Dealers, Detectives, and People Who Use Drugs: Triangulating Perspectives to Understand COVID-19’s Impact on the Rural Appalachian Drug Market and Mitigate Downstream Overdose Risk

摘要：从2019年6月到2020年5月，美国有记录的服药过量死亡人数创下12年来的新高- 一个月内，与2020年3-5月首次采取控制措施时相比大幅增加 实施。这意味着从2019年到2020年，服药过量死亡人数增加了30%。 肯塔基州是阿片类药物流行的中心，与去年同期相比，过量死亡人数增加了56%。 同期：全国第二大涨幅，该州致死过量人数最多 有记录在案的。各种因素可能在这种飙升中发挥了作用。例如，居家订单 社交疏远做法可能会导致PWUD更频繁地单独使用药物--这是致命的风险因素 由于旁观者使用纳洛酮和/或呼叫急救服务的能力有限。早些时候 来自COVID数据的迹象表明，药物市场的变化可能会影响个人水平 服药过量的漏洞。在肯塔基州，从1-9月起，与芬太尼有关的过量服药死亡人数增加了102%。 与2019年同期相比，表明芬太尼在药物供应中的涌入推动了 最近服药过量的增加。为了应对干预的迫切需要，这项提议的目标是 了解COVID给非法芬太尼市场带来的变化，同时努力 确定减少危害的战略，以减少PWUD的脆弱性并培养对这些变化的复原力。这 提议是及时的，不仅因为它回应了与COVID相关的致命ODs的紧急激增，而且还因为 它与SAMHSA资助的芬太尼试纸(FTS)服务在肯塔基州大规模扩大的时期相一致。这个 建议的混合方法、社区参与的R21研究，由一个具有丰富经验的科学团队领导 在农村物质使用研究中，将产生迫切需要的关于减少危害战略的当地数据，这些数据可能 通过实现以下目标遏制阿巴拉契亚农村芬太尼相关ODs的历史性激增：目标1。 描述COVID对非法芬太尼市场的影响以及可能减少与芬太尼相关的危害 通过与州和当地法律的定性访谈，在阿巴拉契亚肯塔基州实施战略(即FTS) 执法和当地减少危害工作人员。目标2.确定农村残疾人MOST的个人特征 通过一项分析，芬太尼的使用和服药风险对冠状病毒感染前/后的变化具有脆弱性和弹性 现有的横跨冠状病毒感染前/后的纵向数据。目标3.描述COVID对当地的影响 非法芬太尼市场和服药过量风险，并探讨对潜在减少危害战略的态度(例如，FTS， 同行和经销商驱动的FTS分销)通过与毒品销售者和 在AIM 2的分析中，PWUD被确定为最脆弱和对COVID相关变化最具弹性的疾病。 苏巴伊姆3a。使用带有PRE的小型试点来检查AIM 3参与者对FTS干预的可接受性 以及为期1个月的定性访谈。

Abstract: From June 2019 to May 2020, the US saw the highest number of OD deaths ever recorded in a 12- month period, with a heightened increase from March-May 2020 when control measures were first implemented. This translated to a 30% increase in the number of overdose deaths from 2019 to 2020. Kentucky, an epicenter of the opioid epidemic, had a 56% increase in the number of overdose deaths over the same period: the second greatest increase nationwide, and the highest number of fatal overdoses the state has ever recorded. Various factors have likely played a role in this surge. For example, stay-at-home orders and social distancing practices may result in PWUD using drugs in isolation more often – a risk factor for fatal OD given the limit to bystanders’ ability to administer naloxone and/or call emergency services. Early indications from data on COVID have some positing that drug market changes may impact individual level vulnerability to OD. In Kentucky, there was a 102% increase in fentanyl-involved OD deaths from Jan-Sept 2020 compared to the same period in 2019, suggesting that an influx of fentanyl in the drug supply has driven the recent increase in ODs. In response to the urgent need for intervention, the goal of this proposal is to understand the changes in the illicit fentanyl market brought about by COVID and simultaneously work to identify harm reduction strategies to reduce PWUD vulnerability and foster resilience to these changes. This proposal is timely not only in that it responds to an urgent, COVID-related surge in fatal ODs, but also because it aligns with a period of mass scale-up of SAMHSA-funded fentanyl test strip (FTS) services in Kentucky. The proposed mixed-methods, community-engaged R21 study, led by a scientific team with extensive experience in rural substance use research, will yield urgently needed, local data on harm reduction strategies that could curb the historic spike in fentanyl-related ODs in rural Appalachia by achieving the following aims: Aim 1. Characterize COVID’s effect on the illicit fentanyl market and potential fentanyl-related harm reduction strategies (i.e., FTS) in Appalachian Kentucky through qualitative interviews with state and local law enforcement and local harm reduction staff. Aim 2. Identify individual-level characteristics of rural PWUD most vulnerable and resilient to pre-/post-COVID changes in fentanyl use and OD risk through an analysis of existing longitudinal data spanning the pre-/post-COVID period. Aim 3. Describe COVID’s impact on the local illicit fentanyl market and OD risk and explore attitudes toward potential harm reduction strategies (e.g., FTS, peer- and dealer-driven distribution of FTS) through qualitative interviews with people who sell drugs and PWUD identified as most vulnerable and most resilient to COVID-related changes in the Aim 2 analysis. Subaim 3a. Examine acceptability of an FTS intervention among Aim 3 participants using a small pilot with pre and 1-month post qualitative interviews.