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Exploring the Risk Environment: Challenges and Opportunities in Reducing Harm among People who Inject Drugs Thomas Kerr, PhD Director, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, Professor, Department of Medicine, University of British Columbia Associate Scientist, Ontario HIV Treatment Network

Conventional Approaches Individual INTERVENTIONS

Risk Environment Framework Social Structural Environmental • Local drug use patters • Economic conditions • Features of built • Peer group norm • Laws & social policies environment Individual INTERVENTIONS

Policing

Mitsampan Community Research Project • A collaborative research effort involving: Thai AIDS Treatment Action Group Chulalongkorn Mitsampan Harm Reduction Center University • Serial cross-sectional mix-methods study • 32 former/active drug users trained as peer researchers • Peer researchers involved in all stages of the project Summer 2008, Bangkok, Thailand

Ever beaten and drug tested* by police 13% Drug tested* by 14% police only None of the two events 45% Ever beaten by 28% police only PWID in Bangkok, 2011 ( n =435) 10 * Refers to the previous 6 months.

Policing exposures and syringe sharing 11 Hayashi et al,. AIDS Behav, 2013

• 13% of PWID with negative or unknown HIV status reporting avoiding HIV testing. • Increased police presence where one buys or uses drugs was significantly associated with HIV test avoidance (OR: 2.06; 95% CI: 1.10–3.84). 12

Fear, Displacement and Risk People are at a higher risk because they are being forced Drug enforcement policing : These days they just take it and shoot it up right away. They to go into areas that they don’t know. Usually there are don’t look at what they have got or think about how strong no services provided in those areas where they can get • Fear and hurried injection it may be. IDU Respondent #25. clean works, or be observed or helped by someone. • Syringe reuse, sharing, lending Service Provider Respondent # 8. • Interruptions in service access due to displacement

Incarceration

Journal of Infectious Diseases, 2011

HAART & Incarceration Factors influencing inmates’ ability to access and adhere to HAART: Short term interruptions in treatment during intake and transfers Delays in obtaining medications through institutional healthcare High levels of HIV discrimination and stigma Problems ensuring continuity of treatment post-release

Changes in policies to : • Improve intake process • Reduce pharmacy-related delays • Ensure contingency supplies of medications • Provide sufficient medication at discharge 18

Hospitals as ‘risk environments’ for people who use drugs?

Leaving Hospital Against Medical Advice • September 2005 - July 2011: 488 PWUD hospitalized • 43% of PWUD left AMA • Younger patients, daily heroin injectors and those recently incarcerated most likely to leave AMA (Ti et al., PloS One, 2015)

Why AMA? •Pain management, withdrawal, under-treated addiction •Social-structural conditions: abstinence-only policies, security guards, lack of access to syringes

Abstinence-only Policies I think they pretty much have zero tolerance in [the hospital]. I was worried about getting kicked out and then not getting the proper health care that I needed to get better. [ . ] I ’ d turn the tap on so, if they came in my room to check to see if I was okay, then they ’ d hear the water running so they ’ d figure oh she ’ s just in the bathroom. [Participant #25, Caucasian Female, 44 years old] McNeil et al, Soc Sci Med, 2014)

Security Guards and Police [Security guards] yell and scream at you. When there’s nobody around, [they say], “You fucking junkie.”…They search you, destroy your property, cause a scene, and make sure everybody there knows that you’re a drug addict. [.] They use their authority to pull power trips more or less. It’s not right. [Participant #12, Aboriginal Female, 29 years old] (McNeil et al, Soc Sci Med, 2014)

Overdose Prevention

Overdose prevention assumes rationality and personal autonomy, emphasizes the self- regulating subject

Social-structural factors : extreme poverty, shifting quality and illegal status of heroin, risky income generating activities Individual factors : entrenched injecting routines, perceived invincibility, ambivalence towards death

Micro-environmental Interventions?

Willingness to use an in-hospital SIF Common reasons: • So they could stay in hospital • To reduce their drug- related risks • To reduce stress about being kicked out because they were using drugs

Socio-economic marginalization

Social Assistance in B.C.: Institutional Design

Provincial Government Cheque Issue • Hospital discharge against • Overall and high-risk drug and medical advice alcohol use • Fatal and non-fatal overdose • Drug-related ED and hospital admissions • Addiction and HIV treatment interruption • Health, social and financial service access barriers • Public disorder • Mental health apprehensions • Police service calls

The impact of alternative social assistance disbursement on drug-related harm (TASA): a randomized controlled trial PI: Lindsey Richardson, DPhil Assistant Professor, Department of Sociology, University of British Columbia Research Scientist, B.C. Centre for Excellence in HIV/AIDS

Which social assistance disbursement schedule most effectively mitigates escalations in drug-related harm coinciding with government cheque issue?

Richardson et al. (2016) BMC Public Health

TASA: Changing payment timing and frequency Social Assistance Payment Control Arm Shelter Allowance Support Allowance • Once monthly payment on cheque day Direct to Direct Staggered Arm landlord deposit • Payments released once per month on day during the first two weeks of the month to avoid cheque issue week • Day randomly chosen after randomization • Gradual transition to new date to avoid unacceptably long period between payments Staggered & Split Arm • Payments released twice per month, first on a day during the week after cheque issue week, second two weeks later • Days randomly chosen after randomization Gradual transition to new date to avoid unacceptably long period between payments

• Prohibited income generation: sex work, drug dealing, theft, squeegeeing, binning, panhandling • Among 687 HIV+ ART-exposed PWUD: – 391 (57%) reported prohibited income generation – Prohibited income generation negatively associated with viral suppression (Adjusted Odds Ratio = 0.74, 95% Confidence Interval: 0.56 – 0.97)

Willing to give‐up if had other employment op ons 63% Sex work 44% Drug dealing Panhandling 37% 29% Binning 0% 10% 20% 30% 40% 50% 60% 70%

Structural Intervention: Low-Threshold Employment Increasing low-threshold employment access Aim: -To evaluate an intervention to increase access to low-threshold jobs for PWUD Intervention: -A digital clearing house of task-based work that PWUD undertake according to availability and preference Outcomes: -Employment, high-risk income generation, drug use and related risk, clinical outcomes

“…medical cannabis laws were associated with a 24.8% lower annual rate of opioid analgesic overdose deaths.” JAMA Internal Medicine, 2014

Figure 1. Frequencies of crack cocaine (Panel A) and cannabis use (Panel B) in each of the intentional cannabis use periods. (Socias et al, under rev

“Drugs have destroyed many people, but wrong policies have destroyed many more.” Kofi Annan, former UN Secretary General

Conclusions • Drug-related harm is shaped by the broader risk environment • Individually-focused interventions are of limited impact • Opportunities to intervene at the social, structural and environmental level exist • Implement and evaluate alternative regulatory approaches

Acknowledgements • The people who use drugs who participate in our research • Research staff • Co-investigators • Funders