CE25-149 - Enhancing Project DHARMA; evaluating a community-based drug checking navigator intervention to prevent overdoses

Fentanyl and xylazine pose new life-threatening risks to people who use drugs (PWUD), particularly in rural areas such as northern New England. In New Hampshire and Maine, 91% and 78% of overdose deaths in 2023, respectively, were attributed to fentanyl. In Maine, nearly one in ten overdose deaths involved xylazine, placing it among the states most impacted by xylazine-adulterated fentanyl. Despite the threat posed by fentanyl and xylazine, PWUD in New Hampshire and Maine have little to no access to drug checking services to inform drug-related decision-making and thus potentially reduce overdose. In Maine, our existing Project DHARMA (Distribution of Harm Reduction Access in Rural Maine Areas) team, which includes syringe service programs (SSPs), has catalyzed the passage of legislation that has made drug checking services available. However, SSPs are understaffed and the impacts of drug checking services in a rural state like Maine remain unknown. Therefore, we propose a difference-in-differences (DID) study to develop, implement, and evaluate an enhanced drug checking navigator (DCN) community-based intervention to prevent overdoses. We will compare differences in overdose prevalence in Maine, where the DCN intervention will be implemented by SSPs, to New Hampshire, where the intervention will not be implemented. We theorize that improving access to community-based drug checking programs will improve PWUD’s knowledge about their drugs, leading to a change in drug use behaviors, and ultimately cause a reduction in overdoses. Our study includes three aims. In Aim 1, we will conduct focus groups and co-design workshops with PWUD and SSP staff to ensure the DCN intervention meets the needs of PWUD and to develop the implementation strategy with tailoring, as needed, for each SSP. In Aim 2, the SSPs will implement the DCN intervention across seven Maine counties while our study team rigorously evaluates its effect on county overdose prevalence using a difference-in-differences design with six counties in New Hampshire serving as the comparison arm. The primary outcome of interest will be the annual nonfatal and fatal overdose prevalence at county-level. We will also examine several secondary outcomes that we theorize the DCN intervention may impact such as improvements in safer drug- use behaviors, linkage to health care, linkage to other SSP harm reduction services, and temporal changes in the drug supply. Finally, in Aim 3, we will use mixed methods to examine the implementation of the DCN intervention in order to understand what worked and what did not work with the approach. We will examine process outcomes such as acceptability, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. If we demonstrate its effectiveness, this DCN community-based intervention model could provide critical information on developing similar community-based interventions in other settings, such as in New Hampshire or other rural areas.