Assistant Professor of Epidemiology
Dr. Saba Rouhani is an Assistant Professor in the Department of Epidemiology at GPH, and joins the school as inaugural faculty at its Center for Anti-racism, Social Justice and Public Health.
Her research is focused on characterizing the structural environment that influences the risk of overdose and other drug-related harms; she investigates the impact of harm reduction and overdose prevention initiatives, using results to identify gaps in implementation and to inform policy. Dr. Rouhani is especially interested in how drug policy has fueled mass incarceration and impacted racial and ethnic minorities in the United States, and she studies how changes to the policy and policing landscape may promote or hinder equity in health and social outcomes. Her current research is focused on characterizing emerging drug decriminalization policies and modeling their impacts on equity in criminal legal involvement and health outcomes.
Prior to joining NYU Dr. Rouhani worked as research faculty in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. She also completed a fellowship funded by the National Institutes of Health/National Institute on Drug Abuse. Her research has been published in the International Journal of Drug Policy, Drug and Alcohol Dependence, the Journal of Urban Health, and the American Journal of Public Health and Preventive Medicine.
Dr. Rouhani received her PhD in global disease epidemiology and control from the Johns Hopkins Bloomberg School of Public Health. She holds an MSc in the control of infectious diseases from the London School of Hygiene and Tropical Medicine, and a BSc in medical microbiology from the University of Edinburgh.
PhD Global Disease Epidemiology & Control, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USAMS Control of Infectious Diseases, The London School of Hygiene & Tropical Medicine, London, United KingdomBS Medical Microbiology, University of Edinburgh, Edinburgh, United Kingdom
Drug Dependency Epidemiology Training (T32) Fellowship, National Institute of Drug Abuse, National Institutes of Health (2018)The R. Bradley Sack Family Scholarship Award, Johns Hopkins Bloomberg School of Public Health (2016)Global Health Established Field Placement Scholarship, Johns Hopkins Bloomberg School of Public Health (2014)Save the Children Program Management Award, Save the Children International (2012)Royal Society of Tropical Medicine and Hygiene Award for Best Poster Presentation of Research in Progress (2012)
De Facto Decriminalization for Drug Possession and Sex Work in Baltimore, MarylandSherman, S. G., Tomko, C., & Rouhani, S. (n.d.).
Journal titleAmerican journal of preventive medicine
Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemicAllen, S. T., Schneider, K. E., Morris, M., Rouhani, S., Harris, S. J., Saloner, B., & Sherman, S. G. (n.d.).
Journal titleHarm Reduction Journal
Issue1AbstractBackground: Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises. Objective: This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19. Methods: From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing. Results: One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing. Conclusions: Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.
Increased solitary drug use during COVID-19: An unintended consequence of social distancingSchneider, K. E., Allen, S. T., Rouhani, S., Morris, M., Haney, K., Saloner, B., & Sherman, S. G. (n.d.).
Journal titleInternational Journal of Drug Policy
Volume111AbstractBackground: During the COVID-19 pandemic, overdose rates substantially increased in the United States. One possible contributor to this phenomenon may be solitary drug use resulting from social distancing efforts to prevent COVID-19 transmission. Methods: We surveyed 458 people who use drugs (PWUD) who were recruited from harm reduction and drug treatment providers located in nine states and the District of Columbia. We assessed if solitary drug use had increased since the start of COVID-19. Associations between increased solitary drug use and sociodemographic characteristics, drug use characteristics, and COVID-19 prevention behaviors were examined using multiple logistic regression. Results: Half the sample identified as men (52.7%), White (49.7%), and single (49.3%). The average age was 43.2 (SD:11.8) years. Two-thirds (66.8%) recently injected drugs. 44% reported increased solitary drug use since COVID-19. Significant correlates of increased solitary drug use included being single (adjusted Odds Ratio [aOR]=1.99, 95% Confidence Interval [CI]: 1.33, 2.98), increasing drug use (aOR=2.74, 95% CI: 1.72, 4.37), using more in private locations (aOR=1.91, 95% CI: 1.34, 2.72), and social distancing behaviors (aOR=1.31, 95% CI: 1.11, 1.54). Experiencing homelessness (aOR=0.45, 95% CI: 0.31, 0.65) and identifying as a sexual minority (aOR=0.53, 95% CI: 0.31, 0.93) were associated with being less likely to increase solitary drug use. Conclusions: Solitary drug use increased during the COVID-19 pandemic. Increases in solitary drug use, in the context of a drug market increasingly permeated by fentanyl, indicates an urgent need for comprehensive harm reduction interventions to reduce overdose mortality.
Interest in treatment with injectable diacetylmorphine among people who use opioids in Baltimore City, Maryland (USA)Allen, S. T., Schneider, K. E., Rouhani, S., White, R. H., Morris, M., Owczarzak, J., & Sherman, S. G. (n.d.).
Journal titleAnnals of Medicine
Issue1AbstractIntroduction: Treatment for opioid use disorder (OUD) with diacetylmorphine is an evidence-based form of drug treatment, but it is not available in the United States (US). Better understanding acceptability of treatment with injectable diacetylmorphine among people who use opioids (PWUO) in the US may expedite future initiatives designed to engage persons in this form of treatment should it become available. The purpose of this research is to examine factors associated with interest in treatment with injectable diacetylmorphine among a sample of PWUO in the US. Methods: Data are from a cross-sectional study of PWUO in Baltimore City, Maryland. Participants were given a brief description of treatment with injectable diacetylmorphine and then asked to rate their level of interest. We used Poisson regression with robust variance to assess factors associated with interest in treatment with injectable diacetylmorphine. Results: The average age of participants was 48 years, 41% were women, and most (76%) identified as non-Hispanic, Black. The most commonly used substances were non-injection heroin (76%), opioid pain relievers (73%), and non-injection crack/cocaine (73%). Two-thirds of participants (68%) indicated interest in treatment with injectable diacetylmorphine. Factors significantly associated with interest in injectable diacetylmorphine treatment included: having at least a high school education (adjusted prevalence ratio [aPR]: 1.23; 95% confidence interval [CI]: 1.04–1.45), not having health insurance (aPR: 1.23; 95% CI: 1.06–1.44), having ever overdosed (aPR: 1.20; 95% CI: 1.01–1.42), and past utilization of medications for opioid use disorder (aPR: 1.22; 95% CI: 1.01–1.47). Recent non-injection cocaine use was inversely associated with interest in treatment with injectable diacetylmorphine (aPR 0.80; 95% CI: 0.68–0.94). Conclusion: The majority of participants reported interest in treatment with injectable diacetylmorphine. Given worsening trends in the addiction and overdose crisis in the US, treatment with injectable diacetylmorphine should be considered as another evidence-based option for treating OUD.KEY MESSAGES Interest in treatment with injectable diacetylmorphine was high among a sample of people who use opioids in the United States. Factors associated with increased interest in treatment with injectable diacetylmorphine included having at least a high school education, having ever overdosed, and not having health insurance. Past utilization of medications for opioid use disorder was associated with interest in treatment with injectable diacetylmorphine.
Persistent Criminalization and Structural Racism in US Drug Policy: The Case of Overdose Good Samaritan LawsPamplin, J. R., Rouhani, S., Davis, C. S., King, C., & Townsend, T. N. (n.d.).
Journal titleAmerican journal of public health
Page(s)S43-S48AbstractThe US overdose crisis continues to worsen and is disproportionately harming Black and Hispanic/Latino people. Although the "War on Drugs" continues to shape drug policy-at the disproportionate expense of Black and Hispanic/Latino people-states have taken some steps to reduce War on Drugs-related harms and adopt a public health-centered approach. However, the rhetoric regarding these changes has, in many cases, outstripped reality. Using overdose Good Samaritan Laws (GSLs) as a case study, we argue that public health-oriented policy changes made in some states are undercut by the broader enduring environment of a structurally racist drug criminalization agenda that continues to permeate and constrict most attempts at change. Drawing from our collective experiences in public health research and practice, we describe 3 key barriers to GSL effectiveness: the narrow parameters within which they apply, the fact that they are subject to police discretion, and the passage of competing laws that further criminalize people who use illicit drugs. All reveal a persisting climate of drug criminalization that may reduce policy effectiveness and explain why current reforms may be destined for failure and further disadvantage Black and Hispanic/Latino people who use drugs. (Am J Public Health. 2023;113(S1):S43-S48. https://doi.org/10.2105/AJPH.2022.307037).
PWUD Experiences of Criminal Justice Reform: Enduring Tensions Between Policing and Harm Reduction in Baltimore, MDFooter, K. H., Urquhart, G. J., Silberzahn, B., Rouhani, S., Weicker, N. P., Owczarzak, J., Park, J. N., Morris, M., & Sherman, S. G. (n.d.).
Journal titleContemporary Drug Problems
Page(s)176-189AbstractIn this paper we explore people who use drugs (PWUD) perceptions and experiences of drug-related law enforcement in a major U.S. city. Maryland recently implemented several harm reduction policies/interventions aiming to improve PWUD-police relationships, such as the Good Samaritan Law (GSL), intended to avoid criminalizing police encounters with PWUD in cases of overdose. PWUD, though most impacted by these efforts, are seldom included in the decision making process. Data collection occurred in Baltimore City, a majority-Black city with a history of structural racism, where high overdose fatalities necessitate collaborative interventions, but where over-policing and abusive practices have generated widespread community mistrust of police. Between October 2018 and December 2019, we conducted in-depth interviews with 20 PWUD in Baltimore City to understand their perspectives of policing and its impact on harm reduction practices (specifically willingness to seek overdose assistance) in the context of the GSL. PWUD reported ongoing police mistrust, which impacted their harm reduction practices and experiences of laws such as the GSL. Results question whether police, as first responders to overdose, can ever avoid criminalizing the encounter. Findings intend to guide future public health-law enforcement collaboration efforts in the context of the current de-policing debate.
Racial Disparities in Drug Arrest Before and After De Facto Decriminalization in BaltimoreRouhani, S., Tomko, C., Silberzahn, B. E., Weicker, N. P., & Sherman, S. G. (n.d.).
Journal titleAmerican journal of preventive medicine
Page(s)560-567AbstractIntroduction: To mitigate the harms of arrest and incarceration on health and racial equity, jurisdictions are increasingly enacting reforms to decriminalize drug possession through prosecutorial discretion (de facto). Impacts on health outcomes rely on whether this policy can reduce exposure to the carceral system among people who use drugs; however, data evaluating effects on arrest are lacking. This study explores the possible impacts of Baltimore City's enactment of de facto decriminalization on arrests by race. Methods: Police and court records were used to explore the possible impacts of Baltimore City's de facto decriminalization on street arrests and (processed) arrests advancing through the courts among people who use drugs. Interrupted time series models were used to compare pre-policy (January 2018–March 2020) trends with post-policy (April 2020–December 2021) trends in arrests for possession of drugs/paraphernalia and estimate racial disparities in street arrests (Black versus other races). Analyses were performed in February–May 2022. Results: The policy was associated with a significant and immediate decline in street and processed arrests for possession, which was not seen for other crime categories. Although declines were concentrated in the Black community, disparities in arresting persisted after the policy. Conclusions: De facto decriminalization may be a promising strategy to reduce exposure to the carceral system, an established risk factor for overdose and other drug-related sequelae and a driver of racial disparities in the U.S. Further research is needed to elucidate the drivers of persisting racial disparities and disentangle policy effects from pandemic-related closures.
Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detectionRosen, J. G., Glick, J. L., Zhang, L., Cooper, L., Olatunde, P. F., Pelaez, D., Rouhani, S., Sue, K. L., & Park, J. N. (n.d.).
Page(s)847-854AbstractBackground and aims: Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). Design: A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews. Setting: Baltimore City, MD, USA. Participants: Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April–September 2021). Measurements: Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. Findings: Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone (‘spotting’) and using drugs in public spaces. Conclusions: WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.
Acceptability of Overdose Prevention Sites in the Business Community in Baltimore, MarylandSherman, S. G., Rouhani, S., White, R. H., Weicker, N., Morris, M., Schneider, K., Park, J. N., & Barry, C. (n.d.).
Journal titleJournal of Urban Health
Page(s)723-732AbstractIntervetions are urgently needed to reduce the trajectory of the US opioid overdose epidemic, yet implementation is often hampered by resistance or opposition from key community stakeholders. While businesses are economically and physically impacted by the opioid epidemic, they are rarely engaged in efforts to reduce its impact. The establishment of overdose prevention sites (OPS) is being discussed throughout many US jurisdictions with limited attention to the potential positive role of businesses in that process. We surveyed business owners and employees of businesses located in neighborhoods with concentrated drug markets. The study’s primary aim was to examine their attitudes to locally-placed OPS. An iterative, two-phase sampling strategy was used to identify recruitment zones. In person (December 2019–March 2020) and telephone-based (April–July 2020) surveys were administered to distinct business owners and employees (N = 149). Sixty-five percent of participants supported OPS in their neighborhood and 47% had recently witnessed an overdose in or around their workplace. While 70% had heard of naloxone, and 38% reported having it on the premises. Correlates of supporting an OPS locally included living in the same neighborhood as work (adjusted odds ratio (aOR) 1.99, 95% confidence intervals (CI): 1.30–3.05); having a more positive attitude towards people who use drugs (aOR 1.33, 95% CI: 1.13–1.58); and having recently seen an overdose in/around the workplace (aOR 2.86, 95% CI: 1.11–7.32). Lack of support being an owner (aOR 0.35, 95% CI: 0.15–0.83). These data indicate the extent to which businesses are directly impacted by the opioid epidemic and the power of personal experience in shaping OPS support in advocacy efforts.
Alternative use of buprenorphine among people who use opioids in three U.S. CitiesGandhi, P., Rouhani, S., Park, J. N., Urquhart, G. J., Allen, S. T., Morales, K. B., Green, T. C., & Sherman, S. G. (n.d.).
Journal titleSubstance Abuse
Page(s)364-370AbstractBackground: Buprenorphine is an effective treatment for opioid use disorder, yet some persons are concerned with its “alternative use” (i.e., any use unintended by the prescriber). There is limited evidence on the factors associated with alternative use of buprenorphine (AUB); in this study, we examined correlates of recent (past 6 months) AUB. Methods: Multivariable logistic regression was used to analyze survey data from a multi-site, cross-sectional study of people who use drugs (PWUD) (N = 334) in Baltimore, Maryland; Boston, Massachusetts; and Providence, Rhode Island. Results: One-fifth (20%) of the sample reported recent AUB. In adjusted analyses, significant negative correlates of AUB were female gender (adjusted odds ratio [aOR] 0.48, 95% confidence intervals [CI] 0.24–0.95), recent emergency room visit (aOR 0.45, 95% CI 0.23–0.89), and recent injection drug use (aOR 0.41, 95% CI 0.19–0.88). Significant positive correlates were alternative use of other prescription opioids (aOR 8.32, 95% CI 4.22–16.38), three or more overdoses in the past year (aOR 3.74, 95% CI 1.53–9.17), recent buprenorphine use as prescribed (aOR 2.50, 95% CI 1.12–5.55), and recent residential rehabilitation treatment (aOR 3.71, 95% CI 1.50–9.16). Conclusions: Structural and behavioral correlates of AUB may help identify PWUD at high risk of overdose with unmet treatment needs.
Businesses in high drug use areas as potential sources of naloxone during overdose emergenciesSchneider, K. E., Rouhani, S., Weicker, N. P., Morris, M., & Sherman, S. G. (n.d.).
Journal titleDrug and alcohol dependence
Volume233AbstractIntroduction: Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable supplemental strategy to preventing fatal overdoses that is underexplored in the literature. Methods: We surveyed business owners and employees (N = 149) located in neighborhoods characterized by high rates of drug use in Baltimore City. Participants reported their interactions with people who use drugs as well as if they had heard of naloxone, if the business had naloxone on the premises, and how many employees were trained to use naloxone. Results: Most participants reported seeing individuals under the influence of drugs (93%), public drug use (80%), and overdose (66%) while at work. 66% of participants had heard of naloxone. Among those who had heard of naloxone, only 39% reported that there was a naloxone kit in the business and 28% of businesses had multiple employees trained to use naloxone. Conclusions: Businesses are underutilized as potential reliable sources of naloxone. While study participants reported high levels of exposure to drug use and overdose in and around their businesses, their ability to intervene was limited. Efforts to train employees to respond to overdoses and to keep naloxone on site are warranted to supplement existing naloxone distribution efforts and can help empower business staff to help prevent overdose mortality in their communities.
Discordance between Self-reported and Biologically Tested Exposure to Fentanyl among People at Risk of Opioid OverdosePark, J. N., Urquhart, G., Morris, M., Dahal, R., Rouhani, S., & Sherman, S. G. (n.d.).
Journal titleJournal of Addiction Medicine
Page(s)722-724AbstractDrug overdose remains a leading cause of death in the US, and the majority of opioid overdose fatalities involve fentanyl. This study aims to measure the degree of concordance between self-reported and biologically tested exposure to fentanyl. We conducted a cross-sectional analysis using survey and urinalysis data collected between 2019 and 2020 from Anne Arundel County, Maryland. Among urinalysis participants (n =113), 30% reported daily fentanyl use, and among this group, only 54% had a fentanyl-positive result. Cohen Kappa between self-reported and biologically detected fentanyl use was 0.26, indicating minimal agreement between the 2 markers. Limitations to interpreting self-reported and urinalysis data are discussed in this report.
HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in MarylandPark, J. N., Owczarzak, J., Urquhart, G., Morris, M., Weicker, N. P., Rouhani, S., & Sherman, S. G. (n.d.).
Journal titleAIDS and Behavior
Page(s)277-283AbstractDrug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors among PWID in Baltimore City (BC) and Anne Arundel Country (AAC), Maryland. PWID (N = 283) were recruited to the study through targeted sampling at street-based locations in BC and AAC from July 2018 to March 2020. Receptive syringe sharing (RSS) [adjusted odds ratio (AOR): 2.8, 95% confidence interval (CI): 1.2–6.3] and daily injecting (AOR: 1.9, 95% CI: 1.0–3.6) were associated with injecting fentanyl and cocaine together. Fentanyl availability and COVID-19 bring new HIV prevention challenges, particularly among those who inject fentanyl with cocaine, highlighting the importance to expand and sustain harm reduction, prevention, and treatment services for PWID to reduce HIV and overdose burden.
Identifying pathways to recent non-fatal overdose among people who use opioids non-medically: How do psychological pain and unmet mental health need contribute to overdose risk?Tomko, C., Schneider, K. E., Rouhani, S., Urquhart, G. J., Nyeong Park, J., Morris, M., & Sherman, S. G. (n.d.).
Journal titleAddictive Behaviors
Volume127AbstractBackground: Significant associations exist between psychological pain, unmet mental health need, and frequency and severity of substance use among people who use drugs (PWUD), but no studies have analyzed the relationship of these variables to non-fatal overdose. Methods: We conducted a cross-sectional survey of people who used opioids non-medically in Baltimore, Maryland (n = 563) as part of a broader harm reduction-focused evaluation (PROMOTE). The outcome was self-reported recent (past 6 months) non-fatal overdose; exposures of interest were recent self-reported unmet mental health need, experiencing daily “long-lasting psychological or mental pain” (vs. < daily), and daily multi-opioid use (vs. none/one opioid used). Path analysis was used to model direct relationships between these variables, personal characteristics (race, gender, experiencing homelessness, drug injection) and overdose. Results: 30% of the sample had experienced a recent non-fatal overdose, 46% reported unmet mental health need, 21% reported daily psychological pain, and 62% used multiple types of opioids daily. After adjusting for covariates, daily multi-opioid use (aOR = 1.78, p = 0.03) and unmet mental health need (aOR = 2.05, p = 0.01) were associated with direct, significant increased risk of recent overdose. Significant pathways associated with increased odds of unmet mental health need included woman gender (aOR = 2.23, p = 0.003) and daily psychological pain (aOR = 4.14, p = 0.002). In turn, unmet mental health need associated was with greater odds of daily multi-opioid use (aOR = 1.57, p = 0.05). Discussion: Unmet mental heath need and daily psychological pain are common experiences in this sample of PWUD. Unmet mental health need appears on several pathways to overdose and associated risk factors; improving access to mental healthcare for PWUD (particularly women) expressing need may be an important harm reduction measure.
NIMBYism and Harm Reduction Programs: Results from Baltimore CityRouhani, S., Schneider, K. E., Weicker, N., Whaley, S., Morris, M., & Sherman, S. G. (n.d.).
Journal titleJournal of Urban Health
Racial resentment and support for decriminalization of drug possession in the United StatesRouhani, S., McGinty, E. E., Weicker, N. P., White, R. H., LaSalle, L., Barry, C. L., & Sherman, S. G. (n.d.).
Journal titlePreventive Medicine
Volume163AbstractDrug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11–30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.
Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in MarylandRosen, J. G., Schneider, K. E., Allen, S. T., Morris, M., Urquhart, G. J., Rouhani, S., & Sherman, S. G. (n.d.).
Journal titleHarm Reduction Journal
Issue1AbstractBackground: Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men’s selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland. Methods: Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors. Results: Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97–0.99, p < 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81–7.37, p < 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05–3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02–3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex. Conclusions: Synergistic sources of social and structural marginalization—from sexuality to hunger, homelessness, and injection drug use—are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO.
Understanding the longitudinal relationship between substance use and violent victimization among street-based women who exchange sex in Baltimore, MarylandSchneider, K. E., Tomko, C., Nestadt, D. F., Rouhani, S., White, R. H., Decker, M. R., Galai, N., & Sherman, S. G. (n.d.).
Journal titleInternational Journal of Drug Policy
Volume109AbstractBackground: Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES. Methods: We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time. Results: Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)). Conclusions: Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population.
Confirmatory Factor Analysis and Construct Validity of the Internalized Sex Work Stigma Scale among a Cohort of Cisgender Female Sex Workers in Baltimore, Maryland, United StatesTomko, C., Nestadt, D. F., Rouhani, S., Silberzahn, B. E., Haney, K., Park, J. N., Galai, N., Logie, C. H., & Sherman, S. G. (n.d.).
Journal titleJournal of Sex Research
Page(s)713-723AbstractInternalized sex work stigma among cisgender female sex workers (FSW) is produced within contexts of social marginalization and associated with a range of ill-effects, including psychological distress, and lower rates of healthcare-seeking. This study seeks to uncover latent domains of the new Internalized Sex Work Stigma Scale (ISWSS) using data from 367 FSW in Baltimore, Maryland, USA. The sample was 56% white with high substance use (82% smoked crack cocaine, 58% injected any drug). The average ISWSS score was 34.8 (s.d. = 5.8, possible range: 12–48) and internal consistency was high (0.82). Confirmatory factor analysis revealed four subscales: worthlessness, guilt and shame, stigma acceptance, and sex work illegitimacy. Internal consistency of subscales was high (0.69–0.90); the scale also demonstrated construct validity with depression and agency. In bivariate logistic regressions, higher ISWSS, worthlessness, shame and guilt, and acceptance scores predicted higher odds of rushing client negotiations due to police. In unadjusted multinomial regressions, feeling respected by police predicted lower ISWSS, worthlessness, guilt and shame, acceptance, and illegitimacy scores. Identified factors are congruent with existing literature about how FSW manage sex work-specific stigma. Understanding the unique dimensions and impacts of internalized sex work stigma can inform interventions and policy to reduce morbidities experienced by FSW.
Food access among people who inject drugs in West VirginiaRouhani, S., Allen, S. T., Whaley, S., White, R. H., O’Rourke, A., Schneider, K. E., Kilkenny, M. E., Weir, B. W., & Sherman, S. G. (n.d.).
Journal titleHarm Reduction Journal
Issue1AbstractBackground: The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food often co-occurs with drug use and contributes to associated sequelae, such as risks for HIV and diabetes. The objective of this study was to examine factors associated with adequate food access among PWID in a rural Appalachian community. Methods: Cross-sectional surveys were used to collect data among PWID aged 18 and older in Cabell County, West Virginia. Frequency of hunger and sociodemographic, structural and drug use characteristics were measured. Adequate food access was defined as reporting ‘never’ going to bed hungry at night in the past six months. Pearson’s χ2 and t-tests and multivariable logistic regression were used to identify factors associated with food access. Results: Only 71 individuals (17%) reported never going to bed hungry at night in the past six months. Adjusted odds of having adequate food access were higher among PWID who completed high school (aOR 2.94; P = 0.010) and usually used drugs alone (aOR 1.97; P = 0.025), and lower among PWID who were female (aOR 0.51; P = 0.037), experienced homelessness (aOR 0.23, P < 0.001), were recently arrested (aOR 0.50 P = 0.047), and engaged in receptive sharing of injection equipment (aOR 0.52, P = 0.035). Conclusions: We found extremely low food access in a population of PWID in Appalachia who are vulnerable to overdose and infectious disease transmission. Integrated interventions promoting food access are needed to improve the public health and wellbeing of people who inject drugs in Appalachia.
Homotypic and Heterotypic Protection and Risk of Reinfection following Natural Norovirus Infection in a Highly Endemic SettingChhabra, P., Rouhani, S., Browne, H., Peñataro Yori, P., Siguas Salas, M., Paredes Olortegui, M., Moulton, L. H., Kosek, M. N., & Vinjé, J. (n.d.).
Journal titleClinical Infectious Diseases
Page(s)222-229AbstractBackground: Norovirus is a leading cause of acute gastroenteritis worldwide, yet there is limited information on homotypic or heterotypic protection following natural infection to guide vaccine development. Methods: A total of 6020 stools collected from 299 Peruvian children between 2010 and 2014 were tested by norovirus real-time reverse-transcription polymerase chain reaction followed by sequence-based genotyping. Cox proportional hazards models were used to derive adjusted hazard ratios (HRs) of infection among children with vs without prior exposure. Results: Norovirus was detected in 1288 (21.3%) samples. GII.4 (26%), GII.6 (19%), and GI.3 (9%) viruses accounted for 54% of infections. Homotypic protection for GI.3 (HR, 0.35; P=.015), GI.7 (HR, 0.19; P=.022), GII.4 (HR, 0.39; P<.001), and GII.6 (HR, 0.52; P=.006) infections was observed. Hazard analysis showed that children with prior GII.4 infection exhibited heterotypic protection with a 48% reduction of subsequent GI.3 infection (HR, 0.52; P=.005). Prior exposure to GI.3, GII.2, and GII.17 infections enhanced susceptibility to subsequent infections with several other norovirus genotypes. Conclusions: Children up to 2 years of age infected with GII.4 noroviruses demonstrated both homotypic and heterotypic protection to reinfection with other genotypes. These data support the need for ongoing vaccine development efforts with GII.4 as the main component and caution the inclusion of genotypes that may enhance susceptibility to infections.
Implications of attitudes and beliefs about COVID-19 vaccines for vaccination campaigns in the United States: A latent class analysisSchneider, K. E., Dayton, L., Rouhani, S., & Latkin, C. A. (n.d.).
Journal titlePreventive Medicine Reports
Volume24AbstractUnprecedented global efforts in vaccine development have resulted in effective vaccines for COVID-19. The pandemic response in the US has been highly politicized, resulting in significant opposition to public health efforts, including vaccines. We aimed to understand patterns of attitudes and beliefs about the COVID-19 vaccine to inform vaccination campaigns. 583 English speaking United States adults were surveyed November 18–29, 2020. Participants answered 11 questions about their attitudes and beliefs about a COVID-19 vaccine, including perceived vaccine effectiveness, likelihood of getting vaccinated, and concerns that vaccine development was rushed/influenced by politics. We conducted a latent class analysis to identify profiles of attitudes/beliefs about a COVID-19 vaccine. We identified four classes of COVID-19 vaccine beliefs. The pro-vaccine class (28.8%) was willing to get vaccinated and had broadly positive beliefs about the vaccine. The development concerns class (27.8%) was willing to get vaccinated but was concerned about the development process. The third class (22.6%) was largely unsure if they would get vaccinated and if their peer groups would be vaccinated. The forth class (anti-vaccine, 20.8%) was dominated by an unwillingness to get vaccinated, vaccine distrust, vaccine development concerns, and peers groups with negative vaccine intentions. Given the large proportion of individuals who were concerned about the COVID-19 vaccine development process, messaging about rigor and approval processes may be critical to securing this group's commitment to vaccination. Having scientific and cultural leaders endorse vaccination may also be influential.
Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex workDecker, M., Rouhani, S., Park, J. N., Galai, N., Footer, K., White, R., Allen, S., & Sherman, S. (n.d.).
Journal titleOccupational and Environmental Medicine
Page(s)160-166AbstractObjective Gender-based violence threatens women's health and safety. Female sex workers (FSWs) experience violence disproportionately, yet prospective data on violence predictors is lacking. In the first US-based prospective FSW cohort study, we examine incidence rates (IRs) and predictors of violence from distinct perpetrators: paying clients, non-paying intimate partners and police. Methods The parent cohort (Sex Workers and Police Promoting Health In Risky Environments) recruited street-based cisgender FSWs in urban Baltimore, MD (n=250) with 5 assessments at 3-month intervals through 12-month follow-up. Stratifying by violence perpetrator, we characterise violence at baseline, IR over the study period and time-varying predictors using Poisson models. Results The violence IR per person year was highest for client-perpetrated violence (0.78), followed by intimate partner violence (IPV; IR 0.39), and police violence (IR 0.25). Prevalence over the 12-month follow-up period among participants with complete visit data (n=103), was 42% for client violence, 22% for IPV and 16% for police violence. In adjusted analyses, risk factors for incident violence varied across perpetrators and included entry to sex work through force or coercion (adjusted IR ratio (aIRR) IPV 2.0; 95% CI 1.2 to 3.6), homelessness (aIRR IPV 2.0; 95% CI 1.3 to 2.9; aIRR police 2.7; 95% CI 1.3 to 5.8) and daily injection drug use (aIRR client 1.9; 95% CI 1.2 to 3.0). Risk of incident client violence and IPV was elevated by past abuse from each respective perpetrator. Help-seeking following abuse was limited. Conclusions FSWs face profound, enduring risk for violence from a range of perpetrators, likely enabled by criminalisation-related barriers to justice and perpetrator impunity. FSWs represent a priority population for access to justice, trauma-informed healthcare and violence-related support services. Structural vulnerabilities including homelessness and addiction represent actionable priorities for improving safety and health.
Perceived vulnerability to overdose-related arrests among people who use drugs in MarylandRouhani, S., Schneider, K. E., Rao, A., Urquhart, G. J., Morris, M., LaSalle, L., & Sherman, S. G. (n.d.).
Journal titleInternational Journal of Drug Policy
Volume98AbstractBackground: People who use drugs (PWUD) must weigh complex legal scenarios when seeking help during overdose events. Good Samaritan laws (GSL) offer limited immunity for certain low-level drug crimes to encourage PWUD to call 911. Drug-induced homicide laws (DHL) allow for criminal prosecution of people delivering drugs that result in overdose death and may exert opposing effects on the decision-making process. We examined whether perceptions of these laws were related to overall perceived vulnerability to overdose-related arrests, which can impact help-seeking and overdose mortality. Methods: We conducted a cross-sectional study of PWUD (N = 173) in Anne Arundel County, Maryland and measured sociodemographic characteristics, structural vulnerabilities, and knowledge of GSL and DHL. Perceived vulnerability to overdose-related arrest was defined as self-reported concern arising from calling 911, receiving medical help, or supplying drugs in the event of an overdose. Multivariable logistic regression was used to identify significant correlates of perceived vulnerability to overdose-related arrest. Results: Most participants were aware of DHL (87%) and half were aware of GSL (53%). Forty-seven percent of PWUD expressed concern about arrest during or due to an overdose. After adjustment, positive correlates of perceived vulnerability to arrest were non-white race (aOR 2.0, 95% CI 1.5-2.5) and hearing of somebody charged with DHL (aOR 3.1, 95%CI 1.9-5.0), and negative correlates were history of drug treatment (aOR 0.6, 95%CI 0.4-1.0), receiving naloxone (aOR 0.6, 95% CI 0.4-1.0), and having made, sold or traded drugs in the past 3 months (aOR 0.4, 95% CI 0.2-0.9). Conclusions: We report persisting concern about arrest during overdose events among street-based PWUD facing a complicated landscape of legal protections and liabilities. Findings demonstrate clear racial disparities in concern outside of an urban centre, where impacts of policing on health are less studied, and present evidence that DHL may compromise overdose prevention efforts. Changes to drug policy and enforcement including police nonattendance at overdose scenes may be necessary to promote help-seeking among PWUD and reduce overdose fatalities.
Practical implications of naloxone knowledge among suburban people who use opioidsSchneider, K. E., Urquhart, G. J., Rouhani, S., Park, J. N., Morris, M., Allen, S. T., & Sherman, S. G. (n.d.).
Journal titleHarm Reduction Journal
Issue1AbstractBackground: Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available. Methods: We used data from 173 PWUO from Anne Arundel County, Maryland, which is located between Baltimore City and Washington, DC. We assessed the prevalence of recently (past 6 months) receiving naloxone and currently having naloxone, the type(s) of the naloxone kits received, and the perceived ease/difficultly of accessing naloxone. We also assessed participants knowledge of where naloxone was available in the community. Results: One third (35.7%) of participants had recently received naloxone. Most who had received naloxone received two doses (72.1%), nasal naloxone (86.9%), and education about naloxone use (72.1%). Most currently had naloxone in their possession (either on their person or at home; 78.7%). One third (34.4%) believed naloxone was difficult to obtain in their community. Only half (56.7%) knew of multiple locations where they could get naloxone. The health department was the most commonly identified naloxone source (58.0%). Identifying multiple sources of naloxone was associated with being more likely to perceive that naloxone is easy to access. Discussion: Our results suggest that additional public health efforts are needed to make PWUO aware of the range of sources of naloxone in their communities in order to ensure easy and continued naloxone access to PWUO.