents? ?strategies ?to ?avoid ?police ? impeded ? their ? access ? to ?healthcare, ? fostered ? risky ? injection ?behaviours, ? and ?facilitated ? the ?misuse ? of ? prescribed ? pharmaceuticals. ? The ? findings ? illustrated that drug policing in Bangkok is characterized by severe injustices, grave human rights abuses, and entrenched corruption. ?The ?epidemiological ?analyses ? in ?Chapters ?4?6 ?explored ? the ?harm ?associated ?with ?specific ?policing ?tactics ?commonly ?used ?against ? IDU ?in ?Bangkok. ?Specifically, ?Chapter ? 4 ? sought ? to ? identify ? the ? prevalence ? and ? correlates ? of ? experiencing ? police ?beatings. ? It ? found ? that ? 38% ? of ? a ? community-???recruited ? sample ? of ? IDU ? in ? Bangkok ?experienced ? beatings ? by ? police. ? Consistent ? with ? the ? findings ? of ? the ? qualitative ?analysis ? in ? Chapter ? 3, ? respondents ? most ? commonly ? reported ? this ? form ? of ? police ?violence ? during ? the ? interrogation ? process. ? In ? multivariate ? analyses, ? experiencing ?police ?beating ?was ?independently ?associated ?with ?various ?indicators ?of ?drug-???related ?harm, ? including ? incarceration, ? compulsory ? drug ? detention, ? syringe ? sharing, ? and ?reporting ?barriers ? to ? accessing ?healthcare. ?These ? findings ? suggested ? that ? the ?over-???reliance ?on ?repressive ?drug ?policing ? in ? the ?absence ?of ?appropriate ?police ?oversight ?and ?measures ? to ? ensure ? accountability ? for ? police ?misconduct ? was ? contributing ? to ?police ?abuse ?against ?IDU ?in ?Bangkok ?and ?to ?IDUs? ?vulnerability ?to ?poor ?health. ? ?Chapter ?5 ?identified ?the ?prevalence ?and ?correlates ?of ?police-???conducted ?urine ?drug ?testing. ?In ?this ?study, ?67% ?of ?a ?community-???recruited ?sample ?of ?IDU ?in ?Bangkok ?reported ? having ? been ? subjected ? to ? urine ? drug ? testing ? by ? police. ? The ? results ? of ?multivariate ?analyses ?indicated ?that ?young ?people ?and ?methamphetamine ?injectors ? ? 120 ?were ?more ? likely ? to ?have ?been ? tested. ?Reports ?of ?drug ? testing ?by ?police ?were ? also ?independently ? and ? positively ? associated ? with ? incarceration, ? compulsory ? drug ?detention, ? and ? healthcare ? avoidance ? whereas ? enrolment ? in ? voluntary ? drug ?treatment ?was ?independently ?and ?negatively ?associated ?with ?reports ?of ?police ?drug ?testing. ?Taken ?together ?with ?the ?findings ?in ?Chapter ?3, ?these ?findings ?indicated ?that ?the ?widespread ? practice ? of ? urine ? drug ? testing ? by ? police ?was ? closely ? linked ? to ? the ?compulsory ? drug ?detention ? system ? and ?might ? be ? interfering ?with ? IDUs? ? access ? to ?healthcare ?and ?voluntary ?treatment. ? ?Chapter ?6 ?examined ?the ?effects ?of ?exposures ?to ?two ?types ?of ?policing ?practices ?on ? syringe ? sharing. ? It ? was ? hypothesized ? that ? both ? experiences ? of ? severe ? police ?violence ? (regardless ? of ? timing) ? and ? a ? recent ? direct ? encounter ? with ? police ? would ?increase ?fear ?of ?police, ?and ?in ?turn, ?increase ?the ?risk ?of ?syringe ?sharing. ?Experiences ?of ?severe ?police ?violence ?were ?measured ?as ?having ?been ?beaten ?by ?police ?anytime ?in ?the ?past, ? and ? a ? recent ?direct ? encounter ?with ?police ?was ? operationalized ? as ? having ?been ?subjected ?to ?urine ?drug ?testing ?by ?police ?in ?the ?past ?six ?months. ?The ?outcome ?of ?interest ?in ?this ?study ?was ?syringe ?sharing ?in ?the ?past ?six ?months. ?In ?multivariate ?analyses, ? after ? adjustment ? for ? potential ? social, ? demographic, ? and ? behavioural ?confounders, ?syringe ?sharing ?was ?independently ?associated ?with ?exposures ?to ?each ?of ?the ?two ?policing ?practices, ?and ?experiencing ?both ?two ?policing ?practices ?had ?the ?greatest ? effect ? on ? syringe ? sharing. ? These ? findings ? highlighted ? the ? importance ? of ?addressing ? the ? policy ? and ? social ? environment ? surrounding ? IDU ? as ? a ? means ? of ?preventing ?blood-???borne ?disease ?transmission. ?Chapter ? 7 ? sought ? to ? assess ? trends ? of ? street-???level ? availability ? of ? illicit ? drugs ?between ? 2009 ? and ? 2011. ? Using ? serial ? cross-???sectional ? data, ? this ? study ? assessed ?changes ? in ? the ? street-???level ? availability ? of ? five ? substances ? commonly ? used ? among ?IDU ? in ? Bangkok ? (i.e., ? heroin, ? methamphetamine, ? crystal ? methamphetamine, ? ? 121 ?midazolam, ?and ?illicit ?methadone) ?between ?2009 ?and ?2011. ?It ?also ?sought ?to ?examine ?social, ? structural, ? and ? individual ? factors ? influencing ? the ? availability ? of ? drugs. ? The ?study ?found ?that, ?after ?controlling ?for ?changes ?in ?respondent ?characteristics ?between ?assessments, ? in ? a ? period ? of ? constant ? nominal ? illicit ? drug ? prices, ? street-???level ?availability ? of ? all ? substances ? increased ? significantly ? between ? 2009 ? and ? 2011. ?Also, ?the ? availability ? of ? methamphetamine ? was ? associated ? with ? incarceration. ? Given ?recent ?media ?reports ?documenting ?an illicit drug trade ?boom? within prisons,230,231 ?the ? results ? suggested ? that ? incarceration ? did ? not ? disconnect ? IDU ? from ?methamphetamine ?dealers ? and ?may ? instead ?have ? facilitated ? the ? formation ? of ? new ?social ?network ?in ?a ?way ?to ? increase ?the ?ease ?of ? future ?drug ?purchases ?after ?release ?from ? prisons. ? In ? summary, ? these ? findings ? suggested ? that ? despite ? the ? Thai ?government?s ? longstanding ?and ?significant ? investment ?in ?drug ?suppression ?efforts, ?illicit ?drug ?markets ?continued ?to ?flourish ?in ?the ?country. ?A ? synthesis ? of ? the ? findings ? from ? all ? chapters ? indicated ? that ? the ? strict ? drug ?prohibition ? policy, ? which ? relies ? heavily ? on ? criminal ? law ? enforcement ? and ?compulsory ? drug ? detention ? (i.e., ? macro-???structures), ? has ? exerted ? tremendous ?influence ? on ? policing ? practices ? in ? the ? streets ? of ? Bangkok. ? Policing ? practices ? were ?further ? shaped ? by ? meso-???level ? social ? and ? environmental ? factors ? (e.g., ? police ?corruption ? and ? financial ? incentives ? within ? the ? police) ? and ? involved ? a ? number ? of ?unlawful ? practices ? (e.g., ? evidence ? planting), ? as ? well ? as ? physically ? and ?psychologically ? harmful ?misconduct ? (e.g., ? beatings ? and ?humiliation). ? The ? findings ?also ? suggested ? that ? policing ? practices ? interacted ?with ? other ?meso-???level ? social ? and ?environmental ?factors ?(e.g., ?compulsory ?detention ?and ?incarceration ?of ?IDU), ?micro-???level ? social ? and ? environmental ? factors ? (e.g., ? intense ? police ? surveillance ? near ?methadone ? clinics), ? and ? individual ? characteristics ? (e.g., ? being ?young), ? and ? thereby ?increased ? IDUs? ? vulnerability ? to ? poor ? health ? by ? constraining ? IDUs? ? access ? to ? ? 122 ?healthcare, ?facilitating ?transitions ?towards ?the ?misuse ?of ?midazolam, ?and ?prompting ?risky ?injection ?behaviours. ? ? ?8.2 ?Human ?Rights ?Implications ? ? Collectively, ? the ? findings ? of ? this ? dissertation ? highlight ? a ? number ? of ? human ?rights ? concerns ? associated ? with ? drug ? policing ? practices ? in ? Bangkok. ? Using ?international ?human ? rights ?norms, ? this ? section ?explores ? concerns ? that ? arise ? from ?a ?consideration ? of ? the ? studies ? as ? a ?whole, ? particularly ? in ? relation ? to ? police ? beatings ?and ? urinalysis. ? First, ? as ? discussed ? in ? Chapter ? 3, ? police?s ? use ? of ? excessive ? force ? to ?coerce ? confessions ? (e.g., ? beating, ? kicking, ? and ? using ? electric ? shock) ? is ? clearly ? a ?violation ?of ? the ? right ? to ? freedom ? from ? torture ? and ? cruel, ? inhuman, ? and ?degrading ?treatment ?under ?Article ?7 ?of ?the ?ICCPR, ?which ?Thailand ?ratified ?in ?1996. ?The ?ICCPR ?designates ? this ?right ?as ?non-???derogable ? (Article ?4), ?meaning ?that ? the ?state ?parties ? to ?the ? ICCPR ? cannot ? derogate ? from ? their ? obligations ? to ? protect ? this ? right ? under ? any ?circumstances, ? including ? a ? public ? emergency. ? Furthermore, ? Thailand ? is ? a ? party ? to ?the ?CAT, ?and ?the ?prohibition ?of ?torture ?is ?enshrined ?in ?Section ?32 ?of ?the ?Constitution ?of ? Kingdom ? of ? Thailand ? B.E. ? 2550 ? (2007).191 ? Despite ? the ? Thai ? government?s ? absolute ?obligation ?to ?protect ?this ?right, ?Chapters ?3 ?and ?4 ?indicate ?that ?police ?beatings ?of ?IDU ?are ?widespread ?in ?Bangkok ?and ?that ?victims ?of ?police ?brutality ?do ?not ?have ?access ?to ?legal ?remedies, ?which ?infringes ?on ?the ?right ?to ?an ?effective ?remedy ?under ?Article ?2 ?of ?the ?ICCPR ?and ?Section ?32 ?of ?the ?Thai ?constitution.191 ? ? While ?the ?violation ?of ?the ?right ?to ?freedom ?from ?torture ?and ?cruel, ?inhuman, ?and ? degrading ? treatment ? is ? in ? itself ? a ? serious ? concern, ? the ? findings ? of ? this ?dissertation ?highlight ? that ? it ? also ? likely ? serves ? to ?undermine ? the ? right ? to ?health ? of ?IDU ? in ? Bangkok. ? Chapters ? 4 ? and ? 6 ? found ? that ? IDU ?who ? experienced ? beatings ? by ?police ?were ?more ? likely ? than ? those ?who ?did ? not ? experience ? beatings ? to ? engage ? in ?syringe ? sharing. ? This ? is ? consistent ? with ? previous ? studies ? from ? other ? countries ? ? 123 ?showing ?that ?extrajudicial ?police ?actions ?are ?associated ?with ?syringe ?sharing ?among ?IDU,69,81,122 ?as ?well ?as ?the ?findings ?in ?Chapter ?3 ?indicating ?that ?IDU ?respond ?to ?police ?pressure ? by ? engaging ? in ? riskier ? drug-???using ? behaviours. ? The ? right ? to ? the ? highest ?attainable ?standard ?of ?physical ?and ?mental ?health ?(?the ?right ?to ?health?) ?is ?enshrined ?in ?a ?number ?of ? international ?human ?rights ? instruments, ? including ?Article ?25 ?of ? the ?Universal ? Declaration ? of ? Human ? Rights ? (UDHR) ? and ? Article ? 12 ? of ? the ? ICESR, ? to ?which ?Thailand ?became ?a ?party ?in ?1999. ?In ?particular, ?Article ?12.2 ?(c) ?of ?the ?ICESCR ?states ?that ??the ?steps ?to ?be ?taken ?by ?the ?State ?Parties?to ?achieve ?the ?full ?realization ?of ?this ?right ?shall ?include ?those ?necessary ?for?the ?prevention, ?treatment ?and ?control ?of ?epidemic?and ?other ?diseases.? ?A ?related ?legal ?provision ?can ?be ?found ?in ?Section ?51 ?of ?the ?Thai ?constitution, ?which ?guarantees ?that ?a ?person ?has ??the ?right ?to ?receive ?public ?health ?services.?191 ?The ?Committee ?on ?Economic, ?Social ?and ?Cultural ?Rights ?(CESCR), ?the ?monitoring ?body ?for ?the ?ICESCR, ?has ?defined ?violations ?of ?the ?state?s ?obligation ? to ? respect ? the ? right ? to ? health ? as ? when ? ?[s]tate ? actions, ? policies ? or ?laws?are ? likely ? to ? result ? in?unnecessary ? morbidity ? and ? preventable ? mortality? ?(para. ?50).192 ?Police ?brutality ?that ?is ?found ?to ?be ?independently ?associated ?with ?high-???risk ? behaviour ? for ? contracting ? blood-???borne ? pathogens ? is ? congruent ? with ? the ?CESCR?s ?definition ?of ?the ?violations ?of ?the ?state?s ?obligations ?to ?respect ?the ?right ?to ?health, ?particularly ?the ?prevention ?and ?control ?of ?epidemics ?of ?infectious ?diseases, ?in ?addition ? to ? other ? strong ?prohibitions ? of ? police ? brutality ? in ? human ? rights ? law. ?The ?same ? claim ? can ? be ? made ? for ? police?s ? use ? of ? urine ? drug ? testing, ? as ? this ? policing ?practice ?was ?also ?independently ?associated ?with ?syringe ?sharing. ?In ?addition, ?the ?findings ?from ?Chapters ?3, ?4, ?and ?5 ?indicating ?that ?both ?police ?beatings ?and ?drug ?testing ?by ?police ?represent ?an ?impediment ?to ?accessing ?healthcare ?among ? IDU, ? and ? suggest ? that ? the ? Thai ? government ? should ? undertake ? efforts ? to ?ensure ? the ? accessibility ? aspect ? of ? the ? right ? to ? health ? among ? this ? population. ? ? 124 ?According ? to ? the ? CESCR, ? accessibility ? includes ? ?physical ? accessibility,? ? which ?means ??health ?facilities, ?goods ?and ?services ?must ?be ?within ?safe ?physical ?reach ?for ?all ?sections ?of ?the ?population, ?especially ?vulnerable ?or ?marginalized ?groups? ?(para. ?12[b]).192 ?It ?is ?likely ?that ?widespread ?use ?of ?excessive ?force ?and ?drug ?testing ?by ?police ?makes ?IDU ?perceive ?health ?services ?being ?out ?of ??safe ?physical ?reach.? ? ? The ?dissertation ?also ?raises ?concern ?about ?the ?degrading ?procedures ?of ?drug ?testing ?by ?police. ?Respondents? ? narratives ?described ? in ?Chapter ? 3 ? suggest ? that ? the ?police ?often ?order ?IDU ?to ?urinate ?in ?public ?places. ?This ?practice ?likely ?conflicts ?with ?Article ?10.1 ?of ? the ? ICCPR, ?which ?states ? that ??[a]ll ?persons ?deprived ?of ? their ? liberty ?shall ? be ? treated ? with ? humanity ? and ? with ? respect ? for ? the ? inherent ? dignity ? of ? the ?human ?person,? ?as ?well ?as ?Article ?16 ?of ? the ?CAT, ?which ?says ? that ? the ??State ?Party ?shall ?undertake ?to ?prevent?other ?acts ?of ?cruel, ?inhuman ?or ?degrading ?treatment ?or ?punishment ?which ?do ?not ?amount ?to ?torture ?as ?defined ?in ?article ?1, ?when ?such ?acts ?are ? committed ?by ?or ?at ? the ? instigation ?of ?or ?with ? the ? consent ?or ? acquiescence ?of ? a ?public ?official ?or ?other ?person ?acting ? in ?an ?official ? capacity.? ?Furthermore, ? forcible ?drug ?testing ?by ?police ?raises ?concern ?regarding ?the ?right ?to ?privacy ?(Article ?17 ?of ?the ?ICCPR) ? and ? the ? right ? to ? security ? of ? those ? being ? tested ? without ? their ? informed ?consent ? (Article ? 9 ? of ? the ? ICCPR). ? Especially ? given ? that ? urinalysis ? cannot ? identify ?those ?who ? pose ? immediate ? threats ? to ? public ? security, ? and ? in ? light ? of ? the ? harmful ?consequences ? of ? such ? testing, ? forcible ? drug ? testing ? by ? police ? violates ? the ? human ?rights ?norms. ? ? ? ? ? ? ? Lastly, ?a ?synthesis ?of ?findings ?from ?Chapters ?3 ?and ?5 ?suggests ?that ?the ?police ?may ?be ?disproportionately ?conducting ?urine ?drug ?testing ?to ?former ?drug ?offenders, ?which ?can ?be ?challenged ?based ?on ?the ?principle ?of ?non-???discrimination ?under ?Article ?26 ? of ? the ? ICCPR. ? This ? principle ? is ? also ? enshrined ? in ? Section ? 30 ? of ? the ? Thai ?constitution, ? which ? prohibits ? ?unjust ? discrimination ? against ? a ? person ? on ? the ? ? 125 ?grounds ?of ? the ?difference ? in ?origin, ? race, ? language, ? sex, ?age, ?disability, ?physical ?or ?health ? condition, ? personal ? status, ? economic ? or ? social ? standing, ? religious ? belief, ?education ?or ?constitutionally ?political ?view.? ?Moreover, ?available ?data ?indicate ?that ?the ?police ?compile ??blacklists? ?of ?suspected ?or ?formerly ?convicted ?drug ?dealers ?and ?users,22,157,189 ?which ? likely ?explains ? the ?observed ?discriminatory ?approach ? to ? former ?drug ?offenders. ?  ?This ?practice ?may ?infringe ?on ?the ?right ?to ?privacy ?provided ?under ?Article ? 17 ? of ? the ? ICCPR. ?The ?Thai ? constitution ? also ?declares ? that ? ?[a] ? person ? shall ?have ?the ?right ?to ?be ?accorded ?protection ?against ?undue ?exploitation ?of ?personal ?data ?related ?to ?his ?or ?her ?individuality, ?as ?provided ?by ?law? ?(Section ?35).191 The ?findings ?of ? this ? dissertation ? suggest ? that ? drug ? testing ? by ? police ? may ? be ? associated ? with ??undue ?exploitation ?of ?personal ?data.? ? ? In ?summary, ?policing ? tactics ? that ? the ?Thai ?police ?commonly ?employ ?against ?IDU ?in ?Bangkok ?involve ?abuse ?of ?many ?rights ?enshrined ?in ?the ?ICCPR ?and ?the ?CAT. ?These ?rights ?abuses ?are ?inextricably ?associated ?with ?threats ?to ?the ?right ?to ?health ?in ?this ?population. ?Given ?that ?Thailand ?ratified ?all ?relevant ?international ?human ?rights ?conventions ?reviewed ?herein ?and ?has ?already ?enacted ?the ?domestic ? legislation ?that ?guarantees ? the ? rights ? included ? in ? these ? conventions, ? the ? Thai ? government ? should ?urgently ?take ?effective ?measures ?to ?prevent ?and ?address ?the ?observed ?rights ?abuses. ?Several ?recommendations ?for ?these ?measures ?are ?described ?in ?section ?8.5. ? ? ? ?8.3 ?Study ?Strengths ?and ?Unique ?Contributions ? ? This ?dissertation ?has ? several ? strengths ?and ?makes ?unique ?contributions ? to ?a ?body ?of ?scientific ? literature ?on ?the ?impacts ?of ?drug ?policing ?on ?public ?health. ?First, ?the ?dissertation ?demonstrates ?that ?the ?use ?of ?a ?mixed-???methods ?study ?design ?resulted ?in ? a ? deeper ? understanding ? of ? some ? key ? findings ? than ? a ? single ? research ? method ?would ?have.245,246 ?Specifically, ?in ?the ?qualitative ?analysis ?in ?Chapter ?3, ?police ?beatings ?and ?the ?use ?of ?urine ?drug ?testing ?by ?police ?emerged ?as ?key ?themes ?(among ?others) ? ? 126 ?characterizing ? IDUs? ? encounters ? with ? police. ? Although ? the ? qualitative ? findings ?contributed ?to ?the ?in-???depth ?understanding ?of ?contexts ?in ?which ?the ?police ?engaged ?in ? these ? practices, ? the ? extent ? to ? which ? these ? policing ? practices ? were ? employed ?against ?IDU ?was ?not ?known, ?nor ?could ?the ?qualitative ?analysis ?discern ?the ?effects ?of ?different ?policing ?practices. ?The ?quantitative ?findings ?of ?Chapters ?4?6 ?corroborated ?the ? qualitative ? study ? findings ? by ? showing ? that ? experiences ? with ? each ? policing ?practice ? were ? common ? among ? a ? larger ? sample ? of ? IDU ? in ? Bangkok. ? They ? also ?identified ? independent ? relationships ? between ? exposures ? to ? the ? two ? policing ?practices ?and ?health-???related ?behaviours ?(i.e., ?syringe ?sharing ?and ?healthcare ?access). ?Thus, ? the ? two ? types ? of ? data ? provided ? complementary ? evidence ? on ? the ? harms ?associated ?with ?police ?beatings ?and ?drug ?testing ?on ?IDU ?in ?Bangkok ?and ?contributed ?to ?a ?deeper ?understanding ?of ?the ?problems ?pertaining ?to ?these ?policing ?practices. ? ? Second, ?the ?dissertation ?generated ?highly ?novel ?evidence ?on ?the ?relationship ?between ? repressive ? drug ? policing ? and ? public ? health. ? The ? novelty ? of ? the ? study ?findings ? is ?attributable, ? in ?part, ? to ? the ? involvement ?of ?peer ?researchers ? in ?the ?early ?stages ?of ? research ? (e.g., ?when ?developing ? research ?questions). ? For ? example, ? it ?was ?the ? peer ? researchers ?who ? first ? raised ? concerns ? about ? urine ?drug ? testing ? by ?police. ?The ? author ? then ? operationalized ? this ? particular ? policing ? practice ? as ? a ? measurable ?variable ? and ? developed ? the ? study ? hypotheses. ? As ? a ? result, ? this ? dissertation ? is ? the ?first ?to ?examine ?the ?harm ?associated ?with ?urine ?drug ?testing ?by ?police. ?In ?Chapters ?3, ?4, ? and ?6, ? this ?previously ?unexplored ?policing ?practice ?was ? shown ? to ?be ?associated ?with ?police ?abuse ?and ?various ?indicators ?of ?drug-???related ?harm. ?Chapter ?7 ?is ?also ?the ?first ?to ?elucidate ?the ?association ?between ?incarceration ?and ?the ?illegal ?drug ?market. ?It ?demonstrated ?that ? incarceration ?experiences ?were ?associated ?with ?more ? immediate ?availability ?of ?methamphetamine ?among ? IDU ? in ?Bangkok, ?even ?after ?adjusting ? for ?potential ? confounders. ?Peer ? researchers ?have ? also ?verified ? the ?plausibility ? of ? these ? ? 127 ?novel ? study ? findings ? with ? their ? experiential ? knowledge. ? These ? findings ? make ?important ? contributions ? to ? the ? scientific ? literature ?and ?have ?direct ? implications ? for ?policy. ? In ? addition, ? the ? dissertation ? highlights ? the ? value ? of ? a ? community-???based ?research ? approach ? in ? ensuring ? that ? research ? products ? directly ? address ? real-???world ?concerns.92,93 ? ? Third, ? the ? dissertation ? successfully ? made ? use ? of ? serial ? cross-???sectional ? data ?and ?produced ?novel ?knowledge ?about ? the ? relationship ?between ?drug ?policing ?and ?the ?illegal ?drug ?market ?in ?Bangkok. ?While ?reducing ?the ?supply ?of ?illicit ?drugs ?is ?one ?of ?the ?major ?goals ?of ?drug ?suppression ?efforts, ?changes ?in ?the ?illegal ?drug ?market ?are ?rarely ? evaluated ?due ? to ?difficulties ? in ?obtaining ?data. ?The ?Mitsampan ?Community ?Research ? Project ? was ? uniquely ? positioned ? to ? contribute ? scientific ? evidence ? in ? this ?area, ?as ?it ?collected ?data ?on ?street-???level ?drug ?availability ?at ?two ?different ?times, ?the ?latter ? of ?which ? followed ? a ? period ? of ? intensified ? crackdowns ? on ? illicit ? drug ? use ? in ?2011. ? Chapter ? 7 ? found ? that ? street-???level ? availability ? of ? all ? five ? drugs ? analyzed ?increased ?significantly ?between ?2009 ?and ?2011. ?The ?findings ?highlight ?the ?limitations ?of ?policing ?efforts ?to ?suppress ?the ?illegal ?drug ?market ?and ?add ?further ?weight ?to ?the ?need ?for ?greater ?support ? for ?and ?investment ? in ?scientifically ?sound ?drug ?treatment ?and ?harm ?reduction ?programming ?for ?IDU. ? ? ? ? Lastly, ? the ? dissertation ?makes ? a ? contribution ? to ? the ? scientific ? evidence ? base ?demonstrating ? that ? human ? rights ? violations ? are ? core ? features ? of ? the ? risk ?environment ? and ? barriers ? to ? care ? in ? this ? setting.98 ?As ? described ? in ?Chapter ? 2, ? few ?scientific ?studies ?have ?applied ?human ?rights ?norms ?to ?investigations ?of ?the ?impacts ?of ? drug ? policing ? on ? the ? health ? of ? IDU. ? The ? dissertation ? accomplished ? this ? by ?embedding ?human ? rights ? factors ? in ? the ?data ? collection ? instruments ? that ?were ? also ?informed ? by ? the ? Risk ? Environment ? Framework. ? Chapter ? 3 ? highlighted ? numerous ?human ? rights ? infringements ? committed ? by ? police ? officers, ? and ? Chapters ? 4 ? and ? 6 ? ? 128 ?demonstrated ? that ? reports ?of ?police ?beatings ?were ?associated ?with ? syringe ? sharing ?and ?reporting ?barriers ?to ?healthcare. ?Chapters ?3, ?5, ?and ?6 ?revealed ?that ?police?s ?use ?of ? urine ? drug ? testing ?was ? an ? affront ? to ? human ? rights ? principles, ? and ? this ? practice ?was ? associated ? with ? indicators ? of ? vulnerability ? to ? poor ? health ? among ? IDU. ? The ?empirical ?evidence ?of ?this ?kind ?is ?useful ?in ?informing ?humane ?and ?pragmatic ?drug ?policy, ?especially ?given ?a ?growing ?recognition ?among ?scholars, ?policy ?makers, ?and ?UN ? agencies ? that ? human ? rights ? norms ? and ? principles ? should ? guide ? international ?drug ?policy.11,180,247 ?8.4 ?Limitations ? ? Like ? all ? research, ? the ? work ? presented ? in ? this ? dissertation ? has ? limitations. ?While ?the ?limitations ?of ?each ?study ?are ?described ?in ?detail ?in ?the ?individual ?chapters, ?those ? common ? to ? all ? studies ? are ? briefly ? noted ? here. ? First, ? self-???reported ? data ? may ?have ?been ?affected ?by ?various ?kinds ?of ?reporting ?biases, ?including ?socially ?desirable ?responding ? and ? recall ? biases. ? However, ? the ? study ? interviewers ? employed ? several ?measures ? to ? minimize ? the ? likelihood ? of ? bias, ? including ? asking ? questions ? about ?sensitive ?matters ?later ?in ?the ?interview ?process ?and ?cross-???checking ?the ?responses ?and ?narratives ? to ? improve ? recall ?during ? interviews. ? In ?addition, ?given ? that ?experiences ?with ? police ? involve ? sensitive ? information, ? extra ? efforts ? were ? made ? to ? assure ? the ?confidentiality ? and ? anonymity ? of ? responses. ? For ? example, ? all ? interviews ? were ?conducted ? in ? private ? space, ? any ? personally ? identifiable ? information ? was ? not ?collected ?or ?removed ?from ?the ?data, ?and ?interviewers ?emphasized ?that ?the ?study ?has ?no ? connection ?with ? the ? state ? authorities. ? It ? should ?also ?be ?noted ? that ? self-???reported ?data ?have ?been ?commonly ?used ?in ?other ?epidemiological ?studies ?on ?illicit ?drug ?use ?and ? found ? to ? be ? valid.209,210,248 ? Second, ? as ? all ? data ? were ? translated ? from ? Thai ? into ?English, ? linguistic ?nuances ?may ?have ?been ? lost ? in ? translation. ?However, ? translated ?interview ? transcripts ? and ? survey ? data, ? as ?well ? as ?manuscripts ? of ? all ? studies, ?were ? ? 129 ?reviewed ?by ?the ?Thai ?research ?partners ?and ?interviewer, ?who ?are ?fluent ?in ?English. ?Lastly, ? as ? with ? all ? observational ? research, ? causality ? cannot ? be ? inferred ? from ? the ?findings ?of ? this ?dissertation. ?Also, ?as ?the ?study ?sample ?was ?not ?randomly ?selected, ?the ?generalizability ?of ?the ?findings ?is ?limited. ?The ?median ?age ?of ?the ?study ?samples ?(37-???38 ? years) ? indicates ? that ? experiences ? of ? younger ? IDU ? may ? have ? been ?underrepresented ? in ? this ? dissertation. ? While ? all ? quantitative ? studies ? employed ?multivariate ?regression ?techniques ?to ?account ?for ?potential ?confounders, ?the ?results ?may ?have ?been ?affected ?by ?unobserved ?or ?residual ?confounding. ? ?8.5 ?Recommendations ? ? Specific ? recommendations ? resulting ? from ? each ? empirical ? analysis ? are ?included ?in ?Chapters ?3?7. ?This ?section ?considers ?all ?study ?findings ?as ?an ?entity ?and ?highlights ? recommendations ? for ? drug ? policy ? and ? harm ? reduction ? measures ? in ?Thailand. ? ? First, ?given ?the ?widespread ?police ?abuse ?of ?IDU ?observed ?in ?this ?research, ?the ?Thai ?government ?should ?urgently ?institute ?effective ?remedies ?for ?the ?victims ?as ?well ?as ?appropriate ?measures ?to ?prevent ?further ?abuse ?in ?accordance ?with ?law. ?Although ?Thailand ? has ? a ? legal ? framework ? that ? prohibits ? state ? corruption, ? excessive ? use ? of ?force, ? and ? the ? use ? in ? court ? of ? evidence ? obtained ? through ? unlawful ? means, ? and ?provides ? a ?mechanism ? for ? the ? victims ? of ? police ? abuse ? to ? seek ? redress,51,194 ? the ? fact ?that ?investigations ?of ?police ?misconduct ?and ?prosecutions ?of ?police ?officers ?who ?are ?charged ?with ? some ?of ? the ?most ? serious ? rights ? abuses ? (e.g., ? extrajudicial ? killings ?of ?alleged ?drug ?dealers ?and ?users) ?during ?the ?2003 ?drug ?war ?have ?not ?been ?completed47 ?indicates ? a ? lack ? of ? political ?willingness ? to ? bring ? the ? perpetrators ? of ? the ? abuses ? to ?account. ?The ?Thai ?government ?should ?urgently ?ensure ?the ?accountability for police abuses ?and ?provide ?greater ?police ?oversight ?to ?prevent ?further ?abuse. ? ? ? 130 ?Second, ? given ? the ? observed ? lack ? of ? knowledge ? and ? access ? to ? legal ? services ?among ?some ?IDU ?in ?Bangkok, ?greater ?efforts ?should ?also ?be ?made ?to ?provide ?legal ?services ? that ? are ? accessible ? to ? IDU ? in ? this ? setting. ?A ? recent ? review165 ? indicates ? that ?legal ?services ?not ?only ?help ?victims ?of ?police ?abuse ?obtain ?redress ?and ?compensation, ?but ? they ? also ? have ? the ? potential ? to ? prevent ? police ? abuse ? in ? a ? number ? of ? ways: ?documenting ? rights ? abuses ? over ? time ? and ? effectively ? serving ? as ? an ? independent ?monitoring ?body ?of ?police ?actions; ?training ?IDU ?to ?know ?and ?assert ?their ?rights; ?and ?convening ? workshops ? for ? the ? police ? and ? prosecutors ? about ? the ? legality ? of ? health ?services ?for ?IDU. ?These ?types ?of ?legal ?interventions ?could ?likely ?serve ?to ?reduce ?the ?harm ?among ?IDU ?in ?Bangkok. ? ? ?Third, ?the ?findings ?from ?this ?dissertation ?call ?into ?question ?the ?justifiability ?of ?the ?ongoing ?repressive ?drug ?policing ?efforts ? to ?address ? illicit ?drug ?use ? in ?Thailand ?and ?point ?to ?the ?need ?for ?alternative ?measures ?to ?respect ?the ?right ?to ?health ?of ?IDU. ?Given ? the ? finding ? suggesting ? that ? illegal ? drug ?markets ? continue ? to ? flourish ? in ? the ?country, ? it ? is ? important ? to ? address ? the ? treatment ? and ? care ? needs ? of ? those ? who ?continue ?to ?engage ?in ?drug ?use. ?Each ?year, ?Thai ?authorities ?set ?numerical ?targets ?for ?drug ?treatment ?enrolment. ?Although ?it ?stipulates ?that ?people ?who ?use ?drugs ?should ?be ? first ? and ? foremost ? encouraged ? to ? seek ? voluntary ? drug ? treatment, ? enrolment ? in ?compulsory ?drug ?detention ?centres ?and ?drug ?treatment ?in ?correctional ?facilities ?are ?counted ? towards ? fulfilment ? of ? the ? policy ? goal.44 ? Consistent ? with ? the ? recent ? joint ?statement ?and ?recommendations ?by ? the ? twelve ?UN ?entities,29 ? the ?Thai ?government ?should ? abolish ? the ? compulsory ? drug ? detention ? system ? and ? instead ? scale ? up ? the ?provision ?of ?voluntary, ?scientifically ?sound, ?long-???term ?drug ?treatment ?in ?community ?settings. ? ?Repressive ? and ? harmful ? drug ? policing ? is ? largely ? attributable ? to ? harsh ?application ? of ? criminal ? penalties ? to ? a ? wide ? range ? of ? drug ? offenses. ? Therefore, ? as ? ? 131 ?discussed ? in ? Chapter ? 2, ? decriminalization ? of ? personal ? drug ? use ? may ? be ? worth ?exploring ?in ?Thailand. ?It ?would ?not ?only ?reduce ?harms ?associated ?with ?incarceration ?and ? pre-???trial ? detention ? of ? IDU, ? but ? could ? also ? facilitate ? access ? to ? voluntary ? drug ?treatment ? among ? IDU.177 ? Such ? legal ? change ? should ? accompany ? improvements ? in ?drug ?policing. ?Currently, ?there ?is ?no ?official ?commitment ?from ?the ?police ?to ?support ?harm ? reduction ? services ? for ? IDU ? and ? no ? systematic ? training ? of ? police ? officers ? to ?understand ? harm ? reduction ? services ? in ? Thailand, ? according ? to ? a ? harm ? reduction ?service ? provider ? in ? Bangkok ? (Tanguay ? P, ? oral ? communication, ? May ? 2013). ? These ?systems ?should ?be ?implemented ?as ?a ?matter ?of ?urgency ?alongside ?of ?greater ?police ?oversight ?and ?efforts ?to ?ensure ?full ?accountability ?for ?police ?abuses. ?Lastly, ?ethical ?guidelines ?for ?the ?use ?of ?urine ?drug ?testing ?by ?police ?need ?to ?be ?established. ?The ? findings ?of ? this ?dissertation ?highlight ? that ? the ?police ? aggressively ?employ ?drug ?testing ?to ?IDU ?in ?Bangkok, ?often ?without ?respecting ?the ?dignity ?of ?the ?persons ?tested, ?and ?this ?practice ?is ?associated ?with ?various ?indicators ?of ?drug-???related ?harm, ? including ? avoidance ? of ? healthcare ? and ? syringe ? sharing. ? First ? of ? all, ? the ?justifiability ? of ? forcible ? drug ? testing ? by ? police, ? in ? its ? current ? form, ? is ? highly ?questionable ?on ?a ?number ?of ?grounds. ?Urinalysis ?carries ?risk ?of ?false ?positives ?and ?cannot ? identify ? those ?who ?pose ? immediate ? threats ? to ?public ?security. ?Furthermore, ?as ? this ?dissertation ? indicates, ?consequences ?of ? testing ? involve ?numerous ?harms. ?As ?noted ?in ?Chapter ?3, ?discussion ?to ?inform ?the ?development ?of ?humane ?and ?pragmatic ?guidelines ? for ? drug ? testing ? by ? police ? is ? urgently ? needed. ? Reports ? from ? Europe ?highlight ? that ? the ? police ? are ? ordered ? to ? respect ? the ? voluntariness ? and ? privacy ? of ?those ? tested ?when ? conducting ? roadside ? drug ? testing ? to ? vehicle ? drivers.197,198 ? These ?experiences ? provide ? some ? useful ? reference ? for ? developing ? guidelines ? in ? Bangkok. ?Given ?the ?significant ?implications ?of ?this ?policing ?tool ?for ?human ?rights ?and ?public ?health, ?a ?thorough ?discussion ?about ?the ?police?s ?use ?of ?drug ?testing ?should ?also ?be ? ? 132 ?held ? at ? the ? international ? level, ? including ? in ? the ? UNODC, ? which ? is ? charged ? with ?providing ? technical ? assistance ? to ? governments ? to ? help ? ensure ? that ? drug ? control ?efforts ?reflect ?human ?rights ?norms ?and ?public ?health ?goals.91,180 ?8.6 ?Future ?Research ? ? The ? studies ? presented ? herein ? provide ? a ? body ? of ? evidence ? on ? the ? negative ?associations ? between ? repressive ? drug ? policing ? and ? the ? health ? of ? IDU ? in ? Bangkok. ?While ? they ? suggest ? new ? directions ? for ? drug ? policy, ? more ? research ? is ? needed ? to ?strengthen ? the ? evidence-???informed, ?human ? rights-???based ? recommendations ? for ?drug ?policy. ? ?First, ?some ?methodological ?limitations ?of ?this ?research ?need ?to ?be ?addressed. ?As ? the ? study ? sample ? was ? restricted ? to ? IDU ? in ? Bangkok, ? future ? research ? should ?examine ?experiences ?of ?IDU ?outside ?of ?Bangkok. ?In ?addition, ?the ?median ?age ?of ?the ?study ? samples ? (37-???38 ? years) ? indicates ? that ? experiences ? of ? younger ? IDU ?may ? have ?been ? underrepresented ? in ? this ? dissertation. ? For ? example, ? while ? some ? female ?respondents ? reported ? instances ?of ? sexual ?harassment ?and ?violence ?by ?police, ? these ?episodes ? took ?place ? long ?before ? the ?study ?was ?conducted ? (typically ?more ? than ? ten ?years ? ago ?when ? the ? respondents ?were ? teenagers ? or ? in ? their ? early ? 20s). ? Therefore, ?future ? research ? should ? explore ? experiences ? of ? young ? drug ? users ? and ? conduct ? a ?gender-???based ? analysis ? focused ? on ? these ? issues. ? Such ? research ? may ? involve ? other ?drug-???using ?populations. ?For ?example, ?previous ?reports ?indicate ?that ?non-???IDU ?drug-???using ?populations ? comprise ?more ?adolescents68 ? and ?women ?of ? child-???bearing ?age249 ?than ?IDU ?populations ?do. ?Therefore, ?health ?and ?human ?rights ?implications ?of ?drug ?policing ?may ? extend ?beyond ? those ? observed ? in ? this ?dissertation ? (e.g., ? implications ?for ?prenatal ?care ?and ?education). ? ? ? Second, ? this ? dissertation ? focused ? on ? experiences ? of ? IDU, ? and ? thus ? did ? not ?explore ? the ? views ? and ? experiences ? of ? police ? officers, ? affected ? families, ? or ? local ? ? 133 ?residents. ?Previous ?studies ?suggest ?that ?efforts ?to ?identify ?the ?ways ?in ?which ?police ?undermine ? harm ? reduction ? programs ? help ? inform ? the ? development ? of ? effective ?policy ? and ? programming ? to ? reduce ? drug-???related ? harm.171,174,175 ? Accordingly, ? future ?research ?should ?involve ?police ?officers ?who ?enforce ?the ?drug ?laws. ?Likewise, ?there ?is ?little ?literature ?that ?examines ?the ?impacts ?of ?drug ?policing ?on ?families ?of ?people ?who ?use ?drugs ?or ? local ? residents ?who ?are ? involved ? in ?drug ? control ? efforts ? in ?Thailand. ?Exploring ?experiences ?of ?these ?broader ?stakeholders ?of ?drug ?policing ?will ?be ?useful ?for ?identifying ?opportunities ?and ?challenges ?to ?reforming ?the ?drug ?policy. ? ? Third, ? public ? health ? advocates ? may ? benefit ? from ? research ? that ? seeks ? to ?identify ?barriers ?to ?translating ?research ?evidence ?regarding ?the ?negative ?impacts ?of ?the ? drug ? prohibition ? approach ? into ? policy ? and ? programming ? in ? Thailand. ? For ?example, ?while ?many ?studies ?have ?shown ?elevated ?risks ?of ?HIV ?and ?HCV ?infection ?in ? Thai ? prisons ? and ? have ? called ? for ? NSPs ? to ? prevent ? these ? infectious ? diseases ? in ?prisons,53,56-???58 ? such ? services ? remain ?non-???existent. ?Likewise, ?past ? investigations ?have ?identified ? significant ? harms ? and ? human ? rights ? violations ? pertaining ? to ? the ?compulsory ? drug ? detention ? system ? in ? Thailand.27,28,216 ? However, ? the ? system ?continues ? to ? proliferate. ? Experiences ? of ? other ? countries ? that ? have ? initiated ? a ? shift ?from ?prohibitionist ?drug ?policies ?that ?rely ?solely ?on ?repressive ?drug ?policing ?to ?more ?balanced ?approaches ?that ?address ?health ?and ?social ?harms ?of ?illicit ?drug ?use ?serve ?as ?useful ?references.250,251 ?Analyses ?of ?the ?political ?landscape ?in ?Thailand ?based ?on ?these ?experiences ? may ? be ? useful ? for ? effectively ? translating ? the ? findings ? and ?recommendations ? of ? this ? dissertation ? into ? policy ? and ? programming, ? as ? well ? as ?identifying ?needs ?for ?future ?research. ?8.7 ?Conclusion ?Over ?the ?past ?several ?decades, ?there ?has ?been ?a ?significant ?recognition ?among ?diverse ?groups ?of ?scientists, ?public ?health ?and ?human ?rights ?advocates, ?and ?policy ? ? 134 ?makers ?that ?drug ?prohibition ?approaches ?have ?failed ?to ?meet ?the ?objectives ?and ?have ?likely ?produced ?an ?array ?of ?unintended ?negative ?consequences, ? including ?violence ?in ? illegal ?drug ?markets, ? stigma ? and ?discrimination ? against ? people ?who ?use ?drugs, ?and ?epidemics ?of ?infectious ?diseases ?among ?IDU.6,10,252 ?Although ?a ?number ?of ?studies ?from ? many ? countries ? have ? identified ? adverse ? impacts ? of ? aggressive ? policing ?practices ?on ?the ?health ?of ?IDU, ?few ?studies ?have ?been ?undertaken ?in ?Southeast ?Asia, ?where ?punitive ?drug ?laws ?and ?the ?operation ?of ?a ?compulsory ?drug ?detention ?system ?may ?uniquely ?shape ?the ?social ?and ?structural ?environment ?surrounding ?illicit ?drug ?use. ?This ?dissertation ?makes ?a ?significant ?contribution ? in ? this ?area ?by ? investigating ?the ?relationship ?between ?drug ?policing ?and ?the ?health ?of ?IDU ?in ?Bangkok, ?Thailand. ?The ?study ?findings ?strongly ?suggest ?that ?policing ?practices ?have ?involved ?numerous ?human ?rights ?abuses, ?have ?increased ?the ?vulnerability ?of ?IDU ?to ?poor ?health, ?and ?yet ?have ?not ?reduced ?the ?supply ?of ?illicit ?drugs ?in ?Bangkok. ?In ?particular, ?they ?suggest ?that ? police ? use ? excessive ? force ? to ? coerce ? confessions ? from ? IDU ? and ? aggressively ?employ ?urine ?testing ?to ?identify ?drug ?offenders. ?These ?practices ?are ?likely ?fostering ?risky ? injection ? behaviour ? and ? reluctance ? to ? seeking ? healthcare ? among ? IDU. ? An ?analysis ? in ? this ? dissertation ? found ? that ? despite ? these ? aggressive ? drug ? suppression ?efforts, ? street-???level ? availability ?of ? illicit ?drugs ? increased ? significantly ?between ?2009 ?and ?2011, ?indicating ?that ?illegal ?drug ?markets ?continue ?to ?flourish ?in ?this ?setting. ?The ?findings ? raise ? serious ? concerns ? about ? the ?drug ?policing ?practices ? and ?point ? to ? the ?need ? for ? providing ? greater ? police ? oversight ? and ? ensuring ? full ? accountability ? for ?police ?abuses, ?as ?well ?as ?a ?shift ?toward ?more ?balanced ?approaches ?to ?drug ?control ?in ?this ?setting. ? ? ? ?  ? ? 135 ?REFERENCES ?1. ? United ?Nations ?Office ?on ?Drugs ?and ?Crime. ?World ?drug ?report ?2012. ?Vienna: ?United ?Nations ?Office ?on ?Drugs ?and ?Crime; ?2012. ?2. ? Mathers ?BM, ?Degenhardt ?L, ?Phillips ?B, ?et ?al. ?Global ?epidemiology ?of ?injecting ?drug ?use ?and ?HIV ?among ?people ?who ?inject ?drugs: ?a ?systematic ?review. ?Lancet. ?2008;372(9651):1733?1745. ?3. ? Degenhardt ?L, ?Bucello ?C, ?Mathers ?B, ?et ?al. ?Mortality ?among ?regular ?or ?dependent ?users ?of ?heroin ?and ?other ?opioids: ?a ?systematic ?review ?and ?meta-???analysis ?of ?cohort ?studies. ?Addiction. ?2011;106(1):32?51. ?4. ? Nelson ?PK, ?Mathers ?BM, ?Cowie ?B, ?et ?al. ?Global ?epidemiology ?of ?hepatitis ?B ?and ?hepatitis ?C ?in ?people ?who ?inject ?drugs: ?results ?of ?systematic ?reviews. ?Lancet. ?2011;378(9791):571?583. ?5. ? Godfrey ?C, ?Stewart ?D, ?Gossop ?M. ?Economic ?analysis ?of ?costs ?and ?consequences ?of ?the ?treatment ?of ?drug ?misuse: ?2-???year ?outcome ?data ?from ?the ?National ?Treatment ?Outcome ?Research ?Study ?(NTORS). ?Addiction. ?2004;99(6):697?707. ?6. ? Wood ?E, ?Werb ?D, ?Kazatchkine ?M, ?et ?al. ?Vienna ?Declaration: ?a ?call ?for ?evidence-???based ?drug ?policies. ?Lancet. ?2010;376(9738):310?312. ?7. ? Global ?Commission ?on ?HIV ?and ?the ?Law. ?Risks, ?rights ?and ?health. ?http://www.hivlawcommission.org. ?Published ?July ?2012. ?Accessed ?May ?21, ?2013. ?8. ? United ?Nations ?Office ?on ?Drugs ?and ?Crime. ?2008 ?World ?drug ?report. ?Vienna: ?United ?Nations ?Office ?on ?Drugs ?and ?Crime; ?2008. ?9. ? Wolfe ?D. ?Alchemies ?of ?inequality: ?the ?United ?Nations, ?illicit ?drug ?policy ?and ?the ?global ?HIV ?epidemic. ?In: ?Malinowska-???Sempruch ?K, ?Gallagher ?S, ?eds. ?War ? ? 136 ?on ?drugs, ?HIV/AIDS ?and ?human ?rights. ?New ?York: ?International ?Debate ?Education ?Association; ?2004:158?190. ?10. ? Barrett ?D, ?Nowak ?M. ?The ?United ?Nations ?and ?drug ?policy: ?towards ?a ?human ?rights-???based ?approach. ?London: ?International ?Harm ?Reduction ?Association; ?2009. ?11. ? Global ?Commission ?on ?Drug ?Policy. ?Report ?of ?the ?Global ?Commission ?on ?Drug ?Policy. ?http://www.globalcommissionondrugs.org/reports/. ?Published ?June ?2011. ?Accessed ?May ?21, ?2013. ?12. ? Beyrer ?C, ?Malinowska-???Sempruch ?K, ?Kamarulzaman ?A, ?Kazatchkine ?M, ?Sidibe ?M, ?Strathdee ?SA. ?Time ?to ?act: ?a ?call ?for ?comprehensive ?responses ?to ?HIV ?in ?people ?who ?use ?drugs. ?Lancet. ?2010;376(9740):551?563. ?13. ? World ?Health ?Organization, ?United ?Nations ?Office ?on ?Drugs ?and ?Crime, ?Joint ?United ?Nations ?Programme ?on ?HIV ?AIDS. ?WHO, ?UNODC, ?UNAIDS ?technical ?guide ?for ?countries ?to ?set ?targets ?for ?universal ?access ?to ?HIV ?prevention, ?treatment ?and ?care ?for ?injecting ?drug ?users. ?Geneva: ?World ?Health ?Organization; ?2009. ?14. ? Reid ?G, ?Costigan ?G. ?Revisiting ?the ?hidden ?epidemic: ?a ?situation ?assessment ?of ?drug ?use ?in ?Asia ?in ?the ?context ?of ?HIV/AIDS. ?Fairfield: ?The ?Center ?for ?Harm ?Reduction, ?The ?Burnet ?Institute; ?2002. ?15. ? McCoy ?AW, ?Read ?CB, ?Adams ?LP ?II. ?The ?politics ?of ?heroin ?in ?Southeast ?Asia. ?New ?York: ?Harper ?Colophon ?Books; ?1972. ?16. ? Global ?SMART ?Programme. ?Patterns ?and ?trends ?of ?amphetamine-???type ?stimulants ?and ?other ?drugs: ?Asia ?and ?the ?Pacific. ?United ?Nations ?Office ?on ?Drugs ?and ?Crime; ?2012. ?17. ? Assanangkornchai ?S, ?Aramrattana ?A, ?Perngparn ?U, ?Kanato ?M, ?Kanika ?N, ?Na ?Ayudhya ?AS. ?Current ?situation ?of ?substance-???related ?problems ?in ?Thailand. ?Journal ?of ?the ?Psychiatric ?Association ?of ?Thailand. ?2008;53(Suppl ?1):24S?36S. ? ? 137 ?18. ? Aceijas ?C, ?Stimson ?GV, ?Hickman ?M, ?Rhodes ?T. ?Global ?overview ?of ?injecting ?drug ?use ?and ?HIV ?infection ?among ?injecting ?drug ?users. ?AIDS. ?2004;18(17):2295?2303. ?19. ? Canadian ?HIV/AIDS ?Legal ?Network. ?HIV ?and ?HCV ?in ?Thailand: ?implications ?for ?national ?drug ?policy. ?Toronto: ?Canadian ?HIV/AIDS ?Legal ?Network; ?2009. ?20. ? Chatterjee ?A, ?Sharma ?M. ?Moving ?from ?a ?project ?to ?programmatic ?response: ?scaling ?up ?harm ?reduction ?in ?Asia. ?Int ?J ?Drug ?Policy. ?2010;21(2):134?136. ?21. ? Bergenstrom ?A, ?Abdul-???Quader ?A. ?Injection ?drug ?use, ?HIV ?and ?the ?current ?response ?in ?selected ?low-???income ?and ?middle-???income ?countries. ?AIDS. ?2010;24(Suppl ?3):S20?S29. ?22. ? Human ?Rights ?Watch. ?Not ?enough ?graves: ?the ?war ?on ?drugs, ?HIV/AIDS, ?and ?violations ?of ?human ?rights. ?New ?York: ?Human ?Rights ?Watch; ?2004. ?23. ? Single ?Convention ?on ?Narcotic ?Drugs, ?1961, ?as ?amended ?by ?the ?Protocol ?amending ?the ?Single ?Convention ?on ?Narcotic ?Drugs, ?1961. ?United ?Nations ?Treaty ?Collection ?Web ?site. ?http://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=VI-???18&chapter=6&lang=en. ?Accessed ?May ?21, ?2013. ?24. ? Convention ?on ?Psychotropic ?Substances. ?United ?Nations ?Treaty ?Collection ?Web ?site. ?http://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=VI-???16&chapter=6&lang=en. ?Accessed ?May ?21, ?2013. ?25. ? United ?Nations ?Convention ?against ?Illicit ?Traffic ?in ?Narcotic ?Drugs ?and ?Psychotropic ?Substances. ?United ?Nations ?Treaty ?Collection ?Web ?site. ?http://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=VI-???19&chapter=6&lang=en. ?Accessed ?May ?21, ?2013. ? ? 138 ?26. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Narcotic ?laws ?of ?Thailand. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2007. ?27. ? Pearshouse ?R. ?Compulsory ?drug ?treatment ?in ?Thailand: ?observations ?on ?the ?Narcotic ?Addict ?Rehabilitation ?Act ?B.E. ?2545 ?(2002). ?Toronto: ?Canadian ?HIV/AIDS ?Legal ?Network; ?2009. ?28. ? Thomson ?N. ?Detention ?as ?treatment: ?detention ?of ?methamphetamine ?users ?in ?Cambodia, ?Laos, ?and ?Thailand. ?New ?York: ?International ?Harm ?Reduction ?Development ?Program, ?Open ?Society ?Institute; ?2010. ?29. ? International ?Labour ?Organisation, ?Office ?of ?the ?High ?Commissioner ?for ?Human ?Rights, ?United ?Nations ?Development ?Programme, ?et ?al. ?Joint ?statement: ?compulsory ?drug ?detention ?and ?rehabilitation ?centres. ?http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/JC2310_Joint%20Statement6March12FINAL_en.pdf. ?Published ?March ?2012. ?Accessed ?May ?21, ?2013. ?30. ? Asian ?Legal ?Resource ?Centre. ?Special ?report: ?extrajudicial ?killings ?of ?alleged ?drug ?dealers ?in ?Thailand. ?Article ?2. ?2003: ?2(3):10-???16. ? ?31. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2009. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2009. ?32. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2005. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2005. ?33. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2006. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ? ? 139 ?Justice, ?Thailand; ?2006. ?34. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2007. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2007. ?35. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2008. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2008. ?36. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?annual ?report ?2002. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Office ?of ?the ?Prime ?Minister, ?Thailand; ?2002. ?37. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?annual ?report ?2003. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2003. ?38. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?annual ?report ?2004. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2004. ?39. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2010. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2010. ?40. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Thailand ?narcotics ?control ?annual ?report ?2011. ?Bangkok: ?Office ?of ?the ?Narcotics ?Control ?Board, ?Ministry ?of ?Justice, ?Thailand; ?2011. ?41. ? Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand. ?Roadmap ?of ?drug ?surveillance ?and ?establishment ?of ?sustainable ?victory ?over ?drugs ?2006-???2008. ?http://en.oncb.go.th/document/Roadmap06-???08.pdf. ?Published ?March ?2006. ? ? 140 ?Accessed ?May ?21, ?2013. ?42. ? Narcotics ?Control ?Board ?of ?Thailand. ?Narcotics ?Control ?Board?s ?order ?No. ?1 ?/ ?B.E. ?2552 ?(2009) ?on ?national ?narcotics ?control ?mechanisms ?under ?the ?five ?fences ?strategy. ?http://en.oncb.go.th/document/NCB%20ORDER1-???52.pdf. ?Published ?April ?2009. ?Accessed ?May ?21, ?2013. ?43. ? Vejjajiva ?A. ?Prime ?Minister?s ?order ?No. ?249/2552 ?(2009): ?the ?national ?strength ?to ?overcome ?drugs ?under ?five-???defensive ?fences ?strategy ?phase ?II ?(November ?2009 ?? ?September ?2010). ?http://en.oncb.go.th/document/ORDER249-???2552.pdf. ?Published ?November ?2009. ?Accessed ?March ?20, ?2013. ?44. ? National ?narcotics ?control ?policy ?on ?kingdom'?s ?unity ?for ?victory ?over ?drugs ?strategy. ?Office ?of ?the ?Narcotics ?Control ?Board ?of ?Thailand ?Web ?site. ?http://en.oncb.go.th/file/information_policy.html. ?Updated ?2011. ?Accessed ?May ?21, ?2013. ?45. ? Ngamkham ?W. ?Govt ?war ?on ?drugs ?hailed ?a ?success. ?Bangkok ?Post. ?August ?17, ?2012. ?46. ? Consideration ?of ?reports ?submitted ?by ?States ?Parties ?under ?Article ?40 ?of ?the ?Covenant: ?concluding ?observations ?of ?the ?Human ?Rights ?Committee: ?Thailand. ?UN ?Doc. ?No. ?CCPR/CO/84/THA. ?United ?Nations ?Human ?Rights ?Committee; ?July ?8, ?2005. ?http://www.unhcr.org/refworld/docid/43f2ff76a.html. ?Accessed ?May ?21, ?2013. ?47. ? Summary ?prepared ?by ?the ?Office ?of ?the ?High ?Commissioner ?for ?Human ?Rights ?in ?accordance ?with ?paragraph ?15 ?(c) ?of ?the ?annex ?to ?Human ?Rights ?Council ?resolution ?5/1: ?Thailand. ?UN ?Doc. ?No. ?A/HRC/WG.6/12/THA/3. ?United ?Nations ?Human ?Rights ?Council; ?July ?25, ?2011. ?http://www.ohchr.org/EN/HRBodies/UPR/PAGES/THSession12.aspx. ?Accessed ?May ?21, ?2013. ? ? 141 ?48. ? Harm ?Reduction ?International, ?Human ?Rights ?Watch. ?Thailand'?s ??war ?on ?drugs?. ?http://www.hrw.org/news/2008/03/12/thailand-???s-???war-???drugs. ?Published ?March ?2008. ?Accessed ?May ?21, ?2013. ?49. ? Thailand: ?convictions ?of ?police ?in ?drug ?campaign ?abuse ?a ??first ?step? ?[news ?release]. ?New ?York: ?Human ?Rights ?Watch; ?December ?14, ?2009. ?http://www.hrw.org/en/news/2009/12/14/thailand-???convictions-???police-???drug-???campaign-???abuse-???first-???step. ?Accessed ?May ?21, ?2013. ?50. ? Quah ?JST. ?Thailand. ?In: ?Research ?in ?public ?policy ?analysis ?and ?management: ?curbing ?corruption ?in ?Asian ?countries: ?an ?impossible ?dream? ?Bingley: ?Emerald ?Group ?Publishing; ?2011:269?306. ?51. ? Srisanit ?PL. ?Effective ?legal ?and ?practical ?measures ?for ?combating ?corruption. ?Tokyo: ?United ?Nations ?Asia ?and ?Far ?East ?Institute ?for ?the ?Prevention ?of ?Crime ?and ?the ?Treatment ?of ?Offenders ?(UNAFEI); ?2011:167?171. ?Resource ?Material ?Series ?No. ?83. ?52. ? Quan ?VM, ?Aramrattana ?A, ?Vongchak ?T, ?et ?al. ?Mortality ?among ?injection ?drug ?users ?in ?northern ?Thailand: ?a ?prospective ?cohort ?study. ?J ?Addict ?Med. ?2010;4(4):217?222. ?53. ? Beyrer ?C, ?Jittiwutikarn ?J, ?Teokul ?W, ?et ?al. ?Drug ?use, ?increasing ?incarceration ?rates, ?and ?prison-???associated ?HIV ?risks ?in ?Thailand. ?AIDS ?Behav. ?2003;7(2):153?161. ?54. ? Number ?of ?convicted ?prisoners ?by ?type ?of ?offences ?[in ?Thai]. ?Department ?of ?Corrections ?of ?Thailand ?Web ?site. ?http://www.correct.go.th/correct2009/upload/files/information/rt103_05_2012.pdf. ?Published ?May ?31, ?2012. ?Accessed ?May ?21, ?2013. ?55. ? Milloy ?MJ, ?Fairbairn ?N, ?Hayashi ?K, ?et ?al. ?Overdose ?experiences ?among ? ? 142 ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?Harm ?Reduct ?J. ?2010;7:9. ? ?56. ? Buavirat ?A, ?Page-???Shafer ?K, ?van ?Griensven ?GJP, ?et ?al. ?Risk ?of ?prevalent ?HIV ?infection ?associated ?with ?incarceration ?among ?injecting ?drug ?users ?in ?Bangkok, ?Thailand: ?case-???control ?study. ?BMJ. ?2003;326(7384):308. ? ?57. ? Choopanya ?K, ?Jarlais ?Des ?DC, ?Vanichseni ?S, ?et ?al. ?Incarceration ?and ?risk ?for ?HIV ?infection ?among ?injection ?drug ?users ?in ?Bangkok. ?J ?Acquir ?Immune ?Defic ?Syndr. ?2002;29(1):86?94. ?58. ? Thomson ?N, ?Sutcliffe ?CG, ?Sirirojn ?B, ?et ?al. ?Penile ?modification ?in ?young ?Thai ?men: ?risk ?environments, ?procedures ?and ?widespread ?implications ?for ?HIV ?and ?sexually ?transmitted ?infections. ?Sex ?Transm ?Infect. ?2008;84(3):195?197. ? ?59. ? J?rgens ?R, ?Betteridge ?G. ?Prisoners ?who ?inject ?drugs: ?public ?health ?and ?human ?rights ?imperatives. ?Health ?Hum ?Rights. ?2005;8(2):46?74. ?60. ? Punpanich ?W, ?Ungchusak ?K, ?Detels ?R. ?Thailand'?s ?response ?to ?the ?HIV ?epidemic: ?yesterday, ?today, ?and ?tomorrow. ?AIDS ?Educ ?Prev. ?2004;16(Suppl ?A):119?136. ?61. ? National ?AIDS ?Prevention ?and ?Alleviation ?Committee. ?UNGASS ?country ?progress ?report ?Thailand: ?reporting ?period: ?January ?2008 ?-??? ?December ?2009. ?http://data.unaids.org/pub/Report/2010/thailand_2010_country_progress_report_en.pdf. ?Published ?2010. ?Accessed ?May ?21, ?2013. ?62. ? Walsh ?N, ?Verster ?A, ?Doupe ?A, ?Vitoria ?M, ?Lo ?Y-???R, ?Wiersma ?S. ?3.1. ?The ?silent ?epidemic: ?responding ?to ?viral ?hepatitis ?among ?people ?who ?inject ?drugs. ?In: ?Cook ?C, ?ed. ?Global ?State ?of ?Harm ?Reduction ?2010: ?Key ?issues ?for ?broadening ?the ?response. ?London: ?International ?Harm ?Reduction ?Association; ?2010. ?63. ? Promotion ?of ?clean ?syringes ?and ?paraphernalia ?for ?HIV ?prevention ?found ?breaching ?the ?law ?[in ?Thai]. ?Matichon ?Online. ?August ?16, ?2011. ? ? 143 ?http://www.matichon.co.th/news_detail.php?newsid=1313497910&grpid=03&catid=&subcatid. ?Accessed ?May ?21, ?2013. ?64. ? Thailand ?AIDS ?response ?progress ?report ?2012: ?reporting ?period: ?2010-???2011. ?Joint ?United ?Nations ?Programme ?on ?HIV/AIDS ?Web ?site. ?http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_TH_Narrative_Report[1].pdf. ?Published ?March ?31, ?2012. ?Accessed ?May ?21, ?2012. ?65. ? Mathers ?BM, ?Degenhardt ?L, ?Ali ?H, ?et ?al. ?HIV ?prevention, ?treatment, ?and ?care ?services ?for ?people ?who ?inject ?drugs: ?a ?systematic ?review ?of ?global, ?regional, ?and ?national ?coverage. ?Lancet. ?2010;375(9719):1014?1028. ?66. ? Ungphakorn ?J, ?Kazatchkine ?M. ?Are ?our ?drug ?policies ?really ?working? ?Bangkok ?Post. ?September ?18, ?2012. ?67. ? Human ?rights ?NGOs ?to ?Thai ?government: ?do ?not ?repeat ?history! ?The ?Nation. ?February ?22, ?2011. ?68. ? Chomchai ?C, ?Manaboriboon ?B. ?Stimulant ?methamphetamine ?and ?dextromethorphan ?use ?among ?Thai ?adolescents: ?implications ?for ?health ?of ?women ?and ?children. ?J ?Med ?Toxicol. ?2012. ?69. ? Sarang ?A, ?Rhodes ?T, ?Sheon ?N, ?Page ?K. ?Policing ?drug ?users ?in ?Russia: ?risk, ?fear, ?and ?structural ?violence. ?Subst ?Use ?Misuse. ?2010;45(6):813?864. ?70. ? Cooper ?H, ?Moore ?L, ?Gruskin ?S, ?Krieger ?N. ?Characterizing ?perceived ?police ?violence: ?implications ?for ?public ?health. ?Am ?J ?Public ?Health. ?2004;94(7):1109?1118. ?71. ? Davis ?SL, ?Triwahyuono ?A, ?Alexander ?R. ?Survey ?of ?abuses ?against ?injecting ?drug ?users ?in ?Indonesia. ?Harm ?Reduct ?J. ?2009;6:28. ? ? ? 144 ?72. ? Aitken ?C, ?Moore ?D, ?Higgs ?P, ?Kelsall ?J, ?Kerger ?M. ?The ?impact ?of ?a ?police ?crackdown ?on ?a ?street ?drug ?scene: ?evidence ?from ?the ?street. ?Int ?J ?Drug ?Policy. ?2002;13(3):193?202. ?73. ? Small ?W, ?Kerr ?T, ?Charette ?J, ?Schechter ?MT, ?Spittal ?PM. ?Impacts ?of ?intensified ?police ?activity ?on ?injection ?drug ?users: ?evidence ?from ?an ?ethnographic ?investigation. ?Int ?J ?Drug ?Policy. ?2006;17(2):85?95. ?74. ? Maher ?L, ?Dixon ?D. ?The ?cost ?of ?crackdowns: ?policing ?Cabramatta'?s ?herion ?market. ?Current ?Issues ?Crim. ?Just. ?2001;13(1):5?22. ?75. ? Wood ?E, ?Spittal ?PM, ?Small ?W, ?et ?al. ?Displacement ?of ?Canada'?s ?largest ?public ?illicit ?drug ?market ?in ?response ?to ?a ?police ?crackdown. ?CMAJ. ?2004;170(10):1551?1556. ?76. ? Pollini ?RA, ?Brouwer ?KC, ?Lozada ?RM, ?et ?al. ?Syringe ?possession ?arrests ?are ?associated ?with ?receptive ?syringe ?sharing ?in ?two ?Mexico-???US ?border ?cities. ?Addiction. ?2008;103(1):101?108. ?77. ? Werb ?D, ?Wood ?E, ?Small ?W, ?et ?al. ?Effects ?of ?police ?confiscation ?of ?illicit ?drugs ?and ?syringes ?among ?injection ?drug ?users ?in ?Vancouver. ?Int ?J ?Drug ?Policy. ?2008;19(4):332?338. ?78. ? Fairbairn ?N, ?Kaplan ?K, ?Hayashi ?K, ?et ?al. ?Reports ?of ?evidence ?planting ?by ?police ?among ?a ?community-???based ?sample ?of ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?BMC ?Int ?Health ?Hum ?Rights. ?2009;9:24. ? ?79. ? Rhodes ?T. ?The ??risk ?environment?: ?a ?framework ?for ?understanding ?and ?reducing ?drug-???related ?harm. ?Int ?J ?Drug ?Policy. ?2002;13(2):85?94. ?80. ? Rhodes ?T. ?Risk ?environments ?and ?drug ?harms: ?a ?social ?science ?for ?harm ?reduction ?approach. ?Int ?J ?Drug ?Policy. ?2009;20(3):193?201. ? ? 145 ?81. ? Strathdee ?SA, ?Hallett ?TB, ?Bobrova ?N, ?et ?al. ?HIV ?and ?risk ?environment ?for ?injecting ?drug ?users: ?the ?past, ?present, ?and ?future. ?Lancet. ?2010;376(9737):268?284. ?82. ? Kerr ?T, ?Small ?W, ?Wood ?E. ?The ?public ?health ?and ?social ?impacts ?of ?drug ?market ?enforcement: ?a ?review ?of ?the ?evidence. ?Int ?J ?Drug ?Policy. ?2005;16(4):210?220. ?83. ? Burris ?S, ?Blankenship ?KM, ?Donoghoe ?M, ?et ?al. ?Addressing ?the ??risk ?environment? ?for ?injection ?drug ?users: ?the ?mysterious ?case ?of ?the ?missing ?cop. ?Milbank ?Q. ?2004;82(1):125?156. ?84. ? Percy ?SL. ?Disability, ?civil ?rights, ?and ?public ?policy: ?the ?politics ?of ?implementation. ?Tuscaloosa: ?University ?of ?Alabama ?Press; ?1989. ?85. ? Cooper ?H, ?Moore ?L, ?Gruskin ?S, ?Krieger ?N. ?The ?impact ?of ?a ?police ?drug ?crackdown ?on ?drug ?injectors'? ?ability ?to ?practice ?harm ?reduction: ?a ?qualitative ?study. ?Soc ?Sci ?Med. ?2005;61(3):673?684. ?86. ? Bluthenthal ?RN, ?Kral ?AH, ?Lorvick ?J, ?Watters ?JK. ?Impact ?of ?law ?enforcement ?on ?syringe ?exchange ?programs: ?a ?look ?at ?Oakland ?and ?San ?Francisco. ?Med ?Anthropol. ?1997;18(1):61?83. ?87. ? Csete ?J, ?Cohen ?J. ?Abusing ?the ?user: ?police ?misconduct, ?harm ?reduction ?and ?HIV/AIDS ?in ?Vancouver. ?New ?York: ?Human ?Rights ?Watch; ?2003. ?88. ? Mann ?JM. ?Medicine ?and ?public ?health, ?ethics ?and ?human ?rights. ?Hastings ?Cent ?Rep. ?1997;27(3):6?13. ?89. ? Cohen ?J, ?Amon ?JJ. ?Governance, ?human ?rights, ?and ?infectious ?disease: ?theoretical, ?empirical ?and ?practical ?perspectives. ?In: ?Mayer ?KH, ?Pizer ?HF, ?eds. ?The ?social ?ecology ?of ?infectious ?diseases. ?Oxford: ?Academic ?Press; ?2008:408?425. ?90. ? Asher ?J. ?The ?right ?to ?health: ?a ?resource ?manual ?for ?NGOs. ?Washington, ?DC: ? ? 146 ?American ?Academy ?for ?the ?Advancement ?of ?Science; ?2004. ?91. ? United ?Nations ?Office ?on ?Drugs ?and ?Crime. ?Drug ?control, ?crime ?prevention ?and ?criminal ?justice: ?a ?human ?rights ?perspective: ?note ?by ?the ?Executive ?Director. ?UN ?Doc. ?No. ?E/CN.7/2010/CRP.6?E/CN.15/2010/CRP.1. ?http://www.unodc.org/documents/commissions/CND-???Uploads/CND-???53-???RelatedFiles/ECN72010_CRP6eV1051605.pdf. ?Published ?March ?3, ?2010. ?Accessed ?May ?21, ?2013. ?92. ? Israel ?BA, ?Schulz ?AJ, ?Parker ?EA, ?Becker ?AB. ?Review ?of ?community-???based ?research: ?Assessing ?partnership ?approaches ?to ?improve ?public ?health. ?Annu ?Rev ?Public ?Health. ?1998;19(1):173?202. ? ?93. ? Wallerstein ?N, ?Duran ?B. ?The ?conceptual, ?historical, ?and ?practice ?roots ?of ?community ?based ?participatory ?research ?and ?related ?participatory ?traditions. ?In: ?Minkler ?M, ?Wallerstein ?N, ?eds. ?Community-???based ?participatory ?research ?for ?health. ?San ?Fransisco, ?CA: ?Jossey-???Bass; ?2003:27?52. ?94. ? Hayashi ?K, ?Fairbairn ?N, ?Suwannawong ?P, ?Kaplan ?K, ?Wood ?E, ?Kerr ?T. ?Collective ?empowerment ?while ?creating ?knowledge: ?a ?description ?of ?a ?community-???based ?participatory ?research ?project ?with ?drug ?users ?in ?Bangkok, ?Thailand. ?Subst ?Use ?Misuse. ?2012;47(5):502?510. ?95. ? Creswell ?JW, ?Plano ?Clark ?VL. ?Choosing ?a ?mixed ?methods ?design. ?In: ?Designing ?and ?conducting ?mixed ?methods ?research. ?1st ?ed. ?Thousand ?Oaks, ?CA: ?Sage ?Publications, ?Inc.; ?2006:58?88. ?96. ? Sherman ?SG, ?Gann ?D, ?German ?D, ?et ?al. ?A ?qualitative ?study ?of ?sexual ?behaviours ?among ?methamphetamine ?users ?in ?Chiang ?Mai, ?Thailand: ?a ?typology ?of ?risk. ?Drug ?Alcohol ?Rev. ?2008;27(3):263?269. ?97. ? Levine ?HG. ?Global ?drug ?prohibition: ?its ?uses ?and ?crises. ?Int ?J ?Drug ?Policy. ? ? 147 ?2003;14(2):145?153. ?98. ? J?rgens ?R, ?Csete ?J, ?Amon ?JJ, ?Baral ?S, ?Beyrer ?C. ?People ?who ?use ?drugs, ?HIV, ?and ?human ?rights. ?Lancet. ?2010;376(9739):475?485. ?99. ? Csete ?J. ?Do ?not ?cross: ?policing ?and ?HIV ?risk ?faced ?by ?people ?who ?use ?drugs. ?Toronto: ?Canadian ?HIV/AIDS ?Legal ?Network; ?2007. ?100. ? Chiu ?J, ?Burris ?S. ?Punitive ?drug ?law ?and ?the ?risk ?environment ?for ?injecting ?drug ?users: ?understanding ?the ?connections. ?http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2102841. ?Published ?July ?9, ?2012. ?Accessed ?May ?21, ?2013. ?101. ? Rosmarin ?A, ?Eastwood ?N. ?A ?quiet ?revolution: ?drug ?decriminalisation ?policies ?in ?practice ?across ?the ?globe. ?London: ?Release; ?2012. ?102. ? Shields ?A. ?The ?effects ?of ?drug ?user ?registration ?laws ?on ?people?s ?rights ?and ?health: ?key ?findings ?from ?Russia, ?Georgia, ?and ?Ukraine. ?New ?York: ?Public ?Health ?Program, ?Open ?Society ?Institute; ?2009. ?103. ? Cohen ?JE, ?Amon ?JJ. ?Health ?and ?human ?rights ?concerns ?of ?drug ?users ?in ?detention ?in ?Guangxi ?Province, ?China. ?PLoS ?Med. ?2008;5(12):e234. ?104. ? Beletsky ?L, ?Thomas ?R, ?Smelyanskaya ?M, ?et ?al. ?Policy ?reform ?to ?shift ?the ?health ?and ?human ?rights ?environment ?for ?vulnerable ?groups: ?the ?case ?of ?Kyrgyzstan'?s ?Instruction ?417. ?Health ?Hum ?Rights. ?2012;14(2):1?15. ?105. ? DeBeck ?K, ?Wood ?E, ?Zhang ?R, ?Tyndall ?M, ?Montaner ?J, ?Kerr ?T. ?Police ?and ?public ?health ?partnerships: ?evidence ?from ?the ?evaluation ?of ?Vancouver'?s ?supervised ?injection ?facility. ?Subst ?Abuse ?Treat ?Prev ?Policy. ?2008;3:11. ? ?106. ? Bewley-???Taylor ?D, ?Trace ?M, ?Stevens ?A. ?Incarceration ?of ?drug ?offenders: ?costs ?and ?impacts. ?Surrey: ?Beckley ?Foundation ?Drug ?Policy ?Programme; ?2005. ? ? 148 ?107. ? May ?T, ?Hough ?M. ?Illegal ?dealings: ?the ?impact ?of ?low-???level ?police ?enforcement ?on ?drug ?markets. ?European ?Journal ?on ?Criminal ?Policy ?and ?Research. ?2001;9(2):137?162. ?108. ? Maher ?L, ?Dixon ?D. ?Policing ?and ?public ?health: ?law ?enforcement ?and ?harm ?minimization ?in ?a ?street-???level ?drug ?market. ?Br ?I ?Criminol. ?1999;39(4):488?512. ?109. ? Weisburd ?D, ?Eck ?JE. ?What ?can ?police ?do ?to ?reduce ?crime, ?disorder, ?and ?fear? ?Ann ?Am ?Acad ?Pol ?Soc ?Sci. ?2004;593(1):42?65. ?110. ? Mazerolle ?L, ?Soole ?DW, ?Rombouts ?S. ?Street-???level ?drug ?law ?enforcement: ?a ?meta-???analytical ?review. ?J ?Exp ?Criminol. ?2006;2(4):409?435. ?111. ? Dixon ?D, ?Maher ?L. ?Anh ?Hai: ?policing, ?culture ?and ?social ?exclusion ?in ?a ?street ?heroin ?market. ?Polic ?Soc. ?2002;12(2):93?110. ?112. ? Human ?Rights ?Watch. ?Rhetoric ?and ?risk: ?human ?rights ?abuses ?impeding ?Ukraine'?s ?fight ?against ?HIV/AIDS. ?New ?York: ?Human ?Rights ?Watch; ?2006. ?113. ? Dunn ?M, ?Degenhardt ?L. ?The ?use ?of ?drug ?detection ?dogs ?in ?Sydney, ?Australia. ?Drug ?Alcohol ?Rev. ?2009;28(6):658?662. ? ?114. ? Otiashvili ?D, ?S?rosi ?P, ?Somogy ?GL. ?Drug ?control ?in ?Georgia: ?drug ?testing ?and ?the ?reduction ?of ?drug ?use? ?Oxford: ?Drug ?Policy ?Programme, ?Beckley ?Foundation; ?2008. ?Briefing ?Paper ?15. ?115. ? Human ?Rights ?Watch. ?Fanning ?the ?flames: ?how ?human ?rights ?abuses ?are ?fueling ?the ?AIDS ?epidemic ?in ?Kazakhstan. ?New ?York: ?Human ?Rights ?Watch; ?2003. ?116. ? Human ?Rights ?Watch. ?Skin ?on ?the ?cable: ?the ?illegal ?arrest, ?arbitrary ?detention ?and ?torture ?of ?people ?who ?use ?drugs ?in ?Cambodia. ?New ?York: ?Human ?Rights ?Watch; ?2010. ?117. ? Human ?Rights ?Watch. ?Lessons ?not ?learned: ?human ?rights ?abuses ?and ?HIV/AIDS ?in ? ? 149 ?the ?Russian ?Federation. ?New ?York: ?Human ?Rights ?Watch; ?2004. ?118. ? Miller ?CL, ?Firestone ?M, ?Ramos ?R, ?et ?al. ?Injecting ?drug ?users'? ?experiences ?of ?policing ?practices ?in ?two ?Mexican-???U.S. ?border ?cities: ?public ?health ?perspectives. ?Int ?J ?Drug ?Policy. ?2008;19(4):324?331. ?119. ? Cohen ?J. ?Law ?enforcement ?and ?drug ?treatment: ?a ?culture ?clash. ?Science. ?2010;329(5988):169. ?120. ? Mimiaga ?MJ, ?Safren ?SA, ?Dvoryak ?S, ?Reisner ?SL, ?Needle ?R, ?Woody ?G. ??We ?fear ?the ?police, ?and ?the ?police ?fear ?us?: ?structural ?and ?individual ?barriers ?and ?facilitators ?to ?HIV ?medication ?adherence ?among ?injection ?drug ?users ?in ?Kiev, ?Ukraine. ?AIDS ?Care. ?2010:1?9. ?121. ? Csete ?J, ?Cohen ?J. ?Lethal ?violations: ?human ?rights ?abuses ?faced ?by ?injection ?drug ?users ?in ?the ?era ?of ?HIV/AIDS. ?In: ?Malinowska-???Sempruch ?K, ?Gallagher ?S, ?eds. ?War ?on ?drugs, ?HIV/AIDS ?and ?human ?rights. ?New ?York: ?International ?Debate ?Education ?Association; ?2004:212?227. ?122. ? Booth ?RE, ?Dvoryak ?S, ?Anderson ?C, ?Brewster ?JT, ?Strathdee ?SA. ?Police ?brutality ?is ?independently ?associated ?with ?sharing ?injection ?equipment ?among ?injection ?drug ?users ?in ?Odessa, ?Ukraine. ?Abstract ?presented ?at: ?The ?18th ?International ?AIDS ?Conference; ?July ?18-???23, ?2010: ?Vienna, ?Austria. ?http://www.iasociety.org/Abstracts/A200737978.aspx. ?Accessed ?May ?21, ?2013. ?123. ? Beletsky ?L, ?Lozada ?R, ?Gaines ?T, ?et ?al. ?Syringe ?confiscation ?as ?an ?HIV ?risk ?factor: ?the ?public ?health ?implications ?of ?arbitrary ?policing ?in ?Tijuana ?and ?Ciudad ?Juarez, ?Mexico. ?J ?Urban ?Health. ?2013;90(2):284?298. ? ?124. ? Sarin ?E, ?Samson ?L, ?Sweat ?M, ?Beyrer ?C. ?Human ?rights ?abuses ?and ?suicidal ?ideation ?among ?male ?injecting ?drug ?users ?in ?Delhi, ?India. ?Int ?J ?Drug ?Policy. ?2011;22(2):161?166. ? ? 150 ?125. ? Strathdee ?SA, ?Lozada ?R, ?Pollini ?RA, ?et ?al. ?Individual, ?social, ?and ?environmental ?influences ?associated ?with ?HIV ?infection ?among ?injection ?drug ?users ?in ?Tijuana, ?Mexico. ?J ?Acquir ?Immune ?Defic ?Syndr. ?2008;47(3):369?376. ? ?126. ? Bluthenthal ?RN, ?Lorvick ?J, ?Kral ?AH, ?Erringer ?EA, ?Kahn ?JG. ?Collateral ?damage ?in ?the ?war ?on ?drugs: ?HIV ?risk ?behaviors ?among ?injection ?drug ?users. ?Int ?J ?Drug ?Policy. ?1999;10(1):25?38. ?127. ? Rhodes ?T, ?Judd ?A, ?Mikhailova ?L, ?et ?al. ?Injecting ?equipment ?sharing ?among ?injecting ?drug ?users ?in ?Togliatti ?City, ?Russian ?Federation: ?maximizing ?the ?protective ?effects ?of ?syringe ?distribution. ?J ?Acquir ?Immune ?Defic ?Syndr. ?2004;35(3):293?300. ?128. ? Koester ?SK. ?Copping, ?running, ?and ?paraphernalia ?laws: ?contextual ?variables ?and ?needle ?risk ?behavior ?among ?injection ?drug ?users ?in ?Denver. ?Hum ?Organ. ?1994;53(3):287?295. ?129. ? Rhodes ?T, ?Mikhailova ?L, ?Sarang ?A, ?et ?al. ?Situational ?factors ?influencing ?drug ?injecting, ?risk ?reduction ?and ?syringe ?exchange ?in ?Togliatti ?City, ?Russian ?Federation: ?a ?qualitative ?study ?of ?micro ?risk ?environment. ?Soc ?Sci ?Med. ?2003;57(1):39?54. ?130. ? Blankenship ?KM, ?Koester ?S. ?Criminal ?law, ?policing ?policy, ?and ?HIV ?risk ?in ?female ?street ?sex ?workers ?and ?injection ?drug ?users. ?J ?Law ?Med ?Ethics. ?2002;30(4):548?559. ?131. ? Broadhead ?RS, ?Kerr ?TH, ?Grund ?J. ?Safer ?injection ?facilities ?in ?North ?America: ?their ?place ?in ?public ?policy ?and ?health ?initiatives. ?J ?Drug ?Issues. ?2002;32(1):329-???355. ?132. ? Murphy ?EL, ?DeVita ?D, ?Liu ?H, ?et ?al. ?Risk ?factors ?for ?skin ?and ?soft-???tissue ?abscesses ?among ?injection ?drug ?users: ?a ?case-???control ?study. ?Clin ?Infect ?Dis. ? ? 151 ?2001;33(1):35?40. ?133. ? Rhodes ?T, ?Singer ?M, ?Bourgois ?P, ?Friedman ?SR, ?Strathdee ?SA. ?The ?social ?structural ?production ?of ?HIV ?risk ?among ?injecting ?drug ?users. ?Soc ?Sci ?Med. ?2005;61(5):1026?1044. ?134. ? Celentano ?DD, ?Vlahov ?D, ?Cohn ?S, ?Anthony ?JC, ?Solomon ?L, ?Nelson ?KE. ?Risk ?factors ?for ?shooting ?gallery ?use ?and ?cessation ?among ?intravenous ?drug ?users. ?Am ?J ?Public ?Health. ?1991;81(10):1291?1295. ?135. ? Jarlais ?Des ?DC, ?Friedman ?SR. ?Shooting ?galleries ?and ?AIDS: ?infection ?probabilities ?and ??tough? ?policies. ?Am ?J ?Public ?Health. ?1990;80(2):142?144. ?136. ? Shannon ?K, ?Rusch ?M, ?Shoveller ?J, ?Alexson ?D, ?Gibson ?K, ?Tyndall ?MW. ?Mapping ?violence ?and ?policing ?as ?an ?environmental-???structural ?barrier ?to ?health ?service ?and ?syringe ?availability ?among ?substance-???using ?women ?in ?street-???level ?sex ?work. ?Int ?J ?Drug ?Policy. ?2008;19(2):140?147. ?137. ? McGregor ?C, ?Darke ?S, ?Ali ?R, ?Christie ?P. ?Experience ?of ?non-???fatal ?overdose ?among ?heroin ?users ?in ?Adelaide, ?Australia: ?circumstances ?and ?risk ?perceptions. ?Addiction. ?1998;93(5):701. ?138. ? Green ?TC, ?Grau ?LE, ?Blinnikova ?KN, ?et ?al. ?Social ?and ?structural ?aspects ?of ?the ?overdose ?risk ?environment ?in ?St. ?Petersburg, ?Russia. ?Int ?J ?Drug ?Policy. ?2009;20(3):270?276. ?139. ? Davis ?CS, ?Burris ?S, ?Kraut-???Becher ?J, ?Lynch ?KG, ?Metzger ?D. ?Effects ?of ?an ?intensive ?street-???level ?police ?intervention ?on ?syringe ?exchange ?program ?use ?in ?Philadelphia, ?PA. ?Am ?J ?Public ?Health. ?2005;95(2):233?236. ? ?140. ? Wood ?E, ?Kerr ?T, ?Small ?W, ?Jones ?J, ?Schechter ?MT, ?Tyndall ?MW. ?The ?impact ?of ?a ?police ?presence ?on ?access ?to ?needle ?exchange ?programs. ?J ?Acquir ?Immune ?Defic ?Syndr. ?2003;34(1):116?118. ? ? 152 ?141. ? Werb ?D, ?Rowell ?G, ?Guyatt ?G, ?Kerr ?T, ?Montaner ?J, ?Wood ?E. ?Effect ?of ?drug ?law ?enforcement ?on ?drug ?market ?violence: ?a ?systematic ?review. ?Int ?J ?Drug ?Policy. ?2011;22(2):87?94. ?142. ? Vongchak ?T, ?Kawichai ?S, ?Sherman ?S, ?et ?al. ?The ?influence ?of ?Thailand'?s ?2003 ??war ?on ?drugs? ?policy ?on ?self-???reported ?drug ?use ?among ?injection ?drug ?users ?in ?Chiang ?Mai, ?Thailand. ?Int ?J ?Drug ?Policy. ?2005;16(2):115?121. ?143. ? Maher ?L, ?Li ?J, ?Jalaludin ?B, ?et ?al. ?Impact ?of ?a ?reduction ?in ?heroin ?availability ?on ?patterns ?of ?drug ?use, ?risk ?behaviour ?and ?incidence ?of ?hepatitis ?C ?virus ?infection ?in ?injecting ?drug ?users ?in ?New ?South ?Wales, ?Australia. ?Drug ?Alcohol ?Depend. ?2007;89(2-???3):244?250. ? ?144. ? Day ?C, ?Degenhardt ?L, ?Hall ?W. ?Documenting ?the ?heroin ?shortage ?in ?New ?South ?Wales. ?Drug ?Alcohol ?Rev. ?2006;25(4):297?305. ?145. ? Friedman ?SR, ?Kottiri ?BJ, ?Neaigus ?A, ?Curtis ?R, ?Vermund ?SH, ?Jarlais ?Des ?DC. ?Network-???related ?mechanisms ?may ?help ?explain ?long-???term ?HIV-???1 ?seroprevalence ?levels ?that ?remain ?high ?but ?do ?not ?approach ?population-???group ?saturation. ?Am ?J ?Epidemiol. ?2000;152(10):913?922. ?146. ? Drucker ?E. ?Drug ?prohibition ?and ?public ?health: ?25 ?years ?of ?evidence. ?Public ?Health ?Rep. ?1999;114(1):14?29. ?147. ? Csete ?J. ?Consequences ?of ?injustice: ?pre-???trial ?detention ?and ?health. ?Int ?J ?Prison ?Health. ?2010;6(1):47?58. ?148. ? J?rgens ?R, ?Ball ?A, ?Verster ?A. ?Interventions ?to ?reduce ?HIV ?transmission ?related ?to ?injecting ?drug ?use ?in ?prison. ?Lancet ?Infect ?Dis. ?2009;9(1):57?66. ?149. ? Iguchi ?MY, ?London ?JA, ?Forge ?NG, ?Hickman ?L, ?Fain ?T, ?Riehman ?K. ?Elements ?of ?well-???being ?affected ?by ?criminalizing ?the ?drug ?user. ?Public ?Health ?Rep. ?2002;117(Suppl ?1):S146?50. ? ? 153 ?150. ? Davies ?S, ?Tanner ?J. ?The ?long ?arm ?of ?the ?law: ?effects ?of ?labeling ?on ?employment. ?Sociol ?Q. ?2003;44(3):385?404. ?151. ? World ?Health ?Organization ?Western ?Pacific ?Regional ?Office. ?Assessment ?of ?compulsory ?treatment ?of ?people ?who ?use ?drugs ?in ?Cambodia, ?China, ?Malaysia ?and ?Viet ?Nam: ?an ?application ?of ?selected ?human ?rights ?principles. ?World ?Health ?Organization; ?2009. ?152. ? Wolfe ?D, ?Saucier ?R. ?In ?rehabilitation'?s ?name? ?Ending ?institutionalised ?cruelty ?and ?degrading ?treatment ?of ?people ?who ?use ?drugs. ?Int ?J ?Drug ?Policy. ?2010;21(3):145?148. ?153. ? Human ?Rights ?Watch. ?The ?rehab ?archipelago: ?forced ?labor ?and ?other ?abuses ?in ?drug ?detention ?centers ?in ?Southern ?Vietnam. ?New ?York: ?Human ?Rights ?Watch; ?2011. ?154. ? M?ndez ?JE. ?Report ?of ?the ?Special ?Rapporteur ?on ?torture ?and ?other ?cruel, ?inhuman ?or ?degrading ?treatment ?or ?punishment. ?UN ?Doc. ?No. ?A/HRC/22/53. ?United ?Nations ?Human ?Rights ?Council; ?March ?22, ?2013. ?http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf. ?Accessed ?May ?21, ?2013. ?155. ? Human ?Rights ?Watch. ?Rehabilitation ?required: ?Russia'?s ?human ?rights ?obligation ?to ?provide ?evidence-???based ?drug ?dependence ?treatment. ?New ?York: ?Human ?Rights ?Watch; ?2007. ?156. ? Bobrova ?N, ?Rhodes ?T, ?Power ?R, ?et ?al. ?Barriers ?to ?accessing ?drug ?treatment ?in ?Russia: ?a ?qualitative ?study ?among ?injecting ?drug ?users ?in ?two ?cities. ?Drug ?Alcohol ?Depend. ?2006;82(Suppl ?1):S57?63. ?157. ? Human ?Rights ?Watch, ?Thai ?AIDS ?Treatment ?Action ?Group. ?Deadly ?denial: ?barriers ?to ?HIV/AIDS ?treatment ?for ?people ?who ?use ?drugs ?in ?Thailand. ?New ?York: ?Human ?Rights ?Watch; ?2007. ? ? 154 ?158. ? Link ?BG, ?Phelan ?JC. ?Conceptualizing ?stigma. ?Annu ?Rev ?Sociol. ?2001;27(1):363?385. ?159. ? Link ?BG, ?Phelan ?JC. ?Stigma ?and ?its ?public ?health ?implications. ?Lancet. ?2006;367(9509):528?529. ? ?160. ? Ahern ?J, ?Stuber ?J, ?Galea ?S. ?Stigma, ?discrimination ?and ?the ?health ?of ?illicit ?drug ?users. ?Drug ?Alcohol ?Depend. ?2007;88(2-???3):188?196. ? ?161. ? Gallahue ?P, ?Lines ?R. ?The ?death ?penalty ?for ?drug ?offences: ?global ?overview ?2010. ?London: ?International ?Harm ?Reduction ?Association; ?2010. ?162. ? Lines ?R. ?The ?death ?penalty ?for ?drug ?offences: ?a ?violation ?of ?international ?human ?rights ?law. ?London: ?International ?Harm ?Reduction ?Association; ?2007. ?163. ? Friedman ?SR, ?Perlis ?T, ?Jarlais ?Des ?DC. ?Laws ?prohibiting ?over-???the-???counter ?syringe ?sales ?to ?injection ?drug ?users: ?relations ?to ?population ?density, ?HIV ?prevalence, ?and ?HIV ?incidence. ?Am ?J ?Public ?Health. ?2001;91(5):791?793. ?164. ? Sharma ?M, ?Oppenheimer ?E, ?Saidel ?T, ?Loo ?V, ?Garg ?R. ?A ?situation ?update ?on ?HIV ?epidemics ?among ?people ?who ?inject ?drugs ?and ?national ?responses ?in ?South-???East ?Asia ?Region. ?AIDS. ?2009;23(11):1405?1413. ?165. ? Csete ?J, ?Cohen ?J. ?Health ?benefits ?of ?legal ?services ?for ?criminalized ?populations: ?the ?case ?of ?people ?who ?use ?drugs, ?sex ?workers ?and ?sexual ?and ?gender ?minorities. ?J ?Law ?Med ?Ethics. ?2010;38(4):816?831. ?166. ?Monaghan ?G. ?Harm ?reduction ?and ?the ?role ?of ?police ?services ?in ?harm ?reduction. ?In: ?Pates ?R, ?Riley ?D, ?eds. ?Harm ?reduction ?in ?substance ?use ?and ?high-???risk ?behaviour: ?international ?policy ?and ?practice. ?West ?Sussex, ?England: ?Blackwell ?Publishing ?Ltd.; ?2012:59?76. ?167. ? Hunter ?G, ?Mcsweeney ?T, ?Turnbull ?PJ. ?The ?introduction ?of ?drug ?Arrest ?Referral ? ? 155 ?schemes ?in ?London: ?a ?partnership ?between ?drug ?services ?and ?the ?police. ?Int ?J ?Drug ?Policy. ?2005;16(5):343?352. ? ?168. ? Midford ?R, ?Acres ?J, ?Lenton ?S, ?Loxley ?W, ?Boots ?K. ?Cops, ?drugs ?and ?the ?community: ?establishing ?consultative ?harm ?reduction ?structures ?in ?two ?Western ?Australian ?locations. ?Int ?J ?Drug ?Policy. ?2002;13(3):185?192. ?169. ? Sharma ?M, ?Chatterjee ?A. ?Partnering ?with ?law ?enforcement ?to ?deliver ?good ?public ?health: ?the ?experience ?of ?the ?HIV/AIDS ?Asia ?regional ?program. ?Harm ?Reduct ?J. ?2012;9(1):24. ?170. ? Hammett ?TM, ?Bartlett ?NA, ?Chen ?Y, ?et ?al. ?Law ?enforcement ?influences ?on ?HIV ?prevention ?for ?injection ?drug ?users: ?observations ?from ?a ?cross-???border ?project ?in ?China ?and ?Vietnam. ?Int ?J ?Drug ?Policy. ?2005;16(4):235?245. ?171. ? Davis ?CS, ?Beletsky ?L. ?Bundling ?occupational ?safety ?with ?harm ?reduction ?information ?as ?a ?feasible ?method ?for ?improving ?police ?receptiveness ?to ?syringe ?access ?programs: ?evidence ?from ?three ?U.S. ?cities. ?Harm ?Reduct ?J. ?2009;6(1):16. ?172. ? Beletsky ?L, ?Agrawal ?A, ?Moreau ?B, ?Kumar ?P, ?Weiss-???Laxer ?N, ?Heimer ?R. ?Police ?training ?to ?align ?law ?enforcement ?and ?HIV ?prevention: ?preliminary ?evidence ?from ?the ?field. ?Am ?J ?Public ?Health. ?2011;101(11):2012?2015. ?173. ? Beletsky ?L, ?Macalino ?GE, ?Burris ?S. ?Attitudes ?of ?police ?officers ?towards ?syringe ?access, ?occupational ?needle-???sticks, ?and ?drug ?use: ?A ?qualitative ?study ?of ?one ?city ?police ?department ?in ?the ?United ?States. ?Int ?J ?Drug ?Policy. ?2005;16(4):267?274. ?174. ? Jardine ?M, ?Crofts ?N, ?Monaghan ?G, ?Morrow ?M. ?Harm ?reduction ?and ?law ?enforcement ?in ?Vietnam: ?influences ?on ?street ?policing. ?Harm ?Reduct ?J. ?2012;9(1):27. ?175. ? Khuat ?TH, ?Nguyen ?VA, ?Jardine ?M, ?Moore ?T, ?Bui ?TH, ?Crofts ?N. ?Harm ?reduction ?and ??Clean? ?community: ?can ?Viet ?Nam ?have ?both? ?Harm ?Reduct ?J. ? ? 156 ?2012;9(1):25. ?176. ? Pearshouse ?R, ?Elliot ?R, ?Csete ?J. ?Module ?1: ?criminal ?law ?issues. ?Toronto: ?Canadian ?HIV/AIDS ?Legal ?Network; ?2006. ?Legislating ?for ?Health ?and ?Human ?Rights: ?Model ?Law ?on ?Drug ?Use ?and ?HIV/AIDS. ?177. ? Hughes ?CE, ?Stevens ?A. ?What ?can ?we ?learn ?from ?the ?Portuguese ?decriminalization ?of ?illicit ?drugs? ?Br ?I ?Criminol. ?2010;50(6):999?1022. ?178. ? Grover ?A. ?Report ?of ?the ?Special ?Rapporteur ?on ?the ?right ?of ?everyone ?to ?the ?enjoyment ?of ?the ?highest ?attainable ?standard ?of ?physical ?and ?mental ?health. ?UN ?Doc. ?No. ?A/65/255. ?United ?Nations; ?August ?6, ?2010. ?http://ap.ohchr.org/documents/alldocs.aspx?doc_id=17520. ?Accessed ?May ?21, ?2013. ?179. ? Elliott ?R, ?Csete ?J, ?Wood ?E, ?Kerr ?T. ?Harm ?reduction, ?HIV/AIDS, ?and ?the ?human ?rights ?challenge ?to ?global ?drug ?control ?policy. ?Health ?Hum ?Rights. ?2005;8(2):104?138. ?180. ? United ?Nations ?Office ?on ?Drugs ?and ?Crime. ?UNODC ?and ?the ?promotion ?and ?protection ?of ?human ?rights. ?Vienna: ?United ?Nations ?Office ?on ?Drugs ?and ?Crime; ?2012. ?181. ? Trace ?M. ?Measuring ?drug ?law ?enforcement?From ?process ?to ?outcomes. ?Int ?J ?Drug ?Policy. ?2012;23(1):17?18. ?182. ? Mackenzie ?S, ?Hamilton-???Smith ?N. ?Measuring ?police ?impact ?on ?organised ?crime: ?Performance ?management ?and ?harm ?reduction. ?Policing. ?2011;34(1):7?30. ?183. ? Ritter ?A. ?Methods ?for ?comparing ?drug ?policies: ?the ?utility ?of ?composite ?Drug ?Harm ?Indexes. ?Int ?J ?Drug ?Policy. ?2009;20(6):475?479. ?184. ? McFadden ?M. ?The ?Australian ?Federal ?Police ?Drug ?Harm ?Index: ?a ?new ? ? 157 ?methodology ?for ?quantifying ?success ?in ?combating ?drug ?use. ?Aust ?J ?Pub ?Admin. ?2006;65(4):68?81. ?185. ? Charoenpo ?A, ?Laohong ?K-???O. ?Govt ?declares ?new ?war ?on ?drug ?trade. ?Bangkok ?Post. ?December ?17, ?2010. ?186. ? Sandelowski ?M. ?Whatever ?happened ?to ?qualitative ?description? ?Res ?Nurs ?Health. ?2000;23:334?340. ?187. ? Strauss ?A, ?Corbin ?J. ?Basics ?of ?qualitative ?research: ?Techniques ?and ?procedures ?for ?developing ?grounded ?theory. ?2nd ?ed. ?Thaousand ?Oaks, ?CA: ?Sage; ?1998. ?188. ? Hayashi ?K, ?Suwannawong ?P, ?Ti ?L, ?Kaplan ?K, ?Wood ?E, ?Kerr ?T. ?High ?rates ?of ?midazolam ?injection ?and ?associated ?harms ?in ?Bangkok, ?Thailand. ?Addiction. ?2013;108(5):944?952. ?189. ? Top ?cop ?orders ?blitz ?on ?drugs. ?Bangkok ?Post. ?August ?18, ?2011. ?190. ? Kerr ?T, ?Kiatying-???Angsule ?N, ?Fairbairn ?N, ?et ?al. ?High ?rates ?of ?midazolam ?injection ?among ?drug ?users ?in ?Bangkok, ?Thailand. ?Harm ?Reduct ?J. ?2010;7(1):7. ?191. ? Constitution ?Drafting ?Commission. ?Constitution ?of ?the ?Kingdom ?of ?Thailand ?B.E. ?2550 ?(2007). ?Bangkok: ?Bureau ?of ?Printing ?Services, ?Secretariat ?of ?the ?House ?of ?Representatives; ?2007. ?192. ? Committee ?on ?Economic, ?Social ?and ?Cultural ?Rights. ?General ?Comment ?14: ?The ?right ?to ?the ?highest ?attainable ?standard ?of ?health. ?UN ?Doc. ?No. ?E/C.12/2000/4. ?United ?Nations ?Economic ?and ?Social ?Council; ?August ?11, ?2000. ?http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En. ?Accessed ?May ?21, ?2013. ?193. ? Human ?Rights ?Watch. ?Somsanga'?s ?secrets: ?arbitrary ?detention, ?physical ?abuse, ?and ?suicide ?inside ?a ?Lao ?drug ?detention ?center. ?New ?York: ?Human ?Rights ?Watch; ?2011. ? ? 158 ?194. ? National ?report ?submitted ?in ?accordance ?with ?paragraph ?15 ?(a) ?of ?the ?annex ?to ?Human ?Rights ?Council ?resolution ?5/1: ?Thailand. ?UN ?Doc. ?No. ?A/HRC/WG.6/12/THA/1. ?United ?Nations ?Human ?Rights ?Council; ?July ?19, ?2011. ?http://www.ohchr.org/EN/HRBodies/UPR/PAGES/THSession12.aspx. ?Accessed ?May ?21, ?2013. ?195. ? Reynolds ?LA. ?Historical ?aspects ?of ?drugs-???of-???abuse ?testing ?in ?the ?United ?States. ?In: ?Wong ?RC, ?Tse ?HY, ?eds. ?Drugs ?of ?abuse: ?body ?fluid ?testing. ?Totowa, ?NJ: ?Humana ?Press ?Inc.; ?2005:1?10. ?196. ? Wong ?AYF. ?Drugs-???of-???abuse ?testing: ?the ?European ?perspective. ?In: ?Wong ?RC, ?Tse ?HY, ?eds. ?Drugs ?of ?abuse: ?body ?fluid ?testing. ?Forensic ?Science ?and ?Medicine. ?Totowa, ?NJ: ?Humana ?Press ?Inc.; ?2005:259?270. ?197. ? Verstraete ?AG. ?The ?results ?of ?the ?roadside ?drug ?testing ?assessment ?project. ?In: ?Wong ?RC, ?Tse ?HY, ?eds. ?Drugs ?of ?abuse: ?body ?fluid ?testing. ?Totowa, ?NJ: ?Humana ?Press ?Inc.; ?2005:271?292. ?198. ? Moeller ?M, ?Steinmyer ?S, ?Aberl ?F. ?Operational, ?user ?and ?legal ?requirements ?across ?EU ?member ?states ?for ?roadside ?drug ?testing ?equipment. ? ?http://www.rosita.org/docs/rosita_d3.doc. ?Published ?August ?30, ?1999. ?Accessed ?May ?21, ?2013. ?199. ? Shenton ?AK. ?Strategies ?for ?ensuring ?trustworthiness ?in ?qualitative ?research ?projects. ?Educ ?Inform. ?2004;22:63?75. ?200. ? Rakrun ?N. ?Husband ?relives ?hell ?of ?wife'?s ?killing. ?Bangkok ?Post. ?April ?15, ?2012. ?201. ? Human ?Rights ?Watch. ?Thailand: ?police ?blamed ?for ?killing ?drug ?suspect: ?parliamentary ?findings ?demand ?strong ?action ?to ?combat ?police ?brutality ?[news ?release]. ?New ?York: ?Human ?Rights ?Watch; ?March ?16, ?2012. ?http://www.hrw.org/news/2012/03/16/thailand-???police-???blamed-???killing-???drug-??? ? 159 ?suspect. ?Accessed ?May ?21, ?2013. ?202. ? Ti ?L, ?Hayashi ?K, ?Kaplan ?K, ?et ?al. ?HIV ?testing ?and ?willingness ?to ?get ?HIV ?testing ?at ?a ?peer-???run ?drop-???in ?centre ?for ?people ?who ?inject ?drugs ?in ?Bangkok, ?Thailand. ?BMC ?Public ?Health. ?2012;12(1):189. ? ?203. ? McNutt ?LA, ?Wu ?C, ?Xue ?X, ?Hafner ?JP. ?Estimating ?the ?relative ?risk ?in ?cohort ?studies ?and ?clinical ?trials ?of ?common ?outcomes. ?Am ?J ?Epidemiol. ?2003;157(10):940?943. ?204. ? Spiegelman ?D, ?Hertzmark ?E. ?Easy ?SAS ?calculations ?for ?risk ?or ?prevalence ?ratios ?and ?differences. ?Am ?J ?Epidemiol. ?2005;162(3):199?200. ? ?205. ? Deddens ?JA, ?Petersen ?MR. ?Approaches ?for ?estimating ?prevalence ?ratios. ?Occup ?Environ ?Med. ?2008;65(7):481?501?6. ?206. ? Barrett ?ME, ?Perngparn ?U. ?Rapid ?assessment ?and ?response: ?preparation ?for ?the ?scale-???up ?of ?comprehensive ?harm ?reduction ?services ?in ?Thailand: ?Bangkok ?province. ?Asian ?Harm ?Reduction ?Network/Public ?Health ?Sciences ?College, ?Chulalongkorn ?University; ?2010. ?http://new.ahrn.net/wp-???content/uploads/2010/06/RAR2010_Pub_ENG_BKK.pdf. ?Accessed ?May ?21, ?2013. ?207. ? Hoonsara ?S, ?Kijchalong ?T, ?Jaichalard ?P. ?Govt ?to ?respond ?to ?Queen'?s ?concerns ?about ?drugs. ?The ?Nation. ?August ?13, ?2011. ?208. ? Kerr ?T, ?Fairbairn ?N, ?Hayashi ?K, ?et ?al. ?Difficulty ?accessing ?syringes ?and ?syringe ?borrowing ?among ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?Drug ?Alcohol ?Rev. ?2010;29(2):157?161. ?209. ? Darke ?S. ?Self-???report ?among ?injecting ?drug ?users: ?a ?review. ?Drug ?Alcohol ?Depend. ?1998;51(3):253?63? ?discussion ?267?8. ? ? 160 ?210. ? Weatherby ?NL, ?Needle ?R, ?Cesari ?H, ?et ?al. ?Validity ?of ?self-???reported ?drug ?use ?among ?injection ?drug ?users ?and ?crack ?cocaine ?users ?recruited ?through ?street ?outreach. ?Eval ?Program ?Plann. ?1994;17(4):347?355. ? ?211. ? World ?Health ?Organization, ?United ?Nations ?Office ?on ?Drugs ?and ?Crime, ?Joint ?United ?Nations ?Programme ?on ?HIV ?AIDS. ?WHO, ?UNODC, ?UNAIDS ?technical ?guide ?for ?countries ?to ?set ?targets ?for ?universal ?access ?to ?HIV ?prevention, ?treatment ?and ?care ?for ?injecting ?drug ?users: ?2012 ?revision. ?Geneva: ?World ?Health ?Organization; ?2012. ?212. ? Cohen ?A, ?McGregor ?C. ?The ?emergence ?of ?methamphetamine ?in ?Thailand: ?interventions ?and ?treatment. ?In: ?Pates ?R, ?Riley ?D, ?eds. ?Interventions ?for ?amphetamine ?misuse. ?West ?Sussex: ?Blackwell ?Publishing ?Ltd.; ?2010:159?171. ?213. ? Riley ?D, ?Pates ?R. ?What ?have ?we ?learned: ?conclusions ?on ?treatment. ?In: ?Pates ?R, ?Riley ?D, ?eds. ?Interventions ?for ?amphetamine ?misuse. ?West ?Sussex: ?Blackwell ?Publishing ?Ltd.; ?2010:227?235. ?214. ? Volkow ?ND, ?Montaner ?J. ?The ?urgency ?of ?providing ?comprehensive ?and ?integrated ?treatment ?for ?substance ?abusers ?with ?HIV. ?Health ?Aff. ?2011;30(8):1411?1419. ?215. ? Human ?Rights ?Watch. ?World ?report ?2012: ?events ?of ?2011. ?New ?York: ?Human ?Rights ?Watch; ?2013. ?216. ? Csete ?J, ?Kaplan ?K, ?Hayashi ?K, ?et ?al. ?Compulsory ?drug ?detention ?center ?experiences ?among ?a ?community-???based ?sample ?of ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?BMC ?Int ?Health ?Hum ?Rights. ?2011;11(1):12. ?217. ? World ?Health ?Organization, ?Joint ?United ?Nations ?Programme ?on ?HIV/AIDS, ?United ?Nations ?Children'?s ?Fund. ?Global ?HIV/AIDS ?response: ?epidemic ?update ?and ?health ?sector ?progress ?towards ?universal ?access: ?progress ?report ?2011. ?Geneva: ?World ? ? 161 ?Health ?Organization; ?2011. ?218. ? 65/277. ?Political ?declaration ?on ?HIV ?and ?AIDS: ?intensifying ?our ?efforts ?to ?eliminate ?HIV ?and ?AIDS. ?UN ?Doc. ?No. ?A/RES/65/277. ?United ?Nations ?General ?Assembly; ?July ?8, ?2011. ?http://www.unaids.org/en/media/unaids/contentassets/documents/document/2011/06/20110610_un_a-???res-???65-???277_en.pdf. ?Accessed ?May ?21, ?2013. ?219. ? International ?Harm ?Reduction ?Association. ?The ?global ?state ?of ?harm ?reduction ?2008: ?mapping ?the ?response ?to ?drug-???related ?HIV ?and ?hepatitis ?C ?epidemics. ?London: ?International ?Harm ?Reduction ?Association; ?2008. ?220. ? Harm ?Reduction ?International. ?The ?global ?state ?of ?harm ?reduction ?2012: ?towards ?an ?integrated ?response. ?(Stoicescu ?C, ?ed.). ?London: ?Harm ?Reduction ?International; ?2012. ?221. ? Philbin ?M, ?Pollini ?RA, ?Ramos ?R, ?et ?al. ?Shooting ?gallery ?attendance ?among ?IDUs ?in ?Tijuana ?and ?Ciudad ?Juarez, ?Mexico: ?correlates, ?prevention ?opportunities, ?and ?the ?role ?of ?the ?environment. ?AIDS ?Behav. ?2008;12(4):552?560. ?222. ? Sirinirund ?P. ?Leading ?the ?way: ?Thailand'?s ?HIV ?and ?AIDS ?strategy ?2012-???2016. ?Abstract ?presented ?at: ?The ?19th ?International ?AIDS ?Conference; ?July ?22-???27, ?2012: ?Washington, ?DC, ?USA. ?http://pag.aids2012.org/session.aspx?s=739. ?Accessed ?May ?21, ?2013. ?223. ? Cooper ?HL, ?Jarlais ?Des ?DC, ?Tempalski ?B, ?Bossak ?BH, ?Ross ?Z, ?Friedman ?SR. ?Drug-???related ?arrest ?rates ?and ?spatial ?access ?to ?syringe ?exchange ?programs ?in ?New ?York ?City ?health ?districts: ?combined ?effects ?on ?the ?risk ?of ?injection-???related ?infections ?among ?injectors. ?Health ?Place. ?2012;18(2):218?228. ?224. ? Friedman ?SR, ?Cooper ?HL, ?Tempalski ?B, ?et ?al. ?Relationships ?of ?deterrence ?and ?law ?enforcement ?to ?drug-???related ?harms ?among ?drug ?injectors ?in ?US ? ? 162 ?metropolitan ?areas. ?AIDS. ?2006;20(1):93?99. ?225. ? Hayashi ?K, ?Wood ?E, ?Suwannawong ?P, ?Kaplan ?K, ?Qi ?J, ?Kerr ?T. ?Methamphetamine ?injection ?and ?syringe ?sharing ?among ?a ?community-???recruited ?sample ?of ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?Drug ?Alcohol ?Depend. ?2011;115(1-???2):145?149. ?226. ? Maldonado ?G, ?Greenland ?S. ?Simulation ?study ?of ?confounder-???selection ?strategies. ?Am ?J ?Epidemiol. ?1993;138(11):923?936. ?227. ? Wattana ?W, ?van ?Griensven ?F, ?Rhucharoenpornpanich ?O, ?et ?al. ?Respondent-???driven ?sampling ?to ?assess ?characteristics ?and ?estimate ?the ?number ?of ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?Drug ?Alcohol ?Depend. ?2007;90(2-???3):228?233. ?228. ? Kerr ?T, ?Kaplan ?K, ?Suwannawong ?P, ?J?rgens ?R, ?Wood ?E. ?The ?Global ?Fund ?to ?Fight ?AIDS, ?Tuberculosis ?and ?Malaria: ?funding ?for ?unpopular ?public-???health ?programmes. ?Lancet. ?2004;364(9428):11?12. ?229. ? Devaney ?M, ?Reid ?G, ?Baldwin ?S. ?Situational ?analysis ?of ?illicit ?drug ?issues ?and ?responses ?in ?the ?Asia?Pacific ?region. ?Canberra: ?Australian ?National ?Council ?on ?Drugs; ?2006. ?230. ? Ministry ?launches ?drug-???free ?prison ?drive. ?Bangkok ?Post. ?May ?25, ?2012. ?231. ? Ruangdit ?P. ?Drug ?trade ?from ?behind ?bars ?booms. ?Bangkok ?Post. ?May ?14, ?2012. ?232. ? Nosyk ?B, ?Marshall ?BD, ?Fischer ?B, ?Montaner ?JS, ?Wood ?E, ?Kerr ?T. ?Increases ?in ?the ?availability ?of ?prescribed ?opioids ?in ?a ?Canadian ?setting. ?Drug ?Alcohol ?Depend. ?2012;126(1-???2):7?12. ?233. ? Johnson ?BD, ?Golub ?A. ?The ?potential ?for ?accurately ?measuring ?behavioral ?and ?economic ?dimensions ?of ?consumption, ?prices, ?and ?markets ?for ?illegal ?drugs. ?Drug ?Alcohol ?Depend. ?2007;90(Suppl ?1):S16?26. ? ? 163 ?234. ? Global ?SMART ?Programme. ?Patterns ?and ?trends ?of ?amphetamine-???type ?stimulants ?and ?other ?drugs: ?Asia ?and ?the ?Pacific. ?United ?Nations ?Office ?on ?Drugs ?and ?Crime; ?2011. ?235. ? Wechsler ?M. ?Tracking ?down ?the ?traffickers: ?faced ?with ?an ?increase ?in ?the ?amount ?of ?drugs ?being ?smuggled ?into ?the ?country, ?officials ?are ?seeking ?closer ?co-???operation ?with ?foreign ?agencies. ?Bangkok ?Post. ?April ?18, ?2010. ?236. ? Caulkins ?JP, ?Reuter ?P, ?Iguchi ?MY, ?Chiesa ?J. ?How ?goes ?the ??war ?on ?drugs??An ?assessment ?of ?U.S. ?drug ?problems ?and ?policy. ?OP-???121. ?Santa ?Monica, ?CA: ?The ?RAND ?Corporation; ?2005. ?237. ? Laohong ?K-???O, ?Rakrun ?N. ?Prison ?officials ?sacked ?after ?contraband ?blitz: ?thousands ?of ?mobile ?phones, ?drugs ?seized. ?Bangkok ?Post. ?April ?28, ?2012. ?238. ? Davis ?WR, ?Johnson ?BD, ?Randolph ?D, ?Liberty ?HJ. ?Gender ?differences ?in ?the ?distribution ?of ?cocaine ?and ?heroin ?in ?Central ?Harlem. ?Drug ?Alcohol ?Depend. ?2005;77(2):115?127. ?239. ? Kerr ?T, ?Small ?W, ?Johnston ?C, ?Li ?K, ?Montaner ?JS, ?Wood ?E. ?Characteristics ?of ?injection ?drug ?users ?who ?participate ?in ?drug ?dealing: ?implications ?for ?drug ?policy. ?J ?Psychoactive ?Drugs. ?2008;40(2):147?152. ?240. ?German ?D, ?Sherman ?SG, ?Sirirojn ?B, ?Thomson ?N, ?Aramrattana ?A, ?Celentano ?DD. ?Motivations ?for ?methamphetamine ?cessation ?among ?young ?people ?in ?northern ?Thailand. ?Addiction. ?2006;101(8):1143?1152. ?241. ? Hayashi ?K, ?Milloy ?MJ, ?Fairbairn ?N, ?et ?al. ?Incarceration ?experiences ?among ?a ?community-???recruited ?sample ?of ?injection ?drug ?users ?in ?Bangkok, ?Thailand. ?BMC ?Public ?Health. ?2009;9(1):492. ?242. ? Department ?of ?Corrections ?of ?Thailand. ?Number ?of ?prisoners ?by ?type ?of ?prisoners ?[in ?Thai]. ? ? 164 ?http://www.correct.go.th/stat102/display/result_pdf.php?date=2012-???07-???01. ?Published ?July ?1, ?2012. ?Accessed ?May ?21, ?2013. ?243. ? Sukphisit ?S. ?Locked ?up ?women ?find ?fresh ?outlook ?thanks ?to ?royal ?programme. ?Bangkok ?Post. ?June ?24, ?2012. ?244. ? Bergenstrom ?A, ?McLeod ?R, ?Sharma ?M, ?et ?al. ?How ?much ?will ?it ?cost? ?Estimation ?of ?resource ?needs ?and ?availability ?for ?HIV ?prevention, ?treatment ?and ?care ?for ?people ?who ?inject ?drugs ?in ?Asia. ?Int ?J ?Drug ?Policy. ?2010;21(2):107?109. ?245. ? Plano ?Clark ?VL, ?Creswell ?JW, ?Green ?DO, ?Shope ?RJ. ?Mixing ?quantiative ?and ?qualitative ?approaches: ?an ?introduction ?to ?emergent ?mixed ?methods ?research. ?In: ?Hesse-???Biber ?SN, ?Leavy ?P, ?eds. ?Handbook ?of ?emergent ?methods. ?New ?York: ?The ?Guilford ?Press; ?2008:363?387. ?246. ? Bryman ?A. ?Combining ?quantitative ?and ?qualitative ?research. ?In: ?Social ?research ?methods. ?2nd ?ed. ?New ?York: ?Oxford ?University ?Press; ?2004:451?465. ?247. ? Hunt ?P. ?Human ?rights, ?health ?and ?harm ?reduction: ?states? ?amnesia ?and ?parallel ?universes. ?London: ?International ?Harm ?Reduction ?Association; ?2008. ?248. ? McElrath ?K, ?Chitwood ?DD, ?Griffin ?DK, ?Comerford ?M. ?The ?consistency ?of ?self-???reported ?HIV ?risk ?behavior ?among ?injection ?drug ?users. ?Am ?J ?Public ?Health. ?1994;84(12):1965?1970. ?249. ? Chomchai ?C, ?Na ?Manorom ?N, ?Watanarungsan ?P, ?Yossuck ?P, ?Chomchai ?S. ?Methamphetamine ?abuse ?during ?pregnancy ?and ?its ?health ?impact ?on ?neonates ?born ?at ?Siriraj ?Hospital, ?Bangkok, ?Thailand. ?Southeast ?Asian ?J ?Trop ?Med ?Public ?Health. ?2004;35(1):228?231. ?250. ? Csete ?J, ?Grob ?PJ. ?Switzerland, ?HIV ?and ?the ?power ?of ?pragmatism: ?Lessons ?for ?drug ?policy ?development. ?Int ?J ?Drug ?Policy. ?2012;23(1):82?86. ? ? 165 ?251. ? Narayanan ?S, ?Vicknasingam ?B, ?Robson ?NM. ?The ?transition ?to ?harm ?reduction: ?understanding ?the ?role ?of ?non-???governmental ?organisations ?in ?Malaysia. ?Int ?J ?Drug ?Policy. ?2011;22(4):311?317. ?252. ? Room ?R, ?Reuter ?P. ?How ?well ?do ?international ?drug ?conventions ?protect ?public ?health? ?Lancet. ?2012;379(9810):84?91. ? ?

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.24.1-0074103/manifest

Comment

Related Items