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Objective To report the clinical characteristics and transmission rate of coronavirus disease 2019 (COVID-19) in a community inpatient long-term care psychiatric rehabilitation facility designed for persons with serious mental illness to provide insight into transmission and symptom patterns and emerging testing protocols, as well as medical complications and prognosis. Methods This study examined a cohort of 54 residents of a long-term care psychiatric rehabilitation program from March to April 2020. Baseline demographics, clinical diagnoses, and vital signs were examined to look for statistical differences between positive versus negative severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) groups. During the early phase of the pandemic, the facility closely followed the local shelter-in-place order (starting March 19, 2020) and symptom-based testing. Results Of the residents, the primary psychiatric diagnoses were schizoaffective disorder: 28 (51.9%), schizophrenia: 21 (38.9%), bipolar I disorder: 3 (5.5%), and unspecified psychotic disorder: 2 (3.7%). Forty (74%) of 54 residents tested positive for SARS-COV-2, with a doubling time of 3.9 days. There were no statistical differences between the positive SARS-COV-2 versus negative groups for age or race/ethnicity. Psychiatric and medical conditions were not significantly associated with contracting SARS-COV-2, with the exception of obesity (n = 17 [43%] positive vs n = 12 [86%] negative, P = .01). Medical monitoring of vital signs and symptoms did not lead to earlier detection. All of the residents completely recovered, with the last resident no longer showing any symptoms 24 days from the index case. Conclusion Research is needed to determine optimal strategies for long-term care mental health settings that incorporate frequent testing and personal protective equipment use to prevent rapid transmission of SARS-COV-2.

We evaluated a case management intervention to increase treatment entry among injecting drug users referred from a needle exchange program (NEP). A randomized trial of a strengths based case management (intervention) versus passive referral (control) was conducted among NEP attenders requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD. Logistic regression identified predictors of treatment entry within 7 days, confirmed through treatment program records. Of 247 potential subjects, 245 (99%) participated. HIV prevalence was 19%. Overall, 34% entered treatment within 7 days (intervention: 40% versus control: 26%, p = 0.03). In a multivariate “intention to treat’ model (i.e., ignoring the amount of case management actually received), those randomized to case management were more likely to enter treatment within 7 days. Additional ‘as treated’ analyses revealed that participants who received 30 min or more of case management within 7 days were 33% more likely to enter treatment and the active ingredient of case management activities was provision of transportation. These findings demonstrate the combined value of offering dedicated treatment referrals from NEP, case management and transportation in facilitating entry into drug abuse treatment. Such initiatives could be implemented at more than 140 needle exchange programs currently operating in the United States. These data also support the need for more accessible programs such as mobile or office-based drug abuse treatment.

Participants of syringe exchange programs (SEPs) exhibit high rates of substance use disorder but remain extremely ambivalent about seeking treatment. This study evaluated the effectiveness of motivational interviewing (MI) for encouraging SEP participants to enroll in substance abuse treatment. New opioid-dependent registrants to the Baltimore Needle Exchange Program (BNEP) (n =302) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), and the Addiction Severity Index (ASI) and were randomly assigned to one of three treatment referral conditions: (1) MI, (2) job readiness (JR) (attention control), or (3) standard referral. Participants in each condition who expressed interest in treatment were referred to a treatment readiness group that provided further encouragement and referral to programs that were accepting new admissions. Participants were observed for 1 year following the intervention. The results showed that 10.9% of study participants enrolled in substance abuse treatment, although no condition effects were observed. White participants and those diagnosed with major depression were most likely to enter treatment. The results suggest that a single motivational interview is insufficient to motivate changes in treatment seeking in this population, whereas the identification of predictors of treatment enrollment is worthy of further investigation.

To describe characteristics of needle-exchange program (NEP) participants who utilized tuberculosis services from an NEP site.Between June 1998 and May 1999, tuberculosis services were advertised and offered to Baltimore, Maryland, NEP participants. Demographic and tuberculosis-specific data were collected on participants who self-selected into services. Analyses were based on being tuberculin skin tested, returning for a skin test reading, and testing tuberculin positive.Among 691 contacts with NEP participants, this service performed 296 tuberculin tests, with an 84% return rate for skin test reading. Participants were 32% female, 87% African American, and 11% employed. Higher frequency of NEP visits was positively associated with requesting tuberculosis services and returning for skin test reading. Among those who returned for skin test reading, longer smoking duration and problems getting food in the past year due to a lack of money were associated with a positive test.Utilization of a tuberculosis service and high return rates can be achieved among NEP participants without formal recruitment strategies. Frequent exchange appears to facilitate return visits for NEP-based tuberculosis screening, which may imply accessibility for frequent exchangers. More extensive health services at sites of the Baltimore NEP appear to be warranted, with particular attention paid to effectiveness for frequent exchangers.

The objective of this study was to examine the association between adolescent exposure to and understanding of needle exchange programs (NEPs) and their perceptions of the impact of NEP on the decision to use illicit drugs. From November 1998 to February 1999, 9th and 10th grade students from 4 Baltimore City high schools completed surveys reporting perceptions of the effect of NEP and other factors on adolescents' decisions regarding illicit drug use. The perceived effect of NEP was compared to that of other factors, using the Wilcoxon signed rank test. The impact of seeing drug users attend NEPs on adolescents' decisions to use drugs was modeled using multiple linear regression. Among 1,110 students, 88% were African American, 58% were female, and the mean age was 15 years. The percentage of students who thought the specified factors promoted drug use follows: peer drug use, 49.9%; parents drug use, 43.5%; seeing drug users attend NEP, 11.1%; school drug education, 6.6%; and anti-drug TV advertisements, 6.1%. The percentage viewing these factors as having no influence on illicit drug use was 21.7, 19.1, 42.4, 36.9, and 29.8% respectively. Students of African American race, female gender, and those with medium/high knowledge about NEP were significantly less likely to consider NEP a promoter of drug use. These data suggest that the influence of NEPs on promoting illicit drug use among adolescents appears to be neutral compared to other factors known to be influential to this population group.

Project Red Box, a pilot project undertaken by the Baltimore City Health Department, is designed to decrease the number of needles and syringes discarded in public locations. The qualitative evaluation consisted of focus groups with a total of 73 people, including injection drug users (IDUs), community residents, police officers, and local pharmacists. Mixed feelings were expressed about the project in each group. Community residents felt that discarded syringes pose a threat but having the boxes acknowledges drug use and send the message that drug use is acceptable. IDUs agreed that the project was a good idea, however, many maintained that the boxes would not be used. The majority of police officers and pharmacists felt that the boxes would not be used due to a lack of concern by IDUs regarding syringe disposal. Follow-up groups revealed that the boxes have had a positive impact on the community. Participants in each of the groups expressed positive opinions about the project and have either used the boxes themselves or have seen others use them. Expansion of the project was recommended.

We assessed the acceptability and the use of a community-based needle and syringe disposal project designed to serve injection drug users. In June 1996, three surplus U.S. mail collection boxes were painted red and used as syringe and needle drop boxes in locations with high drug use in East Baltimore. Acceptance of the drop boxes was measured by focus groups of residents, drug users, and police, held before and after project implementation. Use was measured by weekly counts of needles recovered from the red boxes. A sample of all deposited needles was randomly chosen for needle washing and subsequent HIV antibody testing. Community impact was measured by systematic surveys of needles discarded on public sidewalks, in areas with and areas without drop boxes. Before implementation, members of focus groups expressed concerns that drop boxes could convey mixed messages to youth (e.g., seeming to condone drug use), might result in increased loitering, and could further community stigmatization. After project implementation, all focus groups expressed support of project expansion. In the first 10 months, 2971 needles were collected. Of 156 needles tested, 10.9% were positive for HIV antibody. Needle counts on the street showed no significant change in red box areas compared with control areas. In this pilot project, red boxes were accepted by the community and drug users. Police officers also used the boxes to dispose of confiscated needles. Although limited in the number of drop boxes and follow-up time, this pilot project shows promise as a community-based method of safe needle disposal.

Current understanding of the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and STDs is examined. From recent research on adolescent fertility, findings that have particular relevance to school health or reflect new understandings of adolescent sexuality are summarized. In selected cases, prevention programs that build directly on an understanding of these risk factors are cited.It is important to understand the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and sexually transmitted diseases (STD). This understanding is important in identifying and caring for youths at risk and designing primary and secondary prevention programs for schools and communities. The current understanding of these risk factors and recent findings are summarized in this paper. Intermediate determinants of fertility are broadly discussed with closer attention given to specific biopsychosocial risk factors affecting fertility and the potential for contracting STDs. The roles of demographics, geography, poverty and ethnicity, religion, school performance, family factors, peer influences, puberty, risk-taking behavior, drugs, sexual abuse, self-esteem and psychological variables, school health education, and school-based clinics are considered. The social determinants of contraceptive use/STD protection, pregnancy continuation or abortion, and STDs are also discussed.

Background In response to the high rates of opiate-related overdoses and deaths in the United States, a number of overdose prevention programmes have been implemented that include training drug users to administer naloxone, an opiate antagonist. The purpose of this study was to evaluate the Staying Alive (SA) programme in Baltimore, Maryland, which trained drug users to prevent and respond to opiate overdose using techniques including mouth-to-mouth resuscitation and administration of naloxone. Methods Participants for the SA programme were recruited from multiple locations by Baltimore City Health Department Needle Exchange programme staff. A 1-h training was conducted by two facilitators. Participants who successfully completed the programme were provided with a kit that contained naloxone. Participants in the evaluation study were enrolled prior to the training session. The present analysis includes 85 participants who completed a pre- and post-test evaluation survey. Results At both time points, 43 participants reported having witnessed an overdose. Post-training, naloxone was administered by 19 with no reported adverse effects. Post-training, a greater proportion of participants reported using resuscitation skills taught in the SA programme along with increased knowledge specifically about naloxone. Conclusions Results from this study provide additional evidence to support the effectiveness of overdose prevention training programmes that include skills building for drug users to administer naloxone.

The present study evaluated the effects of psychiatric comorbidity on substance use disorder prevalence, HIV risk behavior, and other problem severity in male and female out-of-treatment injection drug users newly registered at a syringe exchange program. Participants (N = 338) were administered the Structured Clinical Interview for the DSM-IV, the Addiction Severity Index, and the Risk Assessment Battery, and classified into one of four diagnostic groups: (1) no antisocial personality disorder (APD) or Axis I psychiatric disorder (N = 162), (2) APD only (N = 74), (3) Axis I psychiatric disorder only (N = 55), or (4) APD plus Axis I psychiatric disorder (N = 47). Psychiatric comorbidity was associated with higher rates of substance use disorder and more HIV risk and other problem severity. In general, participants with both APD and an Axis I disorder exhibited the most problem severity. APD was uniquely associated with higher prevalence for each substance use disorder assessed in this study and with elevated HIV risk. These results support and extend studies conducted with opioid-dependent individuals recruited from treatment and community settings, and reinforce the need to develop interventions to encourage syringe exchange program participants to enroll in treatment.

Female drug users and their children have many medical and psychosocial problems, yet they often fail to follow through with prescribed treatments. The present study describes a specialized, case management program for children, birth through age 2, exposed to drugs in utero. Evaluation of program efficacy was examined by comparing 2-year outcomes for women who received different intensities of these child case management services. Mothers who received higher intensity care were more likely to be abstinent from illicit drugs and to have retained custody of their child(ren) at 2-year follow-up than those with lower intensity services. Study findings support clinical and economic efficacy of this model of care.

The present study evaluates the prevalence of psychiatric and substance use disorders in male and female intravenous opioid abusers participating at a community needle exchange program (NEP). All participants (n = 422) were administered the Structured Clinical Interview for the DSM-IV (SCID) for Axis I disorders and antisocial personality disorder (APD). Psychiatric and substance abuse comorbidity were highly prevalent. Major depression was the most common current and lifetime Axis I non-substance use disorder (6 and 21% of the sample, respectively); 37% were diagnosed with APD. Over 50% of the sample was diagnosed with at least one non-substance use Axis I disorder or APD. In addition to opioid dependence, cocaine dependence was the most prevalent current and lifetime substance use disorder (68 and 78% of the sample, respectively), followed by alcohol and cannabis dependence. Overall, participants reported a mean of over one current and over three lifetime substance use disorders in addition to opioid dependence. Women reported higher rates of post-traumatic stress disorder (PTSD), while men were more likely diagnosed with APD. Presence of a psychiatric disorder was associated with increased prevalence of substance use disorder for all drug classes. The high rates of comorbidity observed in this sample suggest that the harm reduction efforts of NEPs can be significantly enhanced through referral of participants to programs that treat substance use and/or other psychiatric disorders.

To compare characteristics of needle exchange program (NEP) participants who requested methadone treatment to those who did not, compare participants who subsequently enrolled into treatment to those who did not enroll, and suggest possible barriers to treatment among NEP participants.Between 8/94 and 2/97, data pertaining to demographics and drug use were collected from Baltimore NEP participants upon registration. Participants were made aware that referrals to off-site methadone maintenance were available upon request. Odds ratios and multiple logistic regression models were used to compare those who requested treatment to those who did not and those who entered treatment to those who did not enter.Among 2659 NEP participants, 86% were African-American, 28% were female, 9% were employed, and the median age was 38 years. Requesting a drug user treatment referral was associated with female gender [Adjusted Odds Ratio (AOR) = 2.02], age38 years (AOR = 1.96), use of speedballs during the past 6 months (AOR = 3.38), and age20 years at time of first injection (AOR = 1.59). Among 139 individuals who requested treatment, males were twice as likely as females to enter treatment (OR = 2.45). In an open-ended survey, health insurance (p = .02) and not living with children (p = .01) were associated with drug user treatment entry.Even though female NEP participants were more likely to request methadone treatment, they were less likely than males to enter treatment. Although NEPs can be a bridge to drug user treatment, these data suggest that barriers to utilizing treatment referrals are important issues to resolve, especially for women who use community needle exchange programs.

Objective To compare characteristics of first-time needle exchange participants who enrolled at a mobile van-based exchange site versus a fixed pharmacy-based exchange site, in an area where both types of needle exchange programs were available. Methods Demographic and drug use data were collected on needle exchange program participants on enrollment. Participants were included if they were first-time participants at the Baltimore needle exchange program between December 1997 and March 1999, and if their first visit was at either one van-based site or at one of two pharmacy-based sites. Descriptive statistics and inferences were based on the type of needle exchange into which participants enrolled. Results Among 286 first-time participants, 92% were African American, 28% were women, 11% were currently employed, 55% completed high school, and the median age was 40 years. In multivariate analyses, van-based enrollment was more common among frequent injectors (odds ratio [OR] = 2.0), but less common among African American participants (OR = 0.21). Conclusions Our data suggest that different venues for needle exchange program settings attract different types of drug injecting participants. This suggests that offering different venue types to reach participants with differing drug use patterns will be important to optimize risk reduction strategies.

Objective To examine attitudes of participants of a van-based syringe exchange program (SEP) toward the hypothetical prospect of pharmacy-based syringe access. Design One-time, cross-sectional survey. Setting Baltimore, Maryland. Participants 206 injection drug users who participate in the Baltimore SEP. Interventions Face-to-face interviews. Main Outcome Measures Location preferred for obtaining syringes, drug and syringe use, past experience with pharmacies, and willingness to pay. Results The sample was 67% men, 95% African American, and 95% unemployed; mean age was 39.8 years. A total of 19% of respondents had bought syringes at a pharmacy during the prior six months. Some 37% reported having been turned down when asking for syringes at a pharmacy, most commonly due to lack of identification to prove diabetic status (50%). If legal restrictions were lifted, 92% of respondents would obtain syringes from pharmacies, and would be willing to pay a mean price of $0.80 (median = $1.00) per syringe. Women were more likely than men to report the intention to switch from van-based SEP to pharmacy (57% versus 38%, p = .045). Conclusion If current legal restrictions were lifted, pharmacies would be a viable syringe source appealing particularly to women, suggesting gender-specific access issues that should be addressed. The per-syringe price that study participants would be willing to pay exceeds typical retail prices, suggesting that pharmacists could charge enough per syringe to recoup operational costs.

Objective: To determine whether enrollment in the Baltimore Needle Exchange Program (NEP) was associated with short-term reduction in risky injection practices. Methods: Demographic information was collected on NEP participants upon enrollment. A systematic sample of enrollees was interviewed at program entry, 2 weeks, and 6 months later on recent drug-related behaviors. Comparisons were performed using paired t-tests. Results: Among 221 NEP participants who completed baseline, 2-week and 6-month follow-up visits, significant reductions (p < .01) were reported in using a previously used syringe (21.6%, 11.0%, 7.8%, respectively), lending one's used syringe to a friend (26.7%, 18.4%, 12%, respectively), and several indirect sharing activities. Reductions were reported in the mean number of injections per syringe and the mean number of injections per day (p < .001). Conclusions: These results show rapid and mostly large reductions in a variety of risky injection drug use behaviors. Study findings are consistent with earlier reports showing an association between behavioral risk reduction and participation in a needle exchange program.

This study examines the effect of a Needle Exchange Program (NEP) on the quantity and geographic distribution of discarded needles on the streets of Baltimore, Maryland, and presents methods to survey discarded needles in the community. A random sample of 32 city blocks located within high-drug-use census tracts, stratified by east and west sides of the city and by proximity to the NEP, was selected for survey. Three teams surveyed the number of needles and the number of drug vials and unbroken glass bottles ("trash") to control for practice effects. Surveillance was conducted prior to initiation of the NEP in August 1994 and 1 and 2 months thereafter. Over the three study periods, the absolute count of discarded needles was 106, 130, and 128, respectively; the number of vials and bottles was 3,048, 3,825, and 3,796, respectively. The initial nonstatistically significant increase in needles (mean change = 0.38, 95% confidence interval (CI) -0.18 to 0.93) was offset by accounting for background trash. Regression models fitted with the generalized estimating equation method, which accounted for within-block correlation over time, showed no significant increase in the number of needles after adjustment for trash during the first 2 months of the NEP's operation. These data suggest that the initiation of NEPs does not result in an increase in the number of discarded needles on the street.