Drug overdose is now the leading cause of injury death in the United States. Most overdose fatalities involve opioids, which include prescription medication, heroin, and illicit fentanyl. Current ...data reveal that the overdose crisis affects all demographic groups and that overdose rates are now rising most rapidly among African Americans. We provide a public health perspective that can be used to mobilize a comprehensive local, state, and national response to the opioid crisis. We argue that framing the crisis from a public health perspective requires considering the interaction of multiple determinants, including structural factors (eg, poverty and racism), the inadequate management of pain, and poor access to addiction treatment and harm-reduction services (eg, syringe services). We propose a novel ecological framework for harmful opioid use that provides multiple recommendations to improve public health and clinical practice, including improved data collection to guide resource allocation, steps to increase safer prescribing, stigma-reduction campaigns, increased spending on harm reduction and treatment, criminal justice policy reform, and regulatory changes related to controlled substances. Focusing on these opportunities provides the greatest chance of making a measured and sustained impact on overdose and related harms.
Policing shapes the health risks of people who use drugs (PWUD), but little is understood about interventions that can align officer practices with PWUD health. This study deploys the Theory of ...Planned Behavior (TPB) to understand what influences police intentions to make discretionary referrals to treatment and harm reduction resources rather than arrest on less serious charges.
On-line surveys integrating TPB constructs and adapting an instrument measuring police intentions to make mental health treatment referrals were completed by police employees in Indiana, Massachusetts, and Missouri. They also included items about stigma towards PWUD and attitudes and beliefs about opioid addiction, treatment, and recovery.
Across the sites, 259 respondents perceived control over their decision to arrest for misdemeanors (69%) and confiscate items such as syringes (56%). Beliefs about others' approval of referrals to treatment, its ability to reduce future arrests, and to increase trust in police were associated with stated practices of nonarrest for drug and possession and making referrals (p ≤ .001), and nonarrest for syringe possession (p ≤ .05). Stigma a towards PWUD was negatively associated with stated practices of nonarrest (p ≤ .05). Respondents identified supervisors as having the most influence over use of discretion, seriousness of the offense as the most influential value, and attitude of the suspect as the most important situational factor. The 17 Likert scale items analyzed had a Cronbach's alpha of 0.81.
The TPB offers untapped potential to better understand and modify police practices. In designing interventions to improve the health outcomes of police encounters with PWUD, further research should validate instruments that measure the relationship between these variables and discretionary intentions, and that measure role-relevant police stigma towards PWUD.
Policing, corrections, and other carceral institutions are under scrutiny for driving health harms, while receiving disproportionate resources at the expense of prevention and other services. Amidst ...renewed interest in structural determinants of health, roles of race and class in shaping government investment priorities are poorly understood.
Based on the Social Conflict Model, we assessed relationships between city racial/ economic profiles measured by the Index of Concentration at the Extremes (ICE) and budgetary priorities measured by the novel Carceral Resource Index (CRI), contrasting investments in carceral systems with funding for health and social support across the 50 most populous cities in the United States (U.S.). Bivariate correlations, and unadjusted and adjusted polynomial regression models were used to assess the relationship between budgetary investments and population concentration at extremes in terms of income, racial/ethnic composition, and education, controlling for other demographic characteristics.
In our sample, median CRI was -0.59 (IQR -0.64, -0.45), with only seven cities exhibiting positive CRI values. This indicates that most large U.S. cities spend more on carceral systems than on health and supportive services, combined. Adjusted polynomial models showed a convex relationship between the CRI and ICE-Education, and ICE-Race(White vs. Black)+Income, with quadratic terms that were positive and significant at p<0.05. After controlling for age, the strongest prioritization of carceral systems was observed in cities where the proportion of low-income Black residents approached or exceeded that of high-income white residents.
Municipal prioritization of carceral investments over health and social support is pervasive in the U.S and exacerbated by racial and economic disparities. The CRI offers new opportunities to understand the role of government investments as a structural determinant of health and safety. Longitudinal research is warranted to examine the relationship between budget priorities, structural racism, and health outcomes.
Rising rates of opioid use disorder, overdoses, and opioid-related criminal offenses have prompted US law enforcement agencies to adopt alternatives to arrest and formal criminal processing. Police ...departments frequently implement treatment referral programs and claim an affiliation with the Police Assisted Addiction and Recovery Initiative (PAARI). Although expanding to hundreds of agencies, PAARI efforts may not be equally distributed across communities, raising concerns about access to non-arrest diversion and increasing disparities in the criminal processing of drug-related offenses. This study compares the characteristics and geographic placement of law enforcement agencies with and without PAARI programs in 29 states. Law enforcement agencies situated in communities with lower rates of poverty and smaller Black populations have lower odds of having a PAARI program. Agencies based in counties with more overdose deaths and greater unmet treatment needs have increased odds of deflection programing. This placement of PAARI programs reflects broader inequalities in criminal justice and health. More advantaged, predominantly white communities benefit from diversionary programs while fewer alternatives to formal criminal processing exist for lower-income areas and communities of color. Additional research should explore these growing disparities in the deployment of law enforcement-based treatment referral programs and their consequences on drug law enforcement.
FSWs who inject drugs (FSW-IDUs) can acquire HIV through high risk sexual and injection behaviors. We studied correlates of HIV infection among FSW-IDUs in northern Mexico, where sex work is ...quasi-legal and syringes can be legally obtained without a prescription.
FSW-IDUs>18 years old who reported injecting drugs and recent unprotected sex with clients in Tijuana and Ciudad Juarez underwent surveys and HIV/STI testing. Logistic regression identified correlates of HIV infection.
Of 620 FSW-IDUs, prevalence of HIV, gonorrhea, Chlamydia, trichomonas, syphilis titers ≥1:8, or any of these infections was 5.3%, 4%, 13%, 35%, 10% and 72%, respectively. Compared to other FSW-IDUs, HIV-positive women were more likely to: have syphilis titers ≥1:8 (36% vs. 9%, p<0.001), often/always inject drugs with clients (55% vs. 32%, p = 0.01), and experience confiscation of syringes by police (49% vs. 28%, p = 0.02). Factors independently associated with HIV infection were syphilis titers ≥1:8, often/always injecting with clients and police confiscation of syringes. Women who obtained syringes from NEPs (needle exchange programs) within the last month had lower odds of HIV infection associated with active syphilis, but among non-NEP attenders, the odds of HIV infection associated with active syphilis was significantly elevated.
Factors operating in both the micro-social environment (i.e., injecting drugs with clients) and policy environment (i.e., having syringes confiscated by police, attending NEPs) predominated as factors associated with risk of HIV infection, rather than individual-level risk behaviors. Interventions should target unjustified policing practices, clients' risk behaviors and HIV/STI prevention through NEPs.
The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic ...and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness. Overreliance on opioid medications is emblematic of a health care system that incentivizes quick, simplistic answers to complex physical and mental health needs. In an analogous way, simplistic measures to cut access to opioids offer illusory solutions to this multidimensional societal challenge. We trace the crisis' trajectory through the intertwined use of opioid analgesics, heroin, and fentanyl analogs, and we urge engaging the structural determinants lens to address this formidable public health emergency. A broad focus on suffering should guide both patient- and community-level interventions.
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