"Feeling confident and equipped": Evaluating the acceptability and efficacy of an overdose response and naloxone administration intervention to service industry employees in New York City.

BACKGROUND: The problem of injection drug use in public bathrooms has been documented from the perspectives of people who inject drugs and service industry employees (SIEs). Previous studies suggest that SIEs are unaware of how to respond to opioid overdoses, yet there are no behavioral interventions designed for SIEs to address their specific needs. In response to this gap in the field, we constructed, implemented, and evaluated a three-module behavioral intervention for SIEs grounded in the Information-Motivation-Behavioral skills model. This paper focuses on the evaluation of one module, namely, the intervention component addressing overdose response and naloxone administration (ORNA). METHODS: Participants were SIEs (N = 18 from two separate business establishments) recruited using convenience sampling. The study utilized a pre-/post-test concurrent nested mixed method design and collected quantitative and qualitative data including an evaluation of the intervention module. The primary outcomes were opioid overdose-related knowledge and attitudes. Acceptability was also assessed. RESULTS: SIEs demonstrated significant improvements (p < 0.01, Cohen's d = 1.45) in opioid overdose-related knowledge as well as more positive opioid overdose-related attitudes (p< 0.01, Cohen's d = 2.45) following the intervention. Participants also reported high levels of acceptability of the module and suggestions for improvement (i.e., more role-playing). CONCLUSIONS: This study highlights the acceptability and evidence of efficacy of the ORNA module, as well as the utility of training SIEs in ORNA. The expansion of this training to other SIEs and public employees (librarians, etc.) who manage public bathrooms warrants further investigation.

Perspectives on supervised injection facilities among service industry employees in New York City: A qualitative exploration.

BACKGROUND: Approximately 100 supervised injection facilities (SIFs) operate in 66 cities around the world to reduce overdose deaths, the spread of disease and public disorder, though none legally exist in the United States. Public bathrooms are among the most common public places for injection reported by people who inject drugs in New York City (NYC) and service industry employees (SIEs) inadvertently become first-responders when overdoses occur in business bathrooms. The goal of this study was to assess SIE acceptability of SIFs and the perceived effects that SIFs would have on them, their colleagues, their businesses and communities. METHODS: Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach. RESULTS: Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that 'not in my backyard' arguments from community boards may impede SIF operation. CONCLUSIONS: Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.

Needle acquisition patterns, network risk and social capital among rural PWID in Puerto Rico.

BACKGROUND: People who inject drugs (PWID) take on significant risks of contracting blood-borne infection, including injecting with a large number of partners and acquiring needles from unsafe sources. When combined, risk of infection can be magnified. METHODS: Using a sample of PWID in rural Puerto Rico, we model the relationship between a subject's number of injection partners and the likelihood of having used an unsafe source of injection syringes. Data collection with 315 current injectors identified six sources of needles. RESULTS: Of the six possible sources, only acquisition from a seller (paid or free), or using syringes found on the street, was significantly related to number of partners. CONCLUSIONS: These results suggest that sources of syringes do serve to multiply risk of infection caused by multi-partner injection concurrency. They also suggest that prior research on distinct forms of social capital among PWID may need to be rethought.

Hepatitis C serosorting among people who inject drugs in rural Puerto Rico.

Due to the high cost of treatment, preventative measures to limit Hepatitis C (HCV) transmission among people who inject drugs (PWID) are encouraged by many public health officials. A key one of these is serosorting, where PWID select risk partners based on concordant HCV status. Research on the general U.S. population by Smith et al. (2013) found that knowledge of one's own HCV status facilitated serosorting behaviors among PWID, such that respondents with knowledge of their own status were more likely to ask potential partners about their status prior to sharing risk. Our objective was to see if this held true in rural Puerto Rico. We replicate this study using a sample of PWID in rural Puerto Rico to draw comparisons. We used respondent driven sampling to survey 315 participants, and have a final analytic sample of 154. The survey was heavily modeled after the National HIV Behavioral Survey, which was the dataset used by the previous researchers. We found that among PWID in rural Puerto Rico, unlike in the general population, knowledge of one's own HCV status had no significant effect on the selection of one's most recent injection partner, based on his/her HCV status. We conclude that PWID in rural Puerto Rico differ from the general U.S. population when it comes to serosorting behaviors, and that these differences should be taken into account in future outreaches and intervention strategies.

Drug use in business bathrooms: An exploratory study of manager encounters in New York City.

BACKGROUND: Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses. METHODS: A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches. RESULTS: More than half of managers interviewed (58%, n=50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance. CONCLUSION: The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.

The Portapotty Experiment: Neoliberal approaches to the intertwined epidemics of opioid-related overdose and HIV/HCV, and why we need cultural anthropologists in the South Bronx.

The following report from the field focuses on the authors' collective efforts to operate an ad hoc safer injection facility (SIF) out of portapotties (portable toilets) in an area of the South Bronx that has consistently experienced some of the highest overdose morbidity and mortality rates in New York City over the past decade (New York City Department of Health and Mental Hygiene, 2011, 2015, 2016). Safer injection facilities (also known as supervised injection facilities, drug consumption rooms, etc.) operating outside the US provide a legal, hygienic, and supervised environment for individuals to use drugs in order to minimize the likelihood of fatal overdose and the spread of blood-borne infections while reducing public injection. In the US, the operation of SIFs is federally prohibited by the federal "Crack House" statute though federal, state, and local elected officials can sanction their operation to various degrees (Beletsky, Davis, Anderson, & Burris, 2008). The activists, researchers, undergraduate students and peers from syringe exchange programs who came together to operate the portapotties discovered that they were, in many ways, emblematic of neoliberal solutions to disease prevention: primarily focused on auditing individual risk behaviors and virtually blind to the wider social context that shapes those lives. That social context - the culture of drug injection - was and is out in the open for all of us to see. Going forward, the cultural anthropologist's toolbox will be opened up and used by large groups of undergraduate students to better understand the culture of drug use and how it is changing.

Estimating Vertex Measures in Social Networks by Sampling Completions of RDS Trees.

This paper presents a new method for obtaining network properties from incomplete data sets. Problems associated with missing data represent well-known stumbling blocks in Social Network Analysis. The method of "estimating connectivity from spanning tree completions" (ECSTC) is specifically designed to address situations where only spanning tree(s) of a network are known, such as those obtained through respondent driven sampling (RDS). Using repeated random completions derived from degree information, this method forgoes the usual step of trying to obtain final edge or vertex rosters, and instead aims to estimate network-centric properties of vertices probabilistically from the spanning trees themselves. In this paper, we discuss the problem of missing data and describe the protocols of our completion method, and finally the results of an experiment where ECSTC was used to estimate graph dependent vertex properties from spanning trees sampled from a graph whose characteristics were known ahead of time. The results show that ECSTC methods hold more promise for obtaining network-centric properties of individuals from a limited set of data than researchers may have previously assumed. Such an approach represents a break with past strategies of working with missing data which have mainly sought means to complete the graph, rather than ECSTC's approach, which is to estimate network properties themselves without deciding on the final edge set.

A reexamination of connectivity trends via exponential random graph modeling in two IDU risk networks.

Patterns of risk in injecting drug user (IDU) networks have been a key focus of network approaches to HIV transmission histories. New network modeling techniques allow for a reexamination of these patterns with greater statistical accuracy and the comparative weighting of model elements. This paper describes the results of a reexamination of network data from the SFHR and P90 data sets using Exponential Random Graph Modeling. The results show that "transitive closure" is an important feature of IDU network topologies, and provides relative importance measures for race/ethnicity, age, gender, and number of risk partners in predicting risk relationships.

Estimating the Size of the Methamphetamine-Using Population in New York City Using Network Sampling Techniques.

As part of a recent study of the dynamics of the retail market for methamphetamine use in New York City, we used network sampling methods to estimate the size of the total networked population. This process involved sampling from respondents' list of co-use contacts, which in turn became the basis for capture-recapture estimation. Recapture sampling was based on links to other respondents derived from demographic and "telefunken" matching procedures-the latter being an anonymized version of telephone number matching. This paper describes the matching process used to discover the links between the solicited contacts and project respondents, the capture-recapture calculation, the estimation of "false matches", and the development of confidence intervals for the final population estimates. A final population of 12,229 was estimated, with a range of 8235 - 23,750. The techniques described here have the special virtue of deriving an estimate for a hidden population while retaining respondent anonymity and the anonymity of network alters, but likely require larger sample size than the 132 persons interviewed to attain acceptable confidence levels for the estimate.

The transformation of drug markets and its impact on HIV outreach to injection drug users in New York City, 1987-2008.

This oral history describes three periods of street outreach to injection drug users at risk for HIV in New York City: outreach in an era of public drug markets (1987-1993), outreach in an era of private markets (1993-2006), and network-driven outreach (2006-present). Individual interviews with administrators and supervisors of outreach workers are combined with field notes from the ethnographic research experiences of the first two authors to contextualize, compare, and contrast these distinct periods. The combination and triangulation of these sources of data allow for an analysis of both the specific and the wider social and cultural contexts in which outreach intervention efforts were situated. Through these lenses, the article examines some of the reasons why they were or were not successful and discusses prospects for the future.