Faculty Bibliography

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 overdose crisis is driven in large part by an increasingly unpredictable and contaminated drug supply, including fentanyl and its analogs and emerging adulterants such as xylazine and nitazenes. Drug checking interventions such as fentanyl test strips and Fourier Transform Infrared Spectroscopy are essential for harm reduction, yet they also highlight a central policy failure: they place the burden of safety on people who use drugs (PWUD) and frontline programs after drugs have already entered an unregulated market. We argue for a more pragmatic upstream public health response, authorizing pilots of a safer, regulated drug supply ("safer supply"), broadly defined as legal and regulated access to psychoactive substances or close pharmaceutical alternatives intended to reduce reliance on the unregulated drug market. International experience, particularly models in Switzerland, Canada, and the United Kingdom, demonstrates feasibility and suggests potential benefits, including improved health and social stability, reduced reliance on unregulated supply, and reduced acute care utilization in some settings. For the United States context, we propose a portfolio approach: near-term, healthcare-based pilots leveraging existing controlled-substance infrastructure (eg, opioid treatment programs, clinics, pharmacies, and tech-enabled dispensing) while preserving space for community-governed models with legal protections and longer-horizon, state-regulated pathways. We address predictable concerns (secondary sharing, youth initiation, community impact, mixed population-level findings) and outline guardrails and evaluation strategies that are PWUD-led, nonpunitive, and methodologically rigorous. We conclude with concrete policy actions to authorize pilots, establish legal protections, fund independent evaluation, and scale models that demonstrably reduce harm while integrating with harm reduction and treatment services.

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.

The United States continues to experience a large amount of drug-related harm, including high rates of both overdose mortality and harms associated with lack of access to new drug use equipment such as syringes and pipes. These harms include the spread of bloodborne disease as well as endocarditis, osteomyelitis, and other skin and soft tissue infections. Laws that prohibit or restrict access to drug use equipment may increase these harms. This manuscript provides a comprehensive legal review of laws that criminalize or otherwise restrict the distribution and possession of equipment for both injecting and inhaling drugs from both syringe services programs and other venues. We also report novel data on the severity of penalties associated with violations of prohibitions on the above activities. We find great heterogeneity in these laws. The free distribution of injection equipment for illicit drug use is permitted in 19 states, and the free distribution of smoking equipment is permitted in 14 states. The possession of injection equipment is permitted in 21 states, and the possession of smoking equipment in 15. Where possession or distribution of drug use equipment is prohibited or restricted, we found large differences in the penalties imposed for violations. There is also wide variation in laws governing the operation of syringe services programs, which are permitted in some form in 40 states but often highly regulated. We suggest that states evaluate and, where indicated, remove legal barriers to these supplies.

BACKGROUND:Between 2022 and 2023, overdose mortality decreased among non-Hispanic (NH) white people but stayed the same or increased among people of colour in the USA. County racialised economic segregation may contribute to overdose mortality. METHODS:measures, one for higher-income NH white and lower-income black residents and another for higher-income NH white and lower-income Hispanic residents. Models included random effects for county, year and county-year interaction, and fixed effects for proportion male, proportion aged 25-44, land area, state and year. We estimated relative risk (RR) by quintile (least vs most privileged) and the difference in overdose mortality per 100 000 (RD) had all counties shifted to the risk of the most advantaged counties (Q5). RESULTS:Counties with the highest proportion of lower-income racially minoritised residents (Q1) had an increased RR of overdose deaths compared with Q5 counties, both overall (aRRs 1.64 (1.51-1.78); 1.40 (1.29-1.52)), and among subgroups. Had all counties experienced the risk of Q5 counties, we estimated an average reduction in overdose deaths overall (RDs per 100 000: -7.20 (-8.25 to -6.10); -6.37 (-7.38 to -5.25)) and among subgroups. CONCLUSION/CONCLUSIONS:County racialised economic segregation was associated with overdose mortality risk in 2018-2022. Investment in evidence-based strategies to reduce overdose risk in places experiencing harms related to racialised economic segregation is critical.

The United States faces a profound overdose crisis and a volatile, unregulated drug supply. Despite the availability of effective treatments and harm reduction strategies, many individuals who use drugs have limited access to evidence-based interventions. Punitive approaches to people who use drugs have worsened the situation. In this position statement, we assert that there is a critical need for drug policies to be grounded in public health evidence rather than punitive measures. We focus on 2 case studies to exemplify this idea: (1) xylazine scheduling laws and (2) drug-induced homicide laws. Ultimately, the Association for Multidisciplinary Education and Research in Substance Use and Addiction advocates for a public health approach to drug policy, which is based on the tenets of harm reduction. The organization opposes punitive measures and promotes policies that improve access to healthcare and harm reduction services.

Policy Points There has been a pronounced shift from injecting to smoking drugs in the United States. This shift has the potential to reduce many health harms associated with illicit drug use. State laws are structural barriers to the provision of safer smoking supplies, cause preventable harm, and should be repealed.

Stimulant use disorder (StUD) is a rapidly growing concern in the United States, with escalating rates of death attributed to amphetamines and cocaine. No medications are currently approved for StUD treatment, leaving clinicians to navigate off-label medication options. Recent studies suggest that controlled prescription psychostimulants such as dextroamphetamine, methylphenidate, and modafinil are associated with reductions in self-reported stimulant use, craving, and depressive symptoms. Despite this positive initial evidence, prescribing rates of these medications for StUD treatment remain low, possibly because some clinicians believe that they are subject to the restrictions federal law imposes on medications for opioid use disorder. This is not the case. Rather, at the federal level, these medications are subject only to the general requirement that prescriptions be issued for a legitimate medical purpose within the usual course of professional practice, criteria that are buttressed by recent national guidelines that include controlled prescription psychostimulants as an option within a comprehensive treatment plan for StUD. In this commentary, we review the federal legal landscape regarding the prescription of psychostimulants for StUD and recommend strategies for increasing the utilization of this promising approach. Professional organizations, addiction clinicians, and researchers can reinforce this practice through publishing expert recommendations, developing clinician education materials, and disseminating their real-world experiences and well-documented treatment plans.

BACKGROUND:U.S. state electronic prescription drug monitoring programs (PDMPs) are associated with reduced opioid dispensing among people with chronic pain and may impact use of other chronic pain treatments. In states with medical cannabis laws (MCLs), patients can use cannabis for chronic pain management, reducing their need for chronic-pain related treatment visits and moderating effects of PDMP laws. OBJECTIVE:Given high rates of chronic pain among Medicaid enrollees, we examined associations between PDMP enactment in the presence or absence of MCL on chronic pain-related outpatient and emergency department (ED) visits. DESIGN/METHODS:We created annual cohorts of Medicaid enrollees with chronic pain diagnoses using national Medicaid claims data from 2002-2013 and 2016. Negative binomial hurdle models produced adjusted odds ratios (aOR) for the likelihood of any chronic pain-related outpatient or ED visit and incident rate ratios (IRR) for the rate of visits among patients with ≥ 1 visit. PARTICIPANTS/METHODS:Medicaid enrollees aged 18-64 years with chronic pain (N = 4,878,462). MAIN MEASURES/METHODS:A 3-level state-year variable with the following categories: 1) no PDMP, 2) PDMP enactment in the absence of MCL, or 3) PDMP enactment in the presence of MCL. Healthcare codes for chronic pain-related outpatient and ED visits each year. KEY RESULTS/RESULTS:The sample was primarily female (67.2%), non-Hispanic White (51.2%), and ages 40-55 years (37.2%). Compared to no-PDMP states, PDMP enactment in the absence of MCL was not associated with chronic pain-related outpatient visits but PDMP enactment in the presence of MCL was associated with lower odds of chronic pain-related outpatient visits (aOR = 0.81, 95% CI:0.71-0.92). PDMP enactment was not associated with ED visits, irrespective of MCL. CONCLUSIONS:During a period of PDMP and MCL expansion, our findings suggest treatment shifts for persons with chronic pain away from outpatient settings, potentially related to increased use of cannabis for chronic pain management.

Mandatory prescription drug monitoring programs and cannabis legalization have been hypothesized to reduce overdose deaths. We examined associations between prescription monitoring programs with access mandates ("must-query PDMPs"), legalization of medical and recreational cannabis supply, and opioid overdose deaths in United States counties in 2013-2020. Using data on overdose deaths from the National Vital Statistics System, we fit Bayesian spatiotemporal models to estimate risk differences and 95% credible intervals (CrI) in county-level opioid overdose deaths associated with enactment of these state policies. Must-query PDMPs were independently associated with on average 0.8 (95% CrI: 0.5, 1.0) additional opioid-involved overdose deaths per 100,000 person-years. Legal cannabis supply was not independently associated with opioid overdose deaths in this time period. Must-query PDMPs enacted in the presence of legal (medical or recreational) cannabis supply were associated with 0.7 (95% CrI: 0.4, 0.9) more opioid-involved deaths, relative to must-query PDMPs without any legal cannabis supply. In a time when overdoses are driven mostly by non-prescribed opioids, stricter opioid prescribing policies and more expansive cannabis legalization were not associated with reduced overdose death rates.