Faculty Bibliography

INTRODUCTION:Rates of illicit opioid use are particularly high among young adults, yet research on overdose experience and factors associated with overdose in this population remains limited. This study examines the experiences and correlates of non-fatal overdose among young adults using illicit opioids in New York City (NYC). METHODS:539 participants were recruited via Respondent-Driven Sampling in 2014-2016. Eligibility criteria included: aged 18-29 years old; current residence in NYC; and nonmedical prescription opioid (PO) use and/or heroin use in the past 30 days. Participants completed structured interviews to assess their socio-demographics, drug use trajectories, current substance use and lifetime and most recent overdose experiences, and were tested on-site for hepatitis C virus (HCV) antibodies. RESULTS:43.9% of participants reported lifetime overdose experience; of these, 58.8% had experienced two or more overdose events. The majority of participants' most recent overdoses (63.5%) were due to polysubstance use. In bivariable analyses, after RDS adjustment, having ever overdosed was correlated with: household income of >$100,00 growing up (vs. $51,000-100,000); lifetime homelessness; HCV antibody-positive status; lifetime engagement in regular nonmedical benzodiazepine use, regular heroin injection and regular PO injection; and using a non-sterile syringe in the past 12 months. Multivariable logistic regression identified childhood household income >$100,00 (AOR=1.88), HCV-positive status (AOR=2.64), benzodiazepine use (AOR=2.15), PO injection (AOR=1.96) and non-sterile syringe use (AOR=1.70) as significant independent correlates of lifetime overdose. A multivariable model with multiple overdoses (vs. one) found only lifetime regular heroin use and PO injection to be strong correlates. DISCUSSION:Results indicate a high prevalence of lifetime and repeated overdose among opioid-using young adults in NYC, highlighting a need for intensified overdose prevention efforts for this population. The strong associations of HCV and indices of polydrug use with overdose suggest that prevention efforts should address the complex risk environment in which overdose occurs, attending to the overlapping nature of disease-related risk behavior and overdose risk behavior among young people who inject opioids. Overdose prevention efforts tailored for this group may find it useful to adopt a syndemic conception of overdose that understands such events as resulting from multiple, and often interrelated, risk factors.

Introduction: Although a substantial body of research documents a relationship between traumatic stress in childhood and the initiation of substance use later in the life course, only limited research has examined potential linkages between adverse childhood experiences (ACEs) and the initiation of non-medical prescription opioid use and other opioid use behaviors. The present study contributes to this growing body of work by investigating the association of childhood trauma with early initiation of a series of opioid use behaviors. Methods: New York City young adults (n = 539) ages 18-29 who reported non-medical use of prescription opioids or heroin use in the past 30 days were recruited using Respondent-Driven Sampling in 2014-16. Ten ACEs were assessed via self-report with the ACE Questionnaire. Associations between number of ACEs and self-reported ages of initiating seven opioid use behaviors (e.g., non-medical prescription opioid use, heroin use, heroin injection) were estimated with multivariable logistic regression. Results: Eighty nine percent of participants reported at least one ACE, and 46% reported four or more ACEs, a well-supported threshold indicating elevated risk for negative health consequences. Every increase of one trauma was associated with a 12-23% increase in odds of early initiation across the seven opioid use behaviors. Findings also document that the mean age at initiation increased with increasing risk severity across the behaviors, contributing to evidence of a trajectory from opioid pill misuse to opioid injection. Discussion: Increasing number of childhood traumas was associated with increased odds of earlier initiation of multiple opioid misuse behaviors. In light of prior research linking earlier initiation of substance use with increased substance use severity, present findings suggest the importance of ACEs as individual-level determinants of increased opioid use severity. Efforts to prevent onset and escalation of opioid use among at-risk youth may benefit from trauma prevention programs and trauma-focused screening and treatment, as well as increased attention to ameliorating upstream socio-structural drivers of childhood trauma.

BACKGROUND/UNASSIGNED:: Those with exposure to abuse, homelessness, and both adverse outcomes constitute a high-risk population for substance use. Addressing abuse and homelessness should be a component of preventing drug risk for screening, treatment, and prevention efforts.

BACKGROUND:Research demonstrates strong associations between adverse childhood experiences (ACEs) and non-medical prescription opioid use (NMPO), but pathways are not understood, hindering prevention and treatment responses. METHODS:We assessed hypothesized mediators of the association between ACEs and NMPO in a nationally-representative U.S. SAMPLE/METHODS:National Longitudinal Study of Adolescent to Adult Health data (N = 12,288) yielded an ordinal exposure comprising nine ACEs (neglect; emotional, physical, sexual abuse; parental incarceration and binge drinking; witnessed, threatened with, experienced violence) and a binary lifetime NMPO outcome. Nine potential mediators measured in adolescence and/or adulthood included depression, anxiety, suicidality, delinquency, impulsivity, and risk-taking. We estimated adjusted odds ratios (AOR) and 95% confidence intervals (CI) for sex-stratified associations of: ACEs and mediators; mediators and NMPO; and ACEs and NMPO adjusting for mediators individually and simultaneously. RESULTS:All associations of ACEs and mediators were statistically significant and similar by sex. All mediators had statistically significant associations with NMPO (except one depression measurement for each sex). Delinquency was strongly associated with ACEs and NMPO and was the strongest individual mediator. Every ACE increase was associated with increased NMPO odds of 32% for males and 27% for females. Adjusting for all mediators, odds of NMPO were attenuated partially for males [AOR = 1.18 (95% CI:1.07, 1.31)] and somewhat more for females [AOR = 1.11 (95% CI:1.00, 1.25)]. CONCLUSIONS:Internalizing and externalizing factors partially explained the pathway from ACEs to NMPO. Substance abuse may be more difficult to treat with co-occurring psychopathologies and maladaptive behaviors, highlighting the need to address trauma early in life.

BACKGROUND:Hepatitis C virus (HCV) incidence has increased dramatically in the United States in recent years and is associated with the opioid epidemic due to high HCV transmission risk among people who inject drugs (PWID). HCV transmission knowledge is difficult to ascertain given the lack of psychometrically-tested measures. We developed and validated an HCV injection-risk knowledge scale. METHODS:Analyses used data from 539 New York City opioid users ages 18-29 recruited via respondent-driven sampling in 2014-16. Blood samples yielded HCV antibody status. Principal components analysis (PCA) of nine knowledge items answered true, false, or don't know identified useful scale items. We evaluated internal consistency with the Cronbach's alpha coefficient and assessed construct validity by comparing knowledge levels with those from a previously validated general HCV knowledge scale and by comparing key sub-group knowledge levels. RESULTS:PCA identified one component with five items that explained 45% of the total variance and had high internal consistency (alpha=0.91). All items referred to transmission through drug-injection equipment and practices: sharing cookers, cottons, diluting water, water containers, and cleaning syringes with water. The mean percent correct was 75%, and as expected, was moderately correlated with general HCV knowledge (Spearman's rho=0.55). As hypothesized, knowledge levels were highest for those previously tested for HCV, those with HCV antibody-positive status, PWID, and those who had received harm reduction information in various settings. CONCLUSIONS:The 5-item, validated HCV Injection-Risk Knowledge Scale (HCV-IRKS) may provide educators, care providers, and researchers with critical information for reducing HCV among PWID.

BACKGROUND:While previous research has documented the impact of violence on substance use, none has looked longitudinally across the lifespan to measure independent effects of direct and indirect violence exposure. OBJECTIVE:To examine independent associations between adolescent experiences of violence and subsequent substance use in adolescence and adulthood in the United States. METHOD/METHODS:Using the National Longitudinal Study of Adolescent to Adult Health (N = 12,288), we examined being shot or stabbed ("experienced"), being threatened with a knife or gun ("threatened"), and seeing someone either shot or stabbed ("witnessed") during adolescence (Wave I) as correlates of substance use in adolescence and adulthood (Wave IV) via logistic regression. RESULTS:Violence exposure was a significant correlate of drug use in adolescence and several associations remained significant in adulthood. Witnessing violence had the highest point estimates in the adjusted models in adolescence for each substance use outcome (e.g., Cocaine-Adjusted Odds Ratios [AOR] = 2.59, 95% confidence interval [CI] = 1.21, 5.54). However, the point estimates for threatened with violence or experienced violence were highest in three out of the four drug outcomes in adulthood (e.g., Threatened with violence: Binge drinking-AOR = 1.41, 95% CI = 1.08, 1.83). Conclusion/Importance: Adolescent exposure to witnessing violence had stronger effects on substance use in adolescence, while experiencing and being threatened with violence in adolescence had stronger effects on substance use in adulthood. Violence prevention efforts targeted toward adolescents may lead to a reduction in substance use throughout the life-course, and clinicians and policy makers should be aware of the downstream effects of violence experienced in adolescence.

Incarceration is strongly associated with post-release STI/HIV risk. One pathway linking incarceration and STI/HIV risk may be incarceration-related dissolution of protective network ties. Among African American men released from prison who were in committed partnerships with women at the time of incarceration (N = 207), we measured the association between committed partnership dissolution during incarceration and STI/HIV risk in the 4 weeks after release. Over one-quarter (28%) experienced incarceration-related partnership dissolution. In adjusted analyses, incarceration-related partnership dissolution was strongly associated with post-release binge drinking (adjusted odds ratio (AOR) 4.2, 95% confidence interval (CI); 1.4-15.5). Those who experienced incarceration-related partnership dissolution were much more likely to engage in multiple/concurrent partnerships or sex trade defined as buying or selling sex (64%) than those who returned to the partner (12%; AOR 20.1, 95% CI 3.4-175.6). Policies that promote maintenance of relationships during incarceration may be important for protecting health.

PURPOSE OF REVIEW/OBJECTIVE:The social networks of people who inject drugs (PWID) have long been studied to understand disease transmission dynamics and social influences on risky practices. We illustrate how PWID can be active agents promoting HIV, HCV, and overdose prevention. RECENT FINDINGS/RESULTS:We assessed drug users' connections and interactions with others at risk for HIV/HCV in three cities: New York City (NYC), USA (n = 539); Pereira, Colombia (n = 50); and St. Petersburg, Russia (n = 49). In all three cities, the majority of participants' network members were of a similar age as themselves, yet connections across age groups were also present. In NYC, knowing any opioid user(s) older than 29 was associated with testing HCV-positive. In NYC and St. Petersburg, a large proportion of PWID engaged in intravention activities to support safer injection and overdose prevention; in Pereira, PWID injected, had sex, and interacted with other key groups at risk. People who use drugs can be active players in HIV/HCV and overdose risk- reduction; their networks provide them with ample opportunities to disseminate harm reduction knowledge, strategies, and norms to others at risk. Local communities could augment prevention programming by empowering drug users to be allies in the fight against HIV and facilitating their pre-existing health-protective actions.

BACKGROUND AND AIMS: Examination of longitudinal relationships between childhood traumatic experiences and drug use across the life-course at the national level, with control of confounding by other forms of trauma, is needed. We aimed to estimate the prevalence of nine typologies of childhood traumas and the cumulative number experienced, correlation between traumas, and associations between individual and cumulative number of traumas with drug use during adolescence, emerging adulthood, and adulthood. DESIGN: Secondary data analysis using the National Longitudinal Study of Adolescent to Adult Health SETTING: United States of America. PARTICIPANTS: A nationally-representative sample of individuals in grades 7-12 (ages 11-21) during 1994-95, who were re-interviewed during emerging adulthood (2001-02; ages 18-26) and adulthood (2007-08; ages 24-32). The analytic sample is 12,288 participants with data at all three waves. MEASUREMENTS: Nine typologies of childhood traumas: neglect; emotional, physical, and sexual abuse; parental incarceration and binge drinking; and witnessing, being threatened with, and experiencing violence. Indicators of each were summed to measure cumulative dose. Outcomes were marijuana and cocaine use during adolescence, emerging adulthood, and adulthood. FINDINGS: Approximately 53% experienced at least one childhood trauma; traumas were not highly correlated. We observed a dose-response relationship between the number of traumas and drug use in adolescence (marijuana adjusted odds ratio (AOR) one trauma vs. none=1.65, 95% confidence interval (CI): 1.42, 1.92; two traumas=2.58, 95%CI: 2.17, 3.06; >/=four traumas=6.92, 95%CI: 5.17, 9.26; cocaine AOR one trauma=1.87, 95%CI: 1.23, 2.84; two traumas=2.80, 95%CI: 1.74, 4.51; >/=four trauma=9.54, 95%CI: 5.93, 15.38). Similar dose-response relationships with drug use were observed in emerging adulthood and adulthood. Each individual trauma was independently associated with either marijuana or cocaine use in adolescence, emerging adulthood, and/or adulthood. CONCLUSIONS: Childhood trauma is prevalent in the US and individual types as well as the total number experienced are significantly associated with Marijuana and cocaine use throughout the life-course.

BACKGROUND: Childhood maltreatment, particularly sexual abuse, has been found to be associated with sexual risk behaviors later in life. We aimed to evaluate associations between a broad range of childhood traumas and sexual risk behaviors from adolescence into adulthood. METHODS: Using data from Waves I, III and IV of the National Longitudinal Study of Adolescent to Adult Health (Add Health), we used logistic regression to estimate the unadjusted odds ratio (OR) and adjusted OR (AOR) for associations between 9 childhood traumas and a cumulative trauma score and three sexual risk outcomes (multiple partnerships, sex trade involvement, and sexually transmitted infection [STI]) in adolescence, young adulthood, and adulthood. We also examined modification of these associations by gender. RESULTS: Associations between cumulative trauma score and sexual risk outcomes existed at all waves, though were strongest during adolescence. Dose-response-like relationships were observed during at least 1 wave of the study for each outcome. Violence exposures were strong independent correlates of adolescent sexual risk outcomes. Parental binge drinking was the only trauma associated with biologically confirmed infection in young adulthood (AOR, 1.46; 95% confidence interval [CI], 1.01-2.11), whereas parental incarceration was the trauma most strongly associated with self-reported STI in adulthood (AOR, 1.70; 95% CI, 1.11-2.58). A strong connection was also found between sexual abuse and sex trade in the young adulthood period (AOR, 2.17; 95% CI, 1.43-2.49). CONCLUSIONS: A broad range of traumas are independent correlates of sex risk behavior and STI, with increasing trauma level linked to increasing odds of sexual risk outcomes. The results underscore the need to consider trauma history in STI screening and prevention strategies.