Faculty Bibliography

IMPORTANCE/UNASSIGNED:Syringe services programs (SSPs) are an evidence-based intervention to reduce bloodborne disease transmission and other risks related to injection drug use; however, SSP access is uneven. State and local syringe distribution laws may influence variation in the presence and number of SSPs across local jurisdictions. OBJECTIVE/UNASSIGNED:To assess the association between state and local syringe distribution laws and presence of publicly listed SSPs in a sample of US cities. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study linked state and local laws with information on publicly reported SSPs in 2024 for the largest US municipalities and census-designated places (localities). The outcomes of policy exposure in SSP presence and total number of SSP locations among localities with at least 1 SSP were estimated using a 2-part negative binomial hurdle model, adjusting for state and local policy and demographic and health characteristics. The study team collected the legal data from January 11, 2023, through May 7, 2024. EXPOSURE/UNASSIGNED:State and local syringe distribution policy environment as of December 31, 2022, categorized from most restrictive (state prohibition) to least restrictive (neither state nor locality prohibits syringe distribution). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Publicly reported SSP presence (binary) and total count of SSP locations within each locality as of February 2024. RESULTS/UNASSIGNED:In this study using data from 482 US localities, there was at least 1 SSP in 181 (37.6%) localities. Localities with the least restrictive legal environment had increased odds of SSP presence (adjusted odds ratio, 16.3; 95% CI, 6.0-44.1) compared with those with the most restrictive legal environment. Among localities with 1 or more SSP, localities in the least restrictive legal environment or a legal environment that exempted SSPs from a syringe distribution prohibition had increased rates of SSPs, relative to the most restrictive legal environment (rate ratio for least restrictive policy environment, 2.7; 95% CI, 1.1-6.4; rate ratio for legal environment that exempts SSPs from prohibition, 2.4; 95% CI, 1.1-5.6). Overall, policies that exempted SSPs from syringe distribution prohibitions and those with no syringe distribution prohibitions had the highest estimated SSP counts (1.9 SSPs; 95% CI, 1.5-2.4; 1.5 SSPs; 95% CI, 1.1-1.9, respectively). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study found that state and local syringe distribution laws were associated with publicly listed SSP presence. Legal environments that prohibit or restrict syringe distribution may limit the presence and total number of SSPs, highlighting the role of policy context in shaping access to harm-reduction services.

BACKGROUND:Understanding the interpersonal and environmental dynamics that drive overdose prevention center (OPC) engagement is critical to inform OPC models in other jurisdictions. We described patterns of connectedness from the perspective of clients attending publicly recognized OPCs in the US. METHODS:We analyzed baseline data from the Study Assessing the Effectiveness of Overdose Prevention Centers through Evaluation Research (SAFER), which recruited OPC clients in New York City and Rhode Island from July 2023 to November 2025. Our analysis was restricted to OPC clients. Participants responded to the following statements about their OPC experience: 'I am a part of the community,' 'I can be myself,' 'I can trust the staff,' 'I feel safe,' 'I feel judged for using drugs.' We created a composite scale of OPC connectedness, with higher scores indicating greater connectedness. Multinomial logistic regression models identified associations with OPC connectedness. RESULTS:Among 494 eligible participants (30% cisgender women, 35% Hispanic/Latine), ≥70% reported trusting staff, feeling safe, and being myself 'all of the time' while at the OPC. Thirty-seven percent of participants had the highest connectedness score of 20. Cisgender women (aRR=1.97; 95% CI: 1.17, 3.30), those who keep naloxone nearby while using (aRR=1.91; 95% CI: 1.17, 3.12), and those who visited the OPC more frequently (aRR=2.00; 95% CI: 1.11, 3.58) were more likely to report high OPC connectedness. CONCLUSION/CONCLUSIONS:Findings suggest that US OPCs are successfully fostering environments of safety and belonging for clients. As jurisdictions consider OPC implementation, understanding and actively cultivating connectedness may support OPC accessibility.

BACKGROUND:Systematic social observation (SSO) quantifies changes in the social and built environment and can be useful for evaluating the neighborhood effects of substance use programs. METHODS:We developed, implemented, and validated an SSO instrument in the Bronx, New York City, and Providence, Rhode Island. Research assistants assessed neighborhoods in the Bronx (4/19/2023-6/22/2023) and Providence (11/4/2024-12/20/2024) following a randomization schedule to minimize temporal biases. We used exploratory factor analysis (EFA) and Bayesian multi-level item response theory (IRT) models to derive social and built environment indices and externally validated the measures against arrest data. RESULTS:EFA for the Bronx (n = 564) and Providence (n = 463) identified three factors assessed with the instrument: drug litter, people, and built environment. IRT-based social and built environment indices exhibited positive spatial autocorrelation (the Bronx Moran's I = 0.393, P < 0.001; Providence Moran's I = 0.068, P < 0.001). In the Bronx, item severity and discrimination were highest for the drug litter factor; item parameters were relatively uniform in Providence. The Bronx index was associated with total (incidence rate ratio [IRR] = 1.42, 95% confidence interval [CI] = 1.04-1.95) and drug-related (IRR = 1.60, 95% CI = 1.10-2.32) arrests. The Providence index was not associated with arrests. CONCLUSIONS:Our SSO protocol can be replicated in diverse settings to evaluate the neighborhood effects of substance use programs and broader effects of neighborhood conditions on substance use. The social and built environment indices for the Bronx and Providence may be useful outcomes in future studies. External validation suggests the Bronx index captured drug-related environmental variation; the Providence index may capture variation unrelated to policing patterns.

Socioenvironmental disasters such as wildfires, floods, extreme heat events, and zoonotic epidemics have been increasing in magnitude and frequency. These events are sometimes are followed by increases in overdose mortality. This paper applies an adaptation of the Big Events framework, originally developed to understand macrosocial changes and their effects on HIV, to guide research into the pathways through which socioenvironmental disasters may cause increases in overdose mortality. These pathways include economic disruption, health and social service disruption, population displacement, changes in social networks, and social movements. They also include processes and conditions more causally proximal to overdose events such as housing insecurity and changes in drug markets and drug-use behaviors. The paper also discusses relevant existing measures and variables that must be developed to conduct research on the effects of socioenvironmental disasters on overdose The end goal of this application of the Big Events framework is to encourage scholarship that identifies potential interventions for people who use drugs, public and private service agencies and governments to mitigate the harms that socioenvironmental disasters can cause for people who use drugs.

Nuisance property ordinances are municipal laws that penalize property owners or renters for alleged criminal activity or repeated disturbances, including emergency calls. As these laws have expanded, concerns have grown that they may disproportionately impact marginalized populations, including people who use drugs, by targeting drug-related activities and exacerbating chronic housing instability. This study examines the demographic and municipal-level characteristics associated with the presence of drug-related nuisance property ordinances (DNPOs) across major U.S. municipalities. Municipal codes were systemically analyzed for DNPOs across 482 municipalities in the U.S. DNPOs were classified as ordinances that list specific activities related to drugs, drug paraphernalia, or illegal activity as a nuisance. A chi-square test was used to compare proportions of demographic and socioeconomic characteristics between municipalities with and without DNPOs. 202 of 482 municipalities had DNPOs (41.9%). 73 of 202 municipalities, 36.1% of DNPOs, authorized eviction as a legal method of abatement. DNPOs were more likely to be found in municipalities with higher proportion of Black, non-Hispanic populations, lower median household income, higher poverty rates, higher unemployment rates, higher population density, higher proportions of renters, and moderate to higher rates of overdose (p < 0.05). DNPOs are prevalent across U.S. municipalities and frequently include eviction as a permitted or required abatement strategy. Our findings show that DNPOs are more likely to be present in socioeconomically disadvantaged communities. These findings underscore the need to further evaluate the health and equity consequences of nuisance property ordinances for people who use drugs.

OBJECTIVE:To examine the prevalence of categorical self-reported opioid misuse and compare it to a post hoc corrected indicator in the general Mexican population. MATERIALS AND METHODS/METHODS:We used data from the 2025 Encuesta Nacional de Consumo de Drogas, Alcohol y Tabaco. We constructed indicators from self-reported categorical heroin/fentanyl use, prescription opioids misuse and opioid misuse and post hoc corrected versions based on the review of open-ended follow up questions by two experts. We estimated the prevalence from categorical self-report responses and compared it with the post hoc corrected indicators. RESULTS:The prevalence of self-reported prescription opioid misuse was 1 948.3 per 100 000 people, which decreased to 1 242.4 after correction. Self-reported heroin or fentanyl use was 370.7 per 100 000 people, with a corrected prevalence of 326.2. Self-reported opioid misuse had a prevalence of 2 229.6 per 100 000 people, which decreased to 1 482.3 after correction. CONCLUSION/CONCLUSIONS:Misclassification was more frequent for prescription opioid misuse than for illicit opioid use. Simple categorical questions performed well for measuring illicit opioid use, but they moderately overestimated prescription and overall opioid misuse.

Cannabis policies vary from strict prohibition to commercialised legalisation and are rapidly evolving worldwide. Here, we reviewed evidence for associations between international cannabis policy changes from 2000-25 and cannabis use, cannabis use disorder, and other psychiatric disorders. Commercialised legal markets for non-medical use in Canada and the USA were associated with increased prevalence of cannabis use and cannabis use disorder in adults and increases in cannabis potency since legalisation. There was no consistent evidence for associations between policy change and the prevalence or incidence of psychotic disorders. Commercialised legalisation was associated with an increase in hospital admissions for psychosis, and for psychotic disorders comorbid with cannabis use disorder. Poorly regulated legal access to medical cannabis, in the absence of efficacy and safety data, could increase risk of harm. Policies that limit commercialisation, such as strictly regulated legalisation of medical or non-medical supply, were not as strongly associated with cannabis use or psychiatric disorders, but long-term evaluation is needed. There was little evidence that decriminalisation of non-medical cannabis in Europe, Africa, Oceania, and Asia was associated with cannabis use or psychiatric disorders.

BACKGROUND:Overdose prevention centers (OPCs) may reduce public drug use and, with it, policing of people who use drugs in the communities surrounding these sites. We applied an augmented synthetic control method to assess changes in pedestrian stops before and after the November 2021 opening of two OPCs (Washington Heights and East Harlem) in New York City (NYC). METHODS:We retrieved pedestrian stop information from the New York Police Department's (NYPD) Stop, Question, and Frisk, program from January 2017 to December 2024, and created bimonthly averages using five- and ten-minute walking buffers surrounding the OPCs and 57 donor sites (syringe service and opioid treatment programs) as outcomes. Covariates were derived from American Community Survey, NYPD Calls for Services, and SafeGraph pedestrian mobility estimates. RESULTS:The opening of the Washington Heights OPC was associated with a reduction of 2.8 bimonthly average pedestrian stops in the post-intervention period when using five-minute walking buffers, although results were compatible with increases and reductions (95%CI=-9.4, 4.0). For ten-minute walking buffers, results were compatible with a wide range of reductions (ATT=-9.2 [95%CI=-18.3, -1.3]). East Harlem OPC showed larger point estimates when examining both distances (ATT=-8.4 [95%CI=-12.2, -4.5] and ATT=-13.7 [95%CI=-22.1, -4.2] with five- and ten-minute walking buffers, respectively). For both sites, permutation tests suggested that these reductions fell within the range of possible donor-unit placebo effects. CONCLUSIONS:Our study shows limited evidence of an effect of NYC's first two OPCs on pedestrian stops in their immediate vicinity, with a potential decrease concentrated in the first two years at the East Harlem location.

BACKGROUND/UNASSIGNED:The opioid overdose crisis remains a public health emergency in the United States. Evidence-based practices-including medications for opioid use disorder (MOUD) and naloxone distribution-can reduce harms, but their community-level cost-effectiveness is uncertain and may vary locally. We aimed to evaluate the cost-effectiveness of enhanced community-level implementation of evidence-based practices for opioid use disorder (OUD). METHODS/UNASSIGNED:We used a validated microsimulation model of OUD, calibrated with data from the HEALing Communities Study across 26 highly impacted communities in Massachusetts, New York, and Ohio. Six intervention scenarios for 2025-2030: maintaining 2024 evidence-based practice levels (status quo); improved naloxone distribution; improved MOUD retention; improved MOUD initiation; combined initiation and retention; and combined initiation, retention, and naloxone distribution. Outcomes included opioid overdose deaths (OODs), non-overdose opioid-related deaths, quality-adjusted life years (QALYs), costs (healthcare and societal), and incremental cost-effectiveness ratios (ICERs). FINDINGS/UNASSIGNED:Maintaining 2024 evidence-based practice levels was projected to yield OODs of 39-468 per 100,000 and non-overdose deaths of 238-3018 per 100,000 across communities. Enhancing MOUD initiation, retention, and naloxone distribution reduced OODs by 15-40% and non-overdose deaths by 7-24%, producing the largest QALY gains (1006-38,292). From the healthcare perspective, improved initiation plus retention was cost-effective in all communities (ICER US$11,765-US$91,058 per QALY); from the societal perspective, all enhanced scenarios were cost-saving (US$121 million-US$4.74 billion net savings). INTERPRETATION/UNASSIGNED:Community-level enhancement of MOUD initiation and retention, and for some communities also enhancing naloxone distribution, can substantially reduce opioid-related-overdose and non-overdose-deaths. These strategies are cost-effective from a healthcare perspective and cost-saving from a societal perspective, supporting investment in comprehensive, community-tailored interventions. FUNDING/UNASSIGNED:NIH HEAL Initiative.

IMPORTANCE/UNASSIGNED:Syringe services programs (SSPs) are evidence-based interventions that reduce bloodborne infections and injection-related harms among people who inject drugs, yet access remains limited and geographically uneven across the US. OBJECTIVE/UNASSIGNED:To quantify the travel time, distance, and cost required to reach the nearest SSP from population-weighted census tracts nationwide and to examine differences by urbanicity, state, and SSP legality. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional geospatial study linked all known SSP locations as of August 2024 to the population-weighted centroids of census tracts in the 50 US states and the District of Columbia. Analyses were conducted between December 2024 and February 2026. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Population-weighted mean and median driving time, distance, and cost to access the nearest SSP, stratified by National Center for Health Statistics urban-rural county category and SSP legal status. Costs were estimated using 2024 Internal Revenue Service (IRS) medical mileage deduction rates and 2022 state-specific gasoline prices. RESULTS/UNASSIGNED:In 1338 SSPs across 83 780 census tracts, the population-weighted mean 1-way driving time to the nearest SSP was 46.1 minutes (95% CI, 45.7-46.5 minutes) and the median was 23.3 minutes (IQR, 12.2-58.5 minutes). Altogether, 23.1% of the population lived more than 60 minutes from an SSP and 12.6% lived over 120 minutes away. The mean 1-way driving distance was 41.8 miles (95% CI, 41.3-42.2 miles). The mean 1-way driving cost was $8.77 (95% CI, $8.68-$8.86) using the 2024 IRS mileage rate and $6.91 (95% CI, $6.84-$6.98) using state mean gasoline prices in 2022. In states where SSPs were legal, mean driving time was 30.1 minutes (95% CI, 29.8-30.4 minutes) and mean cost by IRS mileage rates was $4.94 (IQR, $4.88-$5.00), compared with 110.7 minutes (95% CI, 109.6-111.8 minutes) and $24.19 (IQR, $23.92-$24.46) in states where SSPs were illegal. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This cross-sectional study of travel burden to SSPs found substantial geographic and financial barriers to accessing SSPs across the US, particularly in nonmetropolitan areas. Targeting new SSPs to areas with the greatest travel burden could improve utilization and reduce drug-related morbidity.