To our knowledge, this is the first study to examine WWUD’s policing experiences amid the COVID-19 pandemic and nationwide scale back of policing. Compared to a study of WES in Baltimore City recruited using similar methods prior to decriminalization, a smaller proportion of women in our sample reported experiencing enforcement (43.6% vs 81.6%) or egregious (11.3% vs 38.0%) policing practices within the prior 3 months [22]. However, while encounters with police may have generally declined during the pandemic, findings from our study suggest that exposure to policing remained highest among women simultaneously facing unmet needs. Additionally, data illustrated a compounded burden of material insecurity with policing, as WWUD with overlapping unmet needs were more likely to face greater intensity of both police enforcement and egregious policing. While the acute phase of the COVID-19 pandemic has concluded, elaboration of WWUD’s experiences during this time can detail the amplification of risks to adverse health and social outcomes in times of social disruption, including future public health emergencies and natural disasters. This research adds to the growing body of evidence demonstrating a link between structural vulnerability and exposure to more intensive and abusive forms of policing [13, 20, 25].

Our analysis conforms with prior research demonstrating a link between socio-structural vulnerability and exposure to policing, providing evidence that this pattern persisted in the context of the COVID-19 pandemic [25]. Specifically, women struggling to face their most basic needs during the COVID-19 pandemic, including places to stay or use the bathroom, were more likely to report experiencing multiple enforcement practices. Previous studies have highlighted how unstably housed individuals were disproportionately impacted by pandemic-related changes to the delivery of health and social services, including the closure of drop-in centers and shelters [26]. Due to the closure of “safe haven” programs and substandard housing conditions, women experiencing high levels of material insecurity may have resorted to spending extended periods of time in public places while lockdown policies were in effect, likely increasing their visibility and exposure to repeated police enforcement practices. While significant investment was made to increase unstably housed individuals’ access to shelter during the pandemic, for example, the establishment of hotel-based “shelter-in-place” housing, these programs were not designed with the specific needs of PWUD in mind. Many programs enforced curfews, searched properties, and prohibited the possession or consumption of drugs on hotel premises [27, 28]. To retain PWUD in housing amid public health emergencies, there is a need to develop housing interventions that incorporate harm reduction supports.

Experiencing unmet healthcare needs during the pandemic, specifically access to needed medications, was significantly associated with exposure to more intensive and abusive forms of policing. While we did not gather information about the specific medications WWUD in our sample struggled to access, a greater proportion of women with a mental health condition or receiving MOUD treatment reported this challenge. This aligns with prior research that has demonstrated an association between greater jail frequency and unmet physical and mental health needs, highlighting both the destabilizing effect of criminal justice involvement and its contribution to avoidance of healthcare services [13]. These patterns were likely exacerbated during the pandemic, when “shelter-in-place” orders contributed to drastic changes to the delivery of healthcare services. While several initiatives attempted to promote continued access to MOUD during stay-at-home orders, such as the expansion of take-home dispensing protocols [29], research suggests that inequities in treatment access were exacerbated. This was especially true for individuals experiencing housing instability, who were unlikely to have the means to engage in telehealth and were explicitly excluded from take-home dosing [30]. Disruptions in access to needed medications, combined with heightened levels of stress caused by the pandemic, may have led to more frequent engagement with the drug market to cope, increasing vulnerability to policing.

Women who struggled to access harm reduction supplies, including sterile syringes and naloxone, were more likely to experience a greater intensity of enforcement practices, as well as different forms of policing. This suggests that while low-level drug offenses, including simple drug and paraphernalia possession, were effectively decriminalized in Baltimore City, WWUD were still disproportionately targeted by police. The role of police discretion in implementing reforms to drug enforcement has been highlighted as a possible barrier to improving criminal-legal outcomes amid recent decriminalization efforts [31]. Despite the absence of a legal requirement for police to stop arresting for crimes included in the city’s de facto policies, evidence demonstrated substantial reductions in arrests for drug and paraphernalia possession, sex work, and other adjacent crimes in Baltimore City from 2020 to 2021 [10]. However, possible impacts of the policy on other forms of police encounters, including ID checks, searches, and harassment, have not been evaluated to date. This highlights the value of an accumulation approach when studying CLS exposure, rather than focusing on singular outcomes such as arrest or incarceration. This approach accounts for the extension of policing practices into other facets of social life, including the subjection of impoverished, unhoused and participating in the street-based economy to greater surveillance and punishment [32]. Findings also highlight possible limitations of decriminalization in effecting the nature of street interactions between officers and individuals navigating multiple forms of material insecurity. As our data support, even in the absence of arrest, there is a range of routine and egregious practices that officers may employ that can lead to a cascade of negative outcomes. To effectively interrupt these cycles, there is a need for more comprehensive reform that shifts the culture and norms of policing contributing to the disproportionate targeting of PWUD by investing in resources promoting social and economic stability.

Finally, we observed an additive effect of material insecurity, intensity of enforcement practices, and exposure to egregious practices. In other words, the risk of experiencing more intensive and exploitative forms of policing incrementally increased as the quantity of unmet needs increased. The relationship between multiple, overlapping unmet needs and exposure to multiple enforcement practices had a distinct trend from exposure to a singular enforcement practice. This underscores the consistent over-policing of individuals engaged in behaviors that are considered deviant, including drug use, sex work, and homelessness. This demonstrates the inflexibility of this pattern even amid extraordinary circumstances, such as a global pandemic and a co-occurring local decriminalization of these behaviors. While routine enforcement practices, such as being asked to show ID or conducting property searches, are typically considered to be less harmful than more abusive practices, prior research has demonstrated that greater intensity of these practices has a negative impact on psychological well-being and engagement with healthcare services [33]. The significant overlap of this form of policing with material insecurity highlights the pervasive dehumanization that WWUD encounter to survive in challenging circumstances [34].

While there are several strengths to this study, there are also several limitations that should be noted. First, while we measured exposure to a variety of policing practices, we did not collect data about the intensity or frequency of this exposure. This is clearly relevant to capturing the intensity of policing and should be addressed in future studies. Additionally, significant changes to policing policies and the broader pandemic context occurred throughout the data collection period, which may have impacted our findings. While we attempted to control for time in adjusted analyses, this likely did not fully account for these time [33,34,35] dependent variations. Additionally, our sample was the use of targeted recruitment in seven distinct neighborhoods of Baltimore City to recruit a community-based sample of WWUD; however, our results may not be generalizable to WWUD living in other jurisdictions, especially given the implementation of a de facto decriminalization policy in Baltimore. Despite the fact that approximately half of the women in our sample were Black or African American, our analysis does not account for the role of racial discrimination, despite widely acknowledged racial disparities in criminal-legal system exposure. Future research is needed that explicitly interrogates intersections between structural vulnerability, exposure to policing, and racial minoritization. Finally, this cross-sectional analysis precludes causal inferences about the relationship between unmet needs and exposure to policing from being drawn. Future research should investigate the longitudinal relationship between socio-structural vulnerability and policing.