An Investigation of Public Injection Drug Use in New York City: A Mixed-Methods Study

Background: Drug use and injection-related harms are on the rise in the United States (US). As a result, new outbreaks of HIV and viral hepatitis C (HCV) attributed to injection drug use have been identified across the country. In addition to HIV and HCV, skin and soft tissue infection (SSTIs) that result from risky injection practices lead to preventable and costly emergency department (ED) visits. The concurrent opioid overdose epidemic has prompted a national conversation on how to effectively address drug-related harms and associated costs. International studies have identified that the place a person injects is related to adverse health outcomes; public injection drug use is associated with risky injection practices and other health harms. To minimize public injection drug use, eleven countries have implement supervised injection facilities (SIFs) to prevent both injection-related infections and opioid overdose. Despite over 30 years of operation and 100 sites in operation around the world, the US has yet to implement a government-sanctioned SIF. No studies in the US have investigated public injection drug use and the possible association between public injection drug use and health risks. Objectives: To describe the prevalence of public injection drug use and associated risks among people who inject drugs (PWID) enrolled in syringe exchange programs (SEPs) in New York City (NYC) using a mixed-methods multi-phase study design including cross-sectional survey data and qualitative data derived from focus group sessions. Methods: First, I used a grounded theory approach to create a definition of public injection drug through focus group sessions. I applied the PWID-informed definition of public injection drug use to operationalize and define public injection in the survey data. Then, I described where PWID inject drugs in NYC and the prevalence of public injection drug use using survey data from the Injection Drug User Health Alliance Citywide Study (IDUCS) from Wave 2 and Wave 3. Next, I measured the association between public injection drug use and receptive sharing of injecting equipment as a proxy for HIV and HCV transmission risk using bivariate and multivariate logistic regression analyses. Then, I analyzed data from the focus groups identify characteristics of the physical and social environment where PWID inject and how they may be related to risk. Based on these findings, I selected variables to include in logistic regression models to describe socio-demographic characteristics and risk behavior associated with public injection drug use. Lastly, I describe the experience of public injection drug use, the relationship of place to risk, management of health and social risks, and initial attitudes towards SIFs. Results: A total of 820 participants were included in the quantitative analyses and 33 participants included in the focus group sessions. PWID reported that what makes a place public included four components: (a) physical features of a space that supported privacy, (b) sense of control over the space, (c) trust in the people in the space, and (d) exposure to being seen or arrested. Nearly two-thirds (64%) of PWID in the IDUCS study reported public injection drug in the three months preceding the IDUCS survey. The most frequently reported sites of injection drug use included one’s own home (71%), home of a friend or family member (59%), public bathroom (48%), or the street or park (38%). Public injectors are significantly more likely to report receptive sharing of injecting equipment (AOR=1.66, CI: 1.04-2.65). Public injection drug use was significantly associated with unstable housing (AOR=5.04, CI: 3.46-7.34), under 40 years of age (AOR=2.02, CI:1.40-3.13), past 30-day heroin use (AOR=1.99, CI:1.27-3.13), past 30-day cocaine use (AOR=1.52, CI: 1.06-2.12), past year overdose (AOR=1.66, CI: 1.17-2.36), and witnessing an overdose (AOR=1.45, CI: 1.03-2.06). In the unadjusted model, public injectors were significantly more likely to report past year ED admission (OR=1.50, CI: 1.11-2.02) and less likely to have a primary care provider (PCP) (OR=0.37, CI: .23-.59) compared with non-public injectors. Participants described fear of arrest and accidental overdose as predominant factors taken into consideration when identifying a place to inject drugs; other factors included level of withdrawal, fear of violence, and being seen by others (friends/family/public). Participants described complex strategies to manage risk and the impact of hiding or rushing injection on their ability to apply safe injection practices. The place that was perceived as the ‘safest’ place to inject drug was in the SEP bathrooms; sterile injecting equipment and disposal was readily available, it is private enough to take their time and not worry about arrest but public enough that a staff member of a SEP could administer naloxone in the event of an overdose. In all focus group sessions, the response to SIFs was overwhelmingly positive; PWID believed that a SIF would enable them to practice safe injection and that other PWID would use it. Conclusions: PWID are injecting in a variety of public places in NYC. Public injection is associated with risky injection practices and, in turn, potential transmission of HIV and HCV. PWID described that injecting in public increased their risk of being arrested or rushing injections, but was a safer option to prevent fatal overdose. The calculated risks and trade offs (i.e. risking arrest by injecting in public versus fatal overdose if injecting alone) were believed to impede one’s ability to practice safe injection techniques. SEP bathrooms are operating as pseudo-SIFs but remain unsanctioned and unsupervised. SIFs are one strategy to minimize injection related harm and overdose and this study provide initial insight into their potential acceptability among PWID. However, strategies to address drug-related harm must also incorporate housing, healthcare, and drug policy reform