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

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.