Prevalence and Correlates of Syringe Disposal Box Use in a Philadelphia Neighborhood with High Levels of Public Drug Injection

Addressing Fear of Negative Consequences of Overdose Response: A Qualitative Study of the Perceptions of Service Industry Workers Who Encounter an Opioid Overdose in an Urban Commercial District in Atlanta, Georgia

BACKGROUND

The increased contamination of illicit drugs with fentanyl in the United States drug market has contributed to escalating mortality from drug overdose. Leisure and hospitality service industry workers are encountering opioid-triggered overdoses in their workplaces, such as restaurants and bars. Consequently, this increases the need for overdose education and naloxone distribution (OEND) training, which has been limited. We aimed to describe the experiences among service industry workers encountering an overdose in their workplace.

METHODS

We conducted in-depth qualitative interviews with service industry workers in Little Five Points (L5P), Atlanta, between October 2019 and April 2020 and triangulated methods with participant observations and fieldwork. Purposive criterion sampling methods were applied to recruit from different establishments in the L5P commercial district, which comprised restaurants, bars, retail shops, and theaters. After an initial seed sample was identified by engaging key stakeholders during fieldwork (business owners, managers, and the business association), a snowball sample followed for a final sample of N = 15. To contextualize the local population of harm reduction workers, people who use drugs and/or obtain safer drug consumption supplies in L5P (sterile syringes, safer using kits, naloxone), and service industry workers and their customers in L5P, the first author volunteered with an Atlanta syringe services program from October 2019 to April 2020. The first author conducted participant observations during the syringe exchange program and field notes were taken during observation (44 hours). This engagement ensured a rich, thick description. We used a pragmatic approach to thematic data analysis for this study. Data were analyzed iteratively and inductively from interviews and observations. Two independent researchers reviewed transcripts to identify passages in the data related to the question of interest. The passages were contextualized within the full data set independently to understand the relationships in developing a theory of what was commonly occurring across participants' experiences, and these relationships led to emerging salient themes regarding encountering an opioid overdose at work.

RESULTS

One salient theme related to overdose response emerged with the service industry workers included fear of negative consequences of overdose response, specifically, fear of disease transmission from artifacts of drug use and overdose response, including the spread of blood-borne disease, violence, and exposure to unintentional overdose. When discussing drug use, participants' beliefs about the potential for personal danger from drug use artifacts (syringes and discarded drugs) and violence were identified as barriers to opioid overdose responses.

CONCLUSIONS/IMPLICATIONS FOR OCCUPATIONAL HEALTH PRACTICE

Our findings provide valuable insights for tailoring OEND training for service industry workers to confront fears associated with opioid overdose response in their places of work to decrease mortality from the opioid epidemic. Harm reduction approaches need to be sensitive to the places in which overdose occurs and who the overdose responder is likely to be, which requires appropriately tailoring OEND training for service industry workers.

Development of a systematic social observation tool for monitoring use of harm reduction supplies

BACKGROUND

Harm reduction services such as safer injection supply distribution are essential to reducing morbidity and mortality among people who use drugs (PWUD); however, local use of harm reduction supplies (e.g., tourniquets, saline solution) is difficult to routinely and systematically monitor. The purpose of this study was to develop and validate a systematic social observation tool designed to assess use of harm reduction supplies at the street block level.

METHODS

Data collection took place on a random sample of 150 blocks located throughout the Kensington neighborhood of North Philadelphia from November 2021 to January 2022. We measured inter-rater reliability by two-way mixed-effects intra-class correlation coefficients (ICC) with the consistency agreement definition and internal consistency reliability using Cronbach's alpha and McDonald's omega. Exploratory factor analysis with principal component extraction and promax rotation assessed internal consistency. We validated scales against locations of public syringe disposal boxes, a proxy measure for areas of concentrated drug use, using logistic regression.

RESULTS

Naloxone canisters, syringe caps, saline and sterile water solution bottles showed the highest reliability (ICC≥0.7). Items also showed high internal consistency (alpha, omega>0.7). Exploratory factor analysis identified one, three-item scale with high internal consistency: syringe caps, vials, and baggies (alpha = 0.85; omega = 0.85)-all supplies used concurrently with drug injection but not discarded in syringe disposal boxes. Drug use (OR = 1.78, 95 % CI = (1.48, 2.23)), harm reduction (OR = 3.53, 95 % CI = (2.20, 6.12)), and EFA scales (OR = 1.85, 95 %CI = (1.51, 2.34)) were significantly and positively associated with being within walking distance (≤0.25 miles or 0.4 km) of a syringe disposal box.

CONCLUSION

This study provides an efficient tool with high reliability and validity metrics to assess community uptake of harm reduction supplies designed for use by community organizations, policy makers, or other groups providing resources to PWUD.

Improved syringe disposal practices associated with unsanctioned safe consumption site use: A cohort study of people who inject drugs in the United States

BACKGROUND

Community opposition to safe consumption sites often centers around improper syringe disposal. People are concerned these sites might attract people who inject drugs to the neighborhood, which might in turn lead to more used syringes left in public settings.

METHODS

We evaluated an unsanctioned safe consumption site in an undisclosed United States city in 2018-2020 to assess whether use of the site was associated with improper syringe disposal practices. We recruited people who inject drugs (N=494) using targeted sampling methods, and interviewed participants at baseline, 6 months, and 12 months. We employed a quasi-experimental design involving inverse probability of treatment weighting using propensity scores. We used generalized estimating equations and Poisson models to calculate relative risk and incidence rate ratios of improper syringe disposal.

RESULTS

The risk of any improper syringe disposal was comparable among people who used and did not use the unsanctioned safe consumption site in prior 30 days (relative risk 1.03; 95% confidence interval=0.53, 1.17). The rate of improperly disposed syringes per number of injections in prior 30 days was significantly lower among people who had used the unsanctioned safe consumption site during the same period (incident rate ratio 0.42; 95% confidence interval=0.18, 0.88).

CONCLUSION

When people used this unsanctioned safe consumption site, they disposed of significantly fewer syringes in public places, including streets, sidewalks, parks, or parking lots, than people not using the site. This study helps allay concerns that implementing safe consumption sites in the US would lead to increases in improperly disposed syringes.