Covid 19: 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: The COVID-19 pandemic and policies enacted primarily to reduce community transmission have had a widespread effect on all aspects of life for people across the globe. Evidence has emerged that COVID- 19 may increase people who use drugs’ (PWUD) vulnerability to fatal overdoses (ODs). In Kentucky, an epicenter of the opioid epidemic for decades, preliminary data suggests that drug-related OD deaths may have reached an all-time high in 2020. An influx of fentanyl in the drug supply has driven the recent increase in ODs; there was a 102% increase in fentanyl-related OD deaths in January-September 2020 compared to the same period in 2019. 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 COVID-19 control measures were first implemented. 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-19 have some positing that drug market changes may impact individual level vulnerability to OD. The impacts of COVID-19 on PWUD are rapidly evolving, underscoring the time-sensitive nature of needed research in this area. 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-19’s effect on the illicit fentanyl market in Appalachian Kentucky through qualitative interview with state and local law enforcement and local harm reduction staff. In addition to eliciting details on drug market changes, we will query attitudes toward potential harm reduction strategies (e.g., fentanyl test strips [FTSs]). Aim 2. Identify individual-level characteristics of rural PWUD most vulnerable and resilient to pre-/post-COVID changes in fentanyl use along or in combination with other substances through an analysis of existing longitudinal data. Aim 3. Describe COVID-19’s impact on the local illicit fentanyl market and explore attitudes toward potential harm reduction strategies 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 feasibility of an FTS intervention among a subset of Aim 3 participants using a small pilot study with baseline and 1-month post qualitative interviews.