Susan Sherman

• Johns Hopkins University

Objective The Surgeon General released the Framework for Mental Health and Well-being in the Workplace, a call to attention for industry leaders. In this study, we applied this framework to street-based women sex workers (WSW) to understand their mental health outcomes. Methods Fourteen WSW in Baltimore, Maryland completed structured qualitative i...

Background As in much of the United States, there have been significant increases in overdose deaths among non-Hispanic Black and Hispanic/Latinx populations in Rhode Island over the past decade. Given the shifting dynamics of the overdose epidemic, there is an urgent need for focused interventions that address the specific needs of diverse communi...

Aim: The drug supply in New England is increasingly dominated by fentanyl. In 2022, approximately 75% of overdose deaths in Rhode Island (RI) involved fentanyl. This study examines concordance between self-reported suspected fentanyl exposure and fentanyl presence in urine drug testing (UDT). Methods: We utilized baseline data from the Rhode Islan...

Aim: There are increasing reports of benzodiazepine adulteration in Canada's unregulated drug supply. In many Canadian settings, harm reduction drug checking services (DCS) are available for people to identify the ingredients in their drugs, including adulterants. This study examines the relationship between suspected unintentional benzodiazepine c...

Background The COVID-19 pandemic highlighted the salience of material needs and financial precarity on mental health and distress. Women who use drugs (WWUD) experienced significant mental distress and multiple material need insecurities before the pandemic. However, research is limited on the nature of these insecurities during the pandemic despit...

Harm reduction programs provide tools that enable people who use drugs to do so more safely in a nonstigmatizing environment without the goal of them necessarily seeking treatment or abstinence. Most harm reduction programs in the United States distribute sterile syringes and naloxone and safely dispose of used syringes and other drug use supplies....

Background Amidst a national surge in overdose deaths among racial and ethnic minoritized people and people who use stimulants (cocaine or methamphetamines), our objective was to understand how these groups are adapting to a rapidly changing illicit drug supply. Methods We conducted semi-structured interviews with 64 people who use drugs and who s...

Introduction Psychological resilience has emerged as a key construct of interest in the study of substance use. However, very few studies have examined resilience among individuals who are actively using drugs. Furthermore, many studies of psychological resilience have focused on individual‐level factors. This study addresses the call for a more ‘e...

Background Perceived HIV risk may impact willingness to initiate PrEP among people who inject drugs (PWID). Methods We analyzed baseline data from PrEP eligible PWID in Baltimore, MD. Risk perception was assessed by PWID relative to the average risk of their age group categorized as: higher-than, lower-than, or about average. Participants were inf...

Background: Hepatitis C virus (HCV) infection and hazardous alcohol use are both preventable causes of morbidity and mortality among people who inject drugs (PWID). In the general population, hazardous alcohol is associated with a reduced likelihood of HCV treatment initiation. Less is known about the prevalence and impact of hazardous alcohol use...

Background Over 107,000 people died in the United States (U.S.) from drug overdose in 2022, with over one million overdose deaths since 1999. The U.S. drug market is characterized by a highly toxic, unregulated, and rapidly changing supply. Understanding the extent of exposure to fentanyl among people who use drugs (PWUD) will guide public health i...

Background Longitudinal studies of future overdose risk among people who inject drugs (PWID) are needed to inform planning of targeted overdose preventions in the United States. Methods The Integrating Services to Improve Treatment and Engagement (INSITE) study followed 720 PWID between June 2018 and August 2019 to evaluate the delivery of mobiliz...

Background Despite the widespread use of the phrase “harm reduction” and the proliferation of programs based on its principles during the current opioid epidemic, what it means in practice is not universally agreed upon. Harm reduction strategies have expanded from syringe and needle exchange programs that emerged in the mid-1980s primarily in resp...

Background: As in much of the United States, there have been significant increases in overdose deaths among non-Hispanic Black and Hispanic/Latinx populations in Rhode Island over the past decade. Given the shifting dynamics of the overdose epidemic, there is an urgent need for focused interventions that address the specific needs of diverse commun...

Background and aims People who inject drugs (PWID) are at risk for adverse outcomes across multiple dimensions. While evidence‐based interventions are available, services are often fragmented and difficult to access. We measured the effectiveness of an integrated care van (ICV) that offered services for PWID. Design, setting and participants This...

Background Overdose prevention centers (OPCs) are being implemented in the United States as a strategy to reduce drug-related mortality and morbidity. Previous studies have suggested that people who use drugs (PWUD) with a history of criminal legal system (CLS) involvement (e.g. current probation/parole) are at greater risk of overdose but may also...

The continued prevalence of xylazine in the illicit drug market has necessitated development of quick and simple methods for identification, including lateral flow immunoassays (also known as “test strips”), like those frequently used to detect fentanyl. This study explored the drug checking applicability of the first publicly available xylazine te...

Harm reduction and opioid treatment programs (OTPs) modified service delivery based on rapid changes to state and federal regulations during the COVID-19 pandemic. There is little evidence on how these regulations changed the delivery of medication for opioid use disorder and harm reduction services and whether certain regulations should be made pe...

Women who exchange sex and use opioids experience substantial post-traumatic stress disorder (PTSD) symptoms. Among veterans, PTSD increases the risk of concomitant opioid-benzodiazepine use, increasing overdose risk, but this relationship is underexplored in other at-risk populations. We examined correlates of non-medical benzodiazepine use among...

Introduction Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD...

Transgender women who sell sex (TWSS) experience high rates of HIV acquisition. Antiretrovirals for pre-exposure prophylaxis (PrEP) represent an efficacious HIV prevention strategy. The social and structural factors affecting PrEP delivery amongst TWSS are underexplored in the literature. We conducted ethnographic research to examine how multilevel...

Background Co‐use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co‐use of these drugs when obtained both with and without a prescription. We examined associations of daily co‐use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who...

Background The messages used to communicate about harm reduction are critical in garnering public support for adoption of harm reduction interventions. Despite the demonstrated effectiveness of harm reduction interventions at reducing overdose deaths and disease transmission, the USA has been slow to adopt harm reduction to scale. Implementation of...

Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants w...

Objectives: Low public support impedes widespread adoption of harm reduction services in the U.S. There are growing efforts to implement integrated programs offering harm reduction services alongside other services for people who use drugs. We tested how messages depicting integrated programs influence audience attitudes about harm reduction. Met...

The continued prevalence of xylazine in the illicit drug market has necessitated the development of quick and simple methods for identification of adulterated materials. One method that could be employed is lateral flow immunoassays (also known as test strips), which are similar to those frequently used to determine the presence of fentanyl. In thi...

COVID-19 exacerbated health disparities, financial insecurity, and occupational safety for many within marginalized populations. This study, which took place between 2019 and 2022, aimed to explore the way in which sex workers (n = 36) in Chicago were impacted by COVID-19. We analyzed the transcripts of 36 individual interviews with a diverse group...

The continued prevalence of xylazine in the illicit drug market has necessitated the development of quick and simple methods for identification of adulterated materials. One method that could be employed is lateral flow immunoassays (also known as test strips), which are similar to those frequently used to determine the presence of fentanyl. In thi...

Introduction Treatment for opioid use disorder (OUD) with diacetylmorphine is an evidence-based form of drug treatment, but it is not available in the United States (US). Better understanding acceptability of treatment with injectable diacetylmorphine among people who use opioids (PWUO) in the US may expedite future initiatives designed to engage p...

Background. The messages used to communicate about harm reduction are critical in garnering public support for adoption of harm reduction interventions. Despite the demonstrated effectiveness of harm reduction interventions at reducing overdose deaths and disease transmission, the United States has been slow to adopt harm reduction to scale. Implem...

Introduction: To mitigate the harms of arrest and incarceration on health and racial equity, jurisdictions are increasingly enacting reforms to decriminalize drug possession via prosecutorial discretion (de facto). Impacts on health outcomes rely on whether this policy can reduce exposure to the carceral system among people who use drugs (PWUD); h...

Aims The aim of the study was to examine how female sex worker's motivations, desires, intentions and behaviours towards childbearing and childbearing avoidance inform their contraceptive decision‐making. We explored the influence of social determinants of health in the domains of social context (sexual partners and experiences of violence), health...

Background Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about...

Introduction: Female sex workers (FSW) are vulnerable to a number of health issues, but often delay seeking health care due to structural barriers. Multi-service drop-in centers have been shown to increase FSW access to health services globally?, but their impact on FSW in the United States (U.S.) is lacking. This study seeks to evaluate the effec...

Women who use drugs (WWUD) experience structural vulnerabilities (e.g., housing, food insecurities) and comorbidities that elevate their susceptibility to more severe COVID-19 symptoms or fatality compared to similarly-aged women who do not use illicit drugs. Testing is a cornerstone of effective COVID prevention, however, entrenched barriers to he...

In this paper we explore people who use drugs (PWUD) perceptions and experiences of drug-related law enforcement in a major U.S. city. Maryland recently implemented several harm reduction policies/interventions aiming to improve PWUD-police relationships, such as the Good Samaritan Law (GSL), intended to avoid criminalizing police encounters with P...

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experienc...

Few studies have examined HIV testing among people who inject drugs (PWID) during the COVID-19 pandemic. This study examines factors associated with PWID who have been recently (past six months) tested for HIV during the COVID-19 pandemic. PWID were recruited between August 2020 and January 2021 from 22 drug treatment and harm reduction programs in...

Background Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES. Methods We used...

Communication about HIV and sexually transmitted infections (STI) is a cornerstone of risk reduction, yet there is a dearth of research that examines communication patterns among persons with dual risks for HIV/STI acquisition, such as women who sell sex and inject drugs (WSSID). We used logistic regression to identify factors associated with WSSID...

Background . During the COVID-19 pandemic, overdose rates substantially increased in the United States. One possible contributor to this phenomenon may be solitary drug use resulting from social distancing efforts to prevent COVID-19 transmission. Methods . We surveyed 458 people who use drugs (PWUD) who were recruited from harm reduction and drug...

Background: Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men's selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-se...

Background: Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited...

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis...

Background Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one’s environment). Further, substance use is often viewed as antithetical to...

Background Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In th...

Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-risk. Sexual minority WES (SM-WES) face exacerbated HIV-risk, yet relevant research is scant. We examined the role of sexual orientation in the relationship between social c...

Pre-exposure prophylaxis (PrEP) is a vital component of comprehensive HIV prevention among female sex workers (FSW). There are limited PrEP interventions targeting FSW in the U.S., who have high HIV risk. Formative research was conducted to inform PEARL (Promoting Empowerment And Risk Reduction), a PrEP intervention for FSW in Baltimore, MD, includ...

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal pe...

Background Drug overdose deaths remain the primary cause of unintentional injuries in the United States. We examined the validity of a fentanyl test strip (FTS) in detecting fentanyl and its related analogs in water-based illicit drug solutions. Methods Illicit drugs obtained from law enforcement (N=343) were tested using a lateral flow chromatogr...

Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysi...

Background: Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In t...

Intervetions are urgently needed to reduce the trajectory of the US opioid overdose epidemic, yet implementation is often hampered by resistance or opposition from key community stakeholders. While businesses are economically and physically impacted by the opioid epidemic, they are rarely engaged in efforts to reduce its impact. The establishment o...

Background Population-based seroprevalence studies offer comprehensive characterization of coronavirus disease 2019 (COVID-19) spread, but barriers exist and marginalized populations may not be captured. We assessed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody seroprevalence among decedents in Maryland over 6 months in 2020...

Background Skin and soft tissue infections (SSTI) are common among people who inject drugs and can result in severe health consequences, including infective endocarditis. Numerous barriers to accessing care often prevent people who inject drugs from seeking healthcare including past negative healthcare experiences, transportation, and shame around...

We describe patterns of polysubstance use and associations with HIV risk-related behaviors among women engaged in street-based transactional sex, an understudied yet important population and area of research. This sample was restricted to cisgender women who reported drug use (n = 244) in the baseline of the longitudinal SAPPHIRE cohort study. Late...

Drug overdose remains a leading cause of death in the US, and the majority of opioid overdose fatalities involve fentanyl. This study aims to measure the degree of concordance between self-reported and biologically tested exposure to fentanyl. We conducted a cross-sectional analysis using survey and urinalysis data collected between 2019 and 2020 f...

Introduction Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable...

Introduction Despite decades of empirical research in the US and internationally documenting the benefits of implementing syringe services programs (SSPs), their implementation may be controversial in many jurisdictions. Better understanding how research evidence is applied during SSP implementation processes may enable the public health workforce...

Introduction People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD...

Background The role of business employees and community members in the HIV risk environment of female sex workers (FSW) is underexplored, despite sex work often located in commercial and residential urban areas. We explored the effect of negative interactions between business employees and community members on inconsistent condom use with clients o...

Background People who use drugs (PWUD) must weigh complex legal scenarios when seeking help during overdose events. Good Samaritan laws (GSL) offer limited immunity for certain low-level drug crimes to encourage PWUD to call 911. Drug-induced homicide laws (DHL) allow for criminal prosecution of people delivering drugs that result in overdose death...

Background Significant associations exist between psychological pain, unmet mental health need, and frequency and severity of substance use among people who use drugs (PWUD), but no studies have analyzed the relationship of these variables to non-fatal overdose. Methods We conducted a cross-sectional survey of people who used opioids non-medically...

Background Drug overdoses surged during the COVID-19 pandemic, underscoring the need for expanded and accessible substance use disorder (SUD) treatment. Relatively little is known about the experiences of patients receiving treatment during the pandemic. Methods We worked with 21 harm reduction and drug treatment programs in nine states and the Di...

The impact of pre-exposure prophylaxis (PrEP) uptake on sexual and injection-related behaviors among women who inject drugs (WWID) is poorly understood. Over 24-weeks, PrEP uptake among WWID was associated with increased sharing of injection equipment but not syringes and no changes in condomless sex, providing limited evidence of risk compensation...

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population est...

Female sex workers’ (FSWs) risk for HIV/STIs is influenced by their work environments. While previous research has characterized vulnerability in a single workplace, many FSWs solicit clients from multiple settings. Using latent class analysis (LCA), we examined client solicitation patterns and associated HIV/STI-related behaviors (consistent condo...

Background Globally, most female sex workers (FSWs) are mothers but are rarely considered as such in public health and social service programs and research. We aimed to quantitatively describe FSWs who are mothers and to examine correlates of current engagement in sex work to support children among a cohort of FSWs in Baltimore, Maryland, United St...

Objective More than one-half of women sex workers (sex workers) in the United States experience interpersonal violence, defined as physical or sexual violence, by sexual partners, including clients or intimate partners. Women experiencing interpersonal violence by intimate partners often choose hidden, woman-controlled contraception (e.g., intraute...

Background The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food often co-occurs with drug use and contributes to associated sequelae, such as risks for HIV and diabetes. The objective of this study was to examine factors asso...

Background: Considering most people who inject drugs (PWID) received help with the first injection, understanding the perspective of potential 'initiators' is a priority to inform harm reduction interventions. This paper examines how PWID narrate their experiences with injection initiation and assistance from the lens of their lived experience and...

Background Fentanyl test strip (FTS) programs are designed to promote fentanyl awareness and reduce overdose risk by providing people who use drugs (PWUD) with a method of testing drugs for the presence of fentanyl prior to use. In 2018, two large syringe services programs (SSP) in the U.S. Mid-Atlantic—one in Baltimore City, Maryland and one in th...

Background Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations. Objectives We aim to identify factors asso...

Drug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors a...

Background: Buprenorphine is an effective treatment for opioid use disorder, yet some persons are concerned with its "alternative use" (i.e., any use unintended by the prescriber). There is limited evidence on the factors associated with alternative use of buprenorphine (AUB); in this study, we examined correlates of recent (past 6 months) AUB. Met...

Background Immediately after experiencing a non-fatal overdose, many people who inject drugs (PWID) engage in harm-minimizing behavior change, including engagement in drug treatment. To inform the implementation of tailored interventions designed to facilitate drug treatment engagement in rural communities, we sought to identify correlates of start...

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported...

Introduction In 2018, the Baltimore City Health Department launched a mobile clinic called Healthcare on The Spot, which offers low-threshold buprenorphine services integrated with health care services to meet the needs of people who use drugs. In addition to buprenorphine management, The Spot offers testing and treatment for hepatitis C, sexually...

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders’ perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in...

Objective To evaluate racial (Black/White) differences in overdose response training and take-home naloxone (THN) possession and administration among clients and nonclients of the Baltimore syringe service program (SSP). Methods The study derived data from a cross-sectional survey of 263 (183 SSP clients, 80 nonclients) people who inject drugs (PW...

Background Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available. Methods We used data from 173 PWUO from Anne Arundel County, Maryland, which is l...

IMPACT: This work will inform the need for more trauma-informed approaches to violence screenings among marginalized populations by health care providers. OBJECTIVES/GOALS: Female sex workers (FSW) experience high rates of intimate partner violence (IPV) which may have negative reproductive health consequences. Routine IPV screening by healthcare p...

Objectives: To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland. Methods: We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths tha...

Background: Female sex workers (FSW) have elevated rates of sexually transmitted infections (STI) including HIV, yet few studies in the US have characterized the STI burden in this population. Methods: Data were derived from the EMERALD study, a structural community-based intervention with FSW in Baltimore, MD. Participants (n=385) were recruite...

Aim Experiencing a nonfatal overdose (NFOD) is a significant risk factor for a subsequent nonfatal or fatal overdose. Overdose mortality rates in rural Appalachian states are some of the highest in the USA, but little is known about correlates of overdose among rural populations of people who inject drugs (PWID). Our study aimed to identify correla...

Background. The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food co-occurs with illicit drug use and contributes to associated sequelae, such as HIV and diabetes. The objective of this study was to examine factors associated...