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Objectives: Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions., Methods: We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs., Results: We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC., Conclusions: OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs., Competing Interests: Author Disclosures Author disclosure forms can be accessed in the Supplemental Material section. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies or the US government., (Copyright © 2024. Published by Elsevier Inc.)

Background: Racial/ethnic minorities have experienced disproportionate opioid-related overdose death rates in recent years. In this context, we examined inequities in community-based naloxone access across racial/ethnic groups in Massachusetts., Methods: We used data from: the Massachusetts Department of Public Health on community-based overdose education and naloxone distribution (OEND) programs; the Massachusetts Office of the Chief Medical Examiner on opioid-related overdose deaths, and; the United States Census American Community Survey for regional demographic/socioeconomic details to estimate community populations by race/ethnicity and racial segregation between African American/Black and white residents. Race/ethnicity groups included in the analysis were African American/Black (non-Hispanic), Hispanic, white (non-Hispanic), and "other" (non-Hispanic). We evaluated racial/ethnic differences in naloxone distribution across regions in Massachusetts and neighborhoods in Boston descriptively and spatially, plotting the race/ethnicity-specific number of kits per opioid-related overdose death per jurisdiction. Lastly, we constructed generalized estimating equations models with a negative binomial distribution to compare the race/ethnicity-specific naloxone distribution rate by OEND programs., Results: From 2016-2019, the median annual rate of naloxone kits received from OEND programs in Massachusetts per racial/ethnicity group ranged between 160 and 447 per 100,000. In a multivariable analysis, we found that the naloxone distribution rates for racial/ethnic minorities were lower than the rate for white residents. We also found naloxone was more likely to be distributed in racially segregated communities than non-segregated communities., Conclusion: We identified racial/ethnic inequities in naloxone receipt by individuals in Massachusetts. Additional resources focused on designing and implementing OEND programs for racial/ethnic minorities are warranted to ensure equitable access to naloxone., Competing Interests: Conflict of Interest No conflict declared., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Syringe services programs (SSPs) provide critical evidence-based public health services that decrease harms from drug use for people who use drugs (PWUD). Many SSPs have experienced significant and evolving COVID-19-related disruptions. We aimed to characterize the impacts of COVID-19 on SSP operations in the United States approximately one year into the pandemic., Methods: Participating sites, selected from a national sample of SSPs, completed a semi-structured interview via teleconference and brief survey evaluating the impacts of COVID-19 on program operations. Data collection explored aspects of program financing, service delivery approaches, linkages to care, and perspectives on engaging PWUD in services one year into the pandemic. Interview data were analyzed qualitatively using Rapid Assessment Process. Survey data were analyzed using descriptive statistics and triangulated with qualitative findings., Results: 27 SSPs completed study-related interviews and surveys between February 2021 - April 2021. One year into the pandemic, SSPs reported continuing to adapt approaches to syringe distribution in response to COVID-19, and identified multiple barriers that hindered their ability to engage program participants in services, including 1) isolation and decreased connectivity with participants, 2) resource restrictions that limit responsiveness to participant needs, 3) reduced capacity to provide on-site HIV/HCV testing and treatment linkages, and 4) changing OUD treatment modalities that were a "double-edged sword" for PWUD. Quantitative survey responses aligned with qualitative findings, highlighting increases in the number of syringes distributed, increases in mobile and home delivery services, and reductions in on-site HIV and HCV testing., Conclusion: These data illuminate persistent and cascading risks of isolation, reduced access to services, and limited engagement with program participants that resulted from COVID-19 and continue to create barriers to the delivery of critical harm reduction services. Findings emphasize the need to ensure SSPs have the resources and capacity to adapt to changing public health needs, particularly as the COVID-19 pandemic continues to evolve., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier B.V.)

Objectives: This study describes harm reduction and health services provided by U.S syringe services programs (SSPs) in 2019 and changes in provision of those services in 2020., Methods: SSPs were invited to participate in the Dave Purchase Memorial survey in August 2020. We collected programmatic data on services provided in 2019 and at the time of the survey in 2020. We conducted descriptive analyses using Chi-square and McNemar's tests., Results: At the time of the survey, > 60% of SSPs reported increased monthly syringe and naloxone distribution and expansion of home-based and mail-based naloxone delivery in Fall 2020 compared to 2019. Approximately three-quarters of SSPs decreased or stopped providing on-site HIV and HCV testing. Nearly half of SSPs offering on-site medications for opioid use disorder (MOUD) in 2019 increased provision of MOUD in 2020. The proportion of SSPs offering on-site mental health care services and primary care services statistically significantly decreased from 2019 to Fall 2020, but telehealth offerings of these services increased., Conclusions: Many SSPs that offered health services in 2019 and remained operational in 2020 increased telehealth provision of mental health and primary care services, increased MOUD provision, and expanded harm reduction services, but most SSPs reduced or stopped on-site HIV and HCV testing. Sustaining SSP growth and innovation is paramount for preventing overdose deaths and HIV/HCV outbreaks after the deadliest year of the opioid epidemic in 2020., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: In the United States, accessing sterile injection supplies remains challenging for many people who inject drugs (PWID). Although women are less likely to inject drugs than men, women who do inject are disproportionately affected by IDU-related complications. Needle Exchange Technology (NEXT), the first formal online accessed mail delivery syringe services program (SSP) in the US, may overcome access barriers. We evaluated whether NEXT was reaching women participants and people without access to other safe sources of sterile injection supplies., Methods: This cross-sectional study examined NEXT participants who enrolled in the mail-delivery SSP from February 2018 through March 2021. All NEXT participants completed an online questionnaire during enrollment, which included sociodemographic and clinical characteristics and injection-related risk factors (including prior sources of sterile injection supplies). Multivariable logistic regression (MVR) was used to examine associations between gender and prior use of safe sources of injection supplies (i.e., SSPs or pharmacies)., Results: 1,032 participants received injection supplies. Median age was 34 and participants were mostly cis-gendered women (55%) and white (93%). 34% reported infection with HCV; women were more likely to report HCV infection than men (38% vs 28%; p < 0.01). 68% of participants acquired injection supplies from less safe sources. Few participants exclusively used safe sources for injection supplies (26%). In adjusted MVR analysis, women participants had significantly lower odds than men of having exclusively used safe sources for injection supplies (adjusted OR 0.71, 95% CI 0.52, 0.98)., Conclusion: Our findings suggest that NEXT services are utilized by women and people without prior access to sterile injection supplies. Women participants were less likely than men to have exclusively used safe sources for sterile injection supplies. Future research should explore women's preference for mail-delivery over in-person SSPs and determine whether online accessed mail delivery services can reach other underserved populations of PWID., Competing Interests: Declarations of Interest Jamie Favaro is the founder of NEXT Harm Reduction, a non-profit organization whose work is highlighted in the article. Daniel Coello is the Program Coordinator for NEXT Harm Reduction. The other authors have no potential conflicts of interest to disclose., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Rates of fatal opioid overdose in Massachusetts (MA) and Rhode Island (RI) far exceed the national average. Community-based opioid education and naloxone distribution (OEND) programs are effective public health interventions to prevent overdose deaths. We compared naloxone distribution and opioid overdose death rates in MA and RI to identify priority communities for expanded OEND., Methods: We compared spatial patterns of opioid overdose fatalities and naloxone distribution through OEND programs in MA and RI during 2016 to 2019 using public health department data. The county-level ratio of naloxone kits distributed through OEND programs per opioid overdose death was estimated and mapped to identify potential gaps in naloxone availability across geographic regions and over time., Results: From 2016 to 2019, the statewide community-based naloxone distribution to opioid overdose death ratio improved in both states, although more rapidly in RI (from 11.8 in 2016 to 35.6 in 2019) than in MA (from 12.3 to 17.2), driven primarily by elevated and increasing rates of naloxone distribution in RI. We identified some urban/non-urban differences, with higher naloxone distribution relative to opioid overdose deaths in more urban counties, and we observed some counties with high rates of overdose deaths but low rates of naloxone kits distributed through OEND programs., Conclusions: We identified variations in spatial patterns of opioid overdose fatalities and naloxone availability, and these disparities appeared to be widening in some areas over time. Data on the spatial distribution of naloxone distribution and opioid overdose deaths can inform targeted, community-based naloxone distribution strategies that optimize resources to prevent opioid overdose fatalities., Competing Interests: Declarations of Interest The authors have no conflicts of interest to declare., (Copyright © 2021. Published by Elsevier B.V.)

Background: Hepatitis C (HCV) is the most common infectious disease among people who inject drugs (PWID). Engaging PWID in harm reduction services, such as syringe service programs (SSPs), is critical to reduce HCV and HIV transmission. Additionally, testing for HIV and HCV among PWID is important to improve diagnosis and linkage to care. On March 1, 2018, Florida's only legal SSP implemented bundled opt-out HIV/HCV testing at enrollment. We aimed to examine the differences in HIV/HCV testing uptake before and after the implementation of the opt-out testing policy., Methods: Multivariable logistic regression was used to assess predictors of accepting HIV/HCV tests, controlling for opt-in and opt-out policy. Monthly estimates of the percent of participants accepting an HIV test, HCV test, or both were generated. Interrupted Time Series (ITS) analysis evaluated the immediate policy impact on level of uptake and trend in uptake over time for bundled HIV/HCV testing before and after the opt-out testing policy., Results: The total study period was 37 months between December 2016-January 2020 with 512 SSP participants 15 months prior and 547 SSP participants 22 months after implementation of bundled HIV/HCV opt-out testing. Significant predictors of accepting both HIV/HCV tests were cocaine injection (aOR = 2.36), self-reported HIV positive status (aOR = 0.39) and self-reported HCV positive status (aOR = 0.27). Based on the ITS results, there was a significant increase in uptake of HIV/HCV testing by 42.4% (95% CI: 26.2%-58.5%, p < 0.001) immediately after the policy change to opt-out testing., Conclusion: Bundled opt-out HIV/HCV testing substantially increased the percentage of SSP clients who received HIV and HCV rapid tests at enrollment into the program, and the effect remained stable across the 22 months post opt-out testing policy. Future investigation must assess PWID-level perspective of testing preferences and examine whether this testing approach improves HIV/HCV detection among PWID previously unaware of their status., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: We evaluated the cost-effectiveness of a hepatitis C (HCV) screening and active linkage to care intervention in US methadone maintenance treatment (MMT) patients using data from a randomized trial conducted in New York City and San Francisco., Methods: We used a decision analytic model to compare 1) no intervention; 2) HCV screening and education (control); and 3) HCV screening, education, and care coordination (active linkage intervention). We also explored an alternative strategy wherein HCV/HIV co-infected participants linked elsewhere. Trial data include population characteristics (67% male, mean age 48, 58% HCV infected) and linkage rates. Data from published sources include treatment efficacy and HCV re-infection risk. We projected quality-adjusted life years (QALYs) and lifetime medical costs using an established model of HCV (HEP-CE). Incremental cost-effectiveness ratios (ICERs) are in 2015 US$/QALY discounted 3% annually., Results: The control strategy resulted in a projected 35% linking to care within 6 months and 31% achieving sustained virologic response (SVR). The intervention resulted in 60% linking and 54% achieving SVR with an ICER of $24,600/QALY compared to no intervention from the healthcare sector perspective and was a more efficient use of resources than the control strategy. The intervention had an ICER of $76,500/QALY compared to the alternative strategy. From a societal perspective, the intervention had a net monetary benefit of $511,000-$975,600., Conclusions: HCV care coordination interventions that include screening, education and active linkage to care in MMT settings are likely cost-effective at a conventional $100,000/QALY threshold for both HCV mono-infected and HIV co-infected patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)