Attitudes of North Carolina law enforcement officers toward syringe decriminalization

Abstract

Background

North Carolina, like much of the U.S. South, is disproportionately affected by HIV and hepatitis. This persistently high disease burden may be driven in part by laws that criminalize the possession and distribution of syringes for illicit drug use. Legal change to decriminalize syringes may reduce infection rates in the state, but is unlikely absent support from law enforcement actors.

Methods

We analyzed the responses of 350 North Carolina law enforcement officers to a confidential, anonymous survey. The survey instrument collected data regarding self-reported needle-stick injury (NSI), blood borne disease risk perception and attitudes toward syringe decriminalization.

Results

82% of respondents reported that contracting HIV was a “big concern” for them. 3.8% of respondents reported ever receiving a job-related NSI, a rate of 36 NSI per 10,000 officer-years. Majorities of respondents reported positive views regarding syringe decriminalization, with approximately 63% agreeing that it would be “good for the community” and 60% agreeing that it would be “good for law enforcement.” Black and female officers were significantly less likely to agree that on-the-job NSI was a “big concern” and significantly more likely to agree that it would be good for law enforcement.

Conclusions

These findings suggest that many North Carolina LEOs understand the public health benefits of syringe access programs and may be inclined to support syringe decriminalization legislation. Further research is indicated to determine the causes of observed differences in perceptions of bloodborne disease risk and attitudes toward syringe decriminalization by race and sex.

1. Introduction

The burden of bloodborne disease in the United States falls disproportionately on those living in the South (Lansky et al., 2010; Qian et al., 2006), which has higher HIV and hepatitis C (HCV) incidence rates and more people living with HIV than any other region (Centers for Disease Control and Prevention, 2013a,b,c,d; Zou et al., 2010). In 2011, North Carolina had the country's 8th highest HIV incidence rate, the 12th highest number of cumulative AIDS cases, and an HCV incidence rate 50% greater than the national average (Centers for Disease Control and Prevention, 2013a,b,c,d; North Carolina Division of Public Health, 2013).

Nearly 23% of all AIDS cases in North Carolina are attributable to injection drug use (IDU) alone, with an additional 5.6% of cases among men who have sex with men (MSM) who also reported IDU (Centers for Disease Control and Prevention, 2012). Nationwide, IDU is the leading risk factor for HCV infection (Centers for Disease Control and Prevention, 2002, 2013a). While acute HCV infections among Blacks have fallen over the past decade (Centers for Disease Control and Prevention, 2013a,b,c,d), HIV continues to be disproportionately distributed by race: Blacks comprise only 22% of North Carolina's population but 67% of AIDS cases (Centers for Disease Control and Prevention, 2012; United States Census Bureau, 2012).

Law and law enforcement practices that reduce access to new syringes and opportunities to safely dispose of used ones are a key factor in injection-related disease transmission and may contribute to racial disparities in HIV rates (Blankenship and Koester, 2002; Bluthenthal et al., 1997; Burris et al., 2002, 2011; Burris and Koester, 2013; Davis et al., 2005). Increased access to sterile syringes has been associated with a number of positive changes in health behavior and disease risk among people who inject drugs (PWID), including reductions in HIV and HCV infections, risky injecting behavior and improperly discarded syringes (Des Jarlais et al., 2005; Gibson et al., 2001; Hurley et al., 1997; Strathdee et al., 2006; Wodak and Cooney, 2006). Legal change to increase access to syringes has also been associated with reduced needlestick injuries (NSI) among law enforcement officers (LEOs; Groseclose et al., 1995) and may reduce the risk of NSI-related infection.

Modifying law to permit or require evidence-based public health strategies is a critical component in improving health outcomes (Hodge et al., 2013; Mello et al., 2013). Many states have responded to the large body of evidence that increased syringe access reduces infection risk without increasing drug use by modifying criminal law to permit the possession and distribution of syringes, a policy termed syringe decriminalization (Burris, 2014). Southern states have largely failed to make such amendments. As of 2014, only one Southern state (Louisiana) permitted the distribution of syringes intended to be used to inject illegal drugs, and none permitted the possession of syringes for that purpose (Burris, 2014). This failure may contribute to persistently high rates of HIV infection in North Carolina and throughout the South (Adimora et al., 2014; Human Rights Watch, 2010; Reif et al., 2012).

North Carolina has been a leader among Southern states in some areas related to syringe access. It is legal to purchase syringes in pharmacies without a prescription in the state, although sales are at the discretion of the pharmacist and research has demonstrated that Black PWID are far less likely than whites to report receiving syringes from a pharmacy (Costenbader et al., 2010). Additionally, a state law partially decriminalizing syringes was implemented in 2013. The law protects a person from charge or prosecution for paraphernalia possession if he or she is stopped by a law enforcement officer (LEO) and voluntarily reports the syringe or other sharp object to the LEO before a search is conducted (North Carolina General Assembly, 2013a,b). Possession or distribution of syringes for illegal drug use, however, remains illegal.

Law enforcement support is likely an important factor in both the passage and implementation of syringe access and syringe decriminalization laws (Beletsky et al., 2005b; Silverman et al., 2012). Several previous initiatives have bundled LEO occupational safety training with information regarding the legality and beneficial effects of such laws (Beletsky et al., 2011; Davis and Beletsky, 2009; Silverman et al., 2012), but little is known regarding LEO attitudes toward them. Research from several Northern states reported that LEOs were generally supportive of efforts to reduce risks associated with drug use (Banta-Green et al., 2013; Beletsky et al., 2005a; Green et al., 2013), but none asked about syringe decriminalization specifically. We present below the results of the first such survey conducted among LEOs in the Southern United States.

2. Methods

Data were collected via surveys designed and administered by a local non-profit organization that conducted trainings for officers training to join Crisis Intervention Teams (CITs). These teams are comprised of LEOs, often in conjunction with other professionals such as mental health workers, who utilize evidence-based approaches in interacting with people in acute mental health need (Watson and Fulambarker, 2012). The hour-long training, delivered at multiple sites throughout the state in 2012 and 2013, provided an overview of HIV and other bloodborne disease transmission and guidance on ways LEOs can reduce their risk of on-the-job disease transmission.

Staff members from the non-profit organization administered the voluntary, anonymous survey prior to the training session. The survey instrument collected demographic data and queried respondents regarding bloodborne disease risk perception, their NSI experience, and attitudes toward policies such as syringe decriminalization that might reduce NSI. This study was deemed exempt by the University of North Carolina IRB because it was limited to an analysis of already-existing data collected by the non-profit organization in the regular course of its training activities.

Likert scale responses – “strongly agree,” “agree,” “disagree,” and “strongly disagree” – were dichotomized into “agree” and “disagree” for the analysis. Descriptive statistics were compiled for each question and assessed by race (Black vs. non-Black) and gender (male vs. female). Differences in attitudes by race or gender were assessed using a multivariate logistic model with an a priori significance level of 0.05. Adjusted odds ratios (AOR) for race and gender, controlling for age (represented by a quadratic polynomial) were calculated. We further evaluated for any gender by race interactions. Respondents with missing data were excluded from the analysis.

3. Results

The convenience sample consisted of 350 officers from 20 law enforcement agencies throughout North Carolina. Approximately 80% of respondents were male and, on average, had worked in law enforcement for approximately 10 years. Approximately 25% reported their race as Black, and 65% as white (Table 1). Eighty two percent of respondents reported that contracting HIV and 85% reported that contracting hepatitis was a “big concern” for them, far exceeding the percentage that reported ever receiving an NSI (3.8%, a rate of 36 NSI per 10,000 officer-years). Most respondents reported favorable views of syringe decriminalization. Fifty seven percent did not believe that syringe decriminalization would promote drug use, and approximately 60% reported that their impression of it was generally positive, that it would reduce HIV, and that it would be “good for the community” and “good for law enforcement” (Table 2).

Table 1.

Demographics of respondents.

Characteristic	Number (%) reporting
Sex
Male	276 (79.3%)
Female	72 (20.7%)
Race/ethnicity
White	227 (65.0%)
Black	89 (25.5%)
Hispanic	16 (4.6%)
Other	14 (4.0%)
Asian	3 (0.9%)
Age
20-29	91 (26.4%)
30-39	111 (32.2%)
40-49	108 (31.3%)
50-59	31 (9.0%)
60-69	4 (1.2%)
Years in law enforcement
<5	118 (33.8%)
5-10	68 (19.5%)
11-15	54 (15.5%)
16-20	54 (15.5%)
21-25	42 (12.0%)
25+	13 (1.4%)
Mean	10.3 years
NSI risk
Officers reporting NSI	13 (3.8%)
NSI rate	36/10,000

NSI - needlestick injury.

Table 2.

Portion of respondents agreeing with statement, by race and gender.

Proportion of respondents who agreed with statement	All	Race			Gender
		Non-Black (n = 261)	Black (n = 89)	Adjusted odds ratioa	Male (n = 276)	Female (n = 72)	Adjusted odds ratiob
Q1. Getting HIV from drug users is a big concern for me	288(82.3%)	227 (87.0%)	61(68.5%)	0.49 p = 0.027	244(88.4%)	42 (58.3%)	0.18 p < 0.001
Q2. Getting hepatitis from a needle-stick injury is a big concern for me	299(85.4%)	235(90.0%)	64(71.9%)	0.38 p = 0.005	247 (89.5%)	50(69.4%)	0.30 p<0.001
Q3. State wide syringe decriminalization would promote drug use	151(43.1%)	117(44.8%)	34(38.2%)	0.80 p=0.41	124(44.9%)	26(36.1%)	0.72 p=0.25
Q4. My impression of syringe decriminalization is generally positive	214(61.1%)	153(58.6%)	61 (68.5%)	1.38 p=0.24	166(60.1%)	47 (65.3%)	1.16 p=0.61
Q5. Syringe decriminalization would help reduce HIV	216(61.7%)	161(61.7%)	55(61.8%)	0.96 p=0.87	168(60.9%)	46(63.9%)	1.21 p=0.50
Q6. Syringe decriminalization would be good for the community	221(63.1%)	155(59.4%)	66(74.2%)	1.83 p=0.035	168(60.9%)	51 (70.8%)	1.42 p=0.24
Q7. Syringe decriminalization would be good for law enforcement	209(59.7%)	142(54.4%)	67 (75.3%)	2.31 p=0.004	153(55.4%)	54(75.0%)	1.34 p=0.007

^aOdds ratio for respondents identified as Black, adjusting for gender and age, expressed as a quadratic polynomial.

^bOdds ratio for respondents identified as female, adjusting for race and age, expressed as a quadratic polynomial.

Responses to several questions varied by race and gender. Black officers were approximately 20 percentage points less likely than white officers to report concern for on-the-job NSI (Q2: AOR 0.38, p = 0.005), were approximately 15 percentage points more likely to believe syringe decriminalization would be good for the community (Q6: AOR 1.83, p < 0.035), and 20 percentage points more likely to believe that it would be good for law enforcement (Q7: AOR 2.31, p = 0.004). Female officers were approximately 30 percentage points less likely than males to report that they feared contracting HIV (Q1: AOR 0.18, p < 0.001), ten percentage points more likely to believe that syringe decriminalization would be good for the community (Q6: AOR 1.42, p = 0.24), and 20 percentage points more likely to believe that it would be good for law enforcement (Q7: AOR 1.34, p = 0.007). There was no significant interaction between race and gender in the responses.

4. Discussion

Law enforcement support appears to have been an important factor in the passage of North Carolina's 2013 partial decriminalization law. Bills intended to increase access to sterile syringes were introduced in six of the nine legislative sessions between 1997 and 2013 (North Carolina General Assembly, 1997, 2001, 2005, 2007, 2011, 2013b). None garnered the public support of LEO organizations, and all died in committee. Conversely, the 2013 law, which was co-sponsored by a legislator who was a former LEO and was supported by the state Sheriffs’ Association (Sisk, 2013), was approved by nearly unanimous votes in both houses and was quickly signed by the governor (North Carolina General Assembly, 2013a,b). This experience suggests that LEO support for a full decriminalization measure would likely be helpful, and might be necessary, for such a bill to become law.

LEO support is also an important component of successful syringe access law implementation. Research from both the U.S. and abroad finds that LEOs generally do not favor focusing policing activities on drug users (Beyer et al., 2002; Petrocelli et al., 2014), and recent evidence suggests that officers are generally supportive of public health efforts to reduce risks associated with illicit drug use (Banta-Green et al., 2013; Davis et al., 2014; Green et al., 2013). However, there are many documented instances of LEOs failing to properly implement laws improving access to sterile syringes, possibly because they do not support the laws or understand their public health underpinnings (Beletsky et al., 2013; Burris and Koester, 2013; Davis et al., 2005; Heller et al., 2009; Martinez et al., 2007).

The rate of NSI in this cohort was somewhat higher than that reported elsewhere, but data on officer NSI risk is sparse, dated, and difficult to compare directly. A retrospective study of police officers in Amsterdam from 2000–2003 found NSI risk to be 6.7 per 10,000 officers per year (Sonder et al., 2005). A survey of 803 police officers in San Diego in 1996 reported that 46.2% of respondents reported ever having received a job-related NSI, but the response rate was below 50%, and annual rates were not reported (Lorentz et al., 2000). An analysis of police and corrections officers reporting to emergency departments in Rhode Island between 1995 and 2001 found the average yearly incidence of percutaneous exposures to be 3.9 per 10,000 personnel (Merchant et al., 2008). Finally, a retrospective analysis of self-reported NSI among New York City Police Department officers revealed an exposure rate of 4.8 NSI per 10,000 officers in 1992 (Pagane et al., 1996). While these rates are generally lower than those reported among EMS responders (Leiss, 2010; Leiss et al., 2006), they present a non-negligible risk – a risk that would likely be lowered by the adoption of syringe decriminalization laws.

4.1. Limitations

This cohort, which was comprised of LEOs who had volunteered or been selected by their departments to join CITs, is not necessarily representative of all officers in the state. The questionnaire asked if respondents have ever received an NSI, but did not ask if they had received more than one, possibly leading to under-counting. Although multivariate models were utilized in this short communication, future analysis utilizing more sophisticated models would be useful in refining analyses.

4.2. Conclusions

Law enforcement agencies are increasingly adopting evidence-based strategies to reduce the negative effects of drug use (Banta-Green et al., 2013; Davis et al., 2014; Green et al., 2013). A majority of the LEOs in this study reported positive views toward syringe decriminalization, suggesting that they may be inclined to support and properly implement syringe decriminalization legislation.

These findings also highlight several promising areas for further inquiry. Research is indicated to determine whether the variations in perception of NSI risk and attitudes toward syringe decriminalization by race and sex identified here are replicated in other cohorts both in North Carolina and nationwide, and to determine the possible causes of those differences. There is a pressing need for comprehensive, timely data regarding rates of officer NSI as well as the effects of legal changes intended to reduce that risk. Finally, further research is indicated to determine whether receiving information regarding the benefits of increased syringe access to LEO occupational risk modifies attitudes regarding syringe access laws, and whether a causal effect between LEO support for syringe access legislation and the passage of that legislation can be substantiated.