Overdose Deaths from Common Sedatives Have Surged, New Study Finds

 Newswise, February 21, 2016--Headlines about America’s worsening drug epidemic have focused on deaths from opioids—heroin and prescription painkillers such as OxyContin.

But overdose deaths have also soared among the millions of Americans using benzodiazepine drugs, a class of sedatives that includes Xanax, Valium, and Klonopin, according to a study led by researchers at Albert Einstein College of Medicine, Montefiore Health System and the Perelman School of Medicine at University of Pennsylvania. Their findings appear online today in the American Journal of Public Health.

“We found that the death rate from overdoses involving benzodiazepines, also known as ‘benzos,’ has increased more than four-fold since 1996—a public health problem that has gone under the radar,” said lead author Marcus Bachhuber, M.D., MS., assistant professor of medicine at Einstein and attending physician, internal medicine at Montefiore. 

“Overdoses from benzodiazepines have increased at a much faster rate than prescriptions for the drugs, indicating that people have been taking them in a riskier way over time.”

An estimated 1 in 20 U.S. adults fills a benzodiazepine prescription during the course of a year. The drugs are prescribed for conditions including anxiety, mood disorders and insomnia.

In 2013, benzodiazepine overdoses accounted for 31 percent of the nearly 23,000 deaths from prescription drug overdoses in the U.S. But little was known about the national trends in benzodiazepine prescribing or in fatalities from the drugs. To find out, the researchers examined data for the years 1996-2013 from two sources:

•The Medical Expenditure Panel Survey. This federally sponsored survey includes a nationally representative sample of families and individuals who provide information about healthcare purchases including prescription drugs.

•Multiple-cause-of-death data from the Centers for Disease Control and Prevention. The researchers extracted reports from physicians, medical examiners or coroners on all overdose deaths involving a benzodiazepine, including deaths also involving other medications, alcohol or illicit drugs.

Their analysis revealed that the number of adults purchasing a benzodiazepine prescription increased by 67 percent over the 18-year period, from 8.1 million prescriptions in 1996 to 13.5 million in 2013.

 For those obtaining benzodiazepine prescriptions, the average quantity filled during the year more than doubled between 1996 and 2013. Most crucially, the overdose death rate over the 18-year period increased from 0.58 deaths per 100,000 adults in 1996 to 3.14 deaths per 100,000 adults in 2013, a more than four-fold increase.

Overall, the rate of overdose deaths from benzodiazepines has leveled off since 2010. But for a few groups—adults aged 65 and over and for blacks and Hispanics—the rate of overdose deaths after 2010 continued to rise.

“The greater quantity of benzodiazepines prescribed to patients—more than doubling over the time period—suggests a higher daily dose or more days of treatment, either of which could increase the risk of fatal overdose,” said senior author Joanna Starrels, M.D., M.S., associate professor of medicine at Einstein and attending physician, internal medicine at Montefiore.

Dr. Starrels also offered two other possible reasons for the spike in benzodiazepine deaths. “People at high risk for fatal overdose may be obtaining diverted benzodiazepines [i.e., not from medical providers], and we know that combining benzodiazepines with alcohol or drugs—including opioid painkillers—can lead to fatal overdoses,” she said.

She noted that opioid prescribing has increased rapidly during most of the period covered in her study and that opioids are involved in 75 percent of overdose deaths involving benzodiazepines.

“An obvious way to improve benzodiazepine safety would be for people to reduce their use of these medicines,” said study co-author Chinazo Cunningham, M.D., M.S., professor of medicine and of family and social medicine at Einstein and associate chief of the division of general internal medicine at Einstein and Montefiore.

“But we should also be emphasizing the danger of fatal overdose from taking benzodiazepines concurrently with opioid painkillers or with alcohol.”

“This epidemic is almost entirely preventable, as the most common reason to use benzodiazepines is anxiety—which can be treated effectively and much more safely with talk therapy,” said Sean Hennessy, Pharm.D., Ph.D., professor of epidemiology at Penn’s Perelman School of Medicine and co-author of the study.

“Given the high prevalence of anxiety symptoms, we need a more constructive approach to the problem than popping pills.”

The study is titled “Increasing benzodiazepine prescription and overdose mortality in the United States, 1996-2013.” The research was supported by the National Institutes of Health (NIH K24DA036955, R25DA023021 and K23DA027719). The authors report no conflicts of interest.

Marijuana Use Now Could Pose Verbal Memory Risk Later

Newswise, February 10, 2016 — Marijuana is the most frequently used illicit drug in the United States, according to a recent survey from the National Survey on Drug Use and Health, and new data suggest that marijuana use now could pose a serious cognitive function risk later in life.

Stefan Kertesz, M.D., an associate professor with the University of Alabama at Birmingham School of Medicine, is part of a recently published nationwide study reporting potential long-term consequences with implications for public health.

Impaired cognitive functioning is an acute effect of marijuana use, and there is increasing evidence that such effects may persist later in life after marijuana use has ceased. Heavy, long-term use of marijuana has been associated with cognitive impairment, particularly in learning and remembering new information.

Kertesz and other researchers found past exposure to marijuana use to be significantly associated with worse verbal memory in middle age.

Their paper used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study which started in 1985, where more than 5,000 healthy adults were regularly asked about marijuana use. 

In contrast to studies that focus on people known to have an addiction, this study focused on community-based adults, where casual use tends to be more common than addiction.

In the final year of the study, CARDIA participants underwent simple cognitive tests, including a word memory test. Individuals were presented with 15 words and then asked to try to remember them. After 25 minutes, they were later asked to recall the words. 

The tests showed that there was a significant decline in verbal memory among persons whose cumulative marijuana use exceeded the equivalent of one joint a day for five years.

“For every five years of marijuana exposure, one out of two participants would remember one word less,” Kertesz said.

Kertesz also said that it is important to realize that marijuana is more potent today than it was in the 1980s, raising the possibility that users of today’s marijuana may face cognitive consequences of greater magnitude than those reported.

“It’s crucial to recognize that young brains are truly different and not fully developed until age 22 and are at more risk from marijuana,” he said. 

“Parents and teachers need to be vigilant that this poses a larger risk to adolescents.”

Data from 2012 indicates that, among students in the 12th grade (ages 17-18 years), 37 percent had used marijuana within the last year, 23 percent within the last 30 days and 6.5 percent daily.

Alcohol Withdrawal Adds Challenges to Caring for Critically Ill Patients

Article in Critical Care Nurse provides guidance on identifying, managing and assessing critically ill patients experiencing alcohol withdrawal

Newswise, February 1, 2016 — Alcohol withdrawal adds challenges to caring for critically ill patients, and nurses must be diligent at each stage of care to minimize complications, according to an article in the February issue of Critical Care Nurse (CCN).

The article, “Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management,” provides much-needed guidance to critical care nurses and other clinicians whose patients may have alcohol use disorder (AUD), including abuse and dependency conditions of varying severity.

Lead author Lynsey Sutton, RN, MNclin, is associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, Wellington, New Zealand.

“The abrupt cessation of alcohol places patients with an AUD at risk for additional complications, and nurses are perfectly placed at the bedside to obtain histories of alcohol consumption from patients or the patients’ families. This may help identify those at risk for withdrawal early,” she said.

For the study, the researchers reviewed more than 100 articles related to alcohol use and critically ill patients that had been published in peer-reviewed journals.

Their work can help frontline nurses who are caring for critically ill patients at risk for alcohol withdrawal syndrome (AWS).

Managing alcohol withdrawal effectively begins with the identification of patients with an AUD as indicated by the patients’ medical histories. 

Unfortunately, a patient’s history of alcohol consumption is often poorly obtained, not detailed enough or not obtained at all.

The researchers recommend that a validated tool be developed to enable nurses to obtain a more comprehensive history of alcohol use, including past withdrawal or detoxification episodes.

If patients at risk are identified at the time of admission, nurses will be better able to detect signs and symptoms of alcohol withdrawal and initiate treatment early. This practice might halt the progression from mild to severe withdrawal and prevent delirium tremens.

The researchers also suggest development of a laboratory test or biomarker to highlight chronic alcohol use, especially when an alcohol history is unobtainable. Current blood tests focus on recent alcohol consumption, which may not help identify those at risk for withdrawal.

“The clinical manifestations of critical illness and alcohol withdrawal are often similar, and a worsening clinical condition in a patient with AWS should not always be assumed to be withdrawal related,” Sutton said.

The article also discusses various therapies, tools and assessment scales nurses can use to evaluate and monitor response to treatment.

The researchers call for further studies related to nearly every aspect of alcohol withdrawal in critically ill patients to help validate tools and develop evidence-based practice guidelines.

As the American Association of Critical-Care Nurses’ bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org/.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high acuity, progressive and critical care settings. CCN enjoys a circulation of more than 106,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than 500,000 acute and critical care nurses and includes more than 225 chapters worldwide. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. www.aacn.org; www.facebook.com/aacnface; www.twitter.com/aacnme

For Breast Cancer Patients, Never Too Late to Quit Smoking

New Study Clarifies Long-Term Health Consequences of Smoking in Breast Cancer Survivors

Newswise, January 27, 2016 — Documenting that it’s never too late to quit smoking, a large study of breast cancer survivors has found that those who quit smoking after their diagnosis had a 33 percent lower risk of death as a result of breast cancer than those who continued to smoke.

The study involved more than 20,600 women with breast cancer, and is one of the largest studies of survival outcomes according to smoking habits in women with a history of breast cancer, and the first study to assess smoking habits both before and after diagnosis.

The paper was published in the Journal of Clinical Oncology on January 25, 2016.

“Our study shows the consequences facing both active and former smokers with a history of breast cancer,” said first author Michael Passarelli, PhD, a cancer epidemiologist at the UCSF School of Medicine. 

“About one in ten breast cancer survivors smoke after their diagnosis. For them, these results should provide additional motivation to quit.”

The findings come from the Collaborative Breast Cancer Study, conducted by the University of Wisconsin, Dartmouth College and Harvard University.

The observational study quantifies among women with breast cancer the long-term benefits of stopping smoking. The study, which followed participants on average a dozen years after diagnosis, compares the causes of death among four groups:
• Women who never smoked;
• Women who smoked and quit before diagnosis;
• Women who smoked and quit after diagnosis;
• Women who continued to smoke after diagnosis.

The 2014 Report of the Surgeon General on the health consequences of smoking suggested that there may be a causal relationship between breast cancer and smoking. Previous studies have also speculated that the risk of developing breast cancer in smokers might depend on when smoking started and for how long.

There are more than three million breast cancer survivors in the U.S.

Women in the Collaborative Breast Cancer Study were between the ages of 20 and 79, and were diagnosed with localized or invasive breast cancer between 1988 and 2008.

Participants were asked to report on such factors as whether they had smoked at least 100 cigarettes during their lifetime, their age when they started smoking, and the average number of cigarettes they smoked a day. The authors controlled for several important risk factors that could impact survival, including alcohol consumption and body mass index.

By 2010, a total of 6,778 women died – the leading causes of death were breast cancer and cardiovascular disease.

Active smokers a year before breast cancer diagnosis were more likely to die of breast cancer, respiratory cancer, other respiratory disease, or cardiovascular disease than women who had never smoked. The highest risks of death as a result of breast cancer were observed among long-term smokers, people who smoked heavily, or former smokers who quit fewer than five years before breast cancer diagnosis.

Approximately one in ten cancer patients continued to smoke following their diagnosis and they were more likely than people who had never smoked and former smokers to die of breast cancer, the researchers said. Those who quit smoking after diagnosis had lower mortality from breast cancer and respiratory cancer.

“Smoking cessation programs should be considered part of cancer therapy,” Passarelli said. 

“Recent policy statements from leading research and clinical organizations are now urging oncologists to be as aggressive in getting their patients to stop smoking as they are in treating the cancer.”

The study did not assess for exposure to second-hand smoke nor did it include hormone receptor status of breast tumors.

Co-authors are Polly Newcomb, PhD, MPH, of the Fred Hutchinson Cancer Research Center and University of Wisconsin School of Medicine and Public Health; John Hampton, MS, and Amy Trentham-Dietz, PhD, of the University of Wisconsin School of Medicine and Public Health; Linda Titus, PhD, of the Geisel School of Medicine at Dartmouth Medical School; Kathleen Egan, ScD, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa; John Baron, MD, of the University of North Carolina School of Medicine in Chapel Hill; and Walter Willett, MD, DrPH, of Harvard T.H. Chan School of Public Health, Harvard Medical School and Brigham and Women’s Hospital in Boston.

The study was funded by the National Cancer Institute (Grants R01CA47147, R01CA67264, R01CA47305, R01CA69664, R01CA82004, T32CA009168, R25CA112355, K05CA152714, P30CA014520, and P30CA015704) and Susan G. Komen for the Cure.

About UCSF: UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. 

It also includes UCSF Health, which comprises top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – and other partner and affiliated hospitals and healthcare providers throughout the Bay Area. Please visit www.ucsf.edu/news.

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Real-world study shows disturbing images get smokers to think about risks

Newswise, December 23, 2015– A new study is the first to provide real-world evidence of the effectiveness of smoking warning labels that include graphic photos of the damage caused by regular tobacco use.

Researchers found that smokers who saw graphic warning labels on every pack of cigarettes they smoked for four weeks had more negative feelings about smoking compared to those who saw just text warnings, which led them to look more closely at the warnings and put more credence into them.

This was associated with them thinking their habit was more dangerous and being more likely to consider quitting.

They also remembered more of the health risks of their habit.

“The graphic images motivated smokers to think more deeply about their habit and the risks associated with smoking,” said Ellen Peters, co-author of the study and professor of psychology at The Ohio State University.

The study, which was a joint project between Ohio State and the Annenberg Public Policy Center of the University of Pennsylvania, appears in the journal PLOS ONE.

The research is the first to look at the impact of graphic warning labels on smokers outside of a laboratory and over a relatively long period of time.

“Our study provides real-world evidence of how viewing these graphic images over time has an impact on smokers beyond what occurs with simple text warnings,” said Abigail Evans, lead author of the study and a postdoctoral researcher in psychology at Ohio State.

Other co-authors were Daniel Romer of the University of Pennsylvania’s Annenberg Public Policy Center; Andrew Strasser of the University of Pennsylvania; Lydia Emery of Northwestern University; and Kaitlin Sheerin of the University of Missouri.

For the study, the researchers used graphic warning labels created by the U.S. Food and Drug Administration. One of the labels included an image of a man smoking through a hole in his throat, called a tracheostomy. A tracheostomy may be necessary as a result of some smoking-related cancers.

The use of graphic warning labels was mandated by law to appear on cigarette packs in the United States in 2009. The warnings proposed by FDA were later invalidated by a federal appeals court.

The court concluded the labels were unconstitutional in part because the images were “unabashed attempts to evoke emotion … and browbeat consumers into quitting.”

This study suggests that the court was not correct in its assessment of how these images work to discourage smoking, Peters said.

“Smokers weren’t browbeaten by the images. The images definitely did stir their emotions, but those emotions led them to think more carefully about the risks of smoking and how those risks affected them,” Peters said.

“What the court is missing is that without emotions, we can’t make decisions. We require having feelings about information we collect in order to feel motivated to act. These graphic warnings helped people to think more carefully about the risks and to consider them more.”

The study involved 244 adults who smoked between 5 and 40 cigarettes each day.

Participants were provided with their preferred brand of cigarettes for four weeks, in modified packages. All packages had the same text messages, such as “Cigarettes cause fatal lung disease.”

 Some participants received packs with only these messages. Some received packs with the text warnings plus one of nine graphic, somewhat disturbing images showing the dangers of smoking. A third group received the simple text and the image, plus additional text detailing how every cigarette entails risk.

Participants returned to the lab each week to receive additional cigarettes and respond to surveys about their experiences with the new packaging.

Results showed that smokers who had the warning labels with the graphic labels were more likely than those who received only text warnings to report that the packaging made them feel worse about smoking.

They were also more likely to read or look closely at the information on the warning labels and they better remembered what was on the labels.

Smokers who had the graphic labels also saw the warnings as more credible.

“The feelings produced by the graphic images acted as a spotlight. Smokers looked more carefully at the packages and, as a result, the health risks fell into the spotlight and led to more consideration of those risks,” Peters said.

Smokers who viewed the graphic labels were also slightly more likely to say they intended to quit smoking.

“For a health issue like smoking, which causes about a half-million deaths a year in the United States, even small effects can have a large impact in the population,” Peters said.

“The effect was small, but it was not unimportant.”

The results show warning labels with graphic images really do work, Evans said.

“Policies requiring such labels have the potential to reduce the number of Americans who smoke,” she said.

The study was supported by grants from the National Cancer Institute and the FDA Center for Tobacco Products.

Binge Drinking with Chronic Alcohol Use More Destructive than Previously Thought

Newswise, December 18, 2015― Excessive alcohol consumption is a global public health issue. In the United States, binge drinking is the most common form ― so common, in fact, that the Centers for Disease Control and Prevention reports approximately one in six adults binge drinks about four times each month.

Now, a study by University of Missouri School of Medicine researchers shows that chronic alcohol use, when combined with repeated binge drinking, causes more damage to the liver than previously thought.

“Heavy binge drinking by those who habitually consume alcohol is the most common cause of liver damage in chronic alcoholic liver disease,” said Shivendra Shukla, Ph.D., the Margaret Proctor Mulligan Professor of medical pharmacology and physiology at the MU School of Medicine and lead author of the study. 

“We know that this behavior causes large fatty deposits in the liver that ultimately impair the organ’s ability to function properly. However, we wanted to understand the mechanism that causes this damage and the extent of the harm. Our research focused on different forms of alcohol abuse and the results of those behaviors.”

Shukla’s team studied mice to examine the extent of liver injury caused by chronic alcohol use, repeat binge episodes and a combination of both. During a four-week period, the team found that mice exposed to chronic alcohol use and repeated binge consumption exhibited the highest levels of liver damage.

“Either chronic alcohol use or acute repeat binge episodes caused moderate liver damage when compared to the control group not exposed to alcohol,” Shukla said.

“This outcome came as no surprise. However, in the mice exposed to both chronic use and repeat binge episodes, liver damage increased tremendously. Even more shocking was the extent of fatty deposits in the livers of those exposed to chronic plus binge alcohol. It was approximately 13 times higher than the control group.”

The highly amplified fat accumulation was in part caused by metabolic changes within the liver. These changes not only significantly increased fatty liver deposits, but increased stress on the organ while decreasing the liver’s ability to fight the stress.

Shukla also pointed out that chronic and excessive alcohol use should not be associated only with liver damage.

“Drinking alcohol excessively can create an inflammatory response to the liver and other organ systems in the body,” Shukla said.

“If those organs work at a lower level of function, then a whole host of physiological processes can be affected. It is important for us to understand the extent of damage caused by alcohol abuse, which also can lead to other health issues such as diabetes, cardiovascular disease and some forms of cancer.”

The study, “In Vivo Acute on Chronic Ethanol Effects in Liver: A Mouse Model Exhibiting Exacerbated Injury, Altered Metabolic and Epigenetic Responses,” recently was published in Biomolecules, a peer-reviewed journal on biogenic substances published by the Multidisciplinary Digital Publishing Institute.

NYU Study Finds Adults Aged 50-59 Now Largest Age Group in Opioid Treatment Programs

Notable shifts found in demographic background including gender and ethnicity among older adults

Newswise, December 1, 2015 — Recent years have seen a change in drug use patterns, especially for older adults, with an increase in their admission to substance abuse treatment and increased injection drug use among those over the age of 50. 

Yet, there has been little research regarding the epidemiology, health status, and functional impairments in the aging population of adults accessing opioid treatment.

Of the few studies on this population to date, most have been based off of a limited dataset that only accounts for treatment admissions, and therefore may not fully capture the utilization of substance abuse treatment over time. 

Furthermore the treatment episode dataset (TEDS), defines an older adult as aged over 50 or 55, and may not fully demonstrate how the population is aging.

Given the gaps in existing data, researchers affiliated with New York University's Center for Drug Use and HIV Research (CDUHR), and NYU’s School of Medicine (NYUSoM) sought to elucidate age trends for opioid treatment programs, with an emphasis on older adults, in a new study published in the Journal of Substance Use & Misuse. 

The investigation focuses on such trends in New York City, as it has one of the largest methadone treatment systems in the U.S. and consistently provides access to treatment in the public system.

The study, “Demographic Trends of Adults in New York City Opioid Treatment Programs- An Aging Population,” used data collected by New York State's Office of Alcoholism and Substance Abuse Services (OASAS). OASAS provides more detailed information on the treatment population than what is available nationally through the TEDS dataset, allowing the NYU researchers to characterize basic demographic, self-reported other substance use, and self-reported physical impairments.

“Most notably,” says Benjamin Han, MD, MPH, an instructor at NYUSoM and the study’s principle investigator, “we found a pronounced age trend in those utilizing opioid treatment programs from 1996 to 2012, with adults aged 50 and older becoming the majority treatment population.”

Specifically, individuals aged 50-59 which made up 7.8% (N= 2,892) of the total patient population in 1996, accounted for 35.9% (N= 12,301) of the population in 2012. Patients aged 60-69, also saw a dramatic increase in numbers, originally constituting 1.5% of patients (N= 558) to 12.0% of patients (N= 4,099).

“These increases are especially striking, considering there was about a 7.6% decrease in the total patient population over that period of time, and suggests that we are facing a never before seen epidemic of older adults with substance use disorders and increasing numbers of older adults in substance abuse treatment. 

Unfortunately there is a lack of knowledge about the burden of chronic diseases and geriatric conditions or the cognitive and physical function of this growing population” says Dr. Han.

During the same period, those age 40 and below, who in 1996 accounted for 56.2% of patients (N= 20,804), were a fraction of that in 2012, responsible for 20.5% of total patients (N= 7,035).

There were also notable shifts with regards to race and ethnicity. During this period older adults over the age of 60 were increasingly white, with a 10.3% increase in representation, while there was a 13.8% decrease in the percentage of black patients. 

There was a small increase in the Hispanic constituency from 35.0% in 1996 to 38.8% in 2012. These trends, however, were different for those aged 50-59. In this age group there were smaller decreases in both the white (3.5%) and black (5.9%) populations, and a larger increase in Hispanic patients (9.2%). 

However, when looking at all age groups during this period, the overall white population remained steady (-0.4%), with a slight decrease in black patients (3.5%) and a slight increase in Hispanic patients (3.4%).

Researchers believe the increase in older adults utilizing opioid treatment programs is likely to continue into the next decade. Further studies are required to better understand the specific and unique health needs of this growing population from a geriatric perspective. 

More research is also need to understand how other substance use can complicate care and how to address the changing ethnic and racial demographics of this population in New York City.

Researcher Affiliations: Benjamin H. Han, MD, MPH1*; Soteri Polydorou, MD2; Rosie Ferris, MPH1; Caroline Blaum, MD, MS1; Stephen Ross, MD2; Jennifer McNeely, MD, MS3.
1 NYU School of Medicine, Department of Medicine, Division of Geriatrics.
2 NYU School of Medicine, Division of Alcoholism and Substance Abuse
3 NYU School of Medicine, Department of Population Health and the Department of
Medicine.

Declaration of Interest: Gail Dorn, MS1 and Dawn Lambert-Wacey, MA1 provided the aggregated dataset used in this study, and assisted in the editing of the article.

1NYS Office of Alcoholism and Substance Abuse Services
Division of Outcome Management and System Information
1450 Western Ave, Albany, NY 12203-3526

About CDUHR
The mission of the Center for Drug Use and HIV Research (CDUHR) is to end the HIV and HCV epidemics in drug using populations and their communities by conducting transdisciplinary research and disseminating its findings to inform programmatic, policy, and grass roots initiatives at the local, state, national and global levels. CDUHR is a Core Center of Excellence funded by the National Institute on Drug Abuse (Grant #P30 DA011041). It is the first center for the socio-behavioral study of substance use and HIV in the United States and is located at the New York University College of Nursing. For more information, visit www.cduhr.org

About NYU Langone Medical Center
NYU Langone Medical Center, a world-class, patient-centered, integrated academic medical center, is one of the nation’s premier centers for excellence in clinical care, biomedical research, and medical education. Located in the heart of Manhattan, NYU Langone is composed of four hospitals—Tisch Hospital, its flagship acute care facility; Rusk Rehabilitation; the Hospital for Joint Diseases, the Medical Center’s dedicated inpatient orthopaedic hospital; and Hassenfeld Children’s Hospital, a comprehensive pediatric hospital supporting a full array of children’s health services across the Medical Center—plus the NYU School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. The Medical Center’s tri-fold mission to serve, teach, and discover is achieved 365 days a year through the seamless integration of a culture devoted to excellence in patient care, education, and research. For more information, go to www.NYULMC.org

About New York University College of Nursing
NYU College of Nursing is a global leader in nursing education, research, and practice. It offers a Bachelor of Science in Nursing, a Master of Science and Post-Master’s Certificate Programs, a Doctor of Philosophy in Research Theory and Development, and a Doctor of Nursing Practice degree. For more information, visit www.nursing.nyu.edu/