Occupational Safety in the Age of the Opioid Crisis: Needle Stick Injury among Baltimore Police

Experiences of the National Post-Exposure Prophylaxis Hotline (PEPline): Occupational PEP consultation needs and trends, 2014 to 2022

BACKGROUND

The National Clinician Consultation Center operates the Post-Exposure Prophylaxis Hotline (PEPline), a federally-funded educational resource providing bloodborne pathogen exposure management teleconsultation to US clinicians.

METHODS

Sixty-seven thousand one hundred nine occupational post-exposure prophylaxis (PEP) consultations (January 2014 to December 2022) were retrospectively analyzed to describe PEPline utilization and common inquiries addressed by National Clinician Consultation Center consultants.

RESULTS

Most calls involved percutaneous incidents (70%); blood was the most common body fluid discussed (60%). Inpatient units were the most common exposure setting (35%) and licensed nursing professionals were the most common category of exposed workers (28%). Of 2,295 calls where workers had already initiated PEP for human immunodeficiency virus (HIV) prevention and time to first dose was known, 9% had initiated HIV PEP within 2 hours of exposure; almost 80% had initiated HIV PEP between 2 and 24 hours; 3% after 24 to 36 hours; 5% after 36 to 72 hours; and 2% after 72 hours. Calls from urgent care providers increased by 10% over time. Overall, more than 90% of callers requested support on risk assessment, including source person testing; other common questions involved PEP side effects and follow-up care.

CONCLUSIONS

PEPline consultations can help raise awareness about PEP availability and timely initiation, and reduce stigma by addressing common misperceptions about bloodborne pathogen transmission mechanisms and likelihood, particularly regarding HIV.

A Qualitative Investigation into the Trauma Exhibited by First Responders Impacted by the Opioid Epidemic

This qualitative study aimed to capture the lived experiences of first responders (FRs) combatting the opioid epidemic in an effort to better understand how the increase in opioids, opioid-related harm, and opioid-related death has affected the FR profession. FRs (N = 30) from Tennessee partook in semi-structured interviews investigating the impact of responding to opioid-related incidents. Using a phenomenological approach, three response themes emerged including (1) opioid epidemic burden on FR mental health, (2) variable availability and effectiveness of resources, and (3) identified roles of FRs in reducing the impact of the epidemic. The findings indicate that FRs are experiencing posttraumatic stress and secondary traumatic stress symptoms due to a shift in their duties, as well as repeated exposures to the adverse impacts of opioid use. This study finds a deficit in resources and support to combat the mental health repercussions FRs have experienced due to the epidemic. Given that FRs are often directly involved in preventing opioid-related deaths, ensuring that they are well resourced is an essential component of harm reduction and will ultimately augment care for individuals experiencing opioid-related harm.

A Qualitative Study: An Examination of Police Officers' Lived Experiences During the COVID-19 Pandemic

In the spring of 2020, the COVID-19 pandemic spread across the globe prompting stay-at-home orders for all but the most essential workers in society. Policing was one of the professions that is essential for community safety, regardless of the circumstances. Officers were on the front-line of the COVID-19 public health crisis and their preparedness was crucial for officer and community health. During the onset of the pandemic little was known about how officers perceived the virus and how police agencies prepared officers to work in a highly contagious environment. This study used semistructured interviews of police officers in two states in the United States that had elevated cases of the virus. The authors explored the lived experiences of police officers to explore officers' perceptions, concerns, implications the pandemic had on patrol activity, and agency preparedness during the onset of the COVID-19 pandemic. The results revealed structural and cultural forces that resulted in officers and their agency leadership not taking the pandemic seriously, ill-preparation and ill-equipping, and disincentives in reporting exposure. Moreover, officers' fears were largely not based on their own well-being, but on the risk of spreading the disease to their family members.

Evaluation of an Experimental Web-based Educational Module on Opioid-related Occupational Safety Among Police Officers: Protocol for a Randomized Pragmatic Trial to Minimize Barriers to Overdose Response

BACKGROUND

As drug-related morbidity and mortality continue to surge, police officers are on the front lines of the North American overdose (OD) crisis. Drug law enforcement shapes health risks among people who use drugs (PWUD), while also impacting the occupational health and wellness of officers. Effective interventions to align law enforcement practices with public health and occupational safety goals remain underresearched.

OBJECTIVE

The Opioids and Police Safety Study (OPS) aims to shift police practices relating to PWUD. It adapts and evaluates the relative effectiveness of a curriculum that bundles content on public health promotion with occupational risk reduction (ORR) to supplement a web-based OD response and naloxone training platform (GetNaloxoneNow.org, or GNN). This novel approach has the potential to improve public health and occupational safety practices, including using naloxone to reverse ODs, referring PWUD to treatment and other supportive services, and avoiding syringe confiscation.

METHODS

This longitudinal study uses a randomized pragmatic trial design. A sample of 300 active-duty police officers from select counties in Pennsylvania, Vermont, and New Hampshire with high OD fatality rates will be randomized (n=150 each) to either the experimental arm (GNN + OPS) or the control arm (GNN + COVID-19 ORR). A pre- and posttraining survey will be administered to all 300 officers, after which they will be administered quarterly surveys for 12 months. A subsample of police officers will also be qualitatively followed in a simultaneous embedded mixed-methods approach. Research ethics approval was obtained from the New York University Institutional Review Board.

RESULTS

Results will provide an understanding of the experiences, knowledge, and perceptions of this sample of law enforcement personnel. Generalized linear models will be used to analyze differences in key behavioral outcomes between the participants in each of the 2 study arms and across multiple time points (anticipated minimum effect size to be detected, d=0.50). Findings will be disseminated widely, and the training products will be available nationally once the study is completed.

CONCLUSIONS

The OPS is the first study to longitudinally assess the impact of a web-based opioid-related ORR intervention for law enforcement in the U.S. Our randomized pragmatic clinical trial aims to remove barriers to life-saving police engagement with PWUD/people who inject drugs by focusing both on the safety of law enforcement and evidence-based and best practices for working with persons at risk of an opioid OD. Our simultaneous embedded mixed-methods approach will provide empirical evaluation of the diffusion of the naloxone-based response among law enforcement.

TRIAL REGISTRATION

ClinicalTrail.gov NCT05008523; https://clinicaltrials.gov/show/NCT05008523.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33451.

Occupational Safety and Health and Illicit Opioids: State of the Research on Protecting Against the Threat of Occupational Exposure

The nationwide opioid crisis continues to affect not only people who use opioids but also communities at large by increasing the risk of accidental occupational exposure to illicit opioids. In addition, the emergence of highly potent synthetic opioids such as fentanyl and carfentanil increases the need to protect workers who may encounter unknown drug substances during job activities. To support the National Institute for Occupational Safety and Health Opioids Research Gaps Working Group, we examined the state of the literature concerning methods to protect workers against accidental occupational exposure to illicit opioids, and have identified unmet research needs concerning personal protective equipment, decontamination methods, and engineering controls. Additional studies are needed to overcome gaps in technical knowledge about personal protective equipment, decontamination, and control methods, and gaps in understanding how these measures are utilized by workers. Increasing our knowledge of how to protect against exposure to illicit opioids has the potential to improve occupational health across communities.

Reducing police occupational needle stick injury risk following an interactive training: the SHIELD cohort study in Mexico

Objective

At a time of unprecedented attention to the public health impact of policing, it is imperative to understand the role of occupational safety in shaping officer behaviours. We assessed the longitudinal impact of police training in a quasi-experimental hybrid type-1 trial to reduce syringe-related occupational risk, while realigning police practices with public health prevention among people who inject drugs (PWID).

Setting

Tijuana, Mexico.

Participants

Of 1806 Tijuana municipal police trainees, 771 reporting previous exposure to syringes were randomly selected for follow-up. All participants completed at least one follow-up visit; attrition at 24 months was 8%.

Intervention

Between 2015 and 2016, officers received a training intervention (Safety and Health Integration in the Enforcement of Laws on Drugs, SHIELD) bundling occupational needle stick injury (NSI) prevention with health promotion among PWID.

Outcome measures

Longitudinal analysis with generalised linear mixed models to evaluate training impact on occupational NSI risk via NSI incidence and prevalidated Syringe Threat and Injury Correlates (STIC) score. This composite indicator integrates five self-reported risky syringe-handling practices (eg, syringe confiscation, breaking) and was used as a proxy for NSI risk due to reporting bias and concerns about reliability of NSI incidence reports.

Results

No change in self-reported NSI incidence was observed, but significant reductions in risk (16.2% decrease in STIC score) occurred at 3 months, with a sustained decrease of 17.8% through 24 months, compared with pretraining (p<0.001). Police assignment (patrol vs administration) moderated the training effect (p=0.01). Younger age, male gender, lower rank and previous NSI were independently and significantly associated with higher NSI risk overtime, although all groups demonstrated significant reductions post-training.

Conclusions

SHIELD is the first intervention to be associated with significant sustained changes in police practices that pose risk for both occupational and the public’s health. Integrating occupational safety and public health education should inform other interventions to mitigate the community health detriments of policing behaviours.

Trial registration number

NCT02444403.

Preferences and acceptability of law enforcement initiated referrals for people who inject drugs: a mixed methods analysis

BACKGROUND

Law enforcement officers (LEOs) come into frequent contact with people who inject drugs (PWID). Through service referrals, LEOs may facilitate PWID engagement in harm reduction, substance use treatment, and other health and supportive services. Little is known about PWID and LEO attitudes and concerns about service referrals, however. The objective of this mixed-methods study was to examine the alignment of service referral preferences and acceptability among PWID and LEOs in Tijuana, Mexico.

METHODS

We assessed service referral preferences and perceived likelihood of participation in health and social services, integrating data from structured questionnaires with 280 PWID and 306 LEOs, contextualized by semi-structured interviews and focus groups with 15 PWID and 17 LEOs enrolled in two parallel longitudinal cohorts in Tijuana, Mexico.

RESULTS

Among potential service referral options, both PWID (78%) and LEOs (88%) most frequently cited assistance with drug- and alcohol-use disorders. Over half of PWID and LEOs supported including harm reduction services such as syringe service programs, overdose prevention, and HIV testing. The majority of PWID supported LEO referrals to programs that addressed basic structural needs (e.g. personal care [62%], food assistance [61%], housing assistance [58%]). However, the proportion of LEOs (30-45%) who endorsed these service referrals was significantly lower (p <  0.01). Regarding referral acceptability, 71% of PWID reported they would be very likely or somewhat likely to make use of a referral compared to 94% of LEOs reporting that they thought PWID would always or sometimes utilize them. These results were echoed in the qualitative analysis, although practical barriers to referrals emerged, whereby PWID were less optimistic that they would utilize referrals compared to LEOs.

CONCLUSIONS

We identified strong support for LEO service referrals among both LEO and PWID respondents, with the highest preference for substance use treatment. LEO referral programs offer opportunities to deflect PWID contact with carceral systems while facilitating access to health and social services. However, appropriate investments and political will are needed to develop an evidence-based (integrated) service infrastructure.

Addressing Police Occupational Safety During an Opioid Crisis: The Syringe Threat and Injury Correlates (STIC) Score

OBJECTIVE

To develop and validate syringe threat and injury correlates (STIC) score to measure police vulnerability to needlestick injury (NSI).

METHODS

Tijuana police officers (N = 1788) received NSI training (2015 to 2016). STIC score incorporates five self-reported behaviors: syringe confiscation, transportation, breaking, discarding, and arrest for syringe possession. Multivariable logistic regression was used to evaluate the association between STIC score and recent NSI.

RESULTS

Twenty-three (1.5%) officers reported NSI; higher among women than men (3.8% vs 1.2%; P = 0.007). STIC variables had high internal consistency, a distribution of 4.0, a mode of 1.0, a mean (sd) of 2.0 (0.8), and a median (interquartile range [IQR]) of 2.0 (1.2 to 2.6). STIC was associated with recent NSI; odds of NSI being 2.4 times higher for each point increase (P-value <0.0001).

CONCLUSIONS

STIC score is a novel tool for assessing NSI risk and prevention program success among police.

Needlestick injuries and other body substance exposures among police officers in a city police department

BACKGROUND

We determined the incidence and circumstances of needlestick injuries and other body substance exposures among police officers in a city police department.

METHODS

We analyzed data extracted from the city's centralized human resource database on all incidents from January 1, 2011, to December 31, 2016, and characterized their circumstances. We calculated the annual incidence of needlestick injuries per 1,000 officers and per 10,000 reactive calls. We ran a Poisson regression model to determine the trend in the annual incidence over time.

RESULTS

We found 13 needlestick injuries and 37 additional body substance exposures involving city police officers. Needlestick injuries most commonly occurred during pat-down searches and searches of property or vehicles; 9 source persons tested positive for hepatitis C. The annual incidence of needlestick injuries ranged from 0-5.1 per 1,000 police officers and from 0-2.5 per 10,000 reactive calls for service without a significant trend. Most body substance exposures consisted of spitting, human bites, and other contact with blood. No incidents reportedly led to transmission of bloodborne viruses.

CONCLUSIONS

Although these appear to be rare events, police officers in this department are at risk for needlestick injuries and other body substance exposures. We recommended engineering, administrative, and personal protective equipment control improvements.

Police attitudes towards pre-booking diversion in Baltimore, Maryland

BACKGROUND

In the context of high rates of drug-related incarceration that disproportionately affect urban communities of colour, advocates for drug policy criminal justice reform have called for alternatives to mass incarceration. The Law Enforcement Assisted Diversion (LEAD) program redirects low-level drug offenders to health and social services rather than immediately into the criminal justice system. In advance of piloting LEAD in Baltimore City, we assessed police perceptions towards harm reduction and specifically pre-booking diversion in effort to inform training and implementation activities in Baltimore City and elsewhere.

METHODS

We administered a survey to Baltimore City Police Officers (N = 83) in the planned implementation district using two scales: the first measured police attitudes toward people who use drugs (PWUD), current drug policies and public health measures, and the second measured police perceptions of pre-booking diversion programs. We calculated Cronbach's alpha (α) to assess internal consistency of both scales. Bivariate χ2 tests and multivariate logistic regression examined correlates of scale items stratified by new and seasoned officers.

RESULTS

Seasoned officers were significantly less likely to believe that drug treatment is easily available (51% vs. 81%, p = 0.005). The belief that current policies are effective and that PWUD should be arrested for small drug purchases decreased significantly per year on the force (aOR: 0.92; 95%CI 0.85,0.99; aOR: 0.94, 95% CI 0.88, 0.99, respectively), as did concerns about needle-stick injuries (aOR: 0.85, 95% CI 0.74, 0.98). Seasoned officers were significantly more comfortable referring PWUD to social services (100% vs. 83%, p = 0.006), and agree that such pre-booking diversion could be effective in improving public safety within (72% vs. 43%; p = 0.009) and beyond the intervention area (56% vs. 33%, p = 0.04).

CONCLUSIONS

The study indicates the value of intervening early and consistently throughout police career trajectories and engaging seasoned officers as allies to promote recognition and support of public health and harm reduction strategies within ongoing police reform efforts. LEAD provides important and broad opportunities for training police to enhance their understanding the intersection of public safety and public health.

Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey of municipal police in Tijuana, Mexico

Background

Mexican law permits syringe purchase and possession without prescription. Nonetheless, people who inject drugs (PWID) frequently report arrest for syringe possession. Extrajudicial arrests not only violate human rights, but also significantly increase the risk of blood-borne infection transmission and other health harms among PWID and police personnel. To better understand how police practices contribute to the PWID risk environment, prior research has primarily examined drug user perspectives and experiences. This study focuses on municipal police officers (MPOs) in Tijuana, Mexico to identify factors associated with self-reported arrests for syringe possession.

Methods

Participants were active police officers aged ≥18 years, who completed a self-administered questionnaire on knowledge, attitudes and behaviors related to occupational safety, drug laws, and harm reduction strategies. Univariable and multivariable logistic regression was used to identify correlates of recent syringe possession arrest.

Results

Among 1044 MPOs, nearly half (47.9%) reported always/sometimes making arrests for syringe possession (previous 6mo). Factors independently associated with more frequent arrest included being male (Adjusted Odds Ratio [AOR] = 1.62; 95% Confidence Interval [95% CI] =1.04–2.52; working in a district along Tijuana River Canal (where PWID congregate) (AOR = 2.85; 95%CI = 2.16–3.77); having recently experienced a physical altercation with PWID (AOR = 2.83; 95% CI = 2.15–3.74); and having recently referred PWID to social and health services (AOR = 1.97; 95% CI = 1.48–2.61). Conversely, odds were significantly lower among officers reporting knowing that syringe possession is legal (AOR = 0.61; 95% CI = 0.46–0.82).

Conclusions

Police and related criminal justice stakeholders (e.g., municipal judges, prosecutors) play a key role in shaping PWID risk environment. Findings highlight the urgent need for structural interventions to reduce extra-judicial syringe possession arrests. Police training, increasing gender and other forms of diversity, and policy reforms at various governmental and institutional levels are necessary to reduce police occupational risks, improve knowledge of drug laws, and facilitate harm reduction strategies that promote human rights and community health.