Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (helping end addiction long-term®) communities study.

BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

Economic Evaluations of Establishing Opioid Overdose Prevention Centers in 12 North American Cities: A Systematic Review.

OBJECTIVES: Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions. METHODS: We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs. RESULTS: We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC. CONCLUSIONS: OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.

Characterizing Use of Supervised Consumption Services among Street-involved Youth and Young Adults in the Context of an Overdose Crisis.

In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.

Comparison of record linkage software for deduplicating patient identities in California's Prescription Drug Monitoring Program.

BACKGROUND: To help prevent overdose deaths involving prescription drugs, accurate linkage of prescription drug monitoring program (PDMP) records for individual patients is essential. OBJECTIVES: To compare the accuracy of the linkage program used by California's PDMP against various record linkage programs with respect to accuracy in deduplicating patient identities in the PDMP, with implications for identifying high-risk opioid use and outlier behaviors. RESEARCH DESIGN: We evaluated California's program, Link Plus, LinkSolv, and The Link King on 557 861 PDMP identity records with addresses in two 3-digit zip code areas for patients who filled a controlled substance prescription in 2013. Manual review was performed on a stratified sample of 720 paired records identified as matches by at least one program. MEASURES: We estimated sensitivity and positive predictive value, and computed PDMP patient alerts for the patient entities identified by each program. RESULTS: Sensitivity was 95% for LinkSolv and The Link King, 84% for Link Plus, and 73% for California's program; positive predictive value was ≥93% for all programs. The number of patient entities prompting a PDMP alert was similar among the programs for all alerts except multiple provider episodes (obtaining prescriptions from ≥6 prescribers or ≥6 pharmacies in the last 6 months), which were 10.9%, 26.6%, and 16.9% greater using The Link King, Link Plus, and LinkSolv, respectively, compared to California's program. CONCLUSIONS: PDMPs should assess the accuracy of record linkage algorithms and the impacts of these algorithms on patient safety alerts and develop national best practices for PDMP record linkage.

Naloxone Knowledge and Attitudes Towards Overdose Response Among Family Members of People who Misuse Opioids.

Providing family members of individuals with opioid use disorders (OUD) naloxone is a cost-effective way to prevent overdose deaths. However, misconceptions and negative attitudes towards naloxone hinder family engagement with naloxone programs. This study examines factors associated with knowledge and attitudes toward naloxone among adults with close family members who misused opioids. Adults with family members (parent, step-parent, child, spouse, sibling, or step-sibling) who misused opioids (N = 299) completed a web-based survey. Participants were recruited through treatment providers, community groups, and social media. Surveys assessed naloxone knowledge, attitudes toward overdose response, demographics, completion of naloxone training, attitude toward medications for OUD, and family members' overdose history. Multiple regression was used to identify factors associated with naloxone knowledge (Model 1) and attitudes toward overdose response (Model 2). A graduate degree (B = .35, p < .003) and a history of overdose (B = 0.21, p = .032) were associated with greater naloxone knowledge. Age (B = .11, p < .001), race/ethnicity (B = -1.39, p = .037), naloxone training (B = 2.70, p < .001), and more positive attitude toward medications for OUD (B = 1.50, p = .003) were associated with attitudes toward overdose response. Family members are potential allies in reducing drug overdose deaths, and families may need broader education about naloxone. Awareness of previous overdose was associated with greater naloxone knowledge. Findings related to race/ethnicity suggest the need to reach family members of minoritized racial groups to provide access to naloxone training. Findings point to where education and distribution efforts may focus on increasing knowledge and improving attitudes among those closest to people with OUD.

Cannabis donation as a harm reduction strategy: a case study.

BACKGROUND: The United States (US) continues to experience unprecedented rates of overdose mortality and there is increased need to identify effective harm reduction practices. Research from Canada describes cannabis donation through harm reduction agencies as an adjunctive strategy to mitigate the negative consequences of more harmful drugs. This case study describes the operational logistics, feasibility, and potential benefits of a cannabis donation program that was operated through a harm reduction program in rural Michigan. CASE PRESENTATION: We applied a community driven research approach to gather information from harm reduction program staff about the implementation and evolution of cannabis donation efforts in Michigan. We also examined 20-months (September 2021 through May 2023) of administrative data from a cannabis company to compare the sale and donation of cannabis products. Ten cannabis-experienced harm reduction clients received cannabis donations, with clinical staff determining client interest and appropriateness, and providing weekly pick-up or delivery. To expand product availability and sustainability, we examined administrative data from a commercialcannabis company that volunteered to provide donations. This administrative data suggests that while flower products constitute most of the adult and medical sales, edible, oil, and topical products predominated donations. Further, cost analysis suggests that donations represent only 1% of total gross sales and account for much less than the expected yearly donation amount. CONCLUSIONS: Research suggests there is potential to reduce alcohol and drug use related harms of more dangerous substances through substitution with cannabis. This case study is the first to document cannabis donation as a harm reduction practice in the US and suggests potential for sustainability dependent on state laws. Findings from this case study provide a starting point for inquiry into cannabis donation as a harm reduction strategy in the US; future research is needed to fully understand the individual-level outcomes, public health impacts, necessary legal regulations, and best practices for cannabis donation programs through harm reduction organizations.

Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey.

BACKGROUND: With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply. METHODS: Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply. RESULTS: A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00-2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20-3.60)) of prescribed safer supply access, compared to people who did not access these services. CONCLUSIONS: Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.

Association between willingness to use an overdose prevention center and probation or parole status among people who use drugs in Rhode Island.

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 encounter significant barriers to OPC use. The objective of this study was to explore the association between willingness to use an OPC and probation/parole status in a sample of PWUD in Rhode Island. METHODS: This study utilized data from the Rhode Island Prescription and Illicit Drug Study, which enrolled adult PWUD from August 2020 to February 2023. We used Pearson's chi-square and Wilcoxon rank-sum tests to assess bivariate associations between willingness to use an OPC and probation/parole status (current/previous/never), as well as other sociodemographic and behavioral characteristics. In multivariable Poisson analyses, we examined the association between willingness to use an OPC and probation/parole status, adjusting for key sociodemographic and behavioral characteristics. RESULTS: Among 482 study participants, 67% were male, 56% identified as white, 20% identified as Hispanic/Latine, and the median age was 43 (IQR 35-53). Nearly a quarter (24%) had never been on probation/parole, 44% were not currently on probation/parole but had a lifetime history of probation and parole, and 32% were currently on probation/parole. Most participants (71%) reported willingness to use an OPC, and in both bivariate and multivariable analyses, willingness to use an OPC did not vary by probation/parole status. Crack cocaine use and lifetime non-fatal overdose were associated with greater willingness to use an OPC (all p < 0.05). CONCLUSIONS: These data demonstrate high willingness to use OPC among PWUD in Rhode Island regardless of CLS-involvement. As OPCs begin to be implemented in Rhode Island, it will be imperative to engage people with CLS-involvement and to ensure access to the OPC and protection against re-incarceration due to potential barriers, such as police surveillance of OPCs.

Enhancing drug checking services for supply monitoring: perspectives on implementation in syringe service programs in the USA.

BACKGROUND: Shifts in the US drug supply, including the proliferation of synthetic opioids and emergence of xylazine, have contributed to the worsening toll of the overdose epidemic. Drug checking services offer a critical intervention to promote agency among people who use drugs (PWUD) to reduce overdose risk. Current drug checking methods can be enhanced to contribute to supply-level monitoring in the USA, overcoming the selection bias associated with existing supply monitoring efforts and informing public health interventions. METHODS: As a group of analytical chemists, public health researchers, evaluators, and harm reductionists, we used a semi-structured guide to facilitate discussion of four different approaches for syringe service programs (SSPs) to offer drug checking services for supply-level monitoring. Using thematic analysis, we identified four key principles that SSPs should consider when implementing drug checking programs. RESULTS: A number of analytical methods exist for drug checking to contribute to supply-level monitoring. While there is likely not a one-size-fits-all approach, SSPs should prioritize methods that can (1) provide immediate utility to PWUD, (2) integrate seamlessly into existing workflows, (3) balance individual- and population-level data needs, and (4) attend to legal concerns for implementation and dissemination. CONCLUSIONS: Enhancing drug checking methods for supply-level monitoring has the potential to detect emerging threats in the drug supply and reduce the toll of the worsening overdose epidemic.

Systemized approach to equipping medical students with naloxone: a student-driven initiative to combat the opioid crisis.

BACKGROUND: Naloxone is an effective and safe opioid reversal medication now approved by the U.S. Food and Drug Administration (FDA) for use with or without a prescription. Despite this, naloxone dissemination lags at a time when U.S. opioid-related mortality expands. The authors proposed distributing naloxone to all U.S. medical students using established statewide standing prescription orders for naloxone, eliminating the financial burden of over-the-counter costs on students and streamlining workflow for the pharmacy. By focusing naloxone distribution on medical students, we are able to capitalize on a group that is already primed on healthcare intervention, while also working to combat stigma in the emerging physician workforce. METHODS: Beginning August 2022, the authors established a partnership between Harvard Medical School (HMS) and the outpatient pharmacy at Brigham and Women's Hospital (BWH) to facilitate access to naloxone for HMS medical students. BWH developed a HIPAA-secure electronic form to collect individual prescription information. BWH pharmacists processed submissions daily, integrating the naloxone prescription requests into their workflow for in-person pick-up or mail-order delivery. The electronic form was disseminated to medical students through a required longitudinal addiction medicine curriculum, listserv messaging, and an extracurricular harm reduction workshop. RESULTS: Over the 2022-2023 academic year, 63 medical students obtained naloxone kits (two doses per kit) through this collaboration. CONCLUSIONS: We propose that medical schools advocate for a hospital pharmacy-initiated workflow focused on convenience and accessibility to expand naloxone access to medical students as a strategy to strengthen the U.S. emergency response and prevention efforts aimed at reducing opioid-related morbidity and mortality. Expansion of our program to BWH internal medicine residents increased our distribution to over 110 healthcare workers, and efforts to expand the program to other BWH training programs and clinical sites such as the emergency department and outpatient infectious disease clinics are underway. With more than 90,000 medical students in the U.S., we believe that widespread implementation of targeted naloxone training and distribution to this population is an accessible approach to combating the public health crisis of opioid-related overdoses.

Is a randomised controlled trial of take home naloxone distributed in emergency settings likely to be feasible and acceptable? Findings from a UK qualitative study exploring perspectives of people who use opioids and emergency services staff.

OBJECTIVE: Distribution of take-home naloxone (THN) by emergency services may increase access to THN and reduce deaths and morbidity from opioid overdose. As part of a feasibility study for a randomised controlled trial (RCT) of distribution of THN kits and education within ambulance services and Emergency Departments (EDs), we used qualitative methods to explore key stakeholders' perceptions of feasibility and acceptability of delivering the trial. METHODS: We undertook semi-structured interviews and focus groups with 26 people who use opioids and with 20 paramedics and ED staff from two intervention sites between 2019 and 2021. Interviews and focus groups were recorded, transcribed verbatim and analysed using Framework Analysis. RESULTS: People using opioids reported high awareness of overdose management, including personal experience of THN use. Staff perceived emergency service provision of THN as a low-cost, low-risk intervention with potential to reduce mortality, morbidity and health service use. Staff understood the trial aims and considered it compatible with their work. All participants supported widening access to THN but reported limited trial recruitment opportunities partly due to difficulties in consenting patients during overdose. Procedural problems, restrictive recruitment protocols, limited staff buy-in and patients already owning THN limited trial recruitment. Determining trial effectiveness was challenging due to high levels of alternative community provision of THN. CONCLUSIONS: Distribution of THN in emergency settings was considered feasible and acceptable for stakeholders but an RCT to establish the effectiveness of THN delivery is unlikely to generate further useful evidence due to difficulties in recruiting patients and assessing benefits.

Community Collaboration for Suicide and Overdose Prevention: Attitudes, Perceptions, and Practices of Community-Based Professionals and County Leadership in New York State.

Deaths by overdose and suicide have been steadily rising, yet efforts to jointly address them have been limited despite shared risk and protective factors. The purpose of this study was to explore ways of jointly addressing these two significant public health issues at the community level. To accomplish this goal, we distributed an electronic survey via email to all 58 Local Mental Hygiene Directors (LMHDs) and 184 substance use and 57 suicide prevention coalition leads in New York State in March 2019 to better understand attitudes, perceptions, and practice of community-based overdose and suicide prevention. A total of 140 unique individuals completed the survey for a 47% usable response rate. Participants overwhelmingly reported that suicide and overdose are preventable and that individuals with risky substance use would benefit most from suicide prevention services compared to other populations. In addition, substance use prevention coalition leads reported less awareness of key suicide prevention programs than suicide prevention coalition leads and LMHDs; LMHDs were generally most familiar with suicide prevention programs. Finally, substance use and suicide prevention coalition leads were interested in collaborating to raise awareness, provide training, and implement community-based activities. These findings demonstrate a consensus among county leadership and substance use and suicide prevention coalition leads that suicide and overdose are prevalent in their communities and that increased collaboration to address these two public health issues is warranted. Results suggest a need for education, training, and technical assistance to support collaboration.

Willingness to Provide Naloxone Resources for Patients at Risk of Opioid Overdose: A National Survey of Emergency Registered Nurses.

INTRODUCTION: Opioid-related events continue to claim lives in the United States at alarming rates. Naloxone-dispensing rates fall dramatically short of national expectations. Emergency registered nurses are uniquely poised to connect at-risk patients with naloxone resources. This study sought to (1) describe the emergency registered nurses' willingness to provide naloxone resources and (2) explore variables that may influence the nurse's willingness to provide resources. METHODS: A cross-sectional, survey-based design was deployed using an online branch logic approach to include a national sample of emergency registered nurses. The Willingness to Provide, a validated questionnaire, measured the registered nurse's willingness to provide naloxone resources for patients at risk of opioid overdose. Eight variables were assessed for potential influence on willingness. RESULTS: A total of 159 nurses from 32 states and the District of Columbia completed the online survey via the Research Electronic Data Capture platform. The results revealed a mean Willingness to Provide score of 38.64 indicating a willingness to provide naloxone resources. A statistically significant relationship was identified between the nurse's willingness and years of nursing experience (P = .001), knowledge (P = .015), desire (P = .001), and responsibility (P < .001). DISCUSSION: In this representative sample, emergency nurses are willing to provide naloxone resources; furthermore, results indicate that higher knowledge, desire, and responsibility scores increase the nurse's willingness to provide naloxone resources; with education and clear expectations, emergency nurses may be able to improve the connection of patients at risk of opioid overdose with naloxone, a potentially lifesaving connection.

The Nation's First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City.

In November of 2021, multiple factors converged to create a window of opportunity to open overdose prevention centers (OPCs) at two existing syringe service programs (SSPs) in New York City (NYC). Political will exists in NYC, particularly toward the end of the de Blasio administration's term, and the NYC Health Department worked to garner additional support from local and state elected officials given the dire need to address the overdose crisis. This coincided with readiness on the part of one of the NYC SSP providers, OnPoint NYC, to open and operate OPC services. Legal risks were assessed by both the city and the provider. This case study outlines the sequence of events that resulted in NYC supporting OnPoint to open the first two publicly recognized OPCs in the nation, including lessons learned to inform other jurisdictions considering offering such services.

Association of drug overdoses and user characteristics of Canada's national mobile/virtual overdose response hotline: the National Overdose Response Service (NORS).

BACKGROUND: Several novel overdose response technology interventions, also known as mobile overdose response services (MORS), have emerged as adjunct measures to reduce the harms associated with the drug poisoning epidemic. This retrospective observational study aims to identify the characteristics and outcomes of individuals utilizing one such service, the National Overdose Response Service (NORS). METHODS: A retrospective analysis was conducted using NORS call logs from December 2020 to April 2023 imputed by operators. A variety of variables were examined including demographics, substance use and route, location, and call outcomes. Odds ratios and 95% confidence intervals were calculated around variables of interest to test the association between key indicators and drug poisonings. RESULTS: Of the 6528 completed calls on the line, 3994 (61.2%) were for supervised drug consumption, 1703 (26.1%) were for mental health support, 354 (5.42%) were for harm reduction education or resources, and 477 (7.31%) were for other purposes. Overall, there were 77 (1.18%) overdose events requiring a physical/ in-person intervention. Of the total calls, 3235 (49.5%) were from women, and 1070 (16.3%) were from people who identified as gender diverse. Calls mostly originated from urban locations (n = 5796, 88.7%) and the province of Ontario (n = 4137, 63.3%). Odds ratios indicate that using opioids (OR 6.72, CI 95% 3.69-13.52), opioids in combination with methamphetamine (OR 9.70, CI 95% 3.24-23.06), multiple consumption routes (OR 6.54, CI 95% 2.46-14.37), and calls occurring in British Columbia (B.C) (OR 3.55, CI 95% 1.46-7.33) had a significantly higher likelihood of a drug poisoning. No deaths were recorded and only 3 false callouts had occurred. The overall drug poisoning event incidence to phone calls was 1.2%. CONCLUSION: NORS presents a complimentary opportunity to access harm reduction services for individuals that prefer to use alone or face barriers to accessing in-person supervised consumption services especially gender minorities with high-risk use patterns.

Supervised smoking facility access, harm reduction practices, and substance use changes during the COVID-19 pandemic: a community-engaged cross-sectional study.

BACKGROUND: The potential public health benefits of supervised smoking facilities (SSFs) are considerable, and yet implementation of SSFs in North America has been slow. We conducted this study to respond to significant knowledge gaps surrounding SSF utilization and to characterize substance use, harm reduction practices, and service utilization following the onset of the COVID-19 pandemic. METHODS: A questionnaire was self-administered at a single site by 175 clients using an outdoor SSF in Vancouver, Canada, between October-December 2020. Questionnaire responses were summarized using descriptive statistics. Multinomial logistic regression techniques were used to examine factors associated with increased SSF utilization. RESULTS: Almost all respondents reported daily substance use (93% daily use of opioids; 74% stimulants). Most used opioids (85%) and/or methamphetamine (66%) on the day of their visit to the SSF. Respondents reported drug use practice changes at the onset of COVID-19 to reduce harm, including using supervised consumption sites, not sharing equipment, accessing medically prescribed alternatives, cleaning supplies and surfaces, and stocking up on harm reduction supplies. Importantly, 45% of SSF clients reported using the SSF more often since the start of COVID-19 with 65.2% reporting daily use of the site. Increased substance use was associated with increased use of the SSF, after controlling for covariates. CONCLUSIONS: Clients of the SSF reported increasing not only their substance use, but also their SSF utilization and harm reduction practices following the onset of COVID-19. Increased scope and scale of SSF services to meet these needs are necessary.

A scoping review of implementation considerations for harm reduction vending machines.

BACKGROUND: Community-based harm reduction vending machines (HRVM) are not new to the field of public health; numerous countries have implemented them in response to the needs of people who use drugs over the last three decades. However, until recently, few existed in the United States. Given the rapidity with which communities are standing up harm reduction vending machines, there is a pressing need for a consolidated examination of implementation evidence. This scoping review summarizes existing literature using multiple implementation science frameworks. METHODS: The scoping review was conducted in five stages including (1) Identify the research question; (2) Identify relevant studies; (3) Select the publications based on inclusion/exclusion criteria; (4) Review and extract data; and, (5) Summarize results. PubMed, Embase, and Web of Science were searched and authors screened publications in English from any year. Data were extracted by applying implementation constructs from RE-AIM and the Consolidated Framework for Implementation Research (CFIR). Both frameworks provided a useful lens through which to develop knowledge about the facilitators and barriers to HRVM implementation. The review is reported according to PRISMA guidelines. RESULTS: After applying the full inclusion and exclusion criteria, including the intervention of interest ("vending machines") and population of interest ("people who use drugs"), a total of 22 studies were included in the scoping review. None of the studies reported on race, making it difficult to retroactively apply a racial equity lens. Among those articles that examined effectiveness, the outcomes were mixed between clear effectiveness and inconclusive results. Evidence emerged, however, to address all CFIR constructs, and positive outcomes were observed from HRVM's after-hour availability and increased program reach. RECOMMENDATIONS: HRVM implementation best practices include maximizing accessibility up to 24 h, 7 days a week, offering syringe disposal options, ensuring capability of data collection, and allowing for anonymity of use. Organizations that implement HRVM should establish strong feedback loops between them, their program participants, and the broader community upfront. Considerations for future research include rigorous study designs to evaluate effectiveness outcomes (e.g. reduced drug overdose deaths) and examination of HRVM reach among ethnic and racial communities.

High willingness to use overdose prevention sites among suburban people who use drugs who do not inject.

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) via non-injection routes of administration in suburban areas are lacking. METHODS: We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs' likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS. FINDINGS: Participants' median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS. CONCLUSION: Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts.

Racial/ethnic differences in receipt of naloxone distributed by opioid overdose prevention programs in New York City.

INTRODUCTION: We evaluated racial/ethnic differences in the receipt of naloxone distributed by opioid overdose prevention programs (OOPPs) in New York City (NYC). METHODS: We used naloxone recipient racial/ethnic data collected by OOPPs from April 2018 to March 2019. We aggregated quarterly neighborhood-specific rates of naloxone receipt and other covariates to 42 NYC neighborhoods. We used a multilevel negative binomial regression model to assess the relationship between neighborhood-specific naloxone receipt rates and race/ethnicity. Race/ethnicity was stratified into four mutually exclusive groups: Latino, non-Latino Black, non-Latino White, and non-Latino Other. We also conducted racial/ethnic-specific geospatial analyses to assess whether there was within-group geographic variation in naloxone receipt rates for each racial/ethnic group. RESULTS: Non-Latino Black residents had the highest median quarterly naloxone receipt rate of 41.8 per 100,000 residents, followed by Latino residents (22.0 per 100,000), non-Latino White (13.6 per 100,000) and non-Latino Other residents (13.3 per 100,000). In our multivariable analysis, compared with non-Latino White residents, non-Latino Black residents had a significantly higher receipt rate, and non-Latino Other residents had a significantly lower receipt rate. In the geospatial analyses, both Latino and non-Latino Black residents had the most within-group geographic variation in naloxone receipt rates compared to non-Latino White and Other residents. CONCLUSIONS: This study found significant racial/ethnic differences in naloxone receipt from NYC OOPPs. We observed substantial variation in naloxone receipt for non-Latino Black and Latino residents across neighborhoods, indicating relatively poorer access in some neighborhoods and opportunities for new approaches to address geographic and structural barriers in these locations.

Factors Associated with Non-Evidence-Based Overdose Responses among People Who Use Prescription Opioids Non-Medically in Rural Appalachia.

Background: Opioid-related overdose deaths recently accelerated. In response, overdose education and naloxone distribution (OEND) has been implemented widely, though access remains sparse in rural Appalachia. Despite increasing OEND, risk factors for non-evidence-based overdose responses among the training-naïve remain unknown. Methods: We enrolled 169 adults who use prescription opioids non-medically and reside in rural West Virginia (August 2014-March 2015). Participants were interviewed about witnessing overdose (lifetime and prior-year), characteristics of the most recent overdose, responses to the overdose, and OEND acceptability. Logistic regression was used to assess factors associated with non-evidence-based responses to overdose. Results: Among the 73 participants who witnessed an opioid-related overdose, the majority (n = 53, 73%) reported any non-evidence-based responses. Participants were significantly more likely to report a non-evidence-based response when victims were unresponsive (OR = 3.36; 95% CI = 1.07, 10.58). Common evidence-based responses included staying with the victim until help arrived (n = 66, 90%) and calling 911 (n = 63, 86%), while the most common non-evidence-based responses were hitting or slapping the victim (n = 37, 51%) and rubbing the victim with ice or placing them in a cold shower or bath (n = 14, 19%). While most (n = 60, 82%) had never heard of OEND, the majority (n = 69, 95%) were willing to train, particularly those reporting non-evidence-based responses (n = 52, 98%). Conclusions: These findings underscore the need to expand access to OEND in rural communities and indicate OEND is acceptable to training-naïve individuals who use opioids in rural Appalachia. Given the "harm reduction deserts" in the region, approaches to expand OEND should be pursued.