Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Overcoming stigma: Community support for overdose prevention sites

Overdose prevention sites (OPS) are beginning to be examined for their feasibility of implementation in the United States to curb the fatality of overdoses. Support for these sites varies greatly and can impact local policy, implementation, and the long-term viability of such programs. This study examined two communications strategies - research and anecdotal evidence - and their effect on public support for an OPS. One group (n= 106) was presented with a summary of research evidence for the efficacy of implementing an OPS in their community. The other group (n= 109) received similar information framed as personal anecdotes from people who use drugs (PWUD), people who work with PWUD, and community members of neighborhoods with an OPS. Communicating the efficacy of OPS as research evidence was associated with increased support for implementation and a decreased belief that an OPS will attract crime. Lower stigma towards PWUD was also associated with increased support. However, neither condition was associated with changes in stigma towards PWUD. Jurisdictions implementing OPS should utilize research evidence in communicating the program proposal to the public. Further research is needed regarding best practices for reducing stigma towards PWUD and the subsequent support for the implementation of an OPS.

Syringe Services Programs to Reduce Intravenous Disease Transmission in Substance Use Disorders

Syringe services programs (SSPs) are evidence-based programs. SSPs are integral in preventing bloodborne diseases while increasing access to care and reducing drug overdose deaths. SSPs are often the only source of health care for people who use drugs. Several states in the United States support and offer community-based SPPs; however, US prisons do not offer such programs to those incarcerated. Nurses are bridging the gap in support of SSPs and are being backed by organizations such as the American Nurses Association and the Association of Nurses in AIDS Care.

A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives

PURPOSE

As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success.

METHODS

Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data.

FINDINGS

Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

Barriers to engaging people who use drugs in harm reduction services during the COVID-19 pandemic: A mixed methods study of syringe services program perspectives

BACKGROUND

Syringe services programs (SSPs) provide critical evidence-based public health services that decrease harms from drug use for people who use drugs (PWUD). Many SSPs have experienced significant and evolving COVID-19-related disruptions. We aimed to characterize the impacts of COVID-19 on SSP operations in the United States approximately one year into the pandemic.

METHODS

Participating sites, selected from a national sample of SSPs, completed a semi-structured interview via teleconference and brief survey evaluating the impacts of COVID-19 on program operations. Data collection explored aspects of program financing, service delivery approaches, linkages to care, and perspectives on engaging PWUD in services one year into the pandemic. Interview data were analyzed qualitatively using Rapid Assessment Process. Survey data were analyzed using descriptive statistics and triangulated with qualitative findings.

RESULTS

27 SSPs completed study-related interviews and surveys between February 2021 - April 2021. One year into the pandemic, SSPs reported continuing to adapt approaches to syringe distribution in response to COVID-19, and identified multiple barriers that hindered their ability to engage program participants in services, including 1) isolation and decreased connectivity with participants, 2) resource restrictions that limit responsiveness to participant needs, 3) reduced capacity to provide on-site HIV/HCV testing and treatment linkages, and 4) changing OUD treatment modalities that were a "double-edged sword" for PWUD. Quantitative survey responses aligned with qualitative findings, highlighting increases in the number of syringes distributed, increases in mobile and home delivery services, and reductions in on-site HIV and HCV testing.

CONCLUSION

These data illuminate persistent and cascading risks of isolation, reduced access to services, and limited engagement with program participants that resulted from COVID-19 and continue to create barriers to the delivery of critical harm reduction services. Findings emphasize the need to ensure SSPs have the resources and capacity to adapt to changing public health needs, particularly as the COVID-19 pandemic continues to evolve.

Use of laboratory data for illicit drug use surveillance and identification of socioeconomic risk factors

BACKGROUND

Drug overdose is the leading cause of death among people 25-44 years of age in the United States. Existing drug surveillance methods are important for prevention and directing treatment, but are limited by delayed reporting and lack of geographic granularity.

METHODS

Laboratory urine drug screen and complete metabolic panel data from patients presenting to the emergency department was used to observe long-term and short-term temporal and geospatial changes at the zip code-level in St. Louis. Multivariate linear regression was performed to investigate associations between zip code-level socioeconomic factors and drug screening positivity rates.

RESULTS

An increase in the fentanyl positive drug screens was seen during the initial COVID-19 shutdown period in the spring of 2020. A decrease in cocaine positivity was seen in the fall and winter of 2020, with a return to baseline coinciding with the second major COVID-19 shutdown in the summer of 2021. These changes appeared to be independent of changes in emergency department utilization as measured by complete metabolic panels ordered. Significant short-term changes in fentanyl and cocaine positivity rates between specific time periods were able to be localized to individual zip codes. Zip code-level multivariate analysis demonstrated independent associations between socioeconomic/demographic factors and fentanyl/cocaine positivity rates as determined by laboratory drug screening data.

CONCLUSIONS

Analyzing clinical laboratory drug screening data can enable a more temporally and geographically granular view of population-level drug use surveillance. Additionally, laboratory data can be utilized to find population-level socioeconomic associations with illicit drug use, presenting a potential avenue for the use of this data to guide public health and healthcare policy decisions.

Opioid Use Stigma: An Examination of Student Attitudes on Harm Reduction Strategies

Understanding how the public views harm reduction strategies may help inform researchers on how to reduce related stigma and barriers to help-seeking. The current study explored whether stigma towards those who use opioids was affected by gender and type of harm reduction strategy used. Undergraduate students (N = 328) were randomly assigned to read one of six vignettes varying by gender and the type of harm reduction strategy: no harm reduction, opioid agonist therapy (OAT), or safe consumption sites (SCSs). Results demonstrated that participants were less stigmatizing towards the character who engaged in OAT compared to the character with no harm reduction. There was also a pattern demonstrating that SCSs may be perceived more negatively than OAT, although these differences only met conventional significance, not adjusted/corrected alphas. There were no significant effects for gender. Qualitative results revealed that participants held misconceptions about harm reduction. Implications and future directions are discussed.

Families in Crisis: The Relationship Between Opioid Overdoses and Child Maltreatment in Neighborhood Areas

OBJECTIVE

The increase in the use of opioids in Ohio is believed to have contributed to a crisis within county child welfare agencies throughout the state. Prior research has found a connection between opioid use and child abuse and neglect, but no previous studies have examined the relationship between opioid overdoses and child maltreatment rates at the neighborhood level.

METHOD

The sample is 9,231 Census block groups in Ohio for 2015. Bayesian conditionally autoregressive models were used to examine the relationship between naloxone administrations (as a proxy for overdose) and child maltreatment. We controlled for variables representing social disorganization characteristics including unemployment, racial/ethnic heterogeneity, and vacant housing rates. We specifically examined child maltreatment referrals per child population and child maltreatment substantiations per child population.

RESULTS

Higher rates of naloxone administration by emergency medical services were related to higher rates of referrals for child welfare investigations (relative risk = 1.0026) and substantiations (relative risk = 1.0027) at the block group level. Neighborhoods located in Appalachia with higher rates of overdoses were at greater risk for experiencing more referrals for child welfare investigations (relative risk = 1.0043).

CONCLUSIONS

As communities continue to struggle with containing opioid misuse and reducing opioid overdose deaths, they must also contend with addressing problems that may arise from overdoses, including child abuse and neglect. Our findings suggest that the relationship between overdoses and maltreatment occurs at a much smaller spatial scale than has previously been observed. This may allow resources to be targeted more effectively within counties and communities.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Attitudes toward syringe exchange programs in a rural Appalachian community

OBJECTIVES

To evaluate community attitudes concerning syringe exchange programs (SEPs) in a rural community as part of an effort to implement evidence-based harm reduction strategies and improve health outcomes related to opioid use disorder.

METHODS

Dissemination of a 24-item survey to individuals living in a rural community followed by comparative analysis of survey results based on support for SEPs.

RESULTS

Three hundred and sixty-one individuals responded. Overall, 49.3% of respondents indicated support for syringe exchange. Individuals who support syringe exchange as a harm reduction service are more likely to: agree that opioid use disorder is a real illness (p < 0.0001); agree that anyone can become addicted to pain medications (p = 0.01); agree that medication assisted treatment is effective (p < 0.0001); agree that individuals with OUD have the same right to a job (p < 0.0001); be willing to administer naloxone to a stranger (p < 0.0001); support HIV and HCV screening (p < 0.0001), condom distribution (p < 0.0001), and medication for opioid use disorder (p < 0.0001). They are less likely to believe that harm reduction services encourage drug use (p < 0.0001).

CONCLUSIONS

Positive correlations exist between support for SEPs, awareness of OUD as a chronic illness, less stigmatizing attitudes toward individuals with OUD, and support for other harm reduction strategies. Efforts to increase awareness of OUD as a chronic illness may lead to greater acceptance of harm reduction strategies in rural areas, easing evolution of evidence-based healthy policy.

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky

BACKGROUND

Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study's purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky.

METHODS

We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory.

RESULTS

Stigma, a feature of IREF's meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID's individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment.

CONCLUSIONS

Features of the social and healthcare environments operating at the meso-level, as well as PWID's individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.

Geographic Differences and Social Determinants of Health Among People With HIV Attributed to Injection Drug Use, United States, 2017

OBJECTIVE

People who inject drugs are among the groups most vulnerable to HIV infection. The objective of this study was to describe differences in the geographic distribution of HIV diagnoses and social determinants of health (SDH) among people who inject drugs (PWID) who received an HIV diagnosis in 2017.

METHODS

We used data from the National HIV Surveillance System (NHSS) to determine the counts and percentages of PWID aged ≥18 with HIV diagnosed in 2017. We combined these data with data from the US Census Bureau's American Community Survey at the census tract level to examine regional, racial/ethnic, and population-area-of-residence differences in poverty status, education level, income level, employment status, and health insurance coverage.

RESULTS

We observed patterns of disparity in HIV diagnosis counts and SDH among the 2666 PWID with a residential address linked to a census tract, such that counts of HIV diagnosis increased as SDH outcomes became worse. The greatest proportion of PWID lived in census tracts where ≥19% of the residents lived below the federal poverty level, ≥18% of the residents had <high school diploma, the median annual household income was <$40 000, and ≥16% of the residents did not have health insurance or a health coverage plan.

CONCLUSION

To our knowledge, our study is the first large-scale, census tract-level study to describe SDH among PWID with diagnosed HIV in the United States. The findings of substantial disparities in SDH among people with HIV infection attributed to injection drug use should be further examined. Understanding the SDH among PWID is crucial to reducing disparities in HIV diagnoses in this population.

Pharmacists' nonprescription syringe dispensing perceptions and behaviors: A three-state descriptive analysis

BACKGROUND

One approach to increasing the reach of syringe programs in rural areas could be through provision of syringes at community pharmacies. This study evaluated relationships between state-specific syringe policies, pharmacy, and pharmacist characteristics and pharmacists' nonprescription syringe dispensing behaviors in a 3- state Appalachian region at high risk for HIV and HCV transmission.

METHODS

We conducted a telephone census of community pharmacies in the Appalachian counties of North Carolina, Tennessee, and Virginia from April-June 2018. Behaviors studied included having ever sold syringes without a prescription, quantity of individuals to whom nonprescription syringes were dispensed in the past 30 days, having ever denied a request for nonprescription syringes, and past 30-day denial of nonprescription syringe requests. Behavioral intention and perceptions of legality were elicited.

RESULTS

A response rate of 52.3 % was achieved (N = 391). North Carolina pharmacists reported increased past 30-day dispensing, less denial of nonprescription syringe requests, and decreased justification for syringe dispensing (proof of medical need) as compared to Tennessee and Virginia pharmacists. Behavioral intention to dispense did not vary by state but did vary by political affiliation. Perceptions of syringe dispensing legality in NC were significantly different from those in TN and VA.

CONCLUSIONS

Significant differences in pharmacists' perceptions and behaviors were noted across state lines with North Carolina pharmacists reporting more engagement in syringe dispensing as compared to pharmacists in Tennessee and Virginia. Policy allowing pharmacists to dispense syringes to people who inject drugs appears to foster some but not all pharmacist engagement in this harm reduction intervention.

Community Perceptions of Comprehensive Harm Reduction Programs and Stigma Towards People Who Inject Drugs in Rural Virginia

The spread of infectious diseases, including Human Immunodeficiency virus and Hepatitis C virus, is a major risk of injection drug use. The Center for Disease Control's 2015 ranking of counties vulnerable to rapid dissemination of HIV/HCV infection among people who inject drugs (PWID) places Dickenson County, Virginia at 29th in the nation and 2nd in Virginia. Comprehensive Harm Reduction is an evidence-based intervention shown to reduce the negative impacts of drug use including the spread of infectious diseases, overdose and death among people who are unable or not ready to stop using drugs. The aim of this study was to assess community perceptions of comprehensive harm reduction programs and stigma towards PWID in a rural community. Data were collected through the use of an anonymous survey and interviews with community stakeholders. Surveys were distributed online through email and social media, as well as in person. Participants were included based on their zip code as an indicator of residence in Dickenson County. Statistical analysis of survey results was conducted using Sigma Plot. The survey was completed by 153 participants. The perception of PWID in rural Virginia is strikingly negative. Participants consider injection drug use a major problem in their community but have little to no knowledge of harm reduction programs and display high levels of stigma towards PWID. Additionally, higher levels of stigma towards PWID was associated with lower support for CHR programs. The results of this study show a definite and perceived need for harm reduction programs in rural Virginia. Challenges to implementing harm reduction programs include low levels of knowledge and high levels of stigma.

Community Perceptions of Harm Reduction and Its Implications for Syringe Exchange Policy

In the United States, the rising prevalence of opioid addiction has led to an increase in opioid-related overdose deaths and transmission of infectious disease. This resulted in the declaration of a national public health emergency and the need for harm reduction strategies such as syringe exchange. Florida has seen increases in blood-borne diseases and fatal/nonfatal opioid overdoses, yet harm reduction policy integration has been historically limited. To inform policy change, this study explores the perspectives of community members in Manatee County, Florida, on harm reduction services. Six focus groups were conducted with findings centralized around three emergent themes related to the implementation of a syringe exchange program: (a) awareness and acceptability; (b) facilitating factors; and (c) perceived barriers. The results of this qualitative research helped to inform the successful adoption of a local syringe exchange ordinance. Recommendations for community education and engagement regarding harm reduction policy are discussed.

Chronic prescription opioid use predicts stabilization on buprenorphine for the treatment of opioid use disorder

INTRODUCTION

Prescription opioid misuse is a risk factor for opioid use disorder (OUD). Patients who misuse prescribed opioids and those who misuse illicit opioids are demographically and medically distinct groups, and research has shown there is heterogeneity in treatment response between these groups. The objective of this study was to measure the adjusted odds of successful stabilization on buprenorphine in patients with baseline prescription opioid use compared to those not prescribed opioids.

METHODS

A cohort of patients newly prescribed a buprenorphine product indicated for OUD between January 1 and November 30, 2018, were identified from the Texas Prescription Monitoring Program. We excluded those under the age of 15 and those who filled an opioid prescription after initiating buprenorphine to limit misclassification. We then stratified the cohort based on type of prescription opioid use in the pre-index period. We defined chronic opioid use as being prescribed opioids for a period of 90 out of 120 days, ending no sooner than 90 days prior to treatment initiation. We defined acute opioid use as filling any opioid prescription in the 90 days prior to initiating buprenorphine. The outcome of interest-stabilization on buprenorphine-was met by filling two prescriptions totaling 30-days' supply with no more than a six-day gap in therapy. We used multiple logistic regression to estimate the odds of stabilization in the prescription opioid use categories compared to those with no pre-index, opioid prescriptions.

RESULTS

Among 6756 eligible patients, 44.1% used prescription opioids in the 90 days prior to buprenorphine initiation. Of these, 62.2% met the criteria for acute prescription opioid use and 37.8% for chronic prescription opioid use. Patients with prescription opioid use at baseline were more likely to be older and insured compared to those with no prescription opioid use. After adjustment for covariates, both prescription opioid use groups were significantly more likely to be successfully stabilized on therapy (Acute: aOR = 1.53, 95% CI = 1.37-1.72; Chronic: aOR = 2.43, 95% CI = 2.08-2.85). In a second model, those with chronic prescription opioid use were significantly more likely than those with acute prescription opioid use to be successfully stabilized (aOR = 1.60, 95% CI = 1.31-1.90).

CONCLUSION

Persistence to buprenorphine treatment for OUD is, in part, dependent on baseline prescription opioid use. This study suggests that patients with chronic prescription opioid use may be more likely than nonprescription opioid users to be successfully stabilized on treatment and may thus benefit more from pharmacotherapy with buprenorphine than those with no prescription opioid use. Failing to account for this variation in future studies of buprenorphine treatment persistence may lead to significant residual confounding and biased results. Extending access to buprenorphine among those with prescription OUD may have a significant impact on opioid related morbidity and mortality.

Syringe Service Program Utilization, Barriers, and Preferences for Design in Rural Appalachia: Differences between Men and Women Who Inject Drugs

Background People who inject drugs (PWID) in rural areas of the United States have had limited access to syringe service programs (SSP). Rural SSP have recently surged, but accompanying research is lacking about PWID utilization, barriers, and preferences for SSP design and how those preferences vary by gender. Methods: Interviewer-administered surveys elicited information about utilization, barriers, and preferences for SSP design from 234 PWID recruited using respondent-driven sampling in Appalachian, Kentucky. Gender differences among reported barriers to utilizing SSP and preferences for program design were explored using Mantel-Haenszel chi-square tests. Results: Overall, 49% of PWID had ever utilized an SSP. The most common reasons for not utilizing an SSP were lack of awareness (23%), fear of being seen or disclosing drug use (19%), and lack of need (19%). The most preferred SSP design was located within a health department (74%) and operating during afternoon hours (66%). Men were more likely than women to prefer SSP in health departments (80% vs. 65%, p = 0.01), while more women than men preferred staffing by health department personnel (62% vs. 46%, p = 0.02). Women were less likely to favor evening hours (55% vs. 70%, p = 0.02). Fewer women wanted SSP nurses (78% vs. 90%, p = 0.01), social workers (11% vs. 24%, p = 0.01), or people who use drugs (20% vs 34%, p = 0.02) to staff SSP. Conclusions: Despite recent scale-up, SSP in Appalachia remain under-utilized. PWID were open to a range of options for SSP design and staffing, though there were variations by gender. Implementation research that identifies best strategies for tailored SSP scale-up in rural settings should be considered.

The impact of rurality on opioid-related harms: A systematic review of qualitative research

INTRODUCTION

Over the past decade, there has been mounting recognition that opioid use and related mortality and morbidity is a significant public health problem in rural, non-urban areas across the globe. Taking what has been termed the 'opioid crisis' as a starting off point, this article aims to systematically review the qualitative literature on the ways in which rurality shapes the risk for opioid-related harm.

METHODS

A systematic review was undertaken using database searches and secondary reference list searches for qualitative literature on rural and non-urban opioid-related harms. A total of 32 qualitative studies met the inclusion criteria. Data extraction was performed in NVivo 12 using a codebook based on the 'risk environment' framework.

RESULTS

The findings explore how rurality shapes the risk environment for opioid-related harms through four environment influences: (1) economic conditions, including economic transition and deindustrialisation that has occurred in many rural areas, and the high levels of economic distress experienced by rural residents; (2) physical conditions, including a lack of infrastructure and recreation opportunities, larger geographic distances, and limited transportation; (3) social conditions, where social networks could be both protective but also amplify risk through a lack of knowledge about treatment and risk behaviours, a lack of anonymity and stigmatisation of people who use opioids in rural areas; and (4) policy conditions including limited coverage and availability of harm reduction and drug treatment services, and stigmatising service provider practices.

CONCLUSIONS

The impact of rurality on risk of opioid-related harm is multifaceted. We suggest that future research on rural opioid use would benefit from drawing on the theoretical toolkit of rural criminology to attend to the ways the 'rural crisis', and attendant insecurities, anxieties and strains, impacts upon rural communities and shapes risk, along with how socio-cultural characteristics of the rural 'organise' risks of drug use.

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Background

Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic.

Objective

Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP).

Methods

We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire.

Results

The median number of barriers reported was 5 (range 0–19). Fear of arrest by police (72% of PWID “agreed” or “strongly agreed”) and difficulty with purchasing needles from a pharmacy (64% “agreed” or “strongly agreed”) were the most frequently cited barriers.

Conclusions/Importance

Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0295-5) contains supplementary material, which is available to authorized users.