Faculty Bibliography

Given substantial reporting delays in overdose deaths, state health departments increasingly use non-fatal overdose data to inform geographically targeted rapid overdose response efforts. We sought to evaluate the extent to which non-fatal overdose events were associated with concurrent and future overdose deaths in Rhode Island. We aggregated non-fatal overdose data from emergency medical services records (2019-2023) and fatal overdose data from the State Unintentional Drug Overdose Reporting System (2020-2023) in 1-, 3-, and 6-month intervals at census block group and census tract levels. Rates of fatal overdose were estimated, relative to non-fatal overdose lagged by 0-12 months, using negative binomial regression, and relative to monthly spikes in non-fatal overdose burden, using zero-inflated Poisson regression. Estimation was implemented using integrated nested Laplace approximation. Each additional non-fatal overdose event per census block group was associated with fatal overdose rates that were 48% higher (95% credible interval: 1.37-1.59) than expected in concurrent months, with smaller associations at the census tract level, in wider time intervals, and when non-fatal overdose data were lagged. Spikes in non-fatal overdose activity were associated with elevated overdose mortality in concurrent periods with fine temporal and geographic granularity, but not in larger time frames and geographic areas.

We estimated the extent to which different pain management practices, considered together as well as individually, mediated the relationship between chronic pain or physical disability and new-onset opioid use disorder (OUD) in a large cohort of adult Medicaid patients. Considering the plausibility of the assumptions required to identify different mediational estimands, we estimated natural indirect effects when considering mediation through the group of mediators together and estimated interventional indirect effects when considering mediation through each pain management practice individually. We estimated each effect using a nonparametric one-step estimator. The pain management variables we examined mediated all of the total effect of chronic pain on OUD risk and nearly half of the total effect of physical disability on OUD risk. High-dose, long-duration opioid prescribing and co-prescription of opioids with benzodiazepines, gabapentinoids, and muscle relaxants each contributed substantially to the increased risk of OUD due to chronic pain (contributing to 10-37% of the overall effect) and more moderately to the increased risk of OUD due to physical disability (contributing to 3-19% of the overall effect). Antidepressant or anti-inflammatory prescribing and physical therapy generally did not contribute to increased OUD risk, and, in some cases, even contributed to small reductions in risk.

INTRODUCTION/BACKGROUND:A 2021 federal rule permits opioid treatment programs (OTPs) to provide methadone through mobile medication units (MMUs), creating an opportunity to provide medication for people in residential care facilities. We used simulations to quantify the potential of MMUs to expand methadone access to people residing in residential substance use treatment facilities (RTF), skilled nursing facilities (SNF), and nursing facilities (NF) in New York State under different scenarios. METHODS:For each facility (RTF, SNF, and NF), a need score was created using three items: facility opioid use disorder (OUD) population, driving distance to nearest OTP, and county overdose mortality rate. We then demonstrated potential patient reach following the launch of 50 hypothetical MMUs making one stop per day to the highest need facilities. In refinements, we examined three additional scenarios involving more daily stops and prioritizing rural areas. RESULTS:Our sample included 3214 people with OUD estimated to be housed in 1052 facilities in New York, with the majority in RTFs (51.5%). The demonstrated percentage of OUD population served ranged from 23.5% to 35.8%, and the percentage of facilities served ranged from 23.8% to 37.4%. Each scenario reached a large percentage of rural facilities (73-76%). Prioritizing rural facilities decreased the proportion of OUD population served (10% reduction) but did not substantially increase driving time. Allowing multiple stops increased the proportion of OUD population served (32-36% vs. 24-26%). CONCLUSIONS:Using methods based on location information and spatial relationships, state officials can develop priorities and assess tradeoffs of MMU deployment and distribution strategies.

BACKGROUND:Overdose rates in the U.S. rose dramatically during the COVID-19 pandemic. Well-documented racial and sociodemographic inequities in the impact of the pandemic suggest the potential for similar inequities for overdose. Our objective was to identify subgroups of New York State Medicaid enrollees who experienced the greatest increases in non-fatal opioid overdose risk following onset of the COVID-19 pandemic. METHODS:Data are from a retrospective cohort of 1,021,889 people enrolled in New York State Medicaid from 2019-2020. To identify subgroups with the greatest increased risk of non-fatal overdose following onset of the COVID-19 pandemic, we used Heterogeneous Treatment Effect (HTE)-Scan, a novel machine learning method developed for accurate and computationally efficient discovery of heterogeneous treatment effects in complex data. RESULTS:In the total sample, risk of non-fatal opioid overdose increased 22% after onset of the pandemic. We also identified two subgroups with elevated risk relative to the total sample: subgroup 1 (Black and Hispanic males aged 45-64 years old with no baseline documentation of opioid use disorder (OUD); N = 53,065) and subgroup 2 (people aged 45-64 years old with documented aged/blind/disabled status and no baseline documentation of OUD; N = 73,694). These subgroups experienced a 54% and 57% increase in non-fatal overdose risk, respectively. CONCLUSIONS:We estimated heterogeneous effects of onset of the COVID-19 pandemic on non-fatal overdose, with elevated risks estimated for older working-aged, structurally disadvantaged adults without documented OUD. These findings illustrate the importance of structural factors in driving heterogeneous risk of overdose following complex social events.

HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention strategy, yet awareness, knowledge, and willingness to use it among people who inject drugs (PWID) remains inadequate despite widespread eligibility. Stigma, particularly HIV-stigmatizing beliefs and attitudes, may be a key barrier to engagement at early stages of the PrEP care continuum. We examine how HIV-stigmatizing beliefs and attitudes affect PrEP awareness, knowledge, and willingness among PWID. We surveyed 262 HIV-negative PWID in Los Angeles and Denver (2021-2023) and used structural equation modeling to examine associations between HIV-stigmatizing beliefs and attitudes (11-item validated scale with α = 0.899 and 1-factor structure) and three early PrEP outcomes: awareness, knowledge, and willingness, while controlling for race/ethnicity, gender, housing status, and conducted sub-analyses on willingness to use long-acting injectable PrEP. HIV-stigmatizing beliefs and attitudes were significantly associated with lower PrEP awareness (β - 0.212, p < 0.001) and less accurate knowledge (β - 0.179, p = 0.006). Accurate knowledge was associated with greater willingness to use PrEP (β 0.175, p = 0.027). Black, Indigenous, and Other Persons of Color (BIPOC) participants reported higher HIV-stigmatizing beliefs and attitudes than non-Hispanic White participants (β 0.196, p = 0.003). Over half (56%) of participants were willing to take daily oral PrEP once informed, and many were interested in long-acting injectable PrEP. HIV-stigmatizing beliefs and attitudes are associated with lower PrEP care continuum engagement among PWID, particularly through limiting awareness and understanding of PrEP. BIPOC participants reported higher levels of stigmatizing attitudes, suggesting that broader structural and intersectional stigma may shape PrEP engagement, consistent with prior research. Interventions to increase PrEP uptake should address both individual- and structural-level stigma and consider leveraging peer networks and community supports to foster resilience and improve equitable access to HIV prevention tools.

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.

INTRODUCTION/BACKGROUND:The criminal legal system (CLS) is the most common treatment referral source for adolescent cannabis-related problems. Understanding trends in racial/ethnic disparities of CLS-referred treatment could help identify groups in need of additional supports. METHODS:This observational study used repeated cross-sectional data from the Treatment Episode Dataset-Admissions 2010-2022 and Census population denominators to calculate annual specialty CLS-referred cannabis-related treatment admission rates per 10,000 adolescents ages 12-17 by race and ethnicity. Joinpoint models examined trends in CLS-referred treatment rates by race and ethnicity, and group differences in the percent of cannabis admissions referred through the CLS were described. RESULTS:Adolescent cannabis CLS-referred treatment rates decreased overall by 81.6% from 2010 (16.93/10,000) to 2022 (3.11/10,000). Joinpoint models identified different turning points when significant reductions started by race and ethnicity. Compared to non-Hispanic White adolescents across all years, CLS-referred treatment admission rates were higher for American Indian/Alaska Native non-Hispanic adolescents (rate difference [RD]=19.53 95% CI=7.91-31.15) and Black non-Hispanic adolescents (RD=10.14, 95% CI=0.19, 20.08), but not other groups. American Indian/Alaska Native and Black adolescents had higher CLS-referred treatment than white adolescents in 2010 in both absolute and relative terms; differences with wider confidence intervals in 2022 were no longer statistically significant. CONCLUSIONS:CLS-referred cannabis-related treatment admissions decreased substantially across groups over time. High CLS-referral rates among American Indian/Alaska Native and Black non-Hispanic adolescents highlight the importance of distinguishing heterogeneous racial/ethnic groups. Targeted structural interventions are needed to increase non-CLS-related referrals and address cannabis-related treatment gaps in a changing cannabis policy environment.

BACKGROUND:Individuals with opioid use disorder (OUD) may experience fewer barriers to treatment following incarceration if offered in-jail medications for OUD (MOUD). We aimed to identify care trajectories of community OUD treatment after incarceration and examine the association between receiving in-jail MOUD and experiencing specific community treatment trajectories. METHODS:This retrospective cohort study using matched New York City (NYC) health care administrative data included adults with OUD incarcerated on or after May 2011 and discharged during 2014-2017. We defined states of community OUD treatment at the weekly level over one year following index jail discharge and performed state sequence analysis (SSA) to identify trajectories of treatment after jail and assessed the influence of receiving in-jail MOUD on treatment trajectories. RESULTS:Of 14,923 eligible individuals, 26.2% received in-jail MOUD. SSA identified eight clusters of community care trajectories: continuous methadone treatment (9.7%), methadone treatment discontinuation (3.7%), methadone treatment and reincarceration (6.7%), methadone treatment initiation (4.8%), continuous reincarceration (3.5%), short reincarceration with little community treatment (20.3%), long reincarceration with little community treatment (7.0%), and no community OUD treatment or reincarceration (44.5%). Receiving in-jail MOUD was associated with belonging to the continuous methadone treatment cluster compared to the no community OUD treatment or reincarceration cluster (adjusted OR: 12.5, 95% CI: 9.9-15.7). CONCLUSION/CONCLUSIONS:We identified eight unique patterns of community OUD treatment after jail release. Receipt of in-jail MOUD was associated with belonging to the continuous methadone treatment cluster. These findings suggest that provision of in-jail MOUD could improve methadone uptake in the community.

Overdose prevention centers (OPCs) are associated with improved community health and decreased crime, but opponents argue that OPCs depress nearby property values. We estimated the association of the opening of the first two public recognized OPC in the United States with neighborhood residential rents and real estate sales in the East Harlem and Washington Heights neighborhoods of New York City (NYC). Using augmented synthetic controls, we analyzed quarterly and semiannual rental listings and annual and semiannual sales within 300- and 500-meter buffers around the OPCs. Donor units were buffers around syringe service programs without OPCs and opioid treatment programs. Primary outcomes were median quarterly rental listing price and median annual sales price. Overall, we found no changes in neighborhood rental or sales prices. For quarterly rentals at 300 m, we estimated (ATT, 95% CI) $145 (-$780, $1070) in East Harlem and -$505 (-$1279, $269) in Washington Heights. For annual sales at 500 m, we estimated -$542 993 (-$1 228 024, $142038) in East Harlem and $1 121 706 (-$431 285, $2674697) in Washington Heights. Conformal inference identified no detectable time-point effects. Overall, OPC implementation in NYC was not associated with changes in rents or sales, suggesting these facilities may not generate appreciable effects on local housing values.

Stigma in healthcare settings is a critical barrier to HIV prevention and treatment among people who inject drugs (PWID). While previous tools have measured anticipated stigma, few account for the intersectional and provider-specific experiences of PWID-particularly from syringe service programs (SSPs). We developed and validated the Substance Use Anticipated Provider Stigma Scale (SU-APSS), a multidimensional instrument assessing anticipated stigma from four provider types: healthcare workers, substance use treatment staff, pharmacists, and SSP personnel. Data were drawn from a cross-sectional survey of 264 PWID who were 18 or older, HIV-negative, had injected drugs and used opioids within the past 30 days, and showed visible signs of recent injection. We conducted confirmatory factor analysis (CFA) on responses from 218 participants to evaluate structural validity and used Cronbach's alpha to assess internal consistency. The CFA supported a four-factor structure with strong model fit indices (CFI = 0.97, RMSEA = 0.09 [0.07, 0.11], SRMR = 0.04). All items significantly loaded onto their respective factors (loadings: 0.62-1.06). Internal consistency was high across all subscales (α = 0.85-0.96) and for the overall scale (α = 0.87). Attribution analysis revealed drug use, physical appearance, and income level as the most common perceived reasons for anticipated stigma. The SU-APSS offers a practical tool for identifying provider-specific stigma, informing stigma-reduction interventions, and evaluating implementation strategies to improve HIV prevention and care engagement among PWID.