Funding and Delivery of Syringe Services Programs in the United States, 2022.

Objectives. To describe the current financial health of syringe services programs (SSPs) in the United States and to assess the predictors of SSP budget levels and associations with delivery of public health interventions. Methods. We surveyed all known SSPs operating in the United States from February to June 2022 (n = 456), of which 68% responded (n = 311). We used general estimating equations to assess factors influencing SSP budget size and estimated the effects of budget size on multiple measures of SSP services. Results. The median SSP annual budget was $100 000 (interquartile range = $20 159‒$290 000). SSPs operating in urban counties and counties with higher levels of opioid overdose mortality had significantly higher budget levels, while SSPs located in counties with higher levels of Republican voting in 2020 had significantly lower budget levels. SSP budget levels were significantly and positively associated with syringe and naloxone distribution coverage. Conclusions. Current SSP funding levels do not meet minimum benchmarks. Increased funding would help SSPs meet community health needs. Public Health Implications. Federal, state, and local initiatives should prioritize sustained SSP funding to optimize their potential in addressing multiple public health crises. (Am J Public Health. 2024;114(4):435-443. https://doi.org/10.2105/AJPH.2024.307583).

Optimizing naloxone distribution to prevent opioid overdose fatalities: results from piloting the Systems Analysis and Improvement Approach within syringe service programs.

BACKGROUND: Opioid overdose fatalities are preventable with timely administration of naloxone, an opioid antagonist, during an opioid overdose event. Syringe service programs have pioneered naloxone distribution for potential bystanders of opioid overdose. The objective of this study was to pilot test a multi-component implementation strategy-the systems analysis and improvement approach for naloxone (SAIA-Naloxone)-with the goal of improving naloxone distribution by syringe service programs. METHODS: Two syringe service programs participated in a 6-month pilot of SAIA-Naloxone, which included (1) analyzing program data to identify gaps in the naloxone delivery cascade, (2) flow mapping to identify causes of attrition and brainstorm programmatic changes for improvement, and (3) conducting continuous quality improvement to test and assess whether modifications improve the cascade. We conducted an interrupted time series analysis using 52 weeks of data before and 26 weeks of data after initiating SAIA-Naloxone. Poisson regression was used to evaluate the association between SAIA-Naloxone and the weekly number of participants receiving naloxone and number of naloxone doses distributed. RESULTS: Over the course of the study, 11,107 doses of naloxone were distributed to 6,071 participants. Through SAIA-Naloxone, syringe service programs prioritized testing programmatic modifications to improve data collection procedures, proactively screen and identify naloxone-naïve participants, streamline naloxone refill systems, and allow for secondary naloxone distribution. SAIA-Naloxone was associated with statistically significant increases in the average number of people receiving naloxone per week (37% more SPP participants; 95% CI, 12% to 67%) and average number of naloxone doses distributed per week (105% more naloxone doses; 95% CI, 79% to 136%) beyond the underlying pre-SAIA-Naloxone levels. These initial increases were extended by ongoing positive changes over time (1.6% more SSP participants received naloxone and 0.3% more naloxone doses were distributed in each subsequent week compared to the weekly trend in the pre-SAIA Naloxone period). CONCLUSIONS: SAIA-Naloxone has strong potential for improving naloxone distribution from syringe service programs. These findings are encouraging in the face of the worsening opioid overdose crisis in the United States and support testing SAIA-Naloxone in a large-scale randomized trial within syringe service programs.

Availability of telehealth-based services at syringe services programs under the COVID-19 Public Health Emergency.

INTRODUCTION: The expanded capacity of syringe services programs (SSPs) in the USA to integrate telehealth services was largely related to flexibility of buprenorphine prescription in response to the COVID-19 pandemic. SSPs demonstrated the potential of using telehealth to reach participants with both medical and non-medical services. The present study examines the implementation of medical and non-medical telehealth-based health services in 2020 at SSPs in the USA and organizational characteristics associated with adopting specific telehealth services. METHODS: We administered a cross-sectional survey among all known SSPs operating in the USA as of 2021. The two primary study outcomes were (1) implementation of medical telehealth and (2) implementation of non-medical telehealth in 2020. Medical services included HIV counseling/care, hepatitis C virus (HCV) counseling/care, and buprenorphine. Non-medical services included wellbeing/check-ins, overdose prevention training, health navigation, harm reduction and psychological counseling. Bivariate and multivariable mixed effects logistic regression models were used to directly estimate the odds ratio associated with organizational characteristics on the implementation of telehealth-based health services. RESULTS: Thirty percent of programs (n = 290) reported implementing telehealth-based health services. In multivariable logistic regression models, community-based organization SSPs had higher odds of implementing medical (aOR = 4.69, 95% CI [1.96, 11.19]) and non-medical (aOR = 2.18, 95% CI [1.10, 4.31]) health services compared to public health department SSPs. SSPs that received governmental funding had higher odds of implementing medical services via telehealth (aOR = 2.45, 95% CI [1.35, 4.47]) compared to programs without governmental funding. CONCLUSION: Community-based organization SSPs and those with government funding had the highest odds of telehealth implementation in response to the COVID-19 Public Health Emergency. Federal, state, and local governments must increase funding for low-barrier venues like SSPs to support telehealth implementation to serve the needs of people who use drugs.

Reduced Emergency Department Visits and Hospitalisation with Use of an Unsanctioned Safe Consumption Site for Injection Drug Use in the United States.

BACKGROUND: Safe consumption sites (SCS) are an evidence-based intervention to prevent drug use-related harm. In late 2014, an organisation in an undisclosed location in the USA opened an unsanctioned SCS. OBJECTIVE: To evaluate whether use of the unsanctioned SCS affected medical outcomes. DESIGN: A prospective cohort study. SETTING: Neighbourhoods surrounding the SCS. PARTICIPANTS: People who injected drugs were recruited and interviewed at baseline and 6 and 12 months from 2018 to 2020. INTERVENTION: People using the SCS could bring pre-obtained drugs to consume via injection, which were monitored by trained staff with naloxone. MAIN MEASURES: Any overdose, number of non-fatal overdoses, skin and soft tissue infections, emergency department utilisation, number of emergency department visits, hospitalisation and number of nights spent in hospital. KEY RESULTS: A total of 494 participants enrolled in the study; 59 (12%) used the SCS at least once. We used propensity score weighting to analyse the association between SCS utilisation and measures. People using the SCS were 27% (95% CI: 12-46%) less likely to visit the emergency department, had 54% (95% CI: 33-71%) fewer emergency department visits, were 32% (95% CI: 4-57%) less likely to be hospitalised, and spent 50% (95% CI: 1-85%) fewer nights in hospital. Though not significant, people using the SCS had a lower likelihood of overdosing and slightly higher likelihood of skin and soft tissue infections. CONCLUSIONS: Our findings support the use of SCS in the USA to reduce the growing burden of acute care service utilisation related to injection drug use.

Establishment and Enforcement of Operational Rules at an Unsanctioned Safe Drug Consumption Site in the United States, 2014-2020.

Objectives. To examine how operational rules are established and enforced at an unsanctioned safe consumption site (SCS) operating in the United States. Methods. We conducted 44 qualitative interviews with people who use drugs, staff members, and volunteers at an unsanctioned SCS and analyzed them using an inductive thematic approach. Results. Rule-making processes were largely driven by concerns raised by service users rather than driven by external pressures, and iterated rapidly in response to changing needs. The unsanctioned nature of the site produced an environment where bottom-up rule-making was critical to generating a shared sense of ownership of the site and where enforcement was necessarily fluid. Conclusions. Removing external restrictions on operational rules for SCSs results in a flexible set of rules that are highly responsive to the social and public health needs of people who use drugs. Legislation and regulations of SCSs should aim to place as few hard limits on operating conditions as possible to maximize involvement of and responsiveness to people who use drugs. (Am J Public Health. 2022;112(S2):S166-S172. https://doi.org/10.2105/AJPH.2022.306714).

Predictors of protein intake among people who inject drugs in Los Angeles and San Francisco, California.

BACKGROUND AND OBJECTIVES: While inadequate nutrition can weaken the immune system and lead to negative health sequelae for vulnerable populations, little is known about nutritional intake among people who inject drugs (PWID). We aimed to quantify nutritional intake among PWID and to explore associations between protein intake and drug use. METHODS: A cross-sectional design was used to analyze self-reported participant data. PWID were recruited from community settings in California in 2016/2017. Participants reported on food consumption per day for a 30-day period, from which a continuous protein intake variable was created. RESULTS: Modal characteristics of participants (N = 937) were: white (42.5%), male (75.3%), healthy body mass index (BMI) (56.6%), and unhoused (82.9%). Less than 1% of participants met or exceeded recommended guidelines for protein intake (0.80 g/day/1 kg body weight). The final multiple regression model found protein intake to be significantly positively associated with older age, high school or greater education, frequency of opiate and marijuana use, while Latinx ethnicity was inversely associated with protein intake, adjusting for gender. DISCUSSION AND CONCLUSIONS: Our study shows PWID are generally not underweight, yet they are grossly protein deficient, which can be harder to recognize. Poverty, homelessness, and other structural barriers likely contribute to this issue, which demonstrates the need for communities to provide more access to nutrient-rich food to PWID. SCIENTIFIC SIGNIFICANCE: Our study demonstrates the novel findings that opiate and marijuana use frequency, but not stimulants (methamphetamine and cocaine) may increase preference for protein-rich foods among PWID.

Health risk associated with residential relocation among people who inject drugs in Los Angeles and San Francisco, CA: a cross sectional study.

BACKGROUND: Given the housing instability and frequent residential relocation (both volitional and hegemonic) of people who inject drugs, we sought to determine whether residential relocation (defined as sleeping in a different place in the past 30 days) is associated with health outcomes in a sample of people who inject drugs (PWID). METHODS: We recruited 601 PWID using targeted sampling and interviewed them between 2016 and 2018 in San Francisco and Los Angeles, CA about housing, drug use practices, and service utilization. We then developed multivariable regression models to investigate how residential relocation is associated with violence, health outcomes, and social service access. We analyzed our data between June 2018 and October 2019. RESULTS: Participants who relocated in the past 30 days had lower odds of being in substance use treatment (Adjusted Odds Ratio [AOR] = 0.62, 95% Confidence Interval [CI] = 0.42, 0.89) and higher odds of nonfatal overdose (AOR = 2.50, CI = 1.28, 4.90), receptive syringe sharing (AOR = 2.26, CI = 1.18, 4.32), severe food insecurity (AOR = 1.69, CI = 1.14, 2.50), having belongings stolen (AOR = 2.14, CI = 1.42, 3.21), experiencing physical assault (AOR = 1.58, CI = 1.03, 2.43), arrest (AOR = 1.64, CI = 1.02, 2.65), and jail (AOR = 1.90, CI = 1.16, 3.13) in the past 6 months when compared to those who did not relocate. CONCLUSIONS: PWID who have relocated in the past 30 days have higher odds of experiencing violence and life- threatening adverse outcomes, and policies that disrupt living circumstances of PWID should be ended in favor of those that support housing stability.

Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach.

BACKGROUND: Opioid-related overdose deaths have surged in the USA over the last two decades. Overdose fatalities are preventable with the timely administration of naloxone. Syringe service programs (SSP) have pioneered community-based naloxone distribution through overdose prevention and naloxone distribution (OEND) programs. There is a dearth of information with regards to best practices for community-based OEND. METHODS: We utilized a modified Delphi approach to develop a set of best practices for OEND delivery. Starting with an initial list of best practices, we engaged 27 experts, in the field of OEND programming who reviewed, made recommendations for changes, and assigned a priority to each best practice. RESULTS: Two rounds of input resulted in a final list of 20 best practices organized into four categories. The mean priority scores ranged from 1.17 to 2.17 (range 1 to 3). The top 5 ranked best practices were ensuring that SSP participants have low barrier, consistent, needs-based access to naloxone and that there is ample naloxone available within communities. While the remaining fifteen best practices were deemed important, they had more to do with organizational culture and implementation climate. CONCLUSIONS: Increasing community-based OEND delivery is essential to reduce opioid overdose deaths; however, it will be insufficient to add programs without an eye toward quality of implementation and fidelity to the model upon which the evidence is based. This list of best practices summarizes the consensus among OEND experts and can serve as a tool for SSPs providing OEND programming to improve services.

Novel Routes of Potential Hepatitis C Virus Transmission among People Who Inject Drugs: Secondary Blood Exposures Related to Injection Drug Use.

BACKGROUND: The US is in the midst of a national Hepatitis C Virus (HCV) epidemic that appears to be driven by new cases among people who inject drugs (PWID). While HCV transmission among PWID is believed to occur mostly through direct sharing of syringes, some infections may be spread via secondary processes and materials involved in injecting. OBJECTIVES: Here, we present the prevalence of secondary blood exposures on clothing and nearby surfaces after injection episodes and examine the correlations of these exposures to lifetime HCV infection among a targeted sample of 553 PWID in Los Angeles and San Francisco, California in 2016-18. RESULTS: In multivariate logistic regression models, higher odds of blood on clothing in the last 30 days was significantly (p < 0.05) associated with lifetime positive HCV status, opioids as primary drug, injecting with others, sharing cookers, and receptive syringe sharing. Higher adjusted odds of blood on nearby surfaces in the last 30 days was significantly associated with lifetime positive HCV status, sharing cookers, and receptive syringe sharing. Native American race was associated with significantly lower adjusted odds of both outcome variables. Conclusions/Importance: Results indicate the relevance of physical and social micro-environments to the potential for blood exposures secondary to injection episodes. Individuals with chronic HCV seropositivity are potentially more likely to expose others to blood due to decreases in the blood's ability to clot. This highlights the need for increased HCV testing at harm reduction sites and increased supply of first aid and wound-care materials to help stop potential blood exposures after injection episodes.

Overdose Education and Naloxone Distribution Within Syringe Service Programs - United States, 2019.

Syringe service programs (SSPs), which provide access to sterile syringes and other injection equipment and their safe disposal after use,* represent a highly successful human immunodeficiency virus (HIV) prevention intervention. SSPs are associated with a 58% reduction in the incidence of HIV infection among persons who inject drugs (1). In addition, SSPs have led efforts to prevent opioid overdose deaths by integrating evidence-based opioid overdose education and naloxone distribution (OEND) programs (2-4). OEND programs train laypersons to respond during overdose events and provide access to naloxone and directions for drug delivery (2-4). SSPs are ideal places for OEND because they provide culturally relevant services designed to reach persons at high risk for experiencing or observing an opioid overdose. A 2013 survey found that only 55% of SSPs in the United States had implemented OEND (5). To characterize current implementation of OEND among SSPs, and to describe the current reach (i.e., the ratio of persons who received naloxone per opioid overdose death and the ratio of naloxone doses distributed per opioid overdose death) of SSP-based OEND programs by U.S. Census division,† a survey of known U.S. SSPs was conducted in 2019, which found that 94% of SSPs had implemented OEND. In addition, the reach of SSP-based OEND programs varied by U.S. Census division. Scaling up of SSP-based OEND delivery programs could be a critical component for areas of the country with high opioid overdose death rates and low reach.

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California.

Background: Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). Objectives: This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. Methods: A cross-sectional sample of PWID (N = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Results: Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Conclusion: Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.

Correlates of Sexual Coercion among People Who Inject Drugs (PWID) in Los Angeles and San Francisco, CA.

Experiences of coerced or forced sex have been associated with risk for HIV infection for all adults and may be more common for gays, lesbians, bisexuals (GLB) and people who inject drugs (PWID). In this study, we explored factors associated with prior 12-month experiences of forced or coerced sex among a sample of PWID, with a focus on sexual orientation and gender. PWID (N = 772) from Los Angeles and San Francisco were recruited using targeted sampling methods in 2011-2013 and surveyed on a range of items related to demographics, drug use, HIV risk, and violence, including experiences of forced or coerced sex in the prior 12 months. In this racially/ethnically diverse, mostly homeless, and low-income sample of PWID, 25% of participants were female and 15% identified as GLB. Sexual coercion was reported by 9% of gay and bisexual men, 8% of heterosexual females, 5% of lesbians and bisexual women, and less than 1% of heterosexual men. In multivariate analyses, compared to heterosexual males, gay or bisexual males (adjusted odds ratio [AOR] = 10.68; 95% confidence interval [CI] = 2.03, 56.23), and heterosexual females (AOR = 9.69; 95% CI = 2.04, 45.94) had increased odds of coerced sex in the prior 12 months. Having a paying sex partner (AOR = 3.49; 95% CI = 1.42, 8.54) or having had forced sex prior to the age of 16 by someone at least five years older (AOR = 4.74; 95% CI = 1.88, 11.93) also elevated the odds of coercive sex. Sexual coercion is common among PWID, but especially for gay and bisexual men and heterosexual females. Efforts to reduce sexual violence among PWID are urgently needed.

Food insecurity among people who inject drugs in Los Angeles and San Francisco.

OBJECTIVE: We estimated the prevalence of food insecurity among people who inject drugs (PWID) in Los Angeles and San Francisco and explored correlates of food insecurity. DESIGN: A cross-sectional study that measured 30 d food insecurity using the US Adult Food Security Survey ten-item Module developed by the US Department of Agriculture. Food insecurity was defined as including low and very low food security. SETTING: Two cities in the state of California, USA. SUBJECTS: Male and female active PWID (n 777). RESULTS: Among participants, 58 % reported food insecurity and 41 % reported very low food security. Food-insecure PWID were more likely to report being homeless (prevalence ratio (PR)=1·20; 95 % CI 1·05, 1·37), chest pain in the past 12 months (PR=1·19; CI 1·06, 1·35), acquiring syringes from someone who goes to a syringe exchange programme (PR=1·27; 95 % CI 1·13, 1·43) and feeling at risk for arrest for possession of drug paraphernalia (PR=1·30; 95 % CI 1·15, 1·46). CONCLUSIONS: Current food insecurity was common among PWID in these two cities, yet few factors were independently associated with food insecurity. These data suggest that broad strategies to improve food access for this high-risk population are urgently needed.

Consistency of self-reported drug use events in a mixed methods study of people who inject drugs.

BACKGROUND: Little is known about the consistency of information provided by people who inject drugs (PWID) during quantitative and qualitative interviews in mixed methods studies. OBJECTIVES: We illustrate the use of the intraclass correlation coefficient, descriptive statistics, and regression to assess the consistency of information provided during a mixed methods study of PWID living in Los Angeles and San Francisco, California, USA. METHODS: Age of first use of heroin, methamphetamine, marijuana, powder cocaine, and crack cocaine and first injection of heroin, methamphetamine, and powder cocaine were collected during an interviewer administered computer-assisted personal interview followed by an in-depth qualitative interview (n = 102). RESULTS: Participants were 63% male, racially/ethnically diverse. 80.4% between the ages of 40 and 60 years old, 89% US-born, and 57% homeless. Consistency of self-reported data was adequate for most drug use events. Exact concordance between quantitative and qualitative measures of age of onset ranged from 18.2-50%. Event ordering was consistent across qualitative and quantitative results for 90.2% of participants. Analyses indicated that age of onset for heroin use, heroin injection, and injection of any drug was significantly lower when assessed by qualitative methods as compared to quantitative methods. CONCLUSION: While inconsistency will emerge during mixed method studies, confidence in the timing and ordering of major types of events such as drug initiation episodes appear to be warranted.

Health risks associated with smoking versus injecting fentanyl among people who use drugs in California.

BACKGROUND: Given the attention, funding, and services that seek to reduce overdose mortality from fentanyl, it is important to understand whether a potential solution is for more people to switch from injecting to smoking fentanyl. As such, we set out to conduct a study to compare health and healthcare utilization outcomes associated with different modes of illicit fentanyl administration. METHODS: From January to February 2023, we recruited people who use drugs from 34 syringe services programs across California, USA (N=999) and surveyed their substance use, health outcomes, and healthcare utilization. We compared health risks among people who injected fentanyl (78% of whom also smoked) to people who solely smoked fentanyl (n=563). RESULTS: Of the 563 participants, forty-one percent injected fentanyl and 59% only smoked fentanyl. People who injected fentanyl were 40% more likely to have experienced a non-fatal overdose in the past 3 months (27% vs. 19%; aRR=1.40; 95% CI=1.03, 1.93) and 253% more likely to have had a skin and soft tissue infection in the past 3 months (39% vs. 15%; aRR=2.53; 95% CI=1.74, 3.67), compared to people who only smoked fentanyl. The average number of nights spent in the hospital was higher among people who injected fentanyl (average 1.2 nights vs. 0.7 nights; aIRR=1.78; 95% CI=1.02, 3.09; p=0.04).There were non-significant associations between mode of fentanyl administration and number of emergency department visits and probability of hospitalization. CONCLUSIONS: Findings suggested that people who injected fentanyl were at higher risk for overdose and skin and soft tissue infections than people who only smoked fentanyl. Distribution of safe smoking supplies may facilitate transitions from injecting to smoking fentanyl, thereby reducing health risks associated with fentanyl use.

Criminal legal system engagement among people who use drugs in Oregon following decriminalization of drug possession.

BACKGROUND: In February 2021, Measure 110 (M110) in Oregon decriminalized noncommercial possession of drugs. We examined criminal legal system (CLS) involvement of people who use drugs (PWUD) 2 years after decriminalization. METHODS: We conducted a quantitative survey of PWUD (N=468) in eight Oregon counties between March and November 2023. We ran multivariable models to examine predictors of CLS involvement and law enforcement stops. RESULTS: The majority of PWUD (74 %) reported any past year CLS involvement; 67 % had at least one law enforcement stop (mean of 11.4 and median of 3 law enforcement stops) and 33 % had at least one jail incarceration. Among PWUD whom law enforcement had found to possess drugs (n=101), 77 % had their drugs seized at least once, and 63 % (n=56) were taken into custody for charges that did not include drug use or possession at least once. Younger age, cisgender male identity, unstable housing, and nonurban county location were associated with a higher prevalence of any CLS involvement. PWUD who were unstably housed had 6.80 more law enforcement stops than housed PWUD (95 % CI: 4.03-9.57). PWUD in nonurban counties experienced 9.73 more law enforcement stops than those in urban areas (95 % CI: 4.90-14.56). No significant differences were found by race or ethnicity and CLS involvement. Only 13 % of PWUD were aware that all drugs had been decriminalized. CONCLUSIONS: Despite drug decriminalization, the majority of PWUD in our study reported significant CLS engagement and limited M110 knowledge.

Racialized environments and syringe services program implementation: County-level factors.

OBJECTIVE: Racialized health inequities in substance use-related harms might emerge from differential access to syringe service programs (SSPs). To explore this, we examined the association between county-level racialized environments, other factors, and (1) SSP presence, and (2) per capita syringe and (3) naloxone distribution. METHODS: 2021 US National Survey of SSP data (n=295/412;72 % response rate) was used to identify SSP presence and the sum of syringes and naloxone doses distributed in 2020 by county. Study measures included racial residential segregation (RRS; i.e., divergence and dissimilarity indexes for Black:Non-Hispanic White & Hispanic:Non-Hispanic White) and covariates (i.e., demographic proportions, urban/suburban/rural classifications, 2020 US presidential Republican vote share, and overdose mortality from 2019). We used logit Generalized Estimating Equations to determine factors associated with county-level SSP presence, and zero inflated negative binomial regression models to determine factors associated with per capita syringe and naloxone distribution. RESULTS: SSPs were reported in 9 % (283/3106) of US counties. SSP presence was associated with higher divergence and dissimilarity indexes, urban and suburban counties, higher opioid overdose mortality, and lower 2020 Republican presidential vote share. Per capita syringes distributed was associated with lower RRS (divergence and Hispanic:White dissimilarity), lower racially minoritized population proportions and rural counties, while per capita naloxone distribution was associated with lower Hispanic and "other" population proportions, and rural counties. CONCLUSIONS: Racialized environments are associated with SSP presence but not the scope of those programs. Preventing HIV and HCV outbreaks, and overdose deaths requires addressing community level factors that influence SSP implementation and accessibility.

Radical hospitality: Innovative programming to build community and meet the needs of people who use drugs at a government-sanctioned overdose prevention site in San Francisco, California.

BACKGROUND: The Tenderloin Center (TLC), a multi-service center where people could receive or be connected to basic needs, behavioral health care, housing, and medical services, was open in San Francisco for 46 weeks in 2022. Within a week of operation, services expanded to include an overdose prevention site (OPS), also known as safe consumption site. OPSs have operated internationally for over three decades, but government-sanctioned OPSs have only recently been implemented in the United States. We used ethnographic methods to understand the ways in which a sanctioned OPS, situated in a multi-service center, impacts the lives of people who use drugs (PWUD). METHODS: We conducted participant observation and in-depth interviews June-December 2022. Extensive field notes and 39 in-depth interviews with 24 TLC guests and 15 TLC staff were analyzed using an inductive analysis approach. Interviewees were asked detailed questions about their experiences using and working at the TLC. RESULTS: TLC guests and staff described an atmosphere where radical hospitality-welcoming guests with extraordinary warmth, generosity, and unconditional acceptance-was central to the culture. We found that the co-location of an OPS within a multi-service agency (1) allowed for the culture of radical hospitality to flourish, (2) yielded a convenient one-stop shop model, (3) created a space for community building, and (4) offered safety and respite to guests. CONCLUSIONS: The co-location of an OPS within a multi-service drop-in center is an important example of how such an organization can build positive sociality among PWUD while protecting autonomy and reducing overdose mortality. Overdose response and reversal is an act of relational accountability in which friends, peers, and even strangers intervene to protect and revive one another. This powerful intervention was operationalized as an anti-oppressive, horizontal activity through radical hospitality with a built environment that allowed PWUD to be both social and safe.

Organize and mobilize for implementation effectiveness to improve overdose education and naloxone distribution from syringe services programs: a randomized controlled trial.

BACKGROUND: The United States (US) continues to face decades-long increases in opioid overdose fatalities. As an opioid overdose reversal medication, naloxone can dramatically reduce opioid overdose mortality rates when distributed to people likely to experience or witness an opioid overdose and packaged with education on its use, known as overdose education and naloxone distribution (OEND). Syringe services programs (SSPs) are ideal venues for OEND with staff who are culturally competent in providing services for people who are at risk of experiencing or observing an opioid overdose. We carried out a randomized controlled trial of SSPs to understand the effectiveness of the organize and mobilize for implementation effectiveness (OMIE) approach at improving OEND implementation effectiveness within SSPs. METHODS: Using simple randomization, 105 SSPs were enrolled into the trial and assigned to one of two study arms - (1) dissemination of OEND best practice recommendations (Control SSPs) or the OMIE approach along with dissemination of the OEND best practice recommendations (i.e., OMIE SSPs). OMIE SSPs could participate in 60-min OMIE sessions once a month for up to 12 months. At 12-month post-baseline, 102 of 105 SSPs (97%) responded to the follow-up survey. RESULTS: The median number of sessions completed by OMIE SSPs was 10. Comparing OMIE SSPs to control SSPs, we observed significant increases in the number of participants receiving naloxone (incidence rate ratio: 2.15; 95% CI: 1.42, 3.25; p < 0.01) and the rate of naloxone doses distributed per SSP participant (adjusted incidence rate ratio: 1.97; 95% CI: 1.18, 3.30; p = 0.01). We observed no statistically significant difference in the number of adopted best practices between conditions (difference in means 0.2, 95% CI: - 0.7, 1.0; p = 0.68). We also observed a threshold effect where SSPs receiving a higher OMIE dose had greater effect sizes with regard to the number of people given naloxone and the number of naloxone doses distributed. CONCLUSIONS: In conclusion, the multifaceted OMIE approach was effective at increasing naloxone distribution from SSPs, despite substantial external shocks during the trial. These findings have major implications for addressing the overdose crisis, which has continued unabated for decades. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03924505 . Registered 19 April 2019.