Using NYC mortality data from 1990–1999, we found that police activity in a precinct was associated with accidental drug overdose mortality. Specifically, Bayesian hierarchical modeling showed that accidental fatal drug overdose, as well as cocaine-specific and opiate-specific fatal overdose, was significantly higher in police precincts with higher misdemeanor arrest rates, independent of potential confounding by gender, age, race, unemployment, socioeconomic status, and the level of drug use. We infer that greater police activity in a neighborhood is associated with higher rates of drug overdose mortality, possibly due to greater reluctance of persons who witness overdose to call for help. Although increased levels of misdemeanor policing may decrease the rate of drug overdose mortality in a precinct both directly, by reducing levels of drug use, and indirectly, by strengthening the community capacity to maintain informal control over drug use and associated risk behaviors, it may also engender an environment in which drug users are increasingly fearful of police arrest for minor infractions. Fears of arrest may promote behaviors, such as not calling for medical help when witnessing an overdose, which delay medical responses to overdose events and increase the rate of drug overdose mortality in a precinct.
We found that accidental drug overdose mortality for all drugs, cocaine, and opiates was significantly higher in police precincts with greater levels of police activity. The present findings suggest that greater drug overdose mortality may be a negative consequence of greater levels of police activity that may somewhat offset the benefits associated with aggressive enforcement of misdemeanor violations, such as reduced homicide mortality (Cerda et al., 2009
; Messner et al., 2007
; Rosenfeld et al., 2007
). We note that these findings are particularly important when considering that in NYC, where this study was conducted, there have been more deaths due to accidental drug overdose than there have been due to homicide every year since 1996. Therefore, if police activity is indeed a contributor to higher overdose mortality rates, this consequence of greater policing is not trivial, but rather one that may have substantial implications for population health.
There are several possible explanations for the present findings. Based on extant research about the circumstances surrounding drug overdose (Tracy et al., 2005
; Tobin et al., 2005
), we suggest that the primary mechanism linking greater police activity and overdose death is fear of police arrest among persons who witness overdose. It has been amply demonstrated that the vast majority of overdoses are witnessed and that timely calls to emergency medical services may substantially reduce overdose mortality (Powis et al., 1999
). However, extant research shows that fear of police arrest is the primary reason why persons who witness an overdose may be reluctant to call for help (Baca and Grant, 2007
; Pollini et al., 2006
; Tobin et al., 2005
; Tracy et al., 2005
). Delaying the response of emergency medical services to an overdose event may contribute to the rate of overdose mortality in a precinct by increasing the probability of death conditional on drug overdose. A secondary mechanism explaining the observed relation may be that increased police presence, and hence increased fear of police arrest, may increase the rate of drug overdose mortality in a precinct by promoting drug use in more secluded areas (Dovey et al., 2001
) where overdose victims are less likely to receive medical attention (Tracy et al., 2005
). A third possible mechanism is that precincts characterized by increased police activity and fears of police involvement may have increased rates of drug overdose mortality because drug users in these precincts are subjected to psychosocial stressors that increase the likelihood of drug overdose (Sinha, 2001
) and death from drug overdose. Additionally, a forth possible mechanism is that areas with more arrests have more incarcerations, and the period after release from incarceration is a known risk period for both fatal and non-fatal overdose (Bird and Hutchinson, 2003
; Kerr et al., 2007
; Krinsky et al., 2009
). Lastly, we cannot rule out the possibility of unmeasured confounding. Further work is needed to elucidate the specific pathways linking misdemeanor arrest rates to the likelihood of drug overdose death.
There are several limitations to this study. First, with respect to study design, it is important to note that this analysis was ecological and inference should not be made about the risk of individual overdose events. Second, our measure of police activity was based on the number of misdemeanor arrests in a precinct. Although this measure is consistent with prior research (Corman and Mocan, 2002
; Harcourt and Ludwig, 2005
; Lekking and Sousa, 2001
; Cerda et al., 2009
) and has been considered a reasonable measure of misdemeanor policing activity in a given area, it may not fully capture the level of policing perceived by drug users in a particular precinct. In addition, this measure does not address fear of policing per se.
Although we observe an association between greater police activity and drug overdose mortality, we can only posit the possible mechanisms that explain the observed association. We have also focused on how misdemeanor arrests, which include drug possession violations, might influence fear of police arrest for overdose witnesses and consequently delay their getting help for the overdose victim. Consequently, other aspects of policing, such as felony arrest rates and size of the police force, are beyond the scope of this study. Furthermore, we used the proportion of non-overdose accident decedents in whom illegal drugs were detected as a proxy measure for levels of drug use in each police precinct. While this is an accepted practice for measuring drug use on a community level (Cerda et al., 2009
; Galea et al., 2003
; Messner et al., 2007
), it is not a direct measure of use and an inexact measure of the drug use of the larger community. Consequently, caution should be exercised in interpretation of the present findings because residual confounding, specifically due to incomplete measure of the prevalence of frequency of drug use within precincts, may be present.
Notwithstanding these limitations, our findings suggest that the level of misdemeanor police activity in a precinct may be an important determinant of drug overdose mortality. This finding, taken together with evidence that fear of police arrest is the primary reason why those who witness overdose do not call for help (Tracy et al., 2005
) suggests that “broken windows” policing may be associated with greater overdose mortality. It is important to note that this unintended consequence of greater policing is not, in and of itself, an intractable feature of policing activity. The solution is not to reduce policing, but to offset increases in fear due to high enforcement of misdemeanor infractions with complimentary policing practices. Some jurisdictions have implemented efforts that aim to reassure persons who call for help on witnessing an overdose that they will not be prosecuted (Drug Policy Alliance, 2006
). Similarly, policies that prevent police officers from responding to overdose events may reduce fears of arrest and increase the likelihood that witnesses of drug overdoses call for medical help. A broad approach (not specific to concerns about overdose events) is problem-oriented policing, which has been demonstrated to decrease crime and disorder while building positive relationships with the residents of the area being policed (Weisburd and Eck, 2004
The present study highlights the complex consequences of efforts such as increased policing in urban neighborhoods. A comprehensive assessment of the full range of these consequences, coupled with targeted efforts to mitigate the potential negative effects of such efforts, is warranted.