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，美国的OD死亡人数是12年来有史以来最高的。 一个月期间，从2020年3月至5月首次采取控制措施以来， 切实贯彻这意味着2019年至2020年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2008年相比， 同期：全国第二大增幅，该州致命过量人数最多 有史以来记录。各种因素可能在这一激增中发挥了作用。比如说， 和社交距离的做法可能会导致PWUD更频繁地孤立使用药物-这是致命的风险因素 鉴于旁观者管理纳洛酮和/或呼叫紧急服务的能力有限，OD。早期 COVID数据显示，药品市场变化可能会影响个人水平 易受OD影响。在肯塔基州，从1月到9月， 2020年与2019年同期相比，这表明药物供应中芬太尼的涌入推动了 最近吸毒过量的增加为了应对干预的迫切需要，本提案的目标是 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，并促进对这些变化的适应能力。这 该提案是及时的，不仅因为它响应了紧急的，与COVID相关的致命OD激增，而且因为 它与SAMHSA资助的芬太尼测试条（FTS）服务在肯塔基州的大规模扩大时期相一致。的 建议采用混合方法，社区参与R21研究，由具有丰富经验的科学团队领导 在农村药物使用研究中，将产生迫切需要的关于减少危害战略的当地数据， 通过实现以下目标，遏制阿巴拉契亚农村地区芬太尼相关吸毒过量的历史性激增：目标1。 描述COVID对非法芬太尼市场的影响和潜在的芬太尼相关危害减少 策略（即，FTS）在阿巴拉契亚肯塔基州通过定性访谈与国家和地方法律 执法部门和当地的减害工作人员。目标二。最能识别农村PWUD的个人层面特征 通过对芬太尼使用和OD风险的分析， 涵盖COVID前/后时期的现有纵向数据。目标3。描述COVID对当地的影响 非法芬太尼市场和OD风险，并探讨对潜在危害减少策略的态度（例如，FTS， 同行和经销商驱动的FTS分布），通过对销售毒品和 在目标2分析中，PWUD被确定为最脆弱和最能适应COVID相关变化的地区。 Subaim 3a.使用带有预处理的小型试点检查Aim 3参与者中FTS干预的可接受性 和一个月后的定性访谈。

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.