Preventable Harms

Injection Drug Use-Related Infections in New Jersey

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

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.

Acknowledgments

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 Paolo 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
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 serious 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 (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 services 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 exchange 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 trans-mission 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.

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 emer-gency 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.

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, regard-less 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.

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.

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.

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 use-related 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. This is a relatively common occurrence among PWID who are hospitalized, and due to a variety of factors including the undertreatment of withdrawal symptoms and stigma in healthcare settings.¹⁶ Patient-directed discharges are particularly concerning for SBIs, due to their severity and potential to escalate to worse infections or death.¹⁷

It is worth noting that the total number of identified IDU-related infections is likely an underestimation, because claims indicating SBIs may not have an SUD diagnosis, which would exclude them from this analysis. Mortality following IDU-related infection is also likely underestimated, as the 283 deaths that occurred in hospitals do not include individuals who left and died outside the hospital, or those who died of infections without being hospitalized.

FIGURE 1

Frequency of IDU-SBIs across hospital visits*

*Sum of individual SBIs greater than total number of identified SBI hospitalizations because visits could contain more than one SBI

SBI: Severe Bacterial Infection

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

Prevalence of Severe Bacterial Infections

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 have a disproportionately negative impact on Black/non-Hispanic residents, despite higher rates of drug use overall among white residents.⁴

Black/non-Hispanic residents were 1.5 times more likely to be hospitalized than their white counterparts.

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.

People with Medicare or Medicaid were 5.6 times more likely to be hospitalized than those with private insurance.

TABLE 1

Frequencies of IDU-SBI hospitalizations across demographic characteristics^†

Characteristic	Frequency	Percent	N*
SEX			7,310
Male	4,296	58.8
Female	3,014	41.2
AGE			7,310
<21 years old	50	0.7
21-29 years old	874	12.0
30-49 years old	3,143	43.0
50-64 years old	2,301	31.5
65 years and older	942	12.9
RACE/ETHNICITY			7,233
White/Non-Hispanic	4,492	62.1
Black/Non-Hispanic	1,560	21.6
Hispanic	861	11.9
Asian/Pacific Islander & Native American	48	0.7
Other	272	3.8
PATIENT LOCAL INCOME QUARTILE**			7,240
First Quartile	3,266	45.1
Second Quartile	1,981	27.4
Third Quartile	1,309	18.1
Fourth Quartile	684	9.5
EXPECTED PAYER‡			7,310
Medicare	1,687	23.1
Medicaid	3,036	41.5
Private Insurance	1,891	25.9
Self-Pay	336	4.6
Other	360	4.9

†Characteristics are across visits, not individuals.

*Total N varies based on available data from HCUP (Max N =7,310).

**Patient local income quartile calculated based on identified patient’s home zip code.

‡Self-pay includes self-pay, no charge, and no expected payment. Other includes Worker’s Compensation, & other government programs.

IDU: Injection drug use

TABLE 2

Frequency of SBI hospitalizations in 2019 by NJ County*

County	SBI Encounters	Total Encounters	Total Population	Morbidity per 1,000 Encounters	Morbidity 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	1.1
Gloucester	319	26,160	291,636	12.19	1.09
Hudson	471	62,043	672,391	7.59	0.7
Hunterdon	48	11,248	124,371	4.27	0.39
Mercer	405	37,657	367,430	10.75	1.1
Middlesex	335	75,865	825,062	4.42	0.41
Monmouth	374	66,116	618,795	5.66	0.6
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	4.7	0.45
Warren	109	10,768	105,267	10.12	1.04
Total*	7,133	901,504	8,882,190	7.91	0.8

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

Geographic Injection-Related Severe Bacterial Infection (SBI) Trends

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.

In terms of total hospitalizations for injection-related SBIs, Camden, Essex, and Passaic counties had the most events, with 971, 875, and 498 hospitalizations respectively. Frequencies of injection-related SBIs for New Jersey counties are shown in Table 2, along with relative rates per 1,000 hospitalizations and per 1,000 population in the associated county.

Overall hospitalizations for injection drug use-related infections were highest in Camden, Essex, & Passaic counties.

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).

Counties with the highest rates per capita of hospitalizations due to preventable injection drug-use related SBIs were Atlantic, Camden, Cumberland, Mercer, and Salem.

Estimated Charges

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).

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. 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: 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
Burlington	128,604	65,392	1,410,164	48,226,592	108.29
Camden	116,891	63,488	2,094,108	113,500,000	224.1
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	92.1
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*	2,776,941	1,594,618	35,100,572	977,500,211	2,382.34

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-His-panic 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.

New Jersey currently operates only seven syringe service programs in a state with over nine million residents.

Despite the well-known benefits of syringe access programs in preventing injection-re-lated 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

Each program serves an average of 1.29 million residents.

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.

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 can accomplish this through the following recommendations:

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.
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 services 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 exchange 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.
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 trans-mission 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.
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.
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.
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

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
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
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*MTcxMDg2Nzk5Ni4xNjQyMDI0M-DUx*_ga_5PWJJG6642*MTY0NTkwMjAzOC4zLjEuMTY0NTkwMjA2My4w
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-spends-enforcing-the-war-on-drugs/
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Appendix

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 Codes^2,12

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
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
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 classified elsewhere

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
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
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

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Harm reduction is essential. A harm reduction approach to drug use is the best strategy we have to end the overdose crisis, reduce risks associated with drug use, and affirm the dignity and bodily autonomy of every New Jerseyan.