Research PaperPerspectives on supervised injection facilities among service industry employees in New York City: A qualitative exploration
Introduction
Drug overdose mortality rates per year in the United States (US) have nearly tripled between 1999–2014, rising to 64,070 deaths in 2016 with opioids involved in over 75% (Centers for Disease Control & Prevention, 2017; National Institute on Drug Abuse, 2017; Rudd, Seth, David, & Scholl, 2016). New York City (NYC) is home to some of the most robust harm reduction and outreach programs in the US but continues to see escalating rates of unintentional drug overdose deaths in part due to the increasing presence of fentanyl in street heroin (New York City Department of Health & Mental Hygiene, 2017).
When people who inject drugs (PWID) do not have a private place to prepare and inject drugs, they actively search for public spaces that reduce their exposure to non-injectors and law enforcement (Fitzgerald, 2005; Parkin & Coomber, 2011; Parkin, 2013; Rhodes, 2002). Reports suggest that public bathrooms1 are among the most commonly used public injecting locations among PWID in NYC (Injection Drug Users Health Alliance, 2015; New York City Department of Health & Mental Hygiene, 2010, 2013). Some of the motivating factors for the use of this type of location are immediacy and privacy (Crabtree et al., 2013; Parkin & Coomber, 2010; Parkin, 2013) in addition to their cleanliness compared to other alternatives such as parks and alleyways. The privacy afforded by public bathrooms can minimize physical harms to PWID by providing them with adequate time for drug preparation and injection, which can in turn reduce the risk of abscesses and vein damage associated with rushed or interrupted injections (Bourgois, 1998; Cooper, Moore, Gruskin, & Krieger, 2005; DeBeck et al., 2009; Gibson et al., 2011; Marshall, Kerr, Qi, Montaner, & Wood, 2010; Parkin & Coomber, 2011; Salmon et al., 2009; Small, Rhodes, Wood, & Kerr, 2007).
People who inject drugs in public bathrooms typically attempt to be discreet, but establishments may be alerted to their presence in the event of an overdose or when someone finds an improperly disposed syringe. The use of public bathrooms for injection drug use has become so common in some parts of the US and Europe that hospitals (Ramsay, 2002) and businesses (BBC News, 2003; Rubinkam, 2018; Steves, 2010; Watts, 2018) have responded by installing blue lights in an attempt to deter drug use though research suggests that this intervention is not effective in deterring PWID (Crabtree et al., 2013; Parkin & Coomber, 2010; Parkin, 2013). Other businesses have installed locks on bathroom doors that workers can unlock at their discretion, potentially exposing themselves and their business to discriminatory lawsuits. Discriminatory bathroom policies also create a false sense of control as bathroom users can hold the door for one another which leaves workers unaware of who is in the bathroom and for how long. The use of techniques that have questionable effectiveness suggests that those who manage these public bathrooms have few options when trying to curb injection drug use.
In response to public injection and increasing overdose mortality, communities throughout the US are considering implementing supervised injection facilities (SIFs) though none legally operate within the country as of August 2018 (Foderaro, 2016; Goldberg, 2016; Gutman, 2016; Sabatini, 2016). Supervised injection facilities are legally-operated venues where people can consume pre-obtained drugs in a hygienic environment under the supervision of medical staff and harm reduction workers who can manage overdoses and educate PWID on safer injection techniques. The conventional setting for SIFs are low-threshold, non-judgemental and assist in linking PWID to a variety of health and social services (Potier, Laprévote, Dubois-Arber, Cottencin, & Rolland, 2014). Though none currently operate in the US, approximately 100 SIFs operate in 66 cities throughout the world (Drug Policy Alliance, 2016). Research suggests that SIFs are capable of successfully managing overdoses, reducing overdose deaths, reducing HIV/HCV risk behaviour, increasing uptake of addiction treatment, as well as reducing public injection and public disorder (Kerr, Tyndall, Li, Montaner, & Wood, 2005; Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Petrar et al., 2007; Salmon, Thein, Kimber, Kaldor, & Maher, 2007; Small, Van Borek, Fairbairn, Wood, & Kerr, 2009; Stoltz et al., 2007; Wood et al., 2004; Wood, Tyndall, Zhang, Montaner, & Kerr, 2007; Wood, Tyndall, Zhang et al., 2006). Furthermore, SIFs are cost-effective and have not been found to increase drug injecting or drug-related crime in the neighbourhoods in which they operate (Andresen & Boyd, 2010; Freeman et al., 2005; Irwin, Jozaghi, Bluthenthal, & Kral, 2017; Irwin, Jozaghi, Weir et al., 2017; Jozaghi, Reid, Andresen, & Juneau, 2014; Kerr et al., 2006, 2007; Wood, Tyndall, Lai, Montaner, & Kerr, 2006).
Despite the impact that SIFs may have on public bathroom drug use, little is known about the experiences of workers who regularly encounter PWID in their business bathrooms. A better understanding of worker experiences may help guide public policies directed at alleviating the community harms associated with injection drug use and improve worker and customer safety. A previous study of business managers in NYC revealed that 58% of the managers interviewed had encountered drug use in their business bathroom within the past six months and that more than one-third had also encountered improperly discarded syringes (Wolfson-Stofko, Bennett, Elliott, & Curtis, 2017). Additionally, 90% had no training in overdose response & naloxone administration though 14% had encountered someone who was unresponsive, presumably due to drug use, within the past six months (Wolfson-Stofko et al., 2017). More information about these workers’ experiences may be valuable for the SIF feasibility studies that have been requested by policymakers (Goldberg, 2016; Larson, Padron, Mason, & Bogaczyk, 2017; Wilkinson & Fan, 2016) and community groups.
Previous research focused on community stakeholder perspectives of SIFs (Strike, Watson, Kolla, Penn, & Bayoumi, 2015; Wenger, Arreola, & Kral, 2011) have included business owners but not business managers and staff that directly interact with PWID and are, by default, first-responders to overdoses and improperly disposed syringes. Here we explore business manager and staff (collectively referred to as service industry employees (SIEs) herein) perspectives on SIFs in relation to their experiences with injection drug use occurring in their business bathrooms.
Section snippets
Study design & population
This exploratory qualitative study was based on 15 interviews conducted between September 2016 and May 2017 with 15 SIEs (10 managers and 5 staff), from 13 different businesses (each from a different business location) in NYC. Participants provided written informed consent and were compensated $40 for their time. All study procedures were approved by National Development & Research Institutes’ Institutional Review Board and all names reported in this study are pseudonyms.
The eligibility
Participant & business characteristics
Participants’ mean age was 35 years (range = 27–53 years); 67% identified as female; and 60% (n = 9/15) identified as White while the remaining six participants identified as Asian, Biracial, Black, Latino and Guyanese. They had worked at their place of business an average of 4.8 years (range = 1–9 years) and 10 were employed at coffee shops, two at cafés, one at a music store, one at a laundromat and one at a physician’s office.
The businesses in this study were located in four different Tiers.
Discussion
According to participants in this study, the operation of a SIF in a community will yield a variety of advantages and some concerns. The SIEs interviewed in this study overwhelmingly believed that the operation of SIFs near their businesses would reduce the amount of drug use occurring in their business bathrooms as well as their encounters with improperly discarded syringes and unresponsive individuals. This strong support from SIEs working in neighbourhoods with varying levels of overdose
Limitations
The results from this study cannot be generalized to all of NYC, given that this study utilized convenience sampling and consisted of a small sample size. Recruitment from neighbourhoods with historically high drug overdose death rates proved to be challenging because many of these SIEs were sceptical of the anonymity and confidentiality guaranteed by the study and were concerned that participation might jeopardize their employment. However, the goal of this study was to generate preliminary
Conclusion
This study found that SIEs in NYC inadvertently become first-responders in the event of an overdose and incur considerable risks through their exposure to improperly discarded syringes. Nearly all SIEs were supportive of SIFs and believed that SIF operation would reduce drug use, overdose and syringe encounters in their places of business. Providing SIEs and other stakeholders with peer-reviewed scientific evidence prior to inquiring about the potential effects of a public health initiative may
Author contributions
BWS designed and conceptualized most of the project, led recruitment, conducted the interviews, analysed the qualitative data and took the lead in writing the manuscript. LE assisted in project conceptualization, interview guide development, qualitative data analysis and manuscript preparation. ASB assisted in project conceptualization, interview guide development, qualitative data analysis and manuscript preparation. RC assisted in participant recruitment, project conceptualization and
Conflict of interest
The authors of this paper declare no conflict of interest. The opinions of the authors do not necessarily reflect those of National Institutes of Health, National Institute on Drug Abuse, National Development & Research Institutes, Inc., New York University, or City University of New York.
Acknowledgments
The authors wish to thank Efram Thompson for his assistance with recruitment. The authors would also like to thank the Center for Drug Use and HIV Research (CDUHR) for support and guidance. This research was supported by a CDUHR pilot project grant (5P30DA011041-20) and Ruth L. Kirschstein National Service Award (5T32DA007233) awarded to the first author, as well as R01DA036754 awarded to study co-author Alex S. Bennet from the National Institute on Drug Abuse.
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