A qualitative study with criminal-legal-system-involved rural Appalachians who use drugs about experiences with a harm reduction intervention

While fentanyl overdose rates are high in rural Appalachia, access to fentanyl test strips (FTS) and related research remains nascent. Here, we explore the perspectives of criminal-legal-system (CLS) involved rural Appalachian people who use drugs (PWUD) about an FTS education and distribution intervention. This qualitative study sampled CLS-involved PWUD enrolled in a harm reduction intervention that offered FTS education and distribution. The intervention was located in six rural Appalachian Kentucky counties. One-on-one semi-structured interviews queried participants’ prior experiences with FTS; their experience of the FTS intervention and use of FTS; responses to positive test results; and diffusion of FTS. Transcripts were analyzed using hybrid thematic analysis methods. Just seven of the 28 participants had heard of FTS before participating in the intervention. Participants deemed FTS essential because they were a PWUD-controlled option that prevented overdoses from occurring at all, a necessary feature in this environment where naloxone access was suboptimal and poor cell service, long travel distances, and unmapped substance-use sites rendered EMS unreliable. Of the 11 participants who reported receiving a positive FTS result, all but one reported engaging in ≥ 1 behaviors to reduce overdose risk. Eleven participants disseminated FTS to others. Suboptimal naloxone access and unreliable EMS response in this rural Appalachian environment enhanced interest in FTS. Strong social networks, a well-documented local strength, supported FTS diffusion. Future interventions should leverage these networks to extend reach. ClinicalTrials.gov ID: NCT04134767; registration date: October 19th, 2019