Faculty Bibliography

BACKGROUND:Despite high HIV risk among people who inject drugs (PWID), uptake of pre-exposure prophylaxis (PrEP) remains low. Understanding the role of stigma toward PrEP use among PWID can inform interventions to improve engagement along the PrEP care continuum. We examined associations between PrEP stigma and early PrEP care continuum steps: awareness, willingness to take PrEP, and attempts to access PrEP, among PWID. METHODS:We analyzed data from 243 HIV-negative PWID recruited through community-based and peer outreach efforts in Los Angeles, California, and Denver, Colorado, between April 2021 and June 2023. Participants completed a survey assessing stigma toward PrEP, awareness of PrEP, willingness to take PrEP, and attempts to access PrEP, along with sociodemographic and behavioral factors. This study refers specifically to oral PrEP, the predominant formulation available during the study period. A 10-item PrEP stigma scale assessed attitudes and perceptions toward PrEP use. Stigma items were averaged to create a continuous score (range 0-4). Multivariable logistic regression models estimated associations between PrEP stigma and each PrEP care continuum outcome. RESULTS:Overall PrEP stigma was relatively low (mean = 1.64, SD = 0.46). Sixty-three percent of participants had heard of PrEP, 46.2% reported willingness to take PrEP, and 5.0% had attempted to access PrEP. PrEP stigma was not associated with awareness of PrEP (aOR = 0.89; 95% CI: 0.46, 1.70). However, higher stigma was significantly associated with lower willingness to take PrEP; each one-point increase in stigma score was associated with 78% lower odds of willingness (aOR = 0.22; 95% CI: 0.10, 0.48). Higher stigma was also associated with lower odds of attempting to access PrEP in unadjusted analyses (OR = 0.15; 95% CI: 0.04, 0.62), but this association was not statistically significant after adjustment (aOR = 0.10; 95% CI: 0.01, 1.05). CONCLUSION/CONCLUSIONS:Stigma toward PrEP, reflected in negative beliefs and social attitudes about PrEP use, remains an important barrier to willingness to initiate PrEP among PWID. Interventions addressing PrEP-related stigma may improve PrEP engagement and help reduce HIV transmission risk among PWID.

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.

BACKGROUND/UNASSIGNED:The potential of methadone maintenance treatment (MMT) to address the opioid crisis has been limited by restrictive federal and local policies that require frequent clinic visits for medication. Unprecedented federal regulatory changes started in early COVID-19 and were made permanent in 2024, allowing clinics increased flexibility in granting take-home medication to patients. Medicaid payment policies can profoundly shape provider behaviors but may not align with regulatory changes. METHODS/UNASSIGNED:We conducted a systematic synthesis of Medicaid MMT payment and billing policies among 40 states over March 2020-July 2025. RESULTS/UNASSIGNED:More than half of the states continued to adopt a per-dose or per-diem approach to paying for methadone dosing and a per-service approach to paying for addiction counseling, thus tying Medicaid revenue closely to clinic visits. More than one-quarter maintained a flat bundled payment dating back to prepandemic era that provided little incentive for granting patients more than 1 week of take-home medication. Adoption of a 2-tiered bundled payment modeled after Medicare's payment increased over time but remained limited. CONCLUSION/UNASSIGNED:Medicaid payment policies for MMT saw limited changes over the 5 years following initial federal regulatory changes. Practice changes toward more flexible and patient-centered care may be hindered without compatible changes in payment approaches.

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.

The United States continues to grapple with the shifting substance use landscape among the emerging concurrent use of opioids and stimulants. Polysubstance use (PSU) of opioids and stimulants, whether intentionally or unintentionally, has increased substance use related morbidity and mortality. Changes at the policy level are needed to effectively curb overdose and other adverse outcomes. This article outlines 3 policy changes that are particularly relevant to opioid-stimulant PSU: (1) reforms in opioid agonist treatment policy, (2) reforms in payment for evidence-based treatment, and (3) reforms of drug paraphernalia laws. The current overdose crisis requires a multidimensional paradigm shift toward patient-centered and harm reduction focused policies that will expand access to comprehensive evidence-based treatments and services for individuals engaged in opioid and stimulant PSU.

PURPOSE/OBJECTIVE:Opioid overdose survivors are vulnerable to fatal overdose, particularly in the weeks following overdose, a period when health service use is often low. This study explores post-overdose health/medical services engagement among a diverse sample of survivors. METHODS:We conducted semi-structured interviews with 23 recent opioid overdose survivors across seven states. We asked about service utilization and drug use history, contextual factors related to the overdose, service use immediately after and in the months following, and the impact on wellbeing. RESULTS:Over half of participants described calls to 911 (n = 13), and one-third went to the hospital (n = 8). Six key themes guided by Levesque's patient-centered access to care framework emerged. Several themes explored why participants did not seek medical services following an overdose, including 1) the belief they could manage at home, 2) a lack of trust in responders, often based on prior negative experiences, 3) concern about unintended consequences such as legal issues, and 4) the financial, social, and opportunity costs associated with calling 911 or going to the hospital. Of those who did receive emergency services, some declined transport to the hospital for similar reasons, including potential repercussions from their treatment program if they were notified. A fifth theme focused on interactions with providers in the hospital, where individuals were rarely offered medications for opioid use disorder or connected to treatment. Interactions with providers were largely negative, though participants reported more positive experiences with social workers and peer support specialists. A few had early discharges, often due to feelings of vulnerability, unmanaged withdrawal symptoms, or poor interactions with providers. Last, the sixth theme focused on substance use treatment engagement. Treatment engagement was often delayed but was facilitated by factors like a social worker following up, longer hospital stays, or the participant seeking treatment on their own. CONCLUSIONS:Most of the sample did not engage with hospital or substance use treatment services after a nonfatal overdose. Negative prior experiences and fear of negative consequences were major barriers in this sample.

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.