Implementing and evaluating the impact of novel mobile harm reduction services on overdose among women who use drugs: The SHOUT study.

Nearly 92,000 Americans died of drug overdoses in 2020, primarily driven by a lethal drug supply dominated by synthetic opioids (i.e., fentanyl and fentanyl analogs) and increased stimulant-related deaths. We have documented the magnitude of this epidemic experienced by women who use drugs (WWUD) (N=385) in Baltimore City, who reported high rates of experiencing an overdose (28%), witnessing a fatal overdose (35%), and witnessing a non-fatal overdose (52%) in the past 6 months. We have also documented high rates of homelessness, hunger, mental health morbidities (i.e., PTSD, depression), and chaotic drug use patterns (i.e., polysubstance use,) that indirectly and directly drive women’s distinct risk of overdose and other morbidities (i.e., HIV, HCV). Yet WWUD experience numerous barriers to receiving necessary medical and behavioral services that can reduce their risk of overdose and other morbidities, with barriers amplified by the COVID-19 pandemic. We propose conducting the SHOUT (Sustained Health-Enhancing OUTreach) study, a type 1 hybrid effectiveness-implementation design to evaluate the impact and implementation of WWUD-centered, mobile risk reduction services on nonfatal overdose and clinical care engagement among WWUD (N=400) recruited from Baltimore City and County neighborhoods new to Mobile SPARC services. Mobile SPARC is an existing low-barrier, outreach program serving other neighborhood and offers risk reduction supplies, individual counseling, and necessary referrals. The study aims to: 1) adapt and expand Mobile SPARC’s services to identify predisposing (i.e., drug use patterns) and enabling (i.e., access to trusted health services) factors that facilitate or hinder utilization of risk reduction services, employing in-depth interviews with WWUD (N=40) and key informant interviews with Mobile SPARC staff (N=5); 2) evaluate the impact of expanding Mobile SPARC on nonfatal overdose and clinical service engagement (including drug treatment) over 18 months among WWUD (N=400) recruited from neighborhoods in which Mobile SPARC will be newly implemented; and 3) to characterize the implementation of Mobile SPARC using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to inform future implementation and scale up. The SHOUT study will make a significant contribution to the literature in evaluating the impact of tailored, low-barrier mobile outreach on overdose among WWUD. The study’s relevance and sustainability will be enhanced through its partnership with SPARC, input from a community advisory board, and support of long-term collaborating organizations and health department stakeholders as well as the cost effectiveness analysis. This proposal is highly responsive to the RFA DA-22-046’s emphasis on replicable risk reduction service delivery model targeting women with elevated susceptibility of overdose.