Police crackdowns, societal cost, and the need for alternative approaches

In this issue of the International Journal of Drug Policy, Cooper et al., 2005 report results from an ecological study that found that police crackdowns were not associated with elevated hospitalisations for injection-related abscesses and endocarditis in New York City (2005). This paper makes many insightful points in the discussion section related to possible explanations. We would like to discuss three important points regarding the intersection between law enforcement and public health as it pertains to illicit drug users in the US.

First, this study adds to the literature documenting high health care utilisation and costs among injection drug users (IDUs), especially for potentially preventable conditions such as abscesses and endocarditis. This study documented 48,986 hospitalisations for abscesses and cellulitis and 5452 hospitalisations for endocarditis related to drug injection in New York City (NYC) over 5 years. The rates of hospitalisations for these conditions increased overall during the study period, despite studies suggesting that the number of IDUs in NYC declined during the same period (Friedman et al., 2004). As the authors stated, costs at San Francisco General Hospital (SFGH) for 1326 hospital admissions in 1999 for IDU-related abscesses and cellulitis were nearly $10 million (Centers for Disease Control and Prevention, 2001). The hospitalisations documented in Cooper's study represent significant expenditures for hospital care which disproportionately impact hospitals serving poor, minority, and vulnerable patients that are already overburdened and strapped for resources.

Second, these excessive costs are preventable. Interventions aimed at increasing receipt of timely and appropriate ambulatory care by IDUs have been successful in reducing hospitalisation rates and associated health care costs. In response to the high costs at SFGH, an outpatient clinic was opened devoted to ambulatory treatment of abscesses and cellulitis among IDUs. The design of the clinic is specifically tailored to the needs of active IDUs providing wound care along with referrals to substance abuse treatment and social services on a walk-in basis. In the first year of operations, the clinic resulted in a 47% decrease in surgical service admissions, a 34% reduction in ER visits, and estimated savings of over $8 million (Harris & Young, 2002). Provision of timely care for abscesses and cellulitis to IDUs at syringe exchange programmes (SEPs) has also been shown to be feasible and effective (Grau, Arevalo, Catchpool, & Heimer, 2002) and while the impact of these syringe exchange-based wound services on hospitalisations has not been quantified, syringe exchange-based primary care services have been shown to decrease ER utilisation (Pollack, Khoshnood, Blankenship, & Altice, 2002). Along these lines, studies are needed that describe the magnitude of health service utilisation and cost associated with these injection drug-related infections in different populations and geographic areas in order to identify appropriate places and interventions to reduce unnecessary hospitalisations. One promising place to start such studies is by examining the provision of low-threshold ambulatory services for IDUs in settings such as SEPs that are likely to be cost effective relative to hospitalisation of IDUs who delay seeking care.

Third, although not directly addressed in this study, one wonders when, if ever, resources in terms of healthcare, schools, and employment might also be provided in communities that are the targets of police crackdowns. Within the US context, it will escape few readers’ notice that the precincts subject to police crackdown are on average overwhelmingly populated by Latinos and African Americans and have poverty rates twice as high as precincts without police crackdowns. Throughout the US, the heavy reliance on enforcement of drug laws in racial and ethnic minority communities has had devastating and long-term impacts on community socio-economic status and health outcomes (Iguchi et al., 2002), yet has yielded little in terms of short- or long-term trends in levels of substance use and abuse in general or for racial and ethnic minority groups in particular (Caulkins, Reuter, Iguchi, & Chiesa, 2005; Roberts, 2004). Further, the emphasis on arrests and incarceration as a strategy to deter drug use has served to be a costly approach in California. The rate of arrests in California has increased 56% in the past 40 years, and the rate of drug-related arrests for adults recently reversed a 13-year decline and began to increase in 2002 (Bureau of Criminal Information and Analysis, 2000, Bureau of Criminal Information and Analysis, 2003). Furthermore, the rate of incarceration for drug-related offenses in California has skyrocketed, increasing the number of incarcerated drug offenders from 2000 in 1980 to almost 45,000 in 1999—a 25-fold increase in just 20 years (Bureau of Criminal Information and Analysis, 2000, Bureau of Criminal Information and Analysis, 2003). To accommodate these increasing trends in incarceration, prison spending in California over the past 20 years has outpaced that of post-secondary education, with 23 new prisons built compared to 1 new university.

Regardless of conviction and incarceration, being arrested for drug use may initiate a cycle of interaction with police that shapes HIV risk, socio-economic stability and the potential likelihood of future conviction and incarceration. The implications of being involved in the criminal justice system, especially for a drug-related charge, extend much further beyond the immediate sentence and carry a lifetime of stigma and labelling that may perpetuate the cycle of poverty and substance use (Davies & Tanner, 2003), in particular among young African American men (Pettit & Western, 2004).

The high cost of the current medical system for indigent populations, the potential cost savings of using community-based harm reduction programmes to facilitate access to preventive care and primary care, and the apparent futility and expense of arresting and incarcerating hundreds of thousands of drug users in federal and state prisons suggest that we need changes in strategies aimed at reducing societal and individual consequences of illicit drug use. As researchers interested in improving care and health outcomes not just for substance users, but for whole populations, it is incumbent on us, now, more so than at any other time in the last 20 years, to make the argument for alternative public health and medical approaches to addressing illicit substance use. Research, like that of Cooper's and her colleagues, are important to identifying structural factors, such as institutions, laws, and organisations, that might be considered vital and improving health outcomes and reducing societal cost of substance use in the US.