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Health outcomes and quasi-supervised settings for street injecting drug use
International Journal of Drug Policy 15 (2004) 247–257
Health outcomes and quasi-supervised settings for street injecting drug use J. Fitzgerald a,∗ , K. Dovey b , P. Dietze c , G. Rumbold d a Sociology Program, University of Melbourne, Parkville, 3010 Vic., Australia Faculty of Architecture, Building and Planning, University of Melbourne, Parkville, 3010 Vic., Australia Turning Point Alcohol and Drug Centre, Deakin University School of Health Sciences, 54-62 Gertrude Street Fitzroy, Vic. 3065, Australia d Centre for Applied Drug and Alcohol Research, Monash University, 900 Dandenong Rd Caulfied, 3145 Vic., Australia b
c
Received 3 July 2003; received in revised form 2 March 2004; accepted 17 March 2004
Abstract Over a 12-month period during 2000, public injecting in Melbourne’s Central Business District (CBD) was displaced by a range of aggressive policing strategies. Public injecting was displaced into quasi-supervised settings such as public toilets and an outreach-serviced laneway. There is a complex relationship between the setting of drug use and acute health outcomes. Over the period of displacement to quasi-supervised settings, there was a specific reduction in the rate of non-fatal overdose per 1000 syringes used in the CBD. The change in setting of drug use was coincident with a change in the location of non-fatal overdose incidents, with limited evidence of differential changes in the number of overdoses in indoor and outdoor settings. This limited evidence of a differential reduction in overdose according to setting suggests the possibility that a blanket reduction in heroin purity does not solely account for the observed changes in the rate of non-fatal overdose. The findings suggest that there is a complex relationship between better health outcomes and the context of injecting in street drug use locations. Given this complex relationships caution should be exercised when projecting the likely impacts of police displacement and public health strategies to reduce harm in street drug markets. © 2004 Elsevier B.V. All rights reserved. Keywords: Injecting drug use; Policing; Harm reduction; Non-fatal overdose
Introduction Open street drug markets expanded considerably in Australian capital cities between 1995 and 2001. With this change was a cultural shift from relatively private heroin trade in residential settings to a series of public open street drug marketplaces (Darke, Ross, & Kaye, 2001; Dietze & Fitzgerald, 2002; Dovey, Fitzgerald & Choi, 2001; Fitzgerald, Broad, & Dare, 1999). It has previously been suggested in Australia that street-based injecting drug users experience worse health outcomes than injecting drug users who use in other settings (Crofts, Caruana, Bowden, & Kerger, 2000; Darke et al., ∗ Corresponding author. Current address: Centre for the Study of Health and Society, The University of Melbourne, Victoria 3010, Australia. Tel.: +61-38344-9146; fax: +61-38344-0824. E-mail addresses: [email protected] (J. Fitzgerald), [email protected] (K. Dovey), [email protected] (P. Dietze), [email protected] (G. Rumbold).
0955-3959/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2004.03.002
2001; Fitzgerald, Broad, et al., 1999; Dixon & Maher, 1999; Maher et al., 2001). Aggressive street-based law enforcement has been implicated in the production of these negative health outcomes for this population (James & Sutton 2000; Dixon & Maher, 1999). Darke et al., found in a study of a sample of street-based injecting drug users, that nearly all subjects (96%) had injected in a public place, including cars (90%), public toilets (81%), the street (80%) and trains (55%). Frequent injectors in public places were more likely to be male, to have overdosed in the preceding 6 months, injected significantly more drug types, injected in more bodily injecting sites and had more current injection-related problems than other injecting drug users. A pattern of increased harm was associated with frequent public injecting. A recognised European response to open street marketplaces has been the implementation of supervised injecting facilities (Dolan et al., 2000). Whilst a supervised injecting facility is being trialled in one Australian city, two other Australian Cities (Melbourne and Canberra) have unsuc-
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cessfully attempted to introduce these facilities in order to reduce the impact of street drug markets. A key argument for providing supervised injecting is the displacement of injecting from public space to a managed private setting. It has been suggested that related to this displacement are better health outcomes for drug users such as reduced high risk injecting behaviour and reduced overdoses in public space. It has also been suggested that moving injecting to supervised locations also reduces public disorder and the visible presence of injecting paraphernalia (DPEC, 2000). Zinberg noted quite some time ago that the effects of a psychoactive drug are related to the drug, the mindset of the user and the drug use setting (Zinberg, 1984). Accordingly, displacement of public injecting drug use from public to supervised private settings should reduce acute health problems. In the past, local law enforcement has been a major force in displacing street-level drug markets (Edmunds et al., 1996). It has also been suggested that street-based law enforcement may actually reduce participation in drug marketplaces (Weatherburn, Jones, Freeman, & Makkai, 2001). Alternatively, it has been reported that aggressive policing in Australian cities can move street injecting into more secluded locations creating a heightened risk of overdose and harm (Dovey et al., 2001; Dixon & Maher, 1999). With the emergence of street markets and the active deployment of aggressive street-level policing in Melbourne it may be possible to examine the relationship between displacement strategies, injecting drug use location and the level of non-fatal overdose. The current study examines whether changes in injecting drug use settings caused by displacement activities in Melbourne’s Central Business District (CBD) created changes in drug consumption trends which resulted in better health outcomes for drug users and a reduced impact of the street drug market for the community.
Methods Overall the study had a multidisciplinary design with an interpretative cultural anthropology orientation (Geertz, 1983; Schwandt, 2000, Chap. 7) rather than a positivist public health orientation. In this sense, the emphasis was on developing a deeper understanding of public injecting through the interpretation of data rather than on a quasi-experimental research design using a positivist paradigm. We draw on both qualitative and quantitative data, and interpret this data in a similar manner as that used by Parker and colleagues (Parker et al., 1988). Use of multiple data sources and extensive fieldwork ensures a close proximity of researcher to the phenomenon under investigation (Denzin, 1994). This paper reports mostly on findings from the quantitative data. We used a number of data sources to ascertain drug use sites. Triangulation in this study involved the comparison
of data from seven sources: Needle and Syringe Program disposal database; fieldwork observations by the first author; qualitative interviews with drug users in the locations in which they inject (n = 30); quantitative interviews with drug users regarding their use of NSP and primary health services (n = 100); trace analysis (appearance of injecting paraphernalia in injecting locations); conducting syringe disposal with disposal workers; interviews with disposal workers; documentary photography of injecting sites (including systematic documentation of high use sites using digital video between 6.00 and 9.00 a.m. during the mapping period in 2001, and use of still image photography during daylight hours over the 3 years of fieldwork); and cross checking of maps of injecting locations with disposal workers. While we have only report here on data from some of these sources to ensure brevity, we gather some confidence in our observations from using such a variety of data sources. Simultaneous triangulation in this study has been used to achieve completeness of understanding rather than convergence as it is often used in positivist quantitative inquiry (see Quine & Taylor, 1998). The study was ethnographic in nature with a focus on utilising both quantitative and qualitative indicators to assist in this ethnography of place. An ethnography of place is different from ethnographies where the unit of analysis is a social network or bounded sub-cultural grouping. Place ethnographies use the geographic setting as the unit of analysis. Data was collected over a 3-year period from 1998 to 2001 during a long-term fieldwork contact with local service providers. In this period, the first author spent at least 2 days each week in the CBD in two, 4-week blocks of uninterrupted mapping and developed strong relationships with drug users and outreach workers. Routinely collected syringe disposal data Routinely collected syringe disposal data were used as a measure of consumption. Syringe disposal data were obtained from the City of Melbourne NSP disposal database. Loose syringes (those discarded in places other than syringe bins) were systematically collected daily by hand by the Foot Patrol Needle and Syringe Program on a fixed geographic schedule. Syringe bins located in toilets and streets and lanes were cleared regularly by a commercial contractor. Data from these collections were reported to the City of Melbourne on a regular basis. There are 148 disposal bins in the CBD. Over the period 2000–2001 between 70 and 80% of all syringes collected each month were collected in the 10 most-used syringe bins. The database has been in operation since January 1998. Non-systematic syringe collections were also conducted in response to specific demands. Non-systematic collections represented less than 5% of total syringe collection. Only data collected through systematic data collection methods have been included in this analysis. Data from outside the CBD has been ex-
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cluded from the analysis. Analysis of crucial changes in disposal numbers between setting types across times of differential policing activity was undertaken using Stata V8’s case-control procedure. Routinely collected non-fatal heroin overdose data base Summary data of ambulance attendance at non-fatal heroin overdose were obtained from an electronic database based on information extracted from patient care records completed by ambulance officers at the site of attendance. Only confirmed heroin-related non-fatal overdoses were included in the analysis. Confirmed heroin-related overdoses were defined as those overdose cases that responded positively to the administration of naloxone using respiration rate and cyanosis as primary indicators and an increase in respiration rate as the marker for heroin overdose (hereafter referred to as ‘overdose’). Other opioid drugs were excluded where possible (Dietze, Cantwell, & Burgess, 2002). Analysis of crucial changes in overdose numbers between setting types across times of differential policing activity was undertaken using Stata V8’s case-control procedure. The rate of overdose was also examined as a function of drug consumption. Monthly aggregates of non-fatal overdoses were expressed as a function of monthly totals of syringes collected in the study fieldsite. The trend in non-fatal overdose rates per unit consumption was examined using only descriptive statistics as it is a combined measure. Care should be taken when using combined measures as the source of variation in each data set is lost when they are combined. The combined measure should therefore be interpreted with due caution, mindful of an apparent flattening out of variation. The purpose of the combined measure is heuristic rather than explicatory. Interviews with drug users during 2000 In-depth data about drug use were obtained from both structured quantitative interviews (n = 100) and semi-structured qualitative interviews (n = 30) with injecting drug users. Quantitative interviews were conducted in cafés during 1999. Tape-recorded qualitative interviews on the in-depth attributes of drug use settings were conducted in cafés and in injecting sites where drug users prepared and injected their drugs in Melbourne’s CBD. Qualitative interviews were conducted from May 2000 to August 2000. Targeted network sampling (Watters & Biernacki 1989) was employed to recruit injecting drug users into the study. Only illicit drug users who purchased heroin or amphetamine in the CBD in the previous 6 months were interviewed. Recruitment was through contact with the Foot Patrol Needle and Syringe Program. These sampling strategies are consistent with, and developed from those routinely used in studies of hidden populations of drug users (Fitzgerald, Hope, & Dare, 1999; Van de Goor et al., 1992). As in most studies
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of illicit drug use that use non-probability sampling (even large scale cohort studies), it is inappropriate to generalise the results of the study to the broader illicit drug-using population or to other contexts. Indeed it is advised that the specific findings from this study should not be applied to other locations without due consideration of the local contextual factors that shape drug use. Qualitative interviews were tape recorded and emergent themes coded on minidisc. Segments of interview illustrating these emergent themes were transcribed. In the interpretative cultural anthropology tradition, complete transcripts of interview do not necessarily enhance the rigour of the analysis, rather, transcripts are in themselves a version of reality and an interpretation of the social action (Geertz, 1983). Selection of transcript excerpts is itself an interpretative act (see Emerson, Fretz, & Shaw, 1995: 8–9). As we had already completed extensive quantitative interview work in this fieldsite, the in-depth qualitative interviews explored the spatial practices of drug users in specific drug-using locations. Using an explicit focussed coding strategy (Emerson et al., 1995, p. 161) our analysis (and transcription) was delimited to specific content themes (locations, practices) and analytic constructs (such as identity, time and risk). Prior to participation in the study, interviewees were fully informed about the aims and procedures of the study and assured that all responses would be held confidentially subject to legal requirements. Participants received $20 for participation in the study. Findings from the quantitative interviews on primary health care needs of street-based injecting drug users have been reported previously (Fitzgerald, Hope, et al., 1999). Architectural mapping (1999 compared to 2001) Mapping was conducted using available urban planning data and additional data collected to determine accessible space and the degree of social exposure and seclusion in accessible space. Analysis of this data combined spatial syntax analysis with an analysis of functional mix and features of the built form. The spatial analysis consists of a series of layered mappings of the study area including pedestrian access networks, public/private ownership, functional mix and street life volume. These layered mappings of urban space are derived primarily from the field of urban design theory as those most likely to mediate behaviour and meaning in urban space (Dovey, 1999; Hillier, 1996; Jacobs, 1965). Analysis was conducted using a computer assisted design (CAD) package, producing both low resolution maps (drug use at a postcode level) and high resolution maps detailing injecting in shallow alcoves. Mapping the spatial locations of drug injecting involved triangulating across multiple data sources. Syringe disposal data were compared with data collected during fieldwork trace analysis. Fieldwork trace analysis is the systematic observation of spaces with a focus on the materials accu-
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mulating in spaces (see Dovey et al., 2001). In the current study this involved noting the presence of injecting paraphernalia in the systematic mapping of each laneway in the CBD during mapping periods. Fieldworkers between 8.00 a.m. and midday systematically monitored publicly accessible space with detailed maps of the city’s building footprint. Loading bays, window ledges, doorways (any perturbation of the footprint) were coded according to a fixed code that combined the number of syringes, number of open/closed syringe wrappers, swab packets, un/used swabs, spoons, and their physical state (recently used/old, stuck into walls, secreted into drain pipes or in open view) to make a judgement on the use of the site. Preliminary maps were then scrutinised by outreach workers and syringe disposal workers. Mapping fieldwork was conducted in two periods from December 1999 to January 2000 and from May 2001 to June 2001. The first fieldwork period coincided with high levels of loose syringes in public spaces and a highly active street drug marketplace, whereas the second period of fieldwork coincided with a drug market re-emerging from the heroin “drought” experienced from January 2001 to April 2001 (Dietze & Fitzgerald, 2002; Miller, Fry, & Dietze, 2001). The two periods of mapping fieldwork compare two quite different periods of activity in the street heroin market. Trace analysis provides a snapshot of use, measured in a systematic manner, contingent on the period of measurement. As noted above, trace analysis was supplemented with other data sources to account for the time-dependent nature of this data source. Exposure and seclusion is understood through attention to both the geometric properties of space and the social attributes of space (Dovey et al., 2001; Hillier, 1996). A primary mechanism for indexing the degree of seclusion/exposure in any setting is the distance from “co-present” space. Co-present space is space that is occupied at any point in time by more than one person. In spatial syntax terms the presence of another individual confers a type of natural surveillance that disciplines social actors, and reduces marginal or illicit behaviours (Hillier, 1996). Degrees of seclusion can be indexed to this space using physical distance or breaks in the line of sight (Dovey et al., 2001). Space that is “shallow” in a syntactical sense is space that is somewhat exposed. Deep space is space that is either physically distant from co-present space or space that is socially isolated through breaks in the line of sight. Maps describing the degree of seclusion/exposure were overlaid with drug use maps to determine the shifting patterns of injecting drug use across secluded/exposed settings. Ethics This study was approved by the University of Melbourne Human Research Ethics Committee.
Results Policing activity In July 2000 the police initiated ‘Operation Leader’ in Melbourne’s Central Business District (CBD), an aggressive anti-drugs policing operation which involved electronic surveillance of streets, covert buy-busts, plain clothed undercover police, the dog squad and increased uniformed presence (The Age, July 14, 2000: 11). The operation continued through 2000 and into 2001. Ethnographic fieldwork (which included interviews with injecting drug users) was conducted during this period of intense policing activity. Needle and Syringe Programme services in the CBD During 2000 street-based injecting drug users had access to free needle and syringes through contact with a Foot Patrol Needle and Syringe Programme. A pair of outreach workers (called “Foot Patrol”) wearing backpacks (marked with a discreet but recognisable logo) when contacted by either mobile phone or face to face contact, provide unlimited numbers of syringes, swabs and spoons to drug users between midday and 11.00 p.m., 7 days a week. Limited quantities of sterile water are also available for free. Pharmacists in the CBD at this time still sold small quantities of syringes for around $1 per syringe. The outreach service was heavily utilised with approximately 250–300 client contacts a day during 2000. Drug users can also return syringes to the workers, however only small quantities are returned to workers compared to the amounts returned through disposal bins in this busy commercial area. Quasi-supervised settings for injecting drug use During 2000 a public inquiry was held in Melbourne as to the feasibility of introducing supervised injecting facilities in active street drug markets. While the inquiry was being conducted it became apparent that three sites in Melbourne’s CBD had a number of attributes of a supervised setting for injecting without being sanctioned or approved by Government. Quasi-supervised settings are those that provide a limited level of supervision to respond to an overdose incident. Drug users are not assisted with injecting, nor are they provided with sterile injecting equipment in these settings. Quasi-supervised settings confer relative safety from the violence and unpredictability of the street environment through the presence of an independent third party who can respond to life threatening events. Quasi-supervision is a spatial condition where it is recognized that injecting is already occurring and where informal monitoring and supervision develops to ensure intervention if required. The first site, Baptist Place (a short alleyway behind a primary health service providing comfort to homeless young people), was monitored by a team of outreach workers who could respond to emergency calls through an elec-
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Fig. 1. Syringe disposal from January 1999 to August 2001 in Melbourne’s Central Business District (CBD). Vertical bars (left vertical axis) denote syringes collected in bins. Horizontal line (right vertical axis) denotes monthly number of syringes collected loose from the streets and lanes.
tronic buzzer located at the entrance of the laneway. The other two sites, the General Post Office toilets (GPO) and Collins Street public toilets, managed by local government, employed toilet supervisors who had an informal policy to “keep an eye” on drug users without harassing them. This approach to managing public toilets was developed by the Community Services Division of the City of Melbourne in an effort to reduce drug overdose deaths in public toilets. Street-based injecting drug use in the CBD Syringe disposal data illustrate large increases in the collection of syringes in the CBD from 1999 to 2001 (Fig. 1). In this paper, syringe disposal data is taken as an indicator of consumption specific to geographic location as there is little evidence to suggest that drug users who inject in other parts of Melbourne travel to the CBD to dispose of their syringes (Fitzgerald, Hope, et al., 1999). Whilst syringe distribution data could have been used as an indicator of consumption, distribution data does not specify the location of drug use. Syringe disposal is the most reliable local and geographically specific indicator of injecting drug use in the CBD. Whilst carrying used syringes for subsequent or repeated use may occur, we believe this is of limited impact for the findings of this study. Previous surveys in Melbourne (Kelsall et al., 2002) report carrying used syringes to be a major concern for drug users and in fact is the major factor leading to inappropriate disposal. We believe that it is more likely that drug users will dispose of their syringes rapidly after use rather than carry them and risk police harassment in an aggressive policing environment (Weatherburn et al., 1999). The number of loose syringes rarely exceeds 15% of total syringes collected and varies considerably over time (Fig. 1).
The loose syringes collected in the five most heavily used laneways represent 39% of all loose syringes. The loose syringes collected in the 10 most heavily used laneways represent 60% of all loose syringes (24,796 syringes) over the period 1998–2001. Typically, the collection of large numbers of loose syringes in a laneway can last for several months until drug use moves to an adjacent or neighbouring laneway in response to a range of displacement forces. Fig. 2 notes that binned syringe collection in GPO, Collins street toilets and Baptist Place (all supervised settings) increased substantially in the last 6 months of 2000 in contrast to non-supervised settings. Loose syringe collection in Baptist Place also increased in the July–December period compared to non-supervised settings in the CBD. Table 1 illustrates the changes in syringe collection from syringe bins in quasi-supervised settings compared to bins in unsupervised settings. The data suggest an increase in the use of quasi-supervised settings for injecting drug use in the CBD during the period of intense policing activity in July–December 2000. To this effect the percentage increase in binned syringes in quasi-supervised settings was some 70% greater than that in non-supervised settings. There was also a reduction in loose syringes collected in non-supervised settings from January 2000 to June 2000 compared to July 2000 to December 2000 that was 58% different from the increase in number of loose syringes collected observed in supervised settings. Street-based injecting requires only minimal seclusion from public view. Alcoves, doorways and laneways offer easy amenity for the preparation and injection of drugs. This amenity can be provided by either fixed built form or by transitory street furniture. Fig. 3 shows a shallow alcove with incident light from a floodlight that provided enough light to enable injecting to occur. As this young woman injector
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Fig. 2. Syringe disposal from syringe bins from January 2000 to December 2000 in Melbourne’s Central Business District (CBD). Horizontal lines (right vertical axis) denotes monthly number of syringes collected in syringe bins from the 10 most heavily used locations during 2000.
noted: That’s what I like about there [in the alcove], because that light’s on . . . and at night time its enough to see, but it’s not like a sensor light showing you that someone’s there (Bianca) A surveillance camera overlooking the above alcove provided little deterrence to injecting (Fig. 3). Bread crates sheltered the alcove from the view of passers-by. The degree of exposure for the drug user when preparing and injecting is however relatively high in this setting. There is still a risk of being disturbed by passers-by or police. For street-based injecting drug users, there is a balance between the risks of exposure and the risks of seclusion (Dovey et al., 2001).
Injecting in shallow or exposed settings increases the risk of being discovered by police or pedestrians. On the other hand, exposure can confer a degree of safety from other risks. In exposed settings, drug users can be found quite easily if they overdose, or if they are victims of violent drug-related crime. As we have argued elsewhere, injecting drug users are caught in a dilemma where increased safety from police brings increased danger from an overdose. As a result injecting does not necessarily occur in the deepest pockets of urban space but often in the interstitial spaces that reflect this tension between competing risks. In secluded settings drug users run the risk of not being found in an overdose situation. In addition, preparing drugs in seclusion can be risky if other drug users wish to use the opportunity to rob users of drugs or property. Seclusion can
Table 1 Changes in the number of syringes collected from syringe disposal bins (binned syringes) and syringes collected loose from the ground (loose syringes) in Melbourne’s Central Business District in 2000 from supervised settings (Baptist Place, General Post Office toilets and Town Hall toilets) and non-supervised settings
Binned syringes Quasi-supervised setting Non-supervised setting Loose syringes Quasi-supervised setting Non-supervised setting
January– June
July– December
Percent change
Odds ratio (95% CI)
11849
20248
71
0.705∗ (0.68–0.73)
16386
19735
20
742
993
34
5153
3576
−31
0.579∗ (0.52–0.64)
Percentage change column indicates the difference between the number of syringes collected in July–December period and those collected in the January–June period expressed as a percentage of the January–June period.
Fig. 3. Injecting location in Melbourne’s Central Business District (CBD). The alcove under the floodlight is protected from public view by packing crates.
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therefore also confer danger. Drug users inevitably balance these competing risks. Displacement of injecting Mapping data illustrates some important changes in the spatial distribution of public injecting over the period 1999–2001. In the first mapping fieldwork period (December 1999–January 2000) there was a high prevalence of injecting in public space in the retail precinct of the CBD with injecting occurring many times a day in laneways less than 40 m from “co-present” space (Fig. 4, upper panel). In the 1999–2000 fieldwork period, there was a high level of injecting occurring in shallow space as well as deep space in the CBD. These findings reflect similar attributes from another active street heroin market in Melbourne (Dovey et al., 2001). However, in 2001 using the same fieldwork techniques it was noted that the prevalence of areas with high frequency injecting had been reduced dramatically (Fig. 4, lower panel). The number of syringes collected in the syringe bin in Baptist Place (Fig. 5) increased 26% from 600 in January 2000 to 756 in December 2000. When comparing the syringe collection over the 6-month period of January–June to the July–December period, the increase in syringes collected from bins in Baptist Place similarly was 19%. There was a
Fig. 5. Baptist Place, a quasi-supervised injecting location in Melbourne’s Central Business District (CBD) during 2000. The entrance to the laneway is screened by several corners. The actual injecting location is hidden behind the parked car in the car port. Outreach workers supervise from the first floor of the adjacent building.
34% increase in the number of loose syringes collected from the ground in Baptist Place over the July–December period when compared to the previous 6 months. This increase is in contrast to changes in non-supervised laneways over this period (Table 1). This would suggest that displacement to
Fig. 4. The spatial distribution of injecting locations in the retail precinct of Melbourne’s Central Business District (CBD) over the period December 1999–January 2000 (upper panel) and May 2001–June 2001 (lower panel) in Melbourne’s street drug market. The drug use scale denotes the frequency of use (site used more than once daily, site used weekly). The grey distance scale denotes the degree of seclusion in either 10 m units or a turn of a corner. Spatial scale (blue and black shading) denotes publicly accessible or street space, respectively.
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these specific quasi-supervised laneway settings was more pronounced and perhaps more sustained in this period. The increase in the number of syringes, both binned and loose on the ground in Baptist Place is notable and in contrast to a widespread reduction in loose syringes in public space across Melbourne’s CBD in the July–December 2000 period (Table 1). Supervised settings provide a degree of sanctuary from the risk of the street market, however not all risks are eliminated in these quasi-supervised settings. For this interviewee the three primary issues were dirt, violence and police. While quasi-supervision can reduce risks to a certain extent, the setting was still regarded as unsafe. As this drug user noted: Baptist . . . it’s not clean, there’s fits [syringes] and shit [faeces] everywhere, you’re running a risk of getting the shit kicked out of you for whatever you have, . . . you’re running a really big risk with that, and the cops, I mean, in all, three things that I wouldn’t use a place for. Baptist has all three now—it never used to be, but now it does. (Matt) At the height of the displacement activities in the CBD the quasi-supervised laneway (Baptist Place) reduced some, but not all risks for drug users. Uniformed police patrolled the laneway several times each day. Covert police operations were also conducted in the laneway. The use of toilets provides a degree of supervision, however this may not be suitable to all drug users, and certainly not all risks were reduced in this quasi-supervised setting. Outreach workers were available on call through the placement of an alarm button in the laneway that alerted workers to an emergency in the laneway. Above the laneway, drug users could receive counselling and primary health care at specified times. Displacement of non-fatal overdose There are multiple factors that can contribute to the location of a non-fatal overdose. Drug affected people can change locations between the time of injecting and the time of attendance by ambulance officers (Fitzgerald et al., 2000). It is unclear what proportion of those who experience opioid overdose in Melbourne’s CBD were actually revived by ambulance officers in the setting in which they injected. Ambulance officers record the setting of ambulance attendance on patient care records from which distinctions can be drawn between indoor, outdoor, private and public space. Table 2 illustrates the number of overdoses occurring in indoor and outdoor settings independent of public or private ownership of the space. The majority of overdose attendances occur in public space in the CBD. On the basis of available data it is possible to make distinctions between five different types of outdoor settings (outdoors-public building, public space road, public space-park/vacant land, public space-toilet, and public space-railway station). Approximately 23% of non-fatal overdoses in the CBD during 2000 occurred in indoor settings. While the differ-
Table 2 The change in settings for non-fatal overdose in Melbourne’s Central Business District (CBD) in two, 6-month periods during 2000 Setting
January– June
July– December
Indoors
208
150
Outdoors
679
568
Total
Percent reduction
Odds ratio (95% CI)
358
28
1.15 (0.91–1.48)
1247
16
Percentage change indicates the difference between the number of nonfatal overdoses in July–December period and the January–June period, expressed as a percentage of the January–June period.
ences failed to reach statistical significance, Table 2 suggests that in the July–December 2000 period there was a greater reduction in non-fatal overdose in indoor settings (28%) than those reported in outdoor settings (16%) when compared to the January–June 2000 period. It is unclear as to the contribution of various types of public outdoor space to the difference between indoor and outdoor settings. Some outdoor settings actually had an increased number of overdoses over the July–December period when compared to the January–June period. Non-fatal overdoses in railway public toilets increased by 21% and overdoses in parks increased by 11% over the July–December period. These increases however account for only 7% of differences in non-fatal overdoses between the January–June and July–December periods. These increases in overdose in public space need to be seen in light of the 22% reduction in overdoses in roadside public space that accounts for 66% of the difference in total non-fatal overdoses between January–June and July–December periods. The variability accorded in recording location data, the known mobility of drug users in overdose situations (Fitzgerald et al., 2000) and the relatively low number of overdoses in some sub-categories makes comparison between sub-categories of public space difficult. The most salient and perhaps conservative interpretation of these results is that in the July–December period there were some differential changes to non-fatal overdose locations across indoor and outdoor settings compared to the January–June 2000 period. Health outcomes as a function of setting Fig. 6 illustrates the relationship between the number of non-fatal overdoses and syringes systematically collected from bins and street locations in Melbourne’s CBD. The rate of overdose is expressed as a function of drug consumption. The progressive reduction in the rate of non-fatal overdose per 1000 syringes collected over the 12-month period during 2000 is striking. The rate of overdose declined some 67% from 21/1000 syringes in January 2000 to 7/1000 syringes in December 2000. A key question is whether a change in the setting of drug use in some way contributes to a change in an acute health outcome such as drug overdose. Non-fatal overdose,
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Fig. 6. The rate of non-fatal overdose per 1000 syringes collected in Melbourne’s Central Business District (CBD) from June 1998 to December 2000. The horizontal line denotes monthly number of non-fatal overdoses expressed as a fraction of 1000 syringes collected each month.
expressed as a function of syringe use is a gross indicator of drug effect. There are many factors that contribute to the effect of a drug, only one of which is setting. Following from Zinberg’s framework, this relationship may indicate a change in the drug type (or in this situation a change in the combination of drugs consumed), drug purity, a change in setting, or a change in the mindset of the user. There is little indication as to the differential contributions of each of these factors. Data from the Illicit Drug Reporting System (IDRS) suggests a statewide reduction in heroin purity over this time period (Fry & Miller, 2001, 2002). There is little indication to suggest changes in mindset or a uniform change in the mix of drugs used during this period. There is no evidence that there has been a widespread or global change brought about by one of these factors. If there was an overall reduction in heroin purity or an overall change in user mindset, then the changes in non-fatal overdose should have been observed across both indoor and outdoor settings. The differential changes in non-fatal overdose between location types across the two, 6-month periods suggest setting is a substantive factor in determining acute health outcome. The only systematic data recorded over this period provides evidence of a change in drug use settings perhaps caused by displacement strategies. Without controlled scientific conditions, it is difficult to ascertain causal relationships between changes in drug use settings and health outcomes. It would appear however that these findings provide some evidence to suggest that changes in street drug use setting may contribute to health outcomes.
Conclusions The observed reduction in non-fatal overdose in Melbourne’s CBD certainly did not come about because of a reduction in injecting. It is not quite clear to what extent the reduction in the rate of overdose (as a function of consumption) has come about through each of the contributing factors: the displacement of public injecting to quasi-supervised settings, education initiatives with drug users, aggressive policing, displacement to other parts of Melbourne or the reported reduction in heroin purity. Police confiscations are not systematic and are unreliable in predicting localised changes in purity (James & Sutton, 2000; Sutton & James, 1996). A reduction in heroin purity may have been a factor, however the changes in overdose rate per unit consumption noted in Melbourne’s CBD were not noted in other parts of Melbourne. It is unlikely that heroin purity is the only determining factor as the reductions in non-fatal overdose were not experienced uniformly across different settings. Weatherburn et al. (2001) have suggested that aggressive street policing may reduce health harms related to the drug market. One aspect of this seemingly positive outcome from aggressive policing is that the positive outcome may not have come about if there were no quasi-supervised locations for people to move to in response to police pressure. In 2001, when high frequency injecting did occur in public space it was more likely to occur in deep space rather than shallow space. In terms of overdose risk, displacing drug use to more secluded and isolated locations may actually increase the
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risk of overdose. In some senses, if the quasi-supervised settings were not available at the time of the police activity, it could be suggested that there may have been an increase in fatal overdoses, and a much worse outcome from aggressive street policing. A combination of interventions may have resulted in improved health outcomes. The complexity of interrelationships in the social environment makes it difficult to isolate causal factors. Interpreting the impact of interventions in the social environment can be contrasted with controlled scientific interventions. There is a capacity to learn from the experience in Melbourne’s CBD even in the absence of being able to fully control for the factors that contribute to displacement effects. In this case, the combination of law enforcement and the provision of quasi-supervised injecting settings may have contributed substantively to the positive health outcomes. The actual mechanisms underpinning a reduction in non-fatal overdose (as a function of consumption) in the current context are not clear. Loxley and Davidson (1998) have suggested that taking time to inject smaller quantities (in order to titrate the dose more effectively) may reduce overdose. In a street environment however, increasing the amount of time spent preparing an injection increases the risk of detection. In quasi-supervised settings drug users may be able to spend more time titrating the dose used. This may be one mechanism underpinning the observed health outcome. Displacement of drug use to more supervised settings may have enabled drug users to spend more time and care in preparing their drugs. Despite the apparent reduction in non-fatal overdose rates, the quasi-supervised zones should not be seen as a solution to problems of public injecting for a number of reasons. The first is that they do not address the issue of hepatitis C transmission which looms as the most significant blood borne virus problem for Australian public health (Dore, 2001; Kaldor, Dore, & Correll, 2000). Quasi-supervised settings do not ensure the provision of clean equipment and water, nor do they prevent the sharing of drug use equipment. The sanctioning of injecting in these locations could be seen as a sanctioning of these known risks. Second, in terms of social health, it is not clear what impact the displacement of injecting into quasi-supervised settings has on constructions of social identity. As has been argued previously, the spatial context of injecting drug use is crucial to constructions of the self-identity and self-esteem of users (Hassin, 1994). The practices outlined above are enmeshed in a field of discourse, fuelled by the media, wherein images and identities of injecting drug users are reified and stereotyped through the spatial contexts of alleys and toilets (Duterte, Hemphill, Murphy, & Murphy, 2003). Key questions here include the ways in which self-identity and self-esteem are transformed with the shift in spatial context. Does the sanctioning of injecting in toilets undermine public health policies directed at building selfesteem?
It is clear that the state, local business and police generally sanction the use of quasi-supervised zones and they have various motives for doing so: it restores order to the streets, reduces the commercial impact on business and may save lives. Yet, quasi-supervised zones have emerged in the context of a long struggle to set up fully supervised injection facilities in Melbourne. Such moves have failed thus far despite evidence of the effectiveness of such facilities in other parts of Australia and around the world (Dolan et al., 2000; Van Beek, 2001). While the displacement of injecting to quasi-supervised zones appears to reduce the incidence of overdose, it has come about largely as a result of the failure to achieve fully supervised injecting facilities. In this context quasi-supervised zones should not be seen as a solution to problems of street-injecting so much as an interim effect of this failure.
Acknowledgements This work was supported by a project grant from the National Health and Medical Research Council. The authors would also like to thank Mark Young, Kathy Don and the staff at Youth Projects’ Foot Patrol Needle and Syringe Program for their crucial assistance in recruitment and data collection. The authors would also like to acknowledge the research assistance provided by Peta Malins, Ian Wright and Caitlin Hughes. The authors would also like to thank the Metropolitan Ambulance Service and the Department of Human Services for the provision of data on ambulance attendance and the City of Melbourne for the provision of needle and syringe disposal and city mapping data.
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Health outcomes and quasi-supervised settings for street injecting drug use J. Fitzgerald a,∗ , K. Dovey b , P. Dietze c , G. Rumbold d a Sociology Program, University of Melbourne, Parkville, 3010 Vic., Australia Faculty of Architecture, Building and Planning, University of Melbourne, Parkville, 3010 Vic., Australia Turning Point Alcohol and Drug Centre, Deakin University School of Health Sciences, 54-62 Gertrude Street Fitzroy, Vic. 3065, Australia d Centre for Applied Drug and Alcohol Research, Monash University, 900 Dandenong Rd Caulfied, 3145 Vic., Australia b
c
Received 3 July 2003; received in revised form 2 March 2004; accepted 17 March 2004
Abstract Over a 12-month period during 2000, public injecting in Melbourne’s Central Business District (CBD) was displaced by a range of aggressive policing strategies. Public injecting was displaced into quasi-supervised settings such as public toilets and an outreach-serviced laneway. There is a complex relationship between the setting of drug use and acute health outcomes. Over the period of displacement to quasi-supervised settings, there was a specific reduction in the rate of non-fatal overdose per 1000 syringes used in the CBD. The change in setting of drug use was coincident with a change in the location of non-fatal overdose incidents, with limited evidence of differential changes in the number of overdoses in indoor and outdoor settings. This limited evidence of a differential reduction in overdose according to setting suggests the possibility that a blanket reduction in heroin purity does not solely account for the observed changes in the rate of non-fatal overdose. The findings suggest that there is a complex relationship between better health outcomes and the context of injecting in street drug use locations. Given this complex relationships caution should be exercised when projecting the likely impacts of police displacement and public health strategies to reduce harm in street drug markets. © 2004 Elsevier B.V. All rights reserved. Keywords: Injecting drug use; Policing; Harm reduction; Non-fatal overdose
Introduction Open street drug markets expanded considerably in Australian capital cities between 1995 and 2001. With this change was a cultural shift from relatively private heroin trade in residential settings to a series of public open street drug marketplaces (Darke, Ross, & Kaye, 2001; Dietze & Fitzgerald, 2002; Dovey, Fitzgerald & Choi, 2001; Fitzgerald, Broad, & Dare, 1999). It has previously been suggested in Australia that street-based injecting drug users experience worse health outcomes than injecting drug users who use in other settings (Crofts, Caruana, Bowden, & Kerger, 2000; Darke et al., ∗ Corresponding author. Current address: Centre for the Study of Health and Society, The University of Melbourne, Victoria 3010, Australia. Tel.: +61-38344-9146; fax: +61-38344-0824. E-mail addresses: [email protected] (J. Fitzgerald), [email protected] (K. Dovey), [email protected] (P. Dietze), [email protected] (G. Rumbold).
0955-3959/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2004.03.002
2001; Fitzgerald, Broad, et al., 1999; Dixon & Maher, 1999; Maher et al., 2001). Aggressive street-based law enforcement has been implicated in the production of these negative health outcomes for this population (James & Sutton 2000; Dixon & Maher, 1999). Darke et al., found in a study of a sample of street-based injecting drug users, that nearly all subjects (96%) had injected in a public place, including cars (90%), public toilets (81%), the street (80%) and trains (55%). Frequent injectors in public places were more likely to be male, to have overdosed in the preceding 6 months, injected significantly more drug types, injected in more bodily injecting sites and had more current injection-related problems than other injecting drug users. A pattern of increased harm was associated with frequent public injecting. A recognised European response to open street marketplaces has been the implementation of supervised injecting facilities (Dolan et al., 2000). Whilst a supervised injecting facility is being trialled in one Australian city, two other Australian Cities (Melbourne and Canberra) have unsuc-
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cessfully attempted to introduce these facilities in order to reduce the impact of street drug markets. A key argument for providing supervised injecting is the displacement of injecting from public space to a managed private setting. It has been suggested that related to this displacement are better health outcomes for drug users such as reduced high risk injecting behaviour and reduced overdoses in public space. It has also been suggested that moving injecting to supervised locations also reduces public disorder and the visible presence of injecting paraphernalia (DPEC, 2000). Zinberg noted quite some time ago that the effects of a psychoactive drug are related to the drug, the mindset of the user and the drug use setting (Zinberg, 1984). Accordingly, displacement of public injecting drug use from public to supervised private settings should reduce acute health problems. In the past, local law enforcement has been a major force in displacing street-level drug markets (Edmunds et al., 1996). It has also been suggested that street-based law enforcement may actually reduce participation in drug marketplaces (Weatherburn, Jones, Freeman, & Makkai, 2001). Alternatively, it has been reported that aggressive policing in Australian cities can move street injecting into more secluded locations creating a heightened risk of overdose and harm (Dovey et al., 2001; Dixon & Maher, 1999). With the emergence of street markets and the active deployment of aggressive street-level policing in Melbourne it may be possible to examine the relationship between displacement strategies, injecting drug use location and the level of non-fatal overdose. The current study examines whether changes in injecting drug use settings caused by displacement activities in Melbourne’s Central Business District (CBD) created changes in drug consumption trends which resulted in better health outcomes for drug users and a reduced impact of the street drug market for the community.
Methods Overall the study had a multidisciplinary design with an interpretative cultural anthropology orientation (Geertz, 1983; Schwandt, 2000, Chap. 7) rather than a positivist public health orientation. In this sense, the emphasis was on developing a deeper understanding of public injecting through the interpretation of data rather than on a quasi-experimental research design using a positivist paradigm. We draw on both qualitative and quantitative data, and interpret this data in a similar manner as that used by Parker and colleagues (Parker et al., 1988). Use of multiple data sources and extensive fieldwork ensures a close proximity of researcher to the phenomenon under investigation (Denzin, 1994). This paper reports mostly on findings from the quantitative data. We used a number of data sources to ascertain drug use sites. Triangulation in this study involved the comparison
of data from seven sources: Needle and Syringe Program disposal database; fieldwork observations by the first author; qualitative interviews with drug users in the locations in which they inject (n = 30); quantitative interviews with drug users regarding their use of NSP and primary health services (n = 100); trace analysis (appearance of injecting paraphernalia in injecting locations); conducting syringe disposal with disposal workers; interviews with disposal workers; documentary photography of injecting sites (including systematic documentation of high use sites using digital video between 6.00 and 9.00 a.m. during the mapping period in 2001, and use of still image photography during daylight hours over the 3 years of fieldwork); and cross checking of maps of injecting locations with disposal workers. While we have only report here on data from some of these sources to ensure brevity, we gather some confidence in our observations from using such a variety of data sources. Simultaneous triangulation in this study has been used to achieve completeness of understanding rather than convergence as it is often used in positivist quantitative inquiry (see Quine & Taylor, 1998). The study was ethnographic in nature with a focus on utilising both quantitative and qualitative indicators to assist in this ethnography of place. An ethnography of place is different from ethnographies where the unit of analysis is a social network or bounded sub-cultural grouping. Place ethnographies use the geographic setting as the unit of analysis. Data was collected over a 3-year period from 1998 to 2001 during a long-term fieldwork contact with local service providers. In this period, the first author spent at least 2 days each week in the CBD in two, 4-week blocks of uninterrupted mapping and developed strong relationships with drug users and outreach workers. Routinely collected syringe disposal data Routinely collected syringe disposal data were used as a measure of consumption. Syringe disposal data were obtained from the City of Melbourne NSP disposal database. Loose syringes (those discarded in places other than syringe bins) were systematically collected daily by hand by the Foot Patrol Needle and Syringe Program on a fixed geographic schedule. Syringe bins located in toilets and streets and lanes were cleared regularly by a commercial contractor. Data from these collections were reported to the City of Melbourne on a regular basis. There are 148 disposal bins in the CBD. Over the period 2000–2001 between 70 and 80% of all syringes collected each month were collected in the 10 most-used syringe bins. The database has been in operation since January 1998. Non-systematic syringe collections were also conducted in response to specific demands. Non-systematic collections represented less than 5% of total syringe collection. Only data collected through systematic data collection methods have been included in this analysis. Data from outside the CBD has been ex-
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cluded from the analysis. Analysis of crucial changes in disposal numbers between setting types across times of differential policing activity was undertaken using Stata V8’s case-control procedure. Routinely collected non-fatal heroin overdose data base Summary data of ambulance attendance at non-fatal heroin overdose were obtained from an electronic database based on information extracted from patient care records completed by ambulance officers at the site of attendance. Only confirmed heroin-related non-fatal overdoses were included in the analysis. Confirmed heroin-related overdoses were defined as those overdose cases that responded positively to the administration of naloxone using respiration rate and cyanosis as primary indicators and an increase in respiration rate as the marker for heroin overdose (hereafter referred to as ‘overdose’). Other opioid drugs were excluded where possible (Dietze, Cantwell, & Burgess, 2002). Analysis of crucial changes in overdose numbers between setting types across times of differential policing activity was undertaken using Stata V8’s case-control procedure. The rate of overdose was also examined as a function of drug consumption. Monthly aggregates of non-fatal overdoses were expressed as a function of monthly totals of syringes collected in the study fieldsite. The trend in non-fatal overdose rates per unit consumption was examined using only descriptive statistics as it is a combined measure. Care should be taken when using combined measures as the source of variation in each data set is lost when they are combined. The combined measure should therefore be interpreted with due caution, mindful of an apparent flattening out of variation. The purpose of the combined measure is heuristic rather than explicatory. Interviews with drug users during 2000 In-depth data about drug use were obtained from both structured quantitative interviews (n = 100) and semi-structured qualitative interviews (n = 30) with injecting drug users. Quantitative interviews were conducted in cafés during 1999. Tape-recorded qualitative interviews on the in-depth attributes of drug use settings were conducted in cafés and in injecting sites where drug users prepared and injected their drugs in Melbourne’s CBD. Qualitative interviews were conducted from May 2000 to August 2000. Targeted network sampling (Watters & Biernacki 1989) was employed to recruit injecting drug users into the study. Only illicit drug users who purchased heroin or amphetamine in the CBD in the previous 6 months were interviewed. Recruitment was through contact with the Foot Patrol Needle and Syringe Program. These sampling strategies are consistent with, and developed from those routinely used in studies of hidden populations of drug users (Fitzgerald, Hope, & Dare, 1999; Van de Goor et al., 1992). As in most studies
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of illicit drug use that use non-probability sampling (even large scale cohort studies), it is inappropriate to generalise the results of the study to the broader illicit drug-using population or to other contexts. Indeed it is advised that the specific findings from this study should not be applied to other locations without due consideration of the local contextual factors that shape drug use. Qualitative interviews were tape recorded and emergent themes coded on minidisc. Segments of interview illustrating these emergent themes were transcribed. In the interpretative cultural anthropology tradition, complete transcripts of interview do not necessarily enhance the rigour of the analysis, rather, transcripts are in themselves a version of reality and an interpretation of the social action (Geertz, 1983). Selection of transcript excerpts is itself an interpretative act (see Emerson, Fretz, & Shaw, 1995: 8–9). As we had already completed extensive quantitative interview work in this fieldsite, the in-depth qualitative interviews explored the spatial practices of drug users in specific drug-using locations. Using an explicit focussed coding strategy (Emerson et al., 1995, p. 161) our analysis (and transcription) was delimited to specific content themes (locations, practices) and analytic constructs (such as identity, time and risk). Prior to participation in the study, interviewees were fully informed about the aims and procedures of the study and assured that all responses would be held confidentially subject to legal requirements. Participants received $20 for participation in the study. Findings from the quantitative interviews on primary health care needs of street-based injecting drug users have been reported previously (Fitzgerald, Hope, et al., 1999). Architectural mapping (1999 compared to 2001) Mapping was conducted using available urban planning data and additional data collected to determine accessible space and the degree of social exposure and seclusion in accessible space. Analysis of this data combined spatial syntax analysis with an analysis of functional mix and features of the built form. The spatial analysis consists of a series of layered mappings of the study area including pedestrian access networks, public/private ownership, functional mix and street life volume. These layered mappings of urban space are derived primarily from the field of urban design theory as those most likely to mediate behaviour and meaning in urban space (Dovey, 1999; Hillier, 1996; Jacobs, 1965). Analysis was conducted using a computer assisted design (CAD) package, producing both low resolution maps (drug use at a postcode level) and high resolution maps detailing injecting in shallow alcoves. Mapping the spatial locations of drug injecting involved triangulating across multiple data sources. Syringe disposal data were compared with data collected during fieldwork trace analysis. Fieldwork trace analysis is the systematic observation of spaces with a focus on the materials accu-
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mulating in spaces (see Dovey et al., 2001). In the current study this involved noting the presence of injecting paraphernalia in the systematic mapping of each laneway in the CBD during mapping periods. Fieldworkers between 8.00 a.m. and midday systematically monitored publicly accessible space with detailed maps of the city’s building footprint. Loading bays, window ledges, doorways (any perturbation of the footprint) were coded according to a fixed code that combined the number of syringes, number of open/closed syringe wrappers, swab packets, un/used swabs, spoons, and their physical state (recently used/old, stuck into walls, secreted into drain pipes or in open view) to make a judgement on the use of the site. Preliminary maps were then scrutinised by outreach workers and syringe disposal workers. Mapping fieldwork was conducted in two periods from December 1999 to January 2000 and from May 2001 to June 2001. The first fieldwork period coincided with high levels of loose syringes in public spaces and a highly active street drug marketplace, whereas the second period of fieldwork coincided with a drug market re-emerging from the heroin “drought” experienced from January 2001 to April 2001 (Dietze & Fitzgerald, 2002; Miller, Fry, & Dietze, 2001). The two periods of mapping fieldwork compare two quite different periods of activity in the street heroin market. Trace analysis provides a snapshot of use, measured in a systematic manner, contingent on the period of measurement. As noted above, trace analysis was supplemented with other data sources to account for the time-dependent nature of this data source. Exposure and seclusion is understood through attention to both the geometric properties of space and the social attributes of space (Dovey et al., 2001; Hillier, 1996). A primary mechanism for indexing the degree of seclusion/exposure in any setting is the distance from “co-present” space. Co-present space is space that is occupied at any point in time by more than one person. In spatial syntax terms the presence of another individual confers a type of natural surveillance that disciplines social actors, and reduces marginal or illicit behaviours (Hillier, 1996). Degrees of seclusion can be indexed to this space using physical distance or breaks in the line of sight (Dovey et al., 2001). Space that is “shallow” in a syntactical sense is space that is somewhat exposed. Deep space is space that is either physically distant from co-present space or space that is socially isolated through breaks in the line of sight. Maps describing the degree of seclusion/exposure were overlaid with drug use maps to determine the shifting patterns of injecting drug use across secluded/exposed settings. Ethics This study was approved by the University of Melbourne Human Research Ethics Committee.
Results Policing activity In July 2000 the police initiated ‘Operation Leader’ in Melbourne’s Central Business District (CBD), an aggressive anti-drugs policing operation which involved electronic surveillance of streets, covert buy-busts, plain clothed undercover police, the dog squad and increased uniformed presence (The Age, July 14, 2000: 11). The operation continued through 2000 and into 2001. Ethnographic fieldwork (which included interviews with injecting drug users) was conducted during this period of intense policing activity. Needle and Syringe Programme services in the CBD During 2000 street-based injecting drug users had access to free needle and syringes through contact with a Foot Patrol Needle and Syringe Programme. A pair of outreach workers (called “Foot Patrol”) wearing backpacks (marked with a discreet but recognisable logo) when contacted by either mobile phone or face to face contact, provide unlimited numbers of syringes, swabs and spoons to drug users between midday and 11.00 p.m., 7 days a week. Limited quantities of sterile water are also available for free. Pharmacists in the CBD at this time still sold small quantities of syringes for around $1 per syringe. The outreach service was heavily utilised with approximately 250–300 client contacts a day during 2000. Drug users can also return syringes to the workers, however only small quantities are returned to workers compared to the amounts returned through disposal bins in this busy commercial area. Quasi-supervised settings for injecting drug use During 2000 a public inquiry was held in Melbourne as to the feasibility of introducing supervised injecting facilities in active street drug markets. While the inquiry was being conducted it became apparent that three sites in Melbourne’s CBD had a number of attributes of a supervised setting for injecting without being sanctioned or approved by Government. Quasi-supervised settings are those that provide a limited level of supervision to respond to an overdose incident. Drug users are not assisted with injecting, nor are they provided with sterile injecting equipment in these settings. Quasi-supervised settings confer relative safety from the violence and unpredictability of the street environment through the presence of an independent third party who can respond to life threatening events. Quasi-supervision is a spatial condition where it is recognized that injecting is already occurring and where informal monitoring and supervision develops to ensure intervention if required. The first site, Baptist Place (a short alleyway behind a primary health service providing comfort to homeless young people), was monitored by a team of outreach workers who could respond to emergency calls through an elec-
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Fig. 1. Syringe disposal from January 1999 to August 2001 in Melbourne’s Central Business District (CBD). Vertical bars (left vertical axis) denote syringes collected in bins. Horizontal line (right vertical axis) denotes monthly number of syringes collected loose from the streets and lanes.
tronic buzzer located at the entrance of the laneway. The other two sites, the General Post Office toilets (GPO) and Collins Street public toilets, managed by local government, employed toilet supervisors who had an informal policy to “keep an eye” on drug users without harassing them. This approach to managing public toilets was developed by the Community Services Division of the City of Melbourne in an effort to reduce drug overdose deaths in public toilets. Street-based injecting drug use in the CBD Syringe disposal data illustrate large increases in the collection of syringes in the CBD from 1999 to 2001 (Fig. 1). In this paper, syringe disposal data is taken as an indicator of consumption specific to geographic location as there is little evidence to suggest that drug users who inject in other parts of Melbourne travel to the CBD to dispose of their syringes (Fitzgerald, Hope, et al., 1999). Whilst syringe distribution data could have been used as an indicator of consumption, distribution data does not specify the location of drug use. Syringe disposal is the most reliable local and geographically specific indicator of injecting drug use in the CBD. Whilst carrying used syringes for subsequent or repeated use may occur, we believe this is of limited impact for the findings of this study. Previous surveys in Melbourne (Kelsall et al., 2002) report carrying used syringes to be a major concern for drug users and in fact is the major factor leading to inappropriate disposal. We believe that it is more likely that drug users will dispose of their syringes rapidly after use rather than carry them and risk police harassment in an aggressive policing environment (Weatherburn et al., 1999). The number of loose syringes rarely exceeds 15% of total syringes collected and varies considerably over time (Fig. 1).
The loose syringes collected in the five most heavily used laneways represent 39% of all loose syringes. The loose syringes collected in the 10 most heavily used laneways represent 60% of all loose syringes (24,796 syringes) over the period 1998–2001. Typically, the collection of large numbers of loose syringes in a laneway can last for several months until drug use moves to an adjacent or neighbouring laneway in response to a range of displacement forces. Fig. 2 notes that binned syringe collection in GPO, Collins street toilets and Baptist Place (all supervised settings) increased substantially in the last 6 months of 2000 in contrast to non-supervised settings. Loose syringe collection in Baptist Place also increased in the July–December period compared to non-supervised settings in the CBD. Table 1 illustrates the changes in syringe collection from syringe bins in quasi-supervised settings compared to bins in unsupervised settings. The data suggest an increase in the use of quasi-supervised settings for injecting drug use in the CBD during the period of intense policing activity in July–December 2000. To this effect the percentage increase in binned syringes in quasi-supervised settings was some 70% greater than that in non-supervised settings. There was also a reduction in loose syringes collected in non-supervised settings from January 2000 to June 2000 compared to July 2000 to December 2000 that was 58% different from the increase in number of loose syringes collected observed in supervised settings. Street-based injecting requires only minimal seclusion from public view. Alcoves, doorways and laneways offer easy amenity for the preparation and injection of drugs. This amenity can be provided by either fixed built form or by transitory street furniture. Fig. 3 shows a shallow alcove with incident light from a floodlight that provided enough light to enable injecting to occur. As this young woman injector
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Fig. 2. Syringe disposal from syringe bins from January 2000 to December 2000 in Melbourne’s Central Business District (CBD). Horizontal lines (right vertical axis) denotes monthly number of syringes collected in syringe bins from the 10 most heavily used locations during 2000.
noted: That’s what I like about there [in the alcove], because that light’s on . . . and at night time its enough to see, but it’s not like a sensor light showing you that someone’s there (Bianca) A surveillance camera overlooking the above alcove provided little deterrence to injecting (Fig. 3). Bread crates sheltered the alcove from the view of passers-by. The degree of exposure for the drug user when preparing and injecting is however relatively high in this setting. There is still a risk of being disturbed by passers-by or police. For street-based injecting drug users, there is a balance between the risks of exposure and the risks of seclusion (Dovey et al., 2001).
Injecting in shallow or exposed settings increases the risk of being discovered by police or pedestrians. On the other hand, exposure can confer a degree of safety from other risks. In exposed settings, drug users can be found quite easily if they overdose, or if they are victims of violent drug-related crime. As we have argued elsewhere, injecting drug users are caught in a dilemma where increased safety from police brings increased danger from an overdose. As a result injecting does not necessarily occur in the deepest pockets of urban space but often in the interstitial spaces that reflect this tension between competing risks. In secluded settings drug users run the risk of not being found in an overdose situation. In addition, preparing drugs in seclusion can be risky if other drug users wish to use the opportunity to rob users of drugs or property. Seclusion can
Table 1 Changes in the number of syringes collected from syringe disposal bins (binned syringes) and syringes collected loose from the ground (loose syringes) in Melbourne’s Central Business District in 2000 from supervised settings (Baptist Place, General Post Office toilets and Town Hall toilets) and non-supervised settings
Binned syringes Quasi-supervised setting Non-supervised setting Loose syringes Quasi-supervised setting Non-supervised setting
January– June
July– December
Percent change
Odds ratio (95% CI)
11849
20248
71
0.705∗ (0.68–0.73)
16386
19735
20
742
993
34
5153
3576
−31
0.579∗ (0.52–0.64)
Percentage change column indicates the difference between the number of syringes collected in July–December period and those collected in the January–June period expressed as a percentage of the January–June period.
Fig. 3. Injecting location in Melbourne’s Central Business District (CBD). The alcove under the floodlight is protected from public view by packing crates.
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therefore also confer danger. Drug users inevitably balance these competing risks. Displacement of injecting Mapping data illustrates some important changes in the spatial distribution of public injecting over the period 1999–2001. In the first mapping fieldwork period (December 1999–January 2000) there was a high prevalence of injecting in public space in the retail precinct of the CBD with injecting occurring many times a day in laneways less than 40 m from “co-present” space (Fig. 4, upper panel). In the 1999–2000 fieldwork period, there was a high level of injecting occurring in shallow space as well as deep space in the CBD. These findings reflect similar attributes from another active street heroin market in Melbourne (Dovey et al., 2001). However, in 2001 using the same fieldwork techniques it was noted that the prevalence of areas with high frequency injecting had been reduced dramatically (Fig. 4, lower panel). The number of syringes collected in the syringe bin in Baptist Place (Fig. 5) increased 26% from 600 in January 2000 to 756 in December 2000. When comparing the syringe collection over the 6-month period of January–June to the July–December period, the increase in syringes collected from bins in Baptist Place similarly was 19%. There was a
Fig. 5. Baptist Place, a quasi-supervised injecting location in Melbourne’s Central Business District (CBD) during 2000. The entrance to the laneway is screened by several corners. The actual injecting location is hidden behind the parked car in the car port. Outreach workers supervise from the first floor of the adjacent building.
34% increase in the number of loose syringes collected from the ground in Baptist Place over the July–December period when compared to the previous 6 months. This increase is in contrast to changes in non-supervised laneways over this period (Table 1). This would suggest that displacement to
Fig. 4. The spatial distribution of injecting locations in the retail precinct of Melbourne’s Central Business District (CBD) over the period December 1999–January 2000 (upper panel) and May 2001–June 2001 (lower panel) in Melbourne’s street drug market. The drug use scale denotes the frequency of use (site used more than once daily, site used weekly). The grey distance scale denotes the degree of seclusion in either 10 m units or a turn of a corner. Spatial scale (blue and black shading) denotes publicly accessible or street space, respectively.
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these specific quasi-supervised laneway settings was more pronounced and perhaps more sustained in this period. The increase in the number of syringes, both binned and loose on the ground in Baptist Place is notable and in contrast to a widespread reduction in loose syringes in public space across Melbourne’s CBD in the July–December 2000 period (Table 1). Supervised settings provide a degree of sanctuary from the risk of the street market, however not all risks are eliminated in these quasi-supervised settings. For this interviewee the three primary issues were dirt, violence and police. While quasi-supervision can reduce risks to a certain extent, the setting was still regarded as unsafe. As this drug user noted: Baptist . . . it’s not clean, there’s fits [syringes] and shit [faeces] everywhere, you’re running a risk of getting the shit kicked out of you for whatever you have, . . . you’re running a really big risk with that, and the cops, I mean, in all, three things that I wouldn’t use a place for. Baptist has all three now—it never used to be, but now it does. (Matt) At the height of the displacement activities in the CBD the quasi-supervised laneway (Baptist Place) reduced some, but not all risks for drug users. Uniformed police patrolled the laneway several times each day. Covert police operations were also conducted in the laneway. The use of toilets provides a degree of supervision, however this may not be suitable to all drug users, and certainly not all risks were reduced in this quasi-supervised setting. Outreach workers were available on call through the placement of an alarm button in the laneway that alerted workers to an emergency in the laneway. Above the laneway, drug users could receive counselling and primary health care at specified times. Displacement of non-fatal overdose There are multiple factors that can contribute to the location of a non-fatal overdose. Drug affected people can change locations between the time of injecting and the time of attendance by ambulance officers (Fitzgerald et al., 2000). It is unclear what proportion of those who experience opioid overdose in Melbourne’s CBD were actually revived by ambulance officers in the setting in which they injected. Ambulance officers record the setting of ambulance attendance on patient care records from which distinctions can be drawn between indoor, outdoor, private and public space. Table 2 illustrates the number of overdoses occurring in indoor and outdoor settings independent of public or private ownership of the space. The majority of overdose attendances occur in public space in the CBD. On the basis of available data it is possible to make distinctions between five different types of outdoor settings (outdoors-public building, public space road, public space-park/vacant land, public space-toilet, and public space-railway station). Approximately 23% of non-fatal overdoses in the CBD during 2000 occurred in indoor settings. While the differ-
Table 2 The change in settings for non-fatal overdose in Melbourne’s Central Business District (CBD) in two, 6-month periods during 2000 Setting
January– June
July– December
Indoors
208
150
Outdoors
679
568
Total
Percent reduction
Odds ratio (95% CI)
358
28
1.15 (0.91–1.48)
1247
16
Percentage change indicates the difference between the number of nonfatal overdoses in July–December period and the January–June period, expressed as a percentage of the January–June period.
ences failed to reach statistical significance, Table 2 suggests that in the July–December 2000 period there was a greater reduction in non-fatal overdose in indoor settings (28%) than those reported in outdoor settings (16%) when compared to the January–June 2000 period. It is unclear as to the contribution of various types of public outdoor space to the difference between indoor and outdoor settings. Some outdoor settings actually had an increased number of overdoses over the July–December period when compared to the January–June period. Non-fatal overdoses in railway public toilets increased by 21% and overdoses in parks increased by 11% over the July–December period. These increases however account for only 7% of differences in non-fatal overdoses between the January–June and July–December periods. These increases in overdose in public space need to be seen in light of the 22% reduction in overdoses in roadside public space that accounts for 66% of the difference in total non-fatal overdoses between January–June and July–December periods. The variability accorded in recording location data, the known mobility of drug users in overdose situations (Fitzgerald et al., 2000) and the relatively low number of overdoses in some sub-categories makes comparison between sub-categories of public space difficult. The most salient and perhaps conservative interpretation of these results is that in the July–December period there were some differential changes to non-fatal overdose locations across indoor and outdoor settings compared to the January–June 2000 period. Health outcomes as a function of setting Fig. 6 illustrates the relationship between the number of non-fatal overdoses and syringes systematically collected from bins and street locations in Melbourne’s CBD. The rate of overdose is expressed as a function of drug consumption. The progressive reduction in the rate of non-fatal overdose per 1000 syringes collected over the 12-month period during 2000 is striking. The rate of overdose declined some 67% from 21/1000 syringes in January 2000 to 7/1000 syringes in December 2000. A key question is whether a change in the setting of drug use in some way contributes to a change in an acute health outcome such as drug overdose. Non-fatal overdose,
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Fig. 6. The rate of non-fatal overdose per 1000 syringes collected in Melbourne’s Central Business District (CBD) from June 1998 to December 2000. The horizontal line denotes monthly number of non-fatal overdoses expressed as a fraction of 1000 syringes collected each month.
expressed as a function of syringe use is a gross indicator of drug effect. There are many factors that contribute to the effect of a drug, only one of which is setting. Following from Zinberg’s framework, this relationship may indicate a change in the drug type (or in this situation a change in the combination of drugs consumed), drug purity, a change in setting, or a change in the mindset of the user. There is little indication as to the differential contributions of each of these factors. Data from the Illicit Drug Reporting System (IDRS) suggests a statewide reduction in heroin purity over this time period (Fry & Miller, 2001, 2002). There is little indication to suggest changes in mindset or a uniform change in the mix of drugs used during this period. There is no evidence that there has been a widespread or global change brought about by one of these factors. If there was an overall reduction in heroin purity or an overall change in user mindset, then the changes in non-fatal overdose should have been observed across both indoor and outdoor settings. The differential changes in non-fatal overdose between location types across the two, 6-month periods suggest setting is a substantive factor in determining acute health outcome. The only systematic data recorded over this period provides evidence of a change in drug use settings perhaps caused by displacement strategies. Without controlled scientific conditions, it is difficult to ascertain causal relationships between changes in drug use settings and health outcomes. It would appear however that these findings provide some evidence to suggest that changes in street drug use setting may contribute to health outcomes.
Conclusions The observed reduction in non-fatal overdose in Melbourne’s CBD certainly did not come about because of a reduction in injecting. It is not quite clear to what extent the reduction in the rate of overdose (as a function of consumption) has come about through each of the contributing factors: the displacement of public injecting to quasi-supervised settings, education initiatives with drug users, aggressive policing, displacement to other parts of Melbourne or the reported reduction in heroin purity. Police confiscations are not systematic and are unreliable in predicting localised changes in purity (James & Sutton, 2000; Sutton & James, 1996). A reduction in heroin purity may have been a factor, however the changes in overdose rate per unit consumption noted in Melbourne’s CBD were not noted in other parts of Melbourne. It is unlikely that heroin purity is the only determining factor as the reductions in non-fatal overdose were not experienced uniformly across different settings. Weatherburn et al. (2001) have suggested that aggressive street policing may reduce health harms related to the drug market. One aspect of this seemingly positive outcome from aggressive policing is that the positive outcome may not have come about if there were no quasi-supervised locations for people to move to in response to police pressure. In 2001, when high frequency injecting did occur in public space it was more likely to occur in deep space rather than shallow space. In terms of overdose risk, displacing drug use to more secluded and isolated locations may actually increase the
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risk of overdose. In some senses, if the quasi-supervised settings were not available at the time of the police activity, it could be suggested that there may have been an increase in fatal overdoses, and a much worse outcome from aggressive street policing. A combination of interventions may have resulted in improved health outcomes. The complexity of interrelationships in the social environment makes it difficult to isolate causal factors. Interpreting the impact of interventions in the social environment can be contrasted with controlled scientific interventions. There is a capacity to learn from the experience in Melbourne’s CBD even in the absence of being able to fully control for the factors that contribute to displacement effects. In this case, the combination of law enforcement and the provision of quasi-supervised injecting settings may have contributed substantively to the positive health outcomes. The actual mechanisms underpinning a reduction in non-fatal overdose (as a function of consumption) in the current context are not clear. Loxley and Davidson (1998) have suggested that taking time to inject smaller quantities (in order to titrate the dose more effectively) may reduce overdose. In a street environment however, increasing the amount of time spent preparing an injection increases the risk of detection. In quasi-supervised settings drug users may be able to spend more time titrating the dose used. This may be one mechanism underpinning the observed health outcome. Displacement of drug use to more supervised settings may have enabled drug users to spend more time and care in preparing their drugs. Despite the apparent reduction in non-fatal overdose rates, the quasi-supervised zones should not be seen as a solution to problems of public injecting for a number of reasons. The first is that they do not address the issue of hepatitis C transmission which looms as the most significant blood borne virus problem for Australian public health (Dore, 2001; Kaldor, Dore, & Correll, 2000). Quasi-supervised settings do not ensure the provision of clean equipment and water, nor do they prevent the sharing of drug use equipment. The sanctioning of injecting in these locations could be seen as a sanctioning of these known risks. Second, in terms of social health, it is not clear what impact the displacement of injecting into quasi-supervised settings has on constructions of social identity. As has been argued previously, the spatial context of injecting drug use is crucial to constructions of the self-identity and self-esteem of users (Hassin, 1994). The practices outlined above are enmeshed in a field of discourse, fuelled by the media, wherein images and identities of injecting drug users are reified and stereotyped through the spatial contexts of alleys and toilets (Duterte, Hemphill, Murphy, & Murphy, 2003). Key questions here include the ways in which self-identity and self-esteem are transformed with the shift in spatial context. Does the sanctioning of injecting in toilets undermine public health policies directed at building selfesteem?
It is clear that the state, local business and police generally sanction the use of quasi-supervised zones and they have various motives for doing so: it restores order to the streets, reduces the commercial impact on business and may save lives. Yet, quasi-supervised zones have emerged in the context of a long struggle to set up fully supervised injection facilities in Melbourne. Such moves have failed thus far despite evidence of the effectiveness of such facilities in other parts of Australia and around the world (Dolan et al., 2000; Van Beek, 2001). While the displacement of injecting to quasi-supervised zones appears to reduce the incidence of overdose, it has come about largely as a result of the failure to achieve fully supervised injecting facilities. In this context quasi-supervised zones should not be seen as a solution to problems of street-injecting so much as an interim effect of this failure.
Acknowledgements This work was supported by a project grant from the National Health and Medical Research Council. The authors would also like to thank Mark Young, Kathy Don and the staff at Youth Projects’ Foot Patrol Needle and Syringe Program for their crucial assistance in recruitment and data collection. The authors would also like to acknowledge the research assistance provided by Peta Malins, Ian Wright and Caitlin Hughes. The authors would also like to thank the Metropolitan Ambulance Service and the Department of Human Services for the provision of data on ambulance attendance and the City of Melbourne for the provision of needle and syringe disposal and city mapping data.
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