Estimated Charges

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) .

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 .

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 .

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 .

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) .

FIGURE 5

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.

0 300

TABLE 3

82.74

127.55

128.25

36.75

41.98

253.32 69.06

55.84

70.54

92.1

224.10

119.38

122.74 108.29 87.46 54

141.33

151.94

139.55

102.16 173.26

FIGURE 6 IDU-SBI-associated charge per county (in dollars)

IDU-SBI: Injection drug use-related severe bacterial infection

County Mean Median Maximum Total Charges per Capita

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

Per capita charges of SBIs by county

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 .

New Jersey currently operates only seven syringe service programs in a state with over nine million residents . Each program serves an average of 1 .29 million residents .

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

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 .

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

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-Opioids-

Endocarditis-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 .