Saba Rouhani
Saba Rouhani
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Assistant Professor of Epidemiology
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Professional overview
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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.
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Education
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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
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Honors and awards
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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)
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Publications
Publications
Education, Income, Wealth, and Discrimination in Black-White Allostatic Load Disparities
AbstractCuevas, A. G., McSorley, A. M., Lyngdoh, A., Kaba-Diakité, F., Harris, A., Rhodes-Bratton, B., & Rouhani, S. (n.d.).Publication year
2024Journal title
American journal of preventive medicineVolume
67Issue
1Page(s)
97-104AbstractIntroduction: Allostatic load (AL) is a significant marker of aging, associated with disease and mortality. Research has elucidated the impact of education and income on AL. However, the roles of wealth and discrimination in contributing to AL and shaping AL disparities remain underexplored. This study aimed to investigate the association between wealth and AL, while also examining the independent contributions of education, income, wealth, and everyday discrimination in shaping AL disparities. Methods: Using 2016 data from the nationally representative Health and Retirement Study (N=3,866), this study employed multilinear regression analysis to quantify the association between education and income, wealth (calculated as assets minus debts), and everyday discrimination with AL. Oaxaca-Blinder decomposition analysis was conducted to determine the proportion of AL disparities between Black and White participants attributed to education and income, wealth, and everyday discrimination. Analyses were performed in 2023. Results: Having a college degree or more (b = −0.32; 95% CI: −0.46, −0.17), higher income (b = −0.06; 95% CI: −0.11, −0.01), and greater wealth (b = −0.11; 95% CI: −0.16, −0.07) were linked to reduced AL. Conversely, increased experiences of everyday discrimination were associated with heightened AL (b = 0.07; 95% CI: 0.01, 0.16). Collectively, differences in possessing a college degree or more, wealth, and exposure to discrimination accounted for about 18% of the observed Black-White AL disparities. Conclusions: Education, income, wealth, and experiences of discrimination may independently contribute to AL and partially explain Black-White disparities in AL. There is a need to elucidate the underlying mechanisms governing these relationships, particularly wealth, and extend the research to additional social determinants of racial health disparities.Emerging models of de facto drug policy reforms in the United States
AbstractRouhani, S., Zhang, L., Winiker, A. K., Sherman, S. G., & Bandara, S. (n.d.).Publication year
2024Journal title
Drug and alcohol dependenceVolume
260AbstractBackground: Health and human rights organizations have endorsed drug decriminalization to promote public health-oriented approaches to substance use. In the US, policymakers have begun to pursue this via prosecutorial discretion—or the decision by a prosecutor to decline criminal charges for drug possession in their jurisdiction. This study characterizes drivers of adoption, policy design and implementation processes, and barriers to impact and sustainability of this approach to inform evolving policy efforts promoting the health of people who use drugs (PWUD). Methods: We conducted n=22 key informant interviews with policymakers and national policy experts representing 13 jurisdictions implementing de facto drug policy reforms. Analyses were informed by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and analyzed using a hybrid inductive-deductive approach. Results: Drivers of policy adoption included racial inequities, perceived failures of criminalization, and desires to prioritize violent crime given resource constraints. Three distinct policy typologies are described with varying conditions for eligibility, linkage to services, and policy transparency and dissemination. Public misinformation, police resistance and political opposition were seen as threats to sustainability. Conclusions: Given evidence that criminalization amplifies drug-related harms, many policymakers are adopting de facto drug policy reforms in the absence of formal legislation. This is the first study to systematically describe relevant implementation processes and emerging policy models. Findings have implications for designing rigorous evaluations on health outcomes and informing sustainable evidence-based policies to promote health and racial equity of PWUD in the US.Epidemiology of drug arrests in the United States: Evidence from the national survey on drug use and health, 2015–2019
AbstractRouhani, S., Luo, L., Byregowda, H., Weaver, N., & Park, J. N. (n.d.).Publication year
2024Journal title
Preventive MedicineVolume
185AbstractObjective: Following changes to drug criminalization policies, we re-examine the epidemiology of drug arrests among people who use drugs (PWUD) in the U.S. Methods: Serial cross-sectional data from the National Survey on Drug Use and Health (2015–2019) were utilized. Past-year illicit drug use (excluding cannabis) and drug arrests were described by year, area of residence, drug use characteristics and participant demographics. Adjusted associations between race and drug arrest were estimated using multivariable logistic regression. Results: Past-year illicit drug use remained consistent over time and was highest among non-Hispanic (NH) white respondents. Of those reporting past-year illicit drug use (n = 25,429), prevalence of drug arrests remained stable over time overall and in metro areas while increasing in non-metro areas. Arrests were elevated among NH Black participants and those with lower income, unemployment, housing transience, non-metro area residence, polysubstance use, history of drug injection, substance use dependence and past-year drug selling. Adjusted odds of drug arrest remained significantly higher among NH Black individuals [aOR 1.92, 95% CI 1.30, 2.84]. Conclusion: Despite recent shifts away from punitive drug policies, we detected no reduction in drug arrests nationally and increasing prevalence in non-metro areas. Despite reporting the lowest level of illicit substance use and drug selling, NH Black individuals had significantly increased odds of arrest across years. Findings highlight the need for further examination of policy implementation and policing practices in different settings, with more research focused non-metro areas, to address enduring structural racism in drug enforcement and its consequences for health.Factors associated with daily use of benzodiazepines/tranquilizers and opioids among people who use drugs
AbstractKozak, Z., Urquhart, G. J., Rouhani, S., Allen, S. T., Park, J. N., & Sherman, S. G. (n.d.).Publication year
2024Journal title
American Journal on AddictionsVolume
33Issue
1Page(s)
83-91AbstractBackground: Co-use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co-use of these drugs when obtained both with and without a prescription. We examined associations of daily co-use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who use street opioids (PWUO). Methods: PWUO (N = 417) were recruited from Baltimore City and neighboring Anne Arundel County, Maryland, and surveyed on sociodemographic characteristics, structural vulnerabilities, healthcare access and utilization, substance use, and overdose experiences. Multivariable logistic regression was used to identify factors associated with self-reported co-use. Results: Participants were 46 years old on average, and predominantly Black (74%) males (62%). Daily co-use was reported by 22%. In multivariable analyses, odds of co-use were significantly higher among participants who did not have a high school degree/GED (adjusted odds ratio [aOR]: 1.71, 95% confidence interval [CI]: 1.02–2.88), endorsed receiving mental health treatment in the past 6 months (aOR: 2.13, 95% CI: 1.28–3.56), reported daily use of powdered cocaine (aOR: 3.57, 95% CI: 1.98–6.45), and synthetic cannabinoids (aOR: 3.11, 95% CI: 1.40–6.93). Odds of co-use were significantly lower among Black participants compared to white participants (aOR: 0.39, 95% CI: 0.19–0.82). Conclusions and Scientific Significance: Clinicians working with PWUO or who prescribe BZDs or opioids should screen patients who use cocaine or synthetic cannabinoids, have low level of educational attainment, or recently accessed mental health services, as these patients may be at higher risk for daily co-use of BZD/TRQ and opioids, and therefore lethal overdose.Love after lockup: examining the role of marriage, social status, and financial stress among formerly incarcerated individuals
AbstractBather, J. R., McSorley, A. M. M., Rhodes-Bratton, B., Cuevas, A., Rouhani, S., Nafiu, R. T., Harris, A., & Goodman, M. (n.d.).Publication year
2024Journal title
Health and JusticeVolume
12Issue
1AbstractBackground: Upon reintegration into society, formerly incarcerated individuals (FIIs) experience chronic financial stress due to prolonged unemployment, strained social relationships, and financial obligations. This study examined whether marriage and perceived social status can mitigate financial stress, which is deleterious to the well-being of FIIs. We also assessed whether sociodemographic factors influenced financial stress across marital status. We used cross-sectional data from 588 FIIs, collected in the 2023 Survey of Racism and Public Health. The financial stress outcome (Cronbach’s α = 0.86) comprised of five constructs: psychological distress, financial anxiety, job insecurity, life satisfaction, and financial well-being. Independent variables included marital and social status, age, race/ethnicity, gender identity, educational attainment, employment status, and number of dependents. Multivariable models tested whether financial stress levels differed by marital and perceived social status (individual and interaction effects). Stratified multivariable models assessed whether social status and sociodemographic associations varied by marital status. Results: We found that being married/living with a partner (M/LWP, b = -5.2) or having higher social status (b = -2.4) were protective against financial stress. Additionally, the social status effect was more protective among divorced, separated, or widowed participants (b = -2.5) compared to never married (NM, b = -2.2) and M/LWP (b = -1.7) participants. Lower financial stress correlated with Black race and older age, with the age effect being more pronounced among M/LWP participants (b = -9.7) compared to NM participants (b = -7.3). Higher financial stress was associated with woman gender identity (overall sample b = 2.9, NM sample b = 5.1), higher education (M/LWP sample b = 4.4), and having two or more dependents (overall sample b = 2.3, M/LWP sample b = 3.4). Conclusions: We provide novel insights into the interrelationship between marriage, perceived social status, and financial stress among FIIs. Our findings indicate the need for policies and programs which may target the family unit, and not only the individual, to help alleviate the financial burden of FIIs. Finally, programs that offer legal aid to assist in expungement or sealing of criminal records or those offering opportunities for community volunteer work in exchange for vouchers specific to legal debt among FIIs could serve to reduce financial stress and improve social standing.Public support for reinvesting resources from enforcing drug possession to health-promoting alternatives: A nationally representative poll of adults in the United States
AbstractTomko, C., Rouhani, S., LaSalle, L., & Sherman, S. G. (n.d.).Publication year
2024Journal title
International Journal of Drug PolicyVolume
126AbstractBackground: The legal enforcement of drug possession is associated with a host of negative consequences for people who use drugs (PWUD), has demonstrated little effectiveness at curbing drug use, and has contributed to lasting financial, social, and health-related racial disparities in Black and Brown communities in the United States (U.S.). One policy alternative is reinvesting resources typically used for enforcing drug possession into health-promoting services such as drug treatment or harm reduction that can better serve the needs of PWUD than the criminal legal system. We sought to characterize the prevalence and correlates of national public support for this reinvestment in the U.S. Methods: A nationally representative sample of U.S. adults (N = 1,212) completed the Johns Hopkins COVID-19 Civic Life and Public Health Survey (wave three, fielded November 11–30, 2020). The outcome is support for reinvestment of resources spent on enforcing drug possession into health-promoting alternatives (i.e., drug treatment, harm reduction, housing support, or community-based resources). We measured potential correlates including socio-demographics and social/political attitudes, including political ideology (conservative, moderate, liberal) and racial resentment toward the Black community. Analyses accounted for complex survey weights. Results: Weighted prevalence of support for reinvestment of resources was 80 %. Multivariable logistic regression (controlling for confounders) showed that white respondents were more likely than Black (OR = 2.51, 95% CI = 1.08, 5.87) to favor reinvestment. Respondents with moderate (OR = 0.34, 95 % CI = 0.15–0.79) or conservative (OR = 0.21, 95 % CI = 0.09–0.50) political ideology (compared to liberal) and medium (OR = 0.26, 95 % CI = 0.09–0.74) or high (OR = 0.12, 95 % CI = 0.04–0.35) levels of racial resentment (compared to low) were less likely to support reinvestment. Conclusion: There is substantial national support for reinvesting resources into health-promoting alternatives, though political ideology and racial resentment temper support. Results can inform targeted messaging to increase support for moving drug policy from the criminal legal sphere toward public health.Sleep-related impairment among people who use opioids: The critical role of structural vulnerability
AbstractSchneider, K. E., Martin, E. M., Urquhart, G. J., Sisson, L. N., Rouhani, S., Morris, M., Spira, A. P., & Sherman, S. G. (n.d.).Publication year
2024Journal title
Sleep HealthVolume
10Issue
5Page(s)
533-539AbstractObjective: People who use opioids are vulnerable to sleep disturbances due to a range of factors, including the substances they use and the various structural vulnerabilities they face. We aimed to understand the burden of sleep-related impairment and problems pertaining to sleep context and schedule among people who use opioids. Methods: We explored sleep quality and problems among a suburban sample of people who use opioids experiencing extensive structural vulnerabilities (N = 170). Participants reported their most urgent concern in the past week (e.g., sleep, drug use, housing), their sleep context, sleep problems, sleep schedules, and scores on the PROMIS Sleep-Related Impairment measure. We then quantified associations between Sleep-Related Impairment scores and sociodemographics and substance use. Results: Participants were primarily men (66%) and non-Hispanic Black (67%) with a mean age of 42 (SD: 12.1). Many experienced hunger (44%) and literal homelessness (40%). One-quarter (28%) reported that sleep was their most urgent concern in the past week. The most common problems when falling or staying asleep were mental health-related symptoms (81%) and pain/discomfort (32%). Literal homelessness (β = 2.2, 95% CI: 0.6, 3.7), hunger (β = 2.3, 95% CI: 1.0, 3.6), and frequent alcohol use (β = 1.5, 95% CI: 0.2, 2.7) were significantly associated with Sleep-Related Impairment scores. Conclusions: Homelessness and hunger are associated with sleep-related impairment in people who use opioids. Poor sleep quality, substance use, structural vulnerability, and mental health problems are all interrelated sources of functional impairment in this population. Interventions that address poverty as an underlying cause of sleep-related impairment and provide safe sleeping environments are needed.Understanding sensitivity and cross-reactivity of xylazine lateral flow immunoassay test strips for drug checking applications
AbstractSisco, E., Nestadt, D. F., Bloom, M. B., Schneider, K. E., Elkasabany, R. A., Rouhani, S., & Sherman, S. G. (n.d.).Publication year
2024Journal title
Drug Testing and AnalysisVolume
16Issue
9Page(s)
942-947AbstractThe continued prevalence of xylazine in the illicit drug market has necessitated development of quick and simple methods for identification, including lateral flow immunoassays (also known as “test strips”), like those frequently used to detect fentanyl. This study explored the drug checking applicability of the first publicly available xylazine test strips (XTS) using four sub-studies: reproducibility (i.e., consistency of positive results in a highly-concentrated xylazine solution); limit of detection on a calibration curve of xylazine concentrations; cross-reactivity against 77 commonly encountered drugs, cutting agents, and other structurally similar compounds; and applicability for analyzing community-acquired samples—where 100 drug residue samples were analyzed using XTS, direct analysis in real time mass spectrometry (DART-MS), and gas chromatography tandem mass spectrometry (GC–MS/MS). XTS consistently detected xylazine at concentrations ≥2.5 μg/ml, and XTS results were reproducible. Sensitivity and specificity of XTS were calculated by comparing expected versus obtained results based on xylazine concentration of community-acquired samples measured by GC-MS/MS. XTS consistently detected xylazine in samples with concentration >2 μg/ml and yielded a sensitivity of 0.974, specificity of 1.00, and overall accuracy of 0.986. Cross-reactivity with lidocaine, a common cutting agent, and lack of XTS reactivity with other α2-agonists found in the illicit drug supply highlight the need to offer consumers comprehensive drug checking services that identify a range of substances and better inform them about drug contents.“What I should be doing is harm reduction, if I'm doing my job right”: Engagement with harm reduction principles among prosecutors enacting drug policy reform in the United States
AbstractRouhani, S., Winiker, A. K., Zhang, L., Sherman, S. G., & Bandara, S. (n.d.).Publication year
2024Journal title
International Journal of Drug PolicyVolume
131AbstractBackground: Prosecutorial discretion to pursue or decline criminal charges is a powerful mechanism determining criminal justice outcomes among people who use drugs (PWUD). In the US, prosecutors are increasingly employing this tool to prevent arrest, incarceration, and subsequent health and social harms among PWUD. Many cite harm reduction as a basis for these reforms; however, the extent of prosecutors' knowledge and understanding of harm reduction principles, and how they are operationalized in the policy process, remains unclear. Methods: We assess references to and application of harm reduction in the policy design and implementation process of prosecutorial drug policy reform in 14 US jurisdictions. In-depth-interviews (N = 16) were conducted with elected prosecutors and their policy staff from November 2021-April 2022. Through initial structured analysis, policymakers’ understanding and utilization of the term ‘harm reduction’ emerged as a salient theme which we conducted secondary thematic analysis to further explore. Results: While all participants identified as progressive, there was wide variation in their ideologies, policy provisions, and engagement with harm reduction principles. Eleven participants explicitly referred to ‘reducing harms of drug use’ or ‘harm reduction’ as guiding their policy approach; the remainder did not invoke ‘harm reduction’ by name but highlighted relevant concepts like racial equity and ‘public health approaches’ as core policy tenets. While some prosecutors demonstrated familiarity with traditional harm reduction principles (meeting PWUD where they are, reducing harms to them), others focused on harm to the wider community (the ‘public,’ businesses, etc). Invocation of harm reduction was not always consistent with specific policy provisions: prosecutors implemented policies ranging from unconditional non-prosecution of drug possession to diversion, some of which were odds with core harm reduction principles of dignity and justice (i.e., involving coercive treatment incentives/requirements). Conclusions: As prosecutors shift their approach to redress the harms caused by drug criminalization, clarity is needed on what a harm reduction approach to using discretionary powers entails. Targeting reform-minded prosecutors with messaging on the principles, evidence base, and best practices of harm reduction is merited.De Facto Decriminalization for Drug Possession and Sex Work in Baltimore, Maryland
Sherman, S. G., Tomko, C., & Rouhani, S. (n.d.).Publication year
2023Journal title
American journal of preventive medicineVolume
64Issue
4Page(s)
567-568Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic
AbstractAllen, S. T., Schneider, K. E., Morris, M., Rouhani, S., Harris, S. J., Saloner, B., & Sherman, S. G. (n.d.).Publication year
2023Journal title
Harm Reduction JournalVolume
20Issue
1AbstractBackground: 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.High willingness to use overdose prevention sites among suburban people who use drugs who do not inject
AbstractSchneider, K. E., Urquhart, G. J., Rouhani, S., Allen, S. T., Morris, M., & Sherman, S. G. (n.d.).Publication year
2023Journal title
Harm Reduction JournalVolume
20Issue
1AbstractIntroduction: Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD) via non-injection routes of administration in suburban areas are lacking. Methods: We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs’ likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS. Findings: Participants’ median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS. Conclusion: Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts.Implementation of Overdose Prevention in Maryland: Implications for Resource Allocation, Program Scale-Up, and Evaluation
AbstractTomko, C., Rouhani, S., Johnson, R. M., Susukida, R., Byregowda, H., Parnham, T., Schneider, K. E., Gibson, M., Heath, T., Rickard, R., Boyd, C. E., & Park, J. N. (n.d.).Publication year
2023Journal title
Health promotion practiceAbstractOverdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland’s Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state’s response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p =.04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States.Increased solitary drug use during COVID-19: An unintended consequence of social distancing
AbstractSchneider, K. E., Allen, S. T., Rouhani, S., Morris, M., Haney, K., Saloner, B., & Sherman, S. G. (n.d.).Publication year
2023Journal title
International Journal of Drug PolicyVolume
111AbstractBackground: 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)
AbstractAllen, S. T., Schneider, K. E., Rouhani, S., White, R. H., Morris, M., Owczarzak, J., & Sherman, S. G. (n.d.).Publication year
2023Journal title
Annals of MedicineVolume
55Issue
1AbstractIntroduction: 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.Pathways to racial disparities in the effects of Good Samaritan Laws: A mixed methods pilot study
AbstractPamplin, J. R., King, C., Cooper, C., Bennett, A. S., Elliott, L., Davis, C. S., Rouhani, S., & Townsend, T. N. (n.d.).Publication year
2023Journal title
Drug and alcohol dependenceVolume
249AbstractBackground: Drug overdose deaths continue to rise, and considerable racial inequities have emerged. Overdose Good Samaritan laws (GSLs) are intended to encourage overdose witnesses to seek emergency assistance. However, evidence of their effectiveness is mixed, and little is known regarding racial disparities in their implementation. This study examined GSL impact by assessing racial differences in awareness of and trust in New York state's GSL. Methods: Using a sequential mixed methods design, Black and white participants were recruited from an existing longitudinal cohort study of people who use illicit opioids in New York City to participate in a quantitative survey and qualitative interviews. Racially stratified survey responses were analyzed using chi-squared tests, Fisher exact tests, or t-tests. Qualitative interviews were analyzed using a hybrid inductive-deductive approach. Results: Participants (n=128) were 56% male and predominantly aged 50 years or older. Most met criteria for severe opioid use disorder (81%). Fifty-seven percent reported that the New York GSL makes them more likely to call 911 even though 42% reported not trusting law enforcement to abide by the GSL; neither differed by race. Black people were less likely to have heard of the GSL (36.1% vs 60%) and were less likely to have accurate information regarding its protections (40.4% vs 49.6%). Conclusions: Though GSLs may reduce negative impacts of the criminalization of people who use drugs, their implementation may exacerbate existing racial disparities. Resources should be directed towards harm reduction strategies that do not rely on trust in law enforcement.Persistent Criminalization and Structural Racism in US Drug Policy: The Case of Overdose Good Samaritan Laws
AbstractPamplin, J. R., Rouhani, S., Davis, C. S., King, C., & Townsend, T. N. (n.d.).Publication year
2023Journal title
American journal of public healthVolume
113Page(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.PWUD Experiences of Criminal Justice Reform: Enduring Tensions Between Policing and Harm Reduction in Baltimore, MD
AbstractFooter, K. H., Urquhart, G. J., Silberzahn, B., Rouhani, S., Weicker, N. P., Owczarzak, J., Park, J. N., Morris, M., & Sherman, S. G. (n.d.).Publication year
2023Journal title
Contemporary Drug ProblemsVolume
50Issue
2Page(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 Baltimore
AbstractRouhani, S., Tomko, C., Silberzahn, B. E., Weicker, N. P., & Sherman, S. G. (n.d.).Publication year
2023Journal title
American journal of preventive medicineVolume
65Issue
4Page(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 detection
AbstractRosen, J. G., Glick, J. L., Zhang, L., Cooper, L., Olatunde, P. F., Pelaez, D., Rouhani, S., Sue, K. L., & Park, J. N. (n.d.).Publication year
2023Journal title
AddictionVolume
118Issue
5Page(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, Maryland
AbstractSherman, S. G., Rouhani, S., White, R. H., Weicker, N., Morris, M., Schneider, K., Park, J. N., & Barry, C. (n.d.).Publication year
2022Journal title
Journal of Urban HealthVolume
99Issue
4Page(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. Cities
AbstractGandhi, P., Rouhani, S., Park, J. N., Urquhart, G. J., Allen, S. T., Morales, K. B., Green, T. C., & Sherman, S. G. (n.d.).Publication year
2022Journal title
Substance AbuseVolume
43Issue
1Page(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 emergencies
AbstractSchneider, K. E., Rouhani, S., Weicker, N. P., Morris, M., & Sherman, S. G. (n.d.).Publication year
2022Journal title
Drug and alcohol dependenceVolume
233AbstractIntroduction: 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 Overdose
AbstractPark, J. N., Urquhart, G., Morris, M., Dahal, R., Rouhani, S., & Sherman, S. G. (n.d.).Publication year
2022Journal title
Journal of Addiction MedicineVolume
16Issue
6Page(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 Maryland
AbstractPark, J. N., Owczarzak, J., Urquhart, G., Morris, M., Weicker, N. P., Rouhani, S., & Sherman, S. G. (n.d.).Publication year
2022Journal title
AIDS and BehaviorVolume
26Issue
1Page(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.