Preventable Harms: Injection Drug Use-Related Infections in New Jersey

Michael Enich, Claire Marie Kemp, Peter Treitler, Amesika Nyaku, Jenna Mellor, Caitlin O'Neill

Table of Contents

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Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Overall

Prevalence of Severe

Geographic Trends in Injection Drug Use-Related Severe

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dedication

This report was motivated by the deaths of four New Jersey Harm Reduction Coalition program participants who died of the severe infections we write about Their passing motivated this analysis investigating the prevalence of such infections, with the hope that it will help prevent further harms for all of our community members who use drugs It is deeply rooted in a love for and commitment to the people our organization serves

Acknowledgements

We would like to thank Dr . Shashi Kapadia and Cedric for consulting on the content of this report Thanks also to Sabrina Guevara and Louis Di Paulo for your help in crafting our message and making it accessible to a general audience Thanks to José Valdez for your project management and web development skills, and to Kim Henze Walker for bringing all of this to life with your graphic design

This report was developed with the support of the Bloomberg Overdose Prevention Initiative

Acronyms Used

ED: Emergency Department

HCUP: Healthcare Cost and Utilization Project

HIV: Human Immunodeficiency Virus

ICD: International Classification of Diseases

IDU: Injection Drug Use

IDU-SBI: Injection Drug Use-Related Severe Bacterial Infection

IQR: Interquartile Range

NJHRC: New Jersey Harm Reduction Coalition

PWID: People Who Inject Drugs

SBI: Severe Bacterial Infection

SEDD: State Emergency Department Databases

SID: State Inpatient Databases

SSTI: Skin and Soft Tissue Infection

SUD: Substance Use Disorder

Executive Summary

Without access to harm reduction supplies such as sterile needles, skin disinfectants, and injection equipment, many people who inject drugs (PWID) are at risk of painful and costly skin and soft tissue infections

These infections can escalate to other severe bacterial infections (SBIs) of the bone, blood, or heart — such as osteomyelitis, sepsis, bacteremia, or infective endocarditis 1 SBIs are the leading cause of hospitalization for PWID, and all-too-often result in preventable deaths 2

Despite the known harms of injection drug use (IDU) related infections, New Jersey does not consider SBIs when evaluating public health metrics related to the health and wellbeing of PWID 3 To help bridge this gap, New Jersey Harm Reduction Coalition conducted a cross-sectional study of hospitalizations and emergency department (ED) visits with suspected injection drug use-related SBIs (IDU-SBIs) in 2019 using available data from the Healthcare Cost and Utilization Project 4

Among New Jersey residents in 2019, our analysis found:

• 1,967 emergency room visits for IDU-SBIs

• 7,310 hospitalizations for IDU-SBIs, accounting for 0.8% of all hospitalizations and 15.2% of hospitalizations for patients with an injection-related substance use disorder (SUD) diagnosis

• 283 deaths from IDU-SBIs

• More than $1 billion in hospital charges due to IDU-SBIs, with a median charge of $74,406 per hospitalization

The most frequently identified SBI was bacteremia/sepsis, while endocarditis caused the costliest hospitalizations People in all New Jersey counties and across all racial, ethnic, gender, and age demographics experienced SBIs

Most SBI hospitalizations occurred among males and individuals 30-49 years old Although white/non-Hispanic residents were most frequently hospitalized, Black/non-Hispanic individuals were 1.5 times more likely to be hospitalized compared with their white counterparts and comprised 21.6% of hospitalizations for SBIs despite making up 12.7% of New Jersey’s population in 2019 Given that white residents are more likely to use drugs,

this disparity reflects the disproportionate negative consequences the War on Drugs has for people of minoritized racial and ethnic identities 4 SBI visits were also most common among patients in the lowest income quartile and those with Medicaid or Medicare as their expected payer . Individuals covered by public insurance through Medicaid or Medicare were 5.8 times more likely to be hospitalized compared with individuals covered through private health insurance

The counties with both the highest rates of SBI hospitalizations per resident and the highest per capita charges for SBI hospitalizations were Atlantic, Camden, Cumberland, Mercer, and Salem Counties .

IDU-SBIs — and the associated pain, loss of life, and healthcare charges — are preventable when PWID have access to new, sterile syringes for every injection and non-stigmatizing health services to treat infections early

To prevent harms associated with SBIs, New Jersey should:

1 . Include prevalence of IDU-SBIs, as well as deaths related to such infections, in publicly available drug user health metrics . The prevalence and incidence of SBIs should be included in public data dashboards on the health outcomes faced by New Jerseyans who use drugs and who are living with an SUD

2

. Fully fund and implement accessible syringe service programs in all corners of the state . Ensuring PWID have access to sterile syringes and other safer injection supplies is critical to preventing SBIs New Jersey currently has only seven syringe service programs serving over nine million residents In light of recent legislative changes to remove restrictive barriers to syringe access, New Jersey must fully fund and implement syringe service programs New Jersey must also ensure that syringe access is accessible to all residents by increasing access through brick-and-mortar drop-in locations, delivery and mail-based services, and peer-led delivery models

3

. Support harm reduction services that include safer smoking and safer snorting supplies to decrease IDU-related infections . Switching route of administration from injection to smoking or snorting reduces risk of overdose, SBIs, and transmission of HIV and Hepatitis C Funding should be available for safer smoking and snorting supplies, and these supplies should be offered by all harm reduction programs Criminal penalties should be removed for possession and distribution of these supplies in the interest of public health

4

. Increase harm reduction infrastructure in EDs and hospitals . PWID often experience competing priorities that prevent them from accessing medical care, such as knowing they will experience withdrawal while hospitalized, the stigma associated with IDU, and knowing that infections could be life threatening if left

2 Preventable Harms: Injection Drug Use-Related Infections in New Jersey 2022

untreated . All EDs and hospitals should have evidence-informed withdrawal management (consisting primarily of medications for opioid use disorder) readily available for patients Hospitals should provide connection to syringe service programs and prioritize collaborative care plans to address patient-identified needs and reduce the odds of patient-directed discharges It is critical to increase local substance use treatment collaboration between hospitals and treatment centers for individuals who are seeking supported SUD treatment

5 . Decriminalize drug possession and use . SUD is a chronic health condition, expected symptoms of which include continuing to use despite negative consequences or the desire to stop The criminalization of drug use decreases the likelihood that people who use drugs will seek medical care, and increases stigma and discrimination for those seeking medical care Drug use is a matter of public health and community wellbeing; it should be treated as such

6 . Provide training to healthcare providers to reduce stigma against people who use drugs . Studies have found that people who use drugs avoid medical care because of mistreatment by health care providers, often rooted in stigma 5 As a result, minor IDU-related infections may progress to serious and potentially fatal ones before individuals seek treatment More education across health care sectors, especially for first responders, emergency providers, and providers in EDs, is needed to address stigma, promote equitable care, and better meet the medical needs of people who use drugs

3 Preventable Harms: Injection Drug Use-Related Infections in New Jersey

Introduction

While the danger of overdose among people who inject drugs (PWID) is widely recognized today, these individuals are also at significant risk of developing other serious health issues, including infections like HIV, Hepatitis B, and Hepatitis C Severe bacterial infections (SBIs) are also common, and include skin and soft tissue infections (SSTIs), bone infections (osteomyelitis), blood infections (bacteremia and/or sepsis), and heart valve infections (infective endocarditis) Without access to harm reduction supplies such as sterile needles, skin disinfectants, and safer injection equipment, as many as one out of every three PWID will experience painful and costly SSTIs such as abscesses, cellulitis and phlebitis 6

SBIs frequently start as SSTIs and progress to bacteremia, osteomyelitis, and/or infective endocarditis, which require hospitalization and may lead to death 1 Injection drug use-related infective endocarditis is particularly dangerous — it typically requires hospitalization for intravenous antibiotics and may result in the need for heart surgery, and/or lead to organ complications that impose tremendous long-term health consequences 1,7 8 Each of these consequences results in intense stress for PWID and their loved ones and, if left untreated, can result in death

Nationwide, SBIs are a growing cause of hospitalization among PWID and are highly correlated with illness and death 1,2 In 2020, the U S Centers for Disease Prevention and Control reported a New Jersey patient with a rare form of wound botulism caused by injection drug use (IDU) 9 In Oregon, hospitalizations from any injection drug use-related SBIs (IDU-SBIs) multiplied six-fold between 2008 and 2018, and hospitalizations from sepsis/bacteremia increased by a factor of 18 2 An analysis of hospitalizations in Philadelphia found similar trends From 2013-2018, hospitalizations for injection-related SSTIs increased by 91%; bacteremia and sepsis by 253%; osteomyelitis by 73%; and endocarditis by 240% 10 A 2021 study conducted in Stockholm not only found higher morbidity and mortality among PWID, but also discovered PWID faced 100 times the risk of developing endocarditis over ten years compared to the general population . 7

In addition to their devastating impact on individuals and their families, SBIs lead to significant preventable costs for healthcare systems and payers . Medicaid and Medicare are the largest payers of these costs For the uninsured, this cost falls to hospitals 11 The estimated cost of such infections for a single safety net hospital located in Miami was $11 .4 million during a 12-month period . 1,12

Despite these national trends, New Jersey does not consider SBIs when evaluating public health metrics related to the health and wellbeing of PWID, and at the time of publication the state only has seven syringe access programs serving a population of over nine million 3 To help address this gap, this report summarizes statewide data on inpatient and emergency department (ED) visits for IDU-SBIs in New Jersey in 2019 The following analysis shows the frequency of IDU-SBIs statewide and across New Jersey’s 21 counties, the resulting costs of inpatient care for health systems, and demographic characteristics and disparities of residents experiencing SBIs This report makes clear New Jersey’s critical need for efforts to prevent and aggressively treat SBIs among PWID

Harms: Injection Drug Use-Related Infections in New Jersey

Methods

This report describes findings from a cross-sectional study of hospitalizations and ED visits in 2019 using the New Jersey State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) from the Healthcare Cost and Utilization Project (HCUP), collected and maintained by the Agency for Healthcare Research and Quality 12 The SID contains hospital discharge data for all inpatient stays in acute care hospitals, and the SEDD contains ED discharge data for acute care visits that did not result in an inpatient admission These all-payer datasets include data on length of stay, services rendered, charges, patient diagnoses, and patient characteristics (e g , age, race, ethnicity, insurance type)

Hospital visits related to IDU were captured by identifying visits in which patients had a diagnosis for any SUD commonly associated with IDU, and an additional diagnosis of an SBI Qualifying SUDs included cocaine, amphetamine-type stimulants, opioids, sedatives, and "Other" drug use disorders 2,13 SBIs included in the study were bacteremia/sepsis, endocarditis, osteomyelitis, and SSTIs 2,11,14 Each of these are suspected injection-related infections, since the cause of the infection cannot be determined in the billing data International Classification of Diseases, Tenth Revision (ICD-10) codes used to determine diagnoses are included in the appendix

This report presents the overall number, or frequency, of hospital visits for IDU-related infections for individuals visiting New Jersey hospitals during 2019, as well as their associated charges and deaths when applicable Analyses were conducted at the ED or inpatient visit level, rather than by person, as unique person identifiers are not included in the de-identified HCUP datasets for privacy reasons Results are presented for the state overall and by county, shown as total hospitalizations per 1,000 county hospital admissions and total hospitalizations per 1,000 county residents, using county population estimates from the 2019 American Community Survey 15

Total and per capita charges for hospital visits were calculated using a variable from the HCUP dataset which indicates the total amount billed by a hospital for a given visit, regardless of the amount they were ultimately paid SBI-related deaths were determined using a variable indicating whether the person died during their hospitalization . Deaths that resulted from the infection but did not occur during the hospitalization are not included in this variable In compliance with the HCUP data use agreement, frequencies below 11 were collapsed to maintain patient anonymity .

Results

Overall Findings

In 2019, SUD-related ED visits and hospitalizations were common among people receiving care at New Jersey hospitals

Among 3,137,437 documented ED visits that did not result in an inpatient stay, 0.7% (21,182 encounters) had injection-related SUD listed as a primary reason for the visit — indicating this was a main reason for the ED visit — and 2 .0% (62,595 encounters) had injection-related SUDs as a primary or secondary reason for the visit .

Overall, 1,967 visits to the ED were caused by IDU-related infections This is 3.1% of visits by patients with an injection-related SUD .

In 2019, there were 928,786 inpatient hospital stays in New Jersey 5.2% (or 48,048 encounters) of hospitalizations included an injection-related SUD diagnosis, and 0.8% (or 7,812) listed an injection-related SUD as the primary reason for hospitalization Of these, 0.8% of all hospitalizations, or 15.2% of hospitalizations with an injection-related SUD diagnosis (7,310 hospitalizations) were for IDU-SBIs .

The median length of stay for IDU-related infections was five days (inter quartile range [IQR], of 3–10 days) . Median total length of stay was longest for those hospitalized with endocarditis at eight days (IQR 3 – 18 days), and osteomyelitis at eight days (IQR 4 – 14 days), followed by bacteremia/sepsis at six days (IQR 3 – 12 days) and skin and soft tissue infections at four days (IQR 3 – 8 days)

Death was the result of 3.9% of these hospitalizations in other words, 283 people died from IDU-SBIs while hospitalized in the state in 2019

283 people died from injection drug userelated infections while hospitalized in New Jersey in 2019 .

Approximately 20% of hospitalizations resulted in patient-directed discharges (labeled “against medical advice” in data analyzed for this report) A patient-directed discharge occurs when an individual leaves before the care team treating the patient believes the

patient is stable enough to leave

is a relatively common occurrence among PWID who are hospitalized, and due to a variety of factors including the undertreatment of withdrawal

and

in

discharges are particularly concerning for SBIs, due to their severity and

to escalate to worse infections or death

infections is likely

may not have an SUD diagnosis, which would exclude them

infection

also likely

do not include individuals who left and died outside the

those who died of infections without being hospitalized

Prevalence of Severe Bacterial Infections

There were 1,967 visits to the ED due to an SBI contracted from IDU that did not result in hospitalization These included 79 identified cases of endocarditis, 90 cases of osteomyelitis, and 134 cases of sepsis/bacteremia

The most commonly occurring SBI in the ED were soft skin and tissue infections, with 1,708 injection-related SSTIs treated in 2019, accounting for 0.1% of all visits and 8.1% of injection-related SUD visits

Of the 7,310 injection-related inpatient hospitalizations, 4,078 were for bacteremia/sepsis; 3,524 for skin/soft tissue infections; 678 for endocarditis; and 677 for osteomyelitis

Of the 9,277 total SBI encounters, SSTIs were the most common infections, appearing on 55.3% of encounters The most costly and medically severe of the four identified infections was endocarditis, which accounted for 8.2% of all hospital visits due to SBI Figure 1 displays the frequencies of each SBI across ED and inpatient hospital encounters

Demographic Trends

Most New Jersey hospitalizations for IDU-SBIs were among males, individuals aged 30-49, and white/non-Hispanic residents (Table 1)

While the total number of hospitalizations was greatest for white/non-Hispanic residents, Black/non-Hispanic residents were 1.5 times more likely to be hospitalized than their white counterparts This is a notable illustration of how drug use continues to disproportionately harm Black/non-Hispanic residents, despite higher rates of drug use overall among white residents 4

Hospitalization due to IDU-SBIs was also most common among patients who resided in zip codes with the lowest household incomes Nearly two thirds were covered by Medicare or Medicaid at the time of the event People with Medicare or Medicaid were 5.6 times more likely to be hospitalized than those with private insurance coverage

58.8

62.1

21.6

11.9

45.1

27.4

18.1

9.5

23.1

Frequency of severe bacterial infection (SBI) hospitalizations in 2019 by NJ county*

County SBI Hospitalizations Total Hospitalizations Total Population

Infections per 1,000 Hospitalizations

Infections per 1,000 Individuals

Atlantic 497 34,239 263,670 14.52 1.88

Bergen 347 76,983 932,202 4.51 0.37 Burlington 375 45,475 445,349 8.25 0.84 Camden 971 59,772 506,471 16.25 1.92

Cape May 88 11,490 92,039 7.66 0.96

Cumberland 201 19,791 149,527 10.16 1.34

Essex 875 86,861 798,975 10.07 1.10

Gloucester 319 26,160 291,636 12.19 1.09 Hudson 471 62,043 672,391 7.59 0.70

Hunterdon 48 11,248 124,371 4.27 0.39

Mercer 405 37,657 367,430 10.75 1.10

Middlesex 335 75,865 825,062 4.42 0.41

Monmouth 374 66,116 618,795 5.66 0.60

Morris 189 42,631 491,845 4.43 0.38

Ocean 469 79,235 607,186 5.92 0.77

Passaic 498 53,736 501,826 9.27 0.99

Salem 79 7,037 62,385 11.23 1.27

Somerset 137 25,718 328,934 5.33 0.42 Sussex 93 14,804 140,488 6.28 0.66 Union 253 53,875 556,341 4.70 0.45 Warren 109 10,768 105,267 10.12 1.04

Total* 7,133 901,504 8,882,190 7.91 0.80

*Total is less than total number of hospitalizations (7,310) because only patients residing in NJ counties are included in the table.

Geographic Trends in Injection Drug Use-Related Severe Bacterial Infections (IDU-SBIs)

Injection-related infections impacted people across every New Jersey county, but especially in Atlantic, Camden, Cumberland, Essex, Gloucester, Mercer, Salem, and Warren counties – all of which had more than one injection-related SBI hospitalization for every 1,000 people in that county in a single year

When adjusted for the total number of hospitalizations for all causes in each county, Atlantic, Camden, Gloucester, Mercer, and Salem Counties had the highest rates of hospitalization for injection-related SBIs per 1,000 hospitalizations (Figure 3) When expressed as a rate per 1,000 residents, Atlantic, Camden, Cumberland, Mercer, and Salem Counties had the highest rates of injection-related SBI hospitalization (Figure 4)

Estimated Charges

Atlantic, Camden, Cumberland, Mercer, and Salem counties had the highest rates per capita of hospitalizations due to preventable injection drug use-related severe bacterial infections .

The median hospital charges for an SBI-related ED visit were $5,038 (IQR $2,358 –$14,587) The median charge for inpatient hospitalization for IDU-SBIs was $74,406 (IQR: $38,411 – $152,433), with overall hospitalization charges for avoidable IDU-SBIs totaling over $1.0 billion ($1,003,037,694)

Notably, charges for IDU-related infections account for 27.3% of charges for ED/inpatient visits in the state for injection-related SUDs (calculated at $3.7 billion total) This is the equivalent of community college tuition costs for over 160,000 residents or enough to fully fund at least two syringe service programs for every municipality in the state

Charges for injection drug use-related infections total over $1 .0 billion — enough to fully fund at least two syringe service programs in every municipality in the state .

Figure 5 displays the median charges per visit for each type of IDU-SBI hospitalization The most expensive of these was endocarditis, with a median charge of $129,615 (IQR: $54,149 – $301,614), followed by osteomyelitis at $102,794 (IQR: $57,801 – $209,232), bacteremia/sepsis at $97,286 (IQR: $53,069 – $198,651), and SSTIs at $53,506 (IQR 29,234 50 - $105,107)

Counties with the highest per capita charges included Bergen, Hudson, Mercer, Middlesex, Somerset, Sussex, Union, and Warren counties—all of which were above the state-wide median of $74,000

In terms of total charges, Essex and Camden both surpassed $100 million for IDU-SBIs, with Hudson and Mercer counties following close behind (Table 3) Atlantic, Camden, Cumberland, Essex, Gloucester, Hudson, Mercer, Passaic, Salem, and Warren counties all had IDU-SBI per capita charges above the state-wide per capita charge of $113, with Camden and Mercer incurring the highest per capita charges (Figure 6)

Preventable Harms: Injection Drug Use-Related Infections in New Jersey

Charge associated with visit by morbidity*

*Figure displays the charge for hospitalization associated with a visit of an indicated diagnosis. Box denotes the interquartile range with line showing the median. Horizontal line indicates median value. Whiskers display values at 1.5 times below and above the IQR. Values outside this range are hidden.

TABLE 3

IDU-SBI-associated charge per county (in dollars)

IDU-SBI:

County Mean Median Maximum Total

Atlantic 91,918 56,132 1,268,002 45,683,236 173.26

Bergen 145,064 78,021 2,975,607 50,337,124 54.00

Burlington 128,604 65,392 1,410,164 48,226,592 108.29

Camden 116,891 63,488 2,094,108 113,500,000 224.10

Cape May 106,844 54,003 1,502,626 9,402,299 102.16

Cumberland 103,815 51,042 1,618,692 20,866,780 139.55

Essex 138,730 70,819 3,408,917 121,400,000 151.94

Gloucester 109,136 68,191 953,120 34,814,252 119.38

Hudson 201,760 125,684 2,108,900 95,028,872 141.33

Hunterdon 108,763 57,192 1,311,067 5,220,601 41.98

Mercer 229,824 124,083 2,722,060 93,078,840 253.32

Middlesex 173,720 112,019 2,232,791 58,196,048 70.54

Monmouth 152,789 74,027 2,884,294 56,990,344 92.10

Morris 95,633 65,252 707,625 18,074,720 36.75

Ocean 113,227 68,198 1,266,227 53,103,664 87.46

Passaic 128,533 73,560 1,495,636 64,009,528 127.55

Salem 96,929 50,260 557,442 7,657,372 122.74

Somerset 134,072 91,260 1,058,524 18,367,792 55.84

Sussex 124,984 79,778 1,103,769 11,623,514 82.74

Union 151,852 84,848 1,555,779 38,418,608 69.06

Warren 123,853 81,369 865,222 13,500,025 128.25

Total* 137233.2 74,406 3,408,917 1,003,037,694 112.92

Conclusion & Recommendations

Among New Jersey residents in 2019, our analysis found:

• 1,967 ED visits for IDU-SBIs

• 7,310 hospitalizations for IDU-SBIs, accounting for 0.8% of all hospitalizations and 15.2% of hospitalizations with an injection-related SUD diagnosis

• 283 in-hospital deaths from IDU-SBIs

• More than $1 billion in hospital charges due to IDU-SBIs, with a median charge of $74,406 per hospitalization

The most frequently identified SBI was bacteremia/sepsis, while the costliest infection was endocarditis SBIs occurred in all counties and across racial, ethnic, gender, and age groups Most SBI hospitalizations occurred among males and individuals 30-49 years old

Although white/non-Hispanic residents were most frequently hospitalized, Black/non-Hispanic individuals were 1.5 times more likely to be hospitalized compared with their white counterparts and comprised 21.6 percent of hospitalizations for SBIs despite making up 12.7 percent of New Jersey’s population in 2019

Publicly-insured individuals covered by Medicaid or Medicare were 5.8 times more likely to be hospitalized compared with individuals covered by private health insurance

Atlantic, Camden, Cumberland, Mercer, and Salem counties had the highest rates of SBI hospitalizations per resident and the highest per capita charge of SBI hospitalizations

Despite the well-known benefits of syringe service programs in preventing injection-related infections, overdose, and transmission of infectious diseases,18 New Jersey currently operates only seven syringe service programs in a state with over nine million residents Put another way, each syringe access program serves 1/7th of New Jersey's population, or 1.29 million residents Syringe service programs are also each expected to serve around 8,000 residents of the 56,287 who sought SUD treatment in 2019 19,20

To better meet the needs of PWID, it is clear that New Jersey must invest in a harm reduction approach to drug use that reduces stigma, connects people to care, and ensures that PWID have access to sterile syringes and nonjudgmental support .

New Jersey can accomplish this through the following recommendations:

1

. Include prevalence of IDU-SBIs, as well as deaths related to such infections, in publicly available drug user health metrics . The prevalence and incidence of SBIs should be included in public data dashboards on the health outcomes faced by New Jerseyans who use drugs and who are living with an SUD

2

. Fully fund and implement accessible syringe service programs in all corners of the state . Ensuring PWID have access to sterile syringes and other safer injection supplies is critical to preventing SBIs New Jersey currently has only seven syringe service programs serving over nine million residents In light of recent legislative changes to remove restrictive barriers to syringe access, New Jersey must fully fund and implement syringe service programs New Jersey must also ensure that syringe access is accessible to all residents by increasing access through brick-and-mortar drop-in locations, delivery and mail-based services, and peer-led delivery models .

3

. Support harm reduction services that include safer smoking and safer snorting supplies to decrease IDU-related infections . Switching route of administration from injection to smoking or snorting reduces risk of overdose, SBIs, and transmission of HIV and Hepatitis C Funding should be available for safer smoking and snorting supplies, and these supplies should be offered by all harm reduction programs Criminal penalties should be removed for possession and distribution of these supplies in the interest of public health

4

. Increase harm reduction infrastructure in EDs and hospitals . PWID often experience competing priorities that prevent them from accessing medical care, such as knowing they will experience withdrawal while hospitalized, the stigma associated with IDU, and knowing that infections could be life threatening if left untreated All EDs and hospitals should have evidence-informed withdrawal management (consisting primarily of medications for opioid use disorder) readily available for patients Hospitals should provide connection to syringe service

Preventable Harms: Injection Drug Use-Related Infections in New Jersey 2022

5

programs and prioritize collaborative care plans to address patient-identified needs and reduce the odds of patient-directed discharges It is critical to increase local substance use treatment collaboration between hospitals and treatment centers for individuals who are seeking supported SUD treatment .

. Decriminalize drug possession and use . SUD is a chronic health condition, expected symptoms of which include continuing to use despite negative consequences or the desire to stop The criminalization of drug use decreases the likelihood that people who use drugs will seek medical care, and increases stigma and discrimination for those seeking medical care . Drug use is a matter of public health and community wellbeing; it should be treated as such

6

. Provide training to healthcare providers to reduce stigma against people who use drugs . Studies have found that people who use drugs avoid medical care because of mistreatment by health care providers, often rooted in stigma 5 As a result, minor IDU-related infections may progress to serious and potentially fatal ones before individuals seek treatment More education across health care sectors, especially for first responders, emergency providers, and providers in EDs, is needed to address stigma, promote equitable care, and better meet the medical needs of people who use drugs

Preventable Harms: Injection Drug Use-Related Infections in New Jersey 2022

References

1 Tookes H, Diaz C, Li H, Khalid R, Doblecki-Lewis S A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida Paraskevis D, ed PLoS ONE 2015;10(6):e0129360 doi:10 1371/journal pone 0129360

2 Capizzi J, Leahy J, Wheelock H, et al Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018 Zaller ND, ed PLoS ONE 2020;15(11):e0242165 doi:10 1371/journal pone 0242165

3 Office of the Chief State Medical Examiner Drug-Related Death Dashboard Official Site of the State of New Jersey Published February 21, 2022 Accessed February 26, 2022 https://ocsme .nj .gov/Dashboard?_gl=1*crrwcf*_ga*MTcxMDg2Nzk5Ni4xNjQyMDI0MDUx *_ga_5PWJJG6642*MTY0NTkwMjAzOC4zLjEuMTY0NTkwMjA2My4w

4 Mellor J A War on Us: How Much New Jersey Spends Enforcing the War on Drugs New Jersey Policy Perspective; 2021 Accessed September 30, 2021 https://www njpp org/publications/report/a-war-on-us-how-much-new-jersey-spendsenforcing-the-war-on-drugs/

5 Meyerson BE, Russell DM, Kichler M, Atkin T, Fox G, Coles HB I don’t even want to go to the doctor when I get sick now: Healthcare experiences and discrimination reported by people who use drugs, Arizona 2019 International Journal of Drug Policy. 2021;93:103112 doi:10 1016/j drugpo 2021 103112

6 Binswanger IA, Kral AH, Bluthenthal RN, Rybold DJ, Edlin BR High Prevalence of Abscesses and Cellulitis Among Community-Recruited Injection Drug Users in San Francisco Clinical Infectious Diseases 2000;30(3):579-581 doi:10 1086/313703

7 Damlin A, Westling K Patients with infective endocarditis and history of injection drug use in a Swedish referral hospital during 10 years BMC Infect Dis 2021;21(1):236 doi:10 1186/s12879-021-05914-1

8 Thakarar K, Rokas KE, Lucas FL, et al Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: The need to expand substance use disorder treatment and harm reduction services West B, ed PLoS ONE 2019;14(11):e0225460 doi:10 1371/journal pone 0225460

Preventable Harms: Injection Drug Use-Related Infections in New Jersey 2022

9 Waltenburg MA, Larson V, Naor E, et al Notes from the Field: Botulism Type B After Intravenous Methamphetamine Use — New Jersey, 2020 . MMWR Morb Mortal Wkly Rep. 2020;69 doi:10 15585/mmwr mm6939a4

10 Philadelphia Department of Public Health Hospitalizations for Infections Related to Injection Drug Use, 2013–2018 5(1):1-6

11 Weiss AJ, Stocks C Hospital Inpatient Stays Related to Opioid Use Disorder and Endocarditis, 2016 https://www hcup-us ahrq gov/reports/statbriefs/sb256-OpioidsEndocarditis-Inpatient-Stays-2016 jsp

12 . Ronan MV, Herzig SJ . Hospitalizations Related To Opioid Abuse/Dependence And Associated Serious Infections Increased Sharply, 2002–12 Health Affairs. 2016;35(5):832-837 doi:10 1377/hlthaff 2015 1424

13 Healthcare Cost and Utilization Project (HCUP) Opioid Hospital Stays/Emergency Department Visits - HCUP Fast Stats. Agency for Healthcare Research and Quality; 2021 Accessed January 1, 2022 https://www hcup-us ahrq gov/faststats/ OpioidUseServlet

14 Barocas JA, Gai MJ, Amuchi B, Jawa R, Linas BP Impact of medications for opioid use disorder among persons hospitalized for drug use-associated skin and soft tissue infections Drug and Alcohol Dependence. 2020;215:108207 doi:10 1016/j drugalcdep 2020 108207

15 U S Census Bureau, Population Division Annual Estimates of the Resident Population for Counties in New Jersey: April 1, 2010 to July 1, 2019 (CO-EST2019ANNRES-34); 2020

16 Ti L, Ti L Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review Am J Public Health 2015;105(12):e53-e59 doi:10 2105/ AJPH 2015 302885

17 Kimmel SD, Kim JH, Kalesan B, Samet JH, Walley AY, Larochelle MR Against Medical Advice Discharges in Injection and Non-injection Drug Use-associated Infective Endocarditis: A Nationwide Cohort Study Clinical Infectious Diseases. 2021;73(9):e2484-e2492 doi:10 1093/cid/ciaa1126

18 Syringe Services Programs (SSPs) Fact Sheet | CDC Published July 24, 2019 Accessed January 1, 2022 https://www cdc gov/ssp/syringe-services-programs-factsheet html

19 HIV, STD, and TB Services Harm Reduction Centers NJ Department of Health Accessed January 1, 2022 https://www nj gov/health/hivstdtb/sap shtml

20 Office of Planning, Research, Evaluation, Prevention and Olmstead Substance Abuse Overview Statewide Report - 2019 Department of Human Services Division of Mental Health and Addiction Services; 2020

19 Preventable Harms: Injection Drug Use-Related Infections in New Jersey 2022

ICD-10 Diagnosis Codes

The following ICD-10 codes were used to identify hospital visits indicative of infections associated with injection drug use ICD-10 codes were determined through a review of prior literature, which is cited below for each condition

*Denotes use of all subsequent ICD-10 codes

Substance Use-Related Codes2,12

T40.0X1* Poisoning by opium, accidental (unintentional)

T40.0X2* Poisoning by opium, intentional self-harm

T40.0X3* Poisoning by opium, assault

T40.0X4* Poisoning by opium, undetermined

T40.0X5* Adverse effect of opium

T40.1X* Poisoning by and adverse effect of heroin

T40.2X1* Poisoning by other opioids, accidental (unintentional)

T40.2X2* Poisoning by other opioids, intentional self-harm

T40.2X3* Poisoning by other opioids, assault

T40.2X4* Poisoning by other opioids, undetermined

T40.2X5* Adverse effect of other opioids

T40.3X1* Poisoning by methadone, accidental (unintentional)

T40.3X2* Poisoning by methadone, intentional self-harm

T40.3X3* Poisoning by methadone, assault

T40.3X4* Poisoning by methadone, undetermined

T40.3X5* Adverse effect of methadone

T40.4X1* Poisoning by other synthetic narcotics, accidental (unintentional)

T40.4X2* Poisoning by other synthetic narcotics, accidental (unintentional)

T40.4X3* Poisoning by other synthetic narcotics, assault

T40.4X4* Poisoning by other synthetic narcotics, undetermined

T40.4X5* Adverse effect of other synthetic narcotics

T40.411* Poisoning by fentanyl or fentanyl analogs, accidental

Substance Use-Related Codes2,12

continued

T40.412* Poisoning by fentanyl or fentanyl analogs, self-harm

T40.413* Poisoning by fentanyl or fentanyl analogs, assault

T40.414* Poisoning by fentanyl or fentanyl analogs, undetermined

T40.415* Adverse effect of fentanyl or fentanyl analogs

T40.421* Poisoning by tramadol, accidental (unintentional)

T40.422* Poisoning by tramadol, intentional self-harm

T40.423* Poisoning by tramadol, assault

T40.424* Poisoning by tramadol, undetermined

T40.425* Adverse effect of tramadol

T40.491* Poisoning by other synthetic narcotics, accidental

T40.492* Poisoning by other synthetic narcotics, self-harm

T40.493* Poisoning by other synthetic narcotics, assault

T40.494* Poisoning by other synthetic narcotics, undetermined

T40.495* Adverse effect of other synthetic narcotics

T40.601* Poisoning by unspecified narcotics, accidental (unintentional)

T40.602* Poisoning by unspecified narcotics, intentional self-harm

T40.603* Poisoning by unspecified narcotics, assault

T40.604* Poisoning by unspecified narcotics, undetermined

T40.605* Adverse effect of unspecified narcotics

T40.691* Poisoning by other narcotics, accidental (unintentional)

T40.692* Poisoning by other narcotics, intentional self-harm

T40.693* Poisoning by other narcotics, assault

T40.694* Poisoning by other narcotics, undetermined

T40.695* Adverse effect of other narcotics

F11* Opioid related disorders

F13* Sedative, hypnotic, or anxiolytic related disorders

F14* Cocaine related disorders

F15* Other stimulant related disorders

F19* Other psychoactive substance related disorders

Endocarditis10

M32.11 Endocarditis in systemic lupus erythematosus

A32.82 Listerial endocarditis

A39.51 Meningococcal endocarditis

A52.03 Syphilitic endocarditis

A54.83 Gonococcal heart infection

Endocarditis10

B37.6 Candidal endocarditis

I01.1 Acute rheumatic endocarditis

I33.0 Acute and subacute infective endocarditis

I33.9 Acute and subacute endocarditis, unspecified

I38 Endocarditis, valve unspecified

I39 Endocarditis and heart valve disorders in diseases

Bacteremia and Sepsis2

A40* Streptococcal sepsis

A41* Other sepsis

I26.90 Septic pulmonary embolism without acute cor pulmonale

I40.0 Infective myocarditis

I76 Septic arterial embolism

R65.10 SIRS of non-infectious origin w/o acute organ dysfunction

R65.20 Severe sepsis without septic shock

R65.21 Severe sepsis with septic shock

R78.81 Bacteremia

Osteomyelitis2

M46.2* Osteomyelitis of vertebra

M46.3* Infection of intervertebral disc (pyogenic)

M86.1* Other acute osteomyelitis

M86.2* Subacute osteomyelitis

M86.9 Osteomyelitis, unspecified

Skin and Soft Tissue Infections13

A48.0 Gas gangrene

elsewhere

I80.0* Phlebitis and thrombophlebitis of superficial vessels of low extremities

I80.1* Phlebitis and thrombophlebitis of femoral vein

I80.21* Phlebitis and thrombophlebitis of iliac vein

I80.22* Phlebitis and thrombophlebitis of popliteal vein

Skin and Soft Tissue Infections13

— continued

I80.23* Phlebitis and thrombophlebitis of tibial vein

I80.29* Phlebitis and thrombophlebitis of deep vessels of low extremities

I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified

I80.8 Phlebitis and thrombophlebitis of other sites

I80.9 Phlebitis and thrombophlebitis of unspecified site

L02* Cutaneous abscess, furuncle and carbuncle

L03* Cellulitis and acute lymphangitis

M54.02* Panniculitis affecting regions of neck/bk, cervical region

M72.6* Necrotizing fasciitis

M79.3* Panniculitis, unspecified

Preventable Harms: Injection Drug Use-Related Infections in New Jersey