Ian David Aronson

Background: Popular discourse often frames prescription stimulants Ritalin and Adderall as drugs for teens and emerging adults with greater financial resources (eg, students or young professionals), while illicit stimulants such as crack or methamphetamine are often considered drugs for older adults with lower incomes. Crack and methamphetamine are also frequently used in combination with opioids to offset the sedating effects of adulterants such as fentanyl and xylazine in the unregulated drug supply. This combination of stimulant and opioid use creates additional overdose risks and may require new public health approaches. Our team posited that creating effective messages to protect against overdose in the context of stimulant use entailed first developing a better understanding of which stimulants people are using in combination with opioids. Objective: While conducting formative research to develop a new intervention, our team sought to examine prescription stimulant use among participants, including middle-aged, lower-income, and homeless people. This entailed first ascertaining the prevalence of Ritalin and Adderall use among participants, and then asking people why they used them. We also sought to implement a novel AI-assisted coding methodology and to write up the steps we took as a replicable model that other research teams could readily use to facilitate their own data analysis. Methods: We collected substance use screenings during 3 waves of data collection in 2025 (N=102 participants). In early 2026, we conducted 16 qualitative interviews with people who reported using Ritalin or Adderall. We then conducted mixed methods analyses to examine reported substance use, including the use of opioids and Ritalin or Adderall in combination, as well as potential relationships between using opioids with prescription stimulants and reporting a desire to stop using drugs. After conducting the interviews, we implemented a new hybrid methodology using AI tools to code interview transcripts and generate detailed reports accompanied by supporting quotes. Results: Participants described using Ritalin or Adderall to manage negative effects of increasingly powerful opioids, including oversedation and withdrawal symptoms. A subset of participants who reported using both Ritalin or Adderall and opioids were 3.5 times more likely to agree or strongly agree with the statement “I want to stop using drugs but I need help to do that” compared to those who did not report using these substances in combination (19/22, 86.4% vs 18/28, 64.3%; odds ratio 3.52, 95% CI 0.83-14.89; P =.09). Although not statistically significant, this difference may prove practically significant and merits further study. Conclusions: The use of prescription stimulants appears to be increasingly common among new populations of people who use opioids, including those who report very low incomes and even homelessness. Additional research is warranted to examine how this type of polysubstance use may require different types of prevention strategies.

Our team developed content in English and Spanish for a technology-based intervention designed to increase vaccination against COVID-19 among people who inject drugs. From 2022 through 2024, we recruited 545 participants via peer referral, all of whom reported past 90-day injection drug use. Participants completed a tablet-based intervention, and software asked if they would like to vaccinate against COVID. Participants who did not vaccinate at the first visit received follow-up text messages. Participants who completed the intervention in Spanish were more than 2.5 times as likely to vaccinate at first visit (OR 2.525, 95% CI [1.059–6.076], p = 0.039), and 57% more likely to vaccinate at follow-up (OR 1.576, 95% CI [0.441–5.630], p = 0.484) compared to those who completed in English. These findings highlight the importance of developing intervention materials in languages beyond English. Research is warranted to understand how developing content in other languages may influence health outcomes.

To encourage people who inject drugs to vaccinate against COVID-19, our research team collaborated with a harm reduction organization in East Harlem to create a multilevel, technology-based intervention that combined a brief (<6 minute) educational video with pre–post-test items measuring the likelihood of vaccination, attitudes, and vaccine-related heath literacy. A total of 545 participants completed the intervention; 45 vaccinated at the end of their first study visit. The remaining 500 were randomly assigned to two groups that were sent different text message configurations to examine which more effectively encouraged follow-up vaccination. The intervention group received Multimedia Messaging Service text messages featuring combinations of words and images, similar to frames of a graphic novel; the control group received Short Message Service texts consisting solely of words. Among those who did not vaccinate at first visit, 26 (7 intervention group and 19 control) vaccinated at follow-up. Greater vaccine-related knowledge (e.g. the vaccine does not contain a live virus) and positive vaccine attitudes were significantly associated with post intervention vaccination. Misinformation and misconceptions (i.e. vaccines are population control; vaccination is only for people who are already sick) emerged as powerful barriers to vaccination. Further research is warranted to address other forms of vaccine hesitancy among additional high-risk populations.

Background: Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterants such as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increases risks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to a combination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to check drugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many people who use drugs decline to use them.Objective: We sought to better understand why people in the New York City area do or do not check drugs before use. We plan to use study findings to inform the development of technology-based interventions to encourage consistent drug checking.Methods: In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructured qualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interview guide examined participants’ knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines; using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded, transcribed, and analyzed for emerging themes.Results: Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for not checking included lacking convenient access to test supplies, or a place to check samples out of the public’s view, as well as time considerations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterants because they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sell them adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agency staff.Conclusions: New forms of outreach are needed not only to increase people’s knowledge of adulterated substances and awareness of the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. This includes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing and volatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefits public health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted community members including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-cost drug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide.

BACKGROUND Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterants such as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increases risks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to a combination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to check drugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many people who use drugs decline to use them. OBJECTIVE We sought to better understand why people in the New York City area do or do not check drugs before use. We plan to use study findings to inform the development of technology-based interventions to encourage consistent drug checking. METHODS In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructured qualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interview guide examined participants’ knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines; using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded, transcribed, and analyzed for emerging themes. RESULTS Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for not checking included lacking convenient access to test supplies, or a place to check samples out of the public’s view, as well as time considerations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterants because they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sell them adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agency staff. CONCLUSIONS New forms of outreach are needed not only to increase people’s knowledge of adulterated substances and awareness of the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. This includes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing and volatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefits public health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted community members including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-cost drug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide.

Youth between the ages of 13 and 24 account for over 20% of new HIV diagnoses in the United States but are the least likely age group to be HIV tested in healthcare settings including the emergency department. This is in part due to the fact that almost 50% of youth decline testing when offered. We elucidated youth patients’ perspectives on barriers to and facilitators of routine HIV testing of youth in an urban emergency department setting. Thirty-seven patients aged 13–24 years were recruited from the pediatric and adult emergency departments at a high-volume hospital in New York City from August 2019 to March 2020. Semi-structured in-depth interviews were conducted with all participants. Interviews were audio-recorded and transcribed verbatim, and transcripts were coded using an inductive thematic analysis approach. Youths’ main reasons for declining HIV testing when offered included low risk perception, privacy concerns, HIV-related stigma, and low levels of HIV-related knowledge. Participants’ responses suggested that HIV educational materials provided when testing is offered may be insufficient. Participants recommended providing additional HIV education and better incorporating HIV testing into the emergency department routine to increase testing among youth. Efforts are needed to help youth recognize their own HIV risk and increase their HIV-related knowledge. This may be accomplished by providing youth with additional educational materials on HIV, possibly via tablet-based interventions or other methods that may enhance privacy, combined with discussions with healthcare providers. Such efforts may help increase HIV testing acceptance among youth seen in the emergency department.

Background: People who inject drugs are disproportionately impacted by SARS-CoV-2 and COVID-19, yet they do not frequently accept vaccination against SARS-CoV-2 when offered. Objective: This study aimed to explore why people who inject drugs decline free vaccines against SARS-CoV-2 and how barriers to vaccination can potentially be addressed. Methods: We conducted semistructured qualitative interviews with 17 unvaccinated adult persons who inject drugs during August and September 2021 at a New York City syringe service program, where approximately three-fourth of participants identified as Latino (55%) or African American (22%). Interviews lasted roughly 20 minutes. The interview guide examined reasons for declining vaccination, participants’ understanding of COVID-19 risks, and how messages could be developed to encourage vaccine uptake among people who inject drugs. Results: Participants acknowledged that they faced increased risk from SARS-CoV-2 owing to their injection drug use but feared that long-term substance use may have weakened their health, making them especially vulnerable to side effects. Fears of possible side effects, compounded by widespread medical mistrust and questions about the overall value of vaccination contributed to marked ambivalence among our sample. The desire to protect children and older family members emerged as key potential facilitators of vaccination. Conclusions: Community-developed messages are needed in outreach efforts to explain the importance of vaccination, including the far greater dangers of COVID-19 compared to possible unintended side effects. Messages that emphasize vaccines’ ability to prevent inadvertently infecting loved ones, may help increase uptake. Community-focused messaging strategies, such as those used to increase HIV and hepatitis C virus testing and overdose prevention among people who inject drugs, may prove similarly effective.

HIV testing rates among US youth aged 13–24 years are sub-optimal, with high rates of missed testing opportunities in emergency departments (EDs). We assessed barriers to routine HIV testing of youth in urban ED settings from the perspective of healthcare providers. Ten physicians and nurses were recruited from the pediatric and adult EDs at a high-volume hospital in New York City, USA to complete in-depth interviews to provide their perspectives on barriers to routine HIV testing of youth ages 13 to 24 in EDs. Interviews were conducted using a semi-structured interview guide with questions and probes. All interviews were conducted via Zoom due to the COVID-19 pandemic and were audio-recorded and transcribed verbatim. Transcripts were coded independently by two researchers using an inductive thematic analysis approach. Participants often offered HIV testing to youth in the ED based on their perceptions of patients’ HIV risk, with pediatric providers sometimes discouraging adolescents they perceived to be at low HIV risk from testing. Participants cited other priorities, logistics of blood-based testing, and discomfort discussing HIV as other reasons for not offering HIV testing to all youth in the ED. Efforts are needed to encourage providers to offer HIV testing to all youth regardless of perceived risk, as the ED often serves as youths’ only point of contact with the healthcare system. Emphasis on this and the importance of early detection, along with institutional change, clear guidance, and support for the testing process may help increase youth testing and avoid missed HIV diagnosis opportunities.

BACKGROUND People who inject drugs are disproportionately impacted by SARS-CoV-2 and COVID-19, yet they do not frequently accept vaccination against SARS-CoV-2 when offered. OBJECTIVE This study aimed to explore why people who inject drugs decline free vaccines against SARS-CoV-2 and how barriers to vaccination can potentially be addressed. METHODS We conducted semistructured qualitative interviews with 17 unvaccinated adult persons who inject drugs during August and September 2021 at a New York City syringe service program, where approximately three-fourth of participants identified as Latino (55%) or African American (22%). Interviews lasted roughly 20 minutes. The interview guide examined reasons for declining vaccination, participants’ understanding of COVID-19 risks, and how messages could be developed to encourage vaccine uptake among people who inject drugs. RESULTS Participants acknowledged that they faced increased risk from SARS-CoV-2 owing to their injection drug use but feared that long-term substance use may have weakened their health, making them especially vulnerable to side effects. Fears of possible side effects, compounded by widespread medical mistrust and questions about the overall value of vaccination contributed to marked ambivalence among our sample. The desire to protect children and older family members emerged as key potential facilitators of vaccination. CONCLUSIONS Community-developed messages are needed in outreach efforts to explain the importance of vaccination, including the far greater dangers of COVID-19 compared to possible unintended side effects. Messages that emphasize vaccines’ ability to prevent inadvertently infecting loved ones, may help increase uptake. Community-focused messaging strategies, such as those used to increase HIV and hepatitis C virus testing and overdose prevention among people who inject drugs, may prove similarly effective.

Despite federal guidelines, many adolescents and emerging adults are not offered HIV testing by their healthcare providers. As such, many—including those who may be at high-risk for contracting HIV given their sexual and/or substance use risk—are not routinely tested. The current study examines sexual risk and substance use among emergency department patients aged 13–24 years (n = 147), who completed an automated screening as part of a tablet-based intervention designed to increase HIV testing. Twenty seven percent (n = 39) of participants chose to test for HIV after completing the tablet-based intervention. Among this sample, sexual risk was a significant independent predictor of HIV testing (χ² = 16.50, p < 0.001). Problem substance use (e.g. trying but failing to quit) also predicted testing (χ² = 7.43, p < 0.01). When considering these behaviors together, analyses indicated that the effect of problem substance use (ß = 0.648, p = 0.154) on testing is explained by sexual risk behavior (ß = 1.425, p < 0.01). The study’s findings underscore the value of using routine automated risk screenings to collect sensitive data from emergency department patients, followed by computer-based HIV test offers for adolescent youth. Our research indicates tablet-based interventions can facilitate more accurate reporting of sexual behavior and substance use, and can also potentially increase HIV test uptake among those at risk.