Barriers and engagement in harm reduction among adults who use opioids: Feasibility study using social media and drug test verification.

Background and Purpose:
Opioid addiction is associated with health, economic, and social harms. Many people who use drugs utilize harm reduction strategies to reduce risk, including naloxone, syringe services, medications for opioid use disorder (MOUD) and fentanyl test strips (McDonald & Strang, 2016; Green et al., 2020). However, these strategies remain underutilized due to stigma, geographic barriers, and limited access (Noyes et al., 2022; Wilson & Brown, 2024). Little is known about how the social networks of people who use opioids influence their utilization of harm reduction strategies. This study aimed to test the feasibility of (1) using social media and mailed urine drug tests to recruit and verify opioid use among adults, and (2) collecting social network data by having participants report on three close friends or family members. The study also gathered descriptive data on substance use, harm reduction engagement, treatment history, social support, and perceived barriers.

Methods:
U.S. adults who reported non-medical opioid use in the past week and scored ≥6 on the Drug Abuse Screening Test (DAST-10) were recruited online. Participants verified opioid use via at-home urine drug testing. Eligible participants (N = 30) completed an online survey that included self-reported measures as well as questions about three members of their social network (e.g., relationship type, closeness, shared drug use, and perceived support). Descriptive analyses were conducted on participant survey data, including substance use behaviors, harm reduction engagement, and structural and interpersonal barriers.

Results:
Among 992 who accessed the survey, 89 met initial eligibility and 35 completed at-home drug tests. Thirty-two tested positive for opioids (Fentanyl: 62.5%; Morphine/Opiates: 53.1%) and 30 completed the full survey. Participants reported high rates of intravenous drug use (46.7% in past 30 days) and extensive lifetime polysubstance use. While 83.3% believed they needed treatment, only 66.7% had engaged in it within the past year. Most participants had used harm reduction strategies: naloxone (86.7%), fentanyl test strips (76.7%), and syringe services (60%). Common barriers included lack of transportation, cost, stigma, and restrictive service hours. Qualitative responses emphasized stigma, mistrust of healthcare providers, and fears of legal repercussions as deterrents. Many also described personal harm reduction strategies such as using with others nearby, testing drugs, and educating peers. Participants indicated that about half of their social network had used drugs with them (48.9%). Despite this, social network members frequently provided emotional and practical support, with some assisting with transportation, encouraging safer use, or helping participants access services. Participants described several as trusted confidants who supported their harm reduction efforts or motivated them to seek treatment.

Conclusions and Implications:
This study demonstrates the feasibility of combining digital recruitment, at-home drug testing, and ego-reported social network data to reach hidden populations of people who use opioids. Findings highlight both structural and interpersonal barriers to harm reduction. Leveraging existing social networks may be a promising strategy to enhance harm reduction engagement and support treatment pathways. Future research should explore how peer influence and support can be harnessed to increase uptake of harm reduction services and MOUD.

References
Green, T. C., Park, J. N., Gilbert, M., McKenzie, M., Struth, E., Lucas, R., Clarke, W., & Sherman, S. G. (2020). An assessment of the limits of detection, sensitivity and specificity of three devices for public health-based drug checking of fentanyl in street-acquired samples. International Journal of Drug Policy, 77, 102661. https://doi.org/10.1016/j.drugpo.2020.102661
McDonald, R., & Strang, J. (2016). Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction, 111(7), 1177–1187. https://doi.org/10.1111/add.13326
Noyes, E. A., Dunleavy, S., Mail, V., Plakas, I., Keyes, S., Gaeta, J. M., ... & Chatterjee, A. (2022). Awareness, utilization, and preferences of harm reduction interventions among street-involved young adults in Boston. Substance Use & Misuse, 57(5), 827-832. https://doi.org/10.1080/10826084.2022.2040031
Wilson, A. M., & Brown, A. R. (2024). Barriers to utilizing substance use disorder treatment and harm reduction services in Appalachia. Journal of Rural Mental Health, 48(1), 15–25. https://doi.org/10.1037/rmh0000248