Jerel M. Ezell

Objective: To evaluate the effectiveness and implementation of a multicomponent intervention to address the burden of drug use–related infectious diseases and overdose in rural settings. Design: Single-arm hybrid implementation-effectiveness design. Setting: Rural area comprising the Illinois counties of the Delta Regional Authority. Participants: People who use opioids and/or stimulants nonmedically. Intervention: Expansion of community-based harm reduction services, capacity-building for opioid use disorder and hepatitis C treatment. Main Outcome Measures: Harm reduction service expansion intervention Reach, Effectiveness (injection equipment sharing), Adoption and Cost (per participant and budget impact analysis). Results: Three hundred six people who use drugs were enrolled. Of the 207 of who were not previously engaged in harm reduction services, 121 (59%) accepted referral and were retained in services at 6 months past study enrollment (intervention reach). In regards to intervention efficacy, among these individuals, 41 (35%) completed follow-up surveys; compared with their baseline self-report, there was a significant increase in obtaining sterile equipment from the harm reduction organization (43.9% vs. 68.3%, P = 0.03) and decrease in sharing injection equipment (46.3%–19.5%, P = .02). The harm reduction organization experienced an increase of approximately 100–550 program participants and an increase in service delivery area coverage from 1258 to 5509 square miles after intervention implementation (adoption). Cost per participant served by the harm reduction organization was $1486 per year, with annual budget impact to the program of $817 295. In regards to treatment capacity building, a total of 80 providers in the study area completed training in opioid use and/or hepatitis C management. Conclusion: The pragmatic evaluation of harm reduction service expansion supported by a suite of implementation strategies serves to inform the practical considerations and decision-making by community-based organizations seeking to increase services in rural areas heavily affected by substance use, overdose, and related infectious diseases.

Introduction: In recent years, higher rates of overdose deaths have been observed among Black individuals in the United States compared to individuals who are white or other races, as part of the potent fourth wave of the opioid epidemic. However, much of the research addressing this surge has focused on Black individuals in urban areas, despite evidence that usage and overdose rates are accelerating among rural Black People Who Use Drugs (PWUD), a gap we aim to fill here via a qualitative assessment. Methods: Between September 2023 and June 2024, we conducted semi-structured interviews with a sample of Black adult PWUD who live in rural southern Illinois. The interviews were evaluated using abductive analytic methods. Findings: In general, participants highlighted exposure to parental substance use and poor mental health as key factors contributing to drug use initiation. Participants further described their social networks as small, emphasizing a desire to stay hidden to avoid social scrutiny. Finally, participants had mixed feelings about the nature and value of medications for opioid use disorder (e.g., buprenorphine, methadone, etc.) and expressed limited knowledge about where to access harm reduction resources like naloxone. Conclusions: Rural Black PWUD may experience complex early-life exposures to substance use and later-life challenges in terms of communal integration due to stigma and structural disenfranchisment. These dynamics may specifically prevent the manifestation of strong support networks and engagement with treatment and harm reduction.