Education & Certifications

  • Bachelor of Science, Brown University, Human Biology (2010)


  • 2014 Autumn - ANES 300A Anesthesia Operating Room Clerkship
  • 2014 Autumn - SURG 313W Emergency Medicine Clerkship
  • 2014 Spring - MED 313A Ambulatory Medicine Core Clerkship
  • 2014 Spring - OBGYN 300A Obstetrics and Gynecology Core Clerkship
  • 2014 Summer - PEDS 338C Subinternship in Pediatrics
  • 2014 Summer - SURG 313A Emergency Medicine Clerkship
  • 2014 Summer - SURG 313W Emergency Medicine Clerkship
  • 2014 Winter - ANES 306P Critical Care Core Clerkship
  • 2014 Winter - MED 300A Internal Medicine Core Clerkship
  • 2013 Autumn - PEDS 300A Pediatrics Core Clerkship
  • 2013 Autumn - RAD 301A Diagnostic Radiology and Nuclear Medicine Clerkship
  • 2013 Summer - FAMMED 301A Family Medicine Core Clerkship
  • 2013 Summer - SURG 300A General Surgery Clerkship

Stanford Advisors


Journal Articles

  • Characteristics of United States Emergency Departments that Routinely Perform Alcohol Risk Screening and Counseling for Patients Presenting with Drinking-related Complaints. The western journal of emergency medicine Yokell, M. A., Camargo, C. A., Wang, N. E., Delgado, M. K. 2014; 15 (4): 438-445


    Emergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear.We performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors' opinions regarding perceived barriers to offering preventive services in their EDs.Overall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04).To increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors' perceived barriers related to an ED's capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors' concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service.

    View details for DOI 10.5811/westjem.2013.12.18833

    View details for PubMedID 25035750

  • Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments Disparities by Insurance Status JAMA SURGERY Delgado, M. K., Yokell, M. A., Staudenmayer, K. L., Spain, D. A., Hernandez-Boussard, T., Wang, N. E. 2014; 149 (5): 422-430
  • Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments: Disparities by Insurance Status. JAMA surgery Delgado, M. K., Yokell, M. A., Staudenmayer, K. L., Spain, D. A., Hernandez-Boussard, T., Wang, N. E. 2014


    IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non-trauma center emergency departments (EDs). OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non-trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non-trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility. RESULTS In 2009, a total of 4513 observations from 636 non-trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non-trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non-trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non-teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits). CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non-trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

    View details for DOI 10.1001/jamasurg.2013.4398

    View details for PubMedID 24554059

  • Forced withdrawal from methadone maintenance therapy in criminal justice settings: A critical treatment barrier in the United States JOURNAL OF SUBSTANCE ABUSE TREATMENT Fu, J. J., Zaller, N. D., Yokell, M. A., Bazazi, A. R., Rich, J. D. 2013; 44 (5): 502-505


    The World Health Organization classifies methadone as an essential medicine, yet methadone maintenance therapy remains widely unavailable in criminal justice settings throughout the United States. Methadone maintenance therapy is often terminated at the time of incarceration, with inmates forced to withdraw from this evidence-based therapy. We assessed whether these forced withdrawal policies deter opioid-dependent individuals in the community from engaging methadone maintenance therapy in two states that routinely force inmates to withdraw from methadone (N = 205). Nearly half of all participants reported that concern regarding forced methadone withdrawal during incarceration deterred them engaging methadone maintenance therapy in the community. Participants in the state where more severe methadone withdrawal procedures are used during incarceration were more likely to report concern regarding forced withdrawal as a treatment deterrent. Methadone withdrawal policies in the criminal justice system may be a broader treatment deterrent for opioid-dependent individuals than previously realized. Redressing this treatment barrier is both a health and human rights imperative.

    View details for DOI 10.1016/j.jsat.2012.10.005

    View details for Web of Science ID 000316835700006

    View details for PubMedID 23433809

  • The Feasibility of Pharmacy-Based Naloxone Distribution Interventions: A Qualitative Study With Injection Drug Users and Pharmacy Staff in Rhode Island SUBSTANCE USE & MISUSE Zaller, N. D., Yokell, M. A., Green, T. C., Gaggin, J., Case, P. 2013; 48 (8): 590-599


    This study analyzed qualitative data from a Rapid Policy Assessment and Response project to assess the feasibility of a potential pharmacy-based naloxone intervention to reduce opioid overdose mortality among injection drug users (IDUs). We conducted in-depth, semistructured interviews with 21 IDUs and 21 pharmacy staff (pharmacists and technicians). Although most participants supported the idea of a pharmacy-based naloxone intervention, several barriers were identified, including misinformation about naloxone, interpersonal relationships between IDUs and pharmacy staff, and costs of such an intervention. Implications for future pharmacy-based overdose prevention interventions for IDUs, including pharmacy-based naloxone distribution, are considered. The study's limitations are noted.

    View details for DOI 10.3109/10826084.2013.793355

    View details for Web of Science ID 000320699300004

    View details for PubMedID 23750660

  • Syringe Acquisition Experiences and Attitudes among Injection Drug Users Undergoing Short-Term Opioid Detoxification in Massachusetts and Rhode Island JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Zaller, N. D., Yokell, M. A., Nayak, S. M., Fu, J. J., Bazazi, A. R., Rich, J. D. 2012; 89 (4): 659-670


    Access to sterile syringes for injection drug users (IDUs) is a critical part of a comprehensive strategy to combat the transmission of HIV, hepatitis C virus, and other bloodborne pathogens. Understanding IDUs' experiences and attitudes about syringe acquisition is crucial to ensuring adequate syringe supply and access for this population. This study sought to assess and compare IDUs' syringe acquisition experiences and attitudes and HIV risk behavior in two neighboring states, Massachusetts (MA) and Rhode Island (RI). From March 2008 to May 2009, we surveyed 150 opioid IDUs at detoxification facilities in MA and RI, stratified the sample based on where respondents spent most of their time, and generated descriptive statistics to compare responses among the two groups. A large proportion of our participants (83%) reported pharmacies as a source of syringe in the last 6 months, while only 13% reported syringe exchange programs (SEPs) as a syringe source. Although 91% of our sample reported being able to obtain all of the syringes they needed in the past 6 months, 49% had used syringes or injection equipment previously used by someone else in that same time period. In comparison to syringe acquisition behaviors reported by patients of the same detoxification centers in 2001-2003 (data reported in previous publication), we found notable changes among MA participants. Our results reveal that some IDUs in our sample are still practicing high-risk injection behaviors, indicating a need for expanded and renewed efforts to promote safer injection behavior among IDUs. Our findings also indicate that pharmacies have become an important syringe source for IDUs and may represent a new and important setting in which IDUs can be engaged in a wide array of health services. Efforts should be made to involve pharmacists in providing harm reduction and HIV prevention services to IDUs. Finally, despite limited SEP access (especially in MA), SEPs are still used by approximately one of the three IDUs in our overall sample.

    View details for DOI 10.1007/s11524-012-9669-7

    View details for Web of Science ID 000307335300006

    View details for PubMedID 22427232

  • Prescription Drug Monitoring Programs JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Yokell, M. A., Green, T. C., Rich, J. D. 2012; 307 (9): 912-912

    View details for Web of Science ID 000301172100013

    View details for PubMedID 22396508

  • HIV infection and risk of overdose: a systematic review and meta-analysis AIDS Green, T. C., McGowan, S. K., Yokell, M. A., Pouget, E. R., Rich, J. D. 2012; 26 (4): 403-417


    Drug overdose is a common cause of non-AIDS death among people with HIV and the leading cause of death for people who inject drugs. People with HIV are often exposed to opioid medications during their HIV care experience; others may continue to use illicit opioids despite their disease status. In either situation, there may be a heightened risk for nonfatal or fatal overdose. The potential mechanisms for this elevated risk remain controversial. We systematically reviewed the literature on the HIV-overdose association, meta-analyzed results, and investigated sources of heterogeneity, including study characteristics related to hypothesize biological, behavioral, and structural mechanisms of the association. Forty-six studies were reviewed, 24 of which measured HIV status serologically and provided data quantifying an association. Meta-analysis results showed that HIV seropositivity was associated with an increased risk of overdose mortality (pooled risk ratio 1.74, 95% confidence interval 1.45, 2.09), although the effect was heterogeneous (Q = 80.3, P < 0.01, I(2) = 71%). The wide variability in study designs and aims limited our ability to detect potentially important sources of heterogeneity. Causal mechanisms considered in the literature focused primarily on biological and behavioral factors, although evidence suggests structural or environmental factors may help explain the greater risk of overdose among HIV-infected drug users. Gaps in the literature for future research and prevention efforts as well as recommendations that follow from these findings are discussed.

    View details for DOI 10.1097/QAD.0b013e32834f19b6

    View details for Web of Science ID 000300411500002

    View details for PubMedID 22112599

  • Intravenous use of illicit buprenorphine/naloxone to reverse an acute heroin overdose. Journal of opioid management Yokell, M. A., Zaller, N. D., Green, T. C., McKenzie, M., Rich, J. D. 2012; 8 (1): 63-66


    A case of heroin overdose reversed through the intravenous (IV) administration of a crushed sublingual tablet of buprenorphine/naloxone (Suboxone) by a lay responder is described. Although the sublingual administration of buprenorphine/naloxone to reverse an overdose has been reported elsewhere, this is the first report of IV administration. Healthcare professionals should be aware that injection drug users may respond to an opioid overdose by injecting buprenorphine/naloxone and should consequently counsel all opioid-using patients on the proper response to an overdose. Physicians should also consider prescribing naloxone to at-risk patients. The work of community-based naloxone distribution programs should be expanded.

    View details for PubMedID 22479887

  • Illicit Use of Buprenorphine/Naloxone Among Injecting and Noninjecting Opioid Users JOURNAL OF ADDICTION MEDICINE Bazazi, A. R., Yokell, M., Fu, J. J., Rich, J. D., Zaller, N. D. 2011; 5 (3): 175-180


    We examined the use, procurement, and motivations for the use of diverted buprenorphine/naloxone among injecting and noninjecting opioid users in an urban area.A survey was self-administered among 51 injecting opioid users and 49 noninjecting opioid users in Providence, RI. Participants were recruited from a fixed-site syringe exchange program and a community outreach site between August and November 2009.A majority (76%) of participants reported having obtained buprenorphine/naloxone illicitly, with 41% having done so in the previous month. More injection drug users (IDUs) than non-IDUs reported the use of diverted buprenorphine/naloxone (86% vs 65%, P = 0.01). The majority of participants who had used buprenorphine/naloxone reported doing so to treat opioid withdrawal symptoms (74%) or to stop using other opioids (66%) or because they could not afford drug treatment (64%). More IDUs than non-IDUs reported using diverted buprenorphine/naloxone for these reasons. Significantly more non-IDUs than IDUs reported ever using buprenorphine/naloxone to "get high" (69% vs 32%, P < 0.01). The majority of respondents, both IDUs and non-IDUs, were interested in receiving treatment for opioid dependence, with greater reported interest in buprenorphine/naloxone than in methadone. Common reasons given for not being currently enrolled in a buprenorphine/naloxone program included cost and unavailability of prescribing physicians.The use of diverted buprenorphine/naloxone was common in our sample. However, many opioid users, particularly IDUs, were using diverted buprenorphine/naloxone for reasons consistent with its therapeutic purpose, such as alleviating opioid withdrawal symptoms and reducing the use of other opioids. These findings highlight the need to explore the full impact of buprenorphine/naloxone diversion and improve the accessibility of buprenorphine/naloxone through licensed treatment providers.

    View details for DOI 10.1097/ADM.0b013e3182034e31

    View details for Web of Science ID 000293832500004

    View details for PubMedID 21844833

  • Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review. Current drug abuse reviews Yokell, M. A., Zaller, N. D., Green, T. C., Rich, J. D. 2011; 4 (1): 28-41


    The diversion, misuse, and non-medically supervised use of buprenorphine and buprenorphine/naloxone by opioid users are reviewed. Buprenorphine and buprenorphine/naloxone are used globally as opioid analgesics and in the treatment of opioid dependency. Diversion of buprenorphine and buprenorphine/naloxone represents a complex medical and social issue, and has been widely documented in various geographical regions throughout the world. We first discuss the clinical properties of buprenorphine and its abuse potential. Second, we discuss its diversion and illicit use on an international level, as well as motivations for those activities. Third, we examine the medical risks and benefits of buprenorphine's non-medically supervised use and misuse. These risks and benefits include the effect of buprenorphine's use on HIV risk and the risk of its concomitant use with other medications and drugs of abuse. Finally, we discuss the implications of diversion, misuse, and non-medically supervised use (including potential measures to address issues of diversion); and potential areas for further research.

    View details for PubMedID 21466501

  • Opioid Overdose Prevention and Naloxone Distribution in Rhode Island Med Health RI Yokell MA, Green TC, Bowman S, McKenzie M, Rich JD 2011; 94 (8): 240-242
  • Adverse event associated with a change in nonprescription syringe sale policy JOURNAL OF THE AMERICAN PHARMACISTS ASSOCIATION Zaller, N. D., Yokell, M. A., Jeronimo, A., Bratberg, J. P., Case, P., Rich, J. D. 2010; 50 (5): 619-622


    To report and describe the possible correlation of a change in syringe sale policy at a community pharmacy with an adverse clinical outcome.Providence, RI, in summer 2009. PATIENT DESCRIPTION: 27-year-old white woman with a long-standing history of chronic relapsing opiate addiction and human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfection.The patient presented to the hospital emergency department with 5 days of severe diffuse pain, swelling in her hands and feet, and several days of rigors with fevers, sweats, and chills. She was diagnosed with sepsis resulting from a disseminated methicillin-resistant Staphylococcus aureus (MRSA) infection. The patient was treated with intravenous antibiotics, neurosurgical drainage of an epidural abscess, intensive care unit care for 1 week, and acute hospitalization for 8 weeks.Not applicable.A few weeks before the patient was hospitalized, pharmacists at her local neighborhood pharmacy decided to stop selling syringes in packages of 10. Instead, syringes were sold at a minimum quantity of 100. The patient did not know where to obtain sterile syringes and began reusing syringes.The patient introduced pathogenic bacteria from her skin into her bloodstream through unsafe injection practices. The change in syringe sale policy at her local pharmacy likely inadvertently contributed to this severe and life-threatening situation. Consideration of the implications of syringe sale policy must include an understanding of the barriers that influence individual pharmacist's decisions regarding particular store policies that affect over-the-counter syringe sales. Legalized sale of nonprescription syringes in community pharmacies alone is not enough to curb the epidemic of unsafe injection practices in the United States. All medical risks that are inherent in the use of unsafe syringes, including blood-borne viral pathogens (e.g., HIV, HCV) and bacterial infections (e.g., MRSA), should be considered.

    View details for DOI 10.1331/JAPhA.2010.09162

    View details for Web of Science ID 000284281200003

    View details for PubMedID 20833621

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