A Scoping Review of Syringe Service Programs and Naloxone Distribution in Rural Areas Following COVID-19

Background and Purpose: Overdose deaths have risen significantly in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities yet less is known about harm reduction services in rural settings, especially following the COVID-19 pandemic. We undertook a scoping review to highlight the state of knowledge around rural harm reduction services, specifically for syringe service programs and naloxone distribution for people who use drugs (PWUD), to identify barriers and facilitators of providing rural harm reduction services following the onset of COVID-19.

Methods: This scoping review scanned literature using PsycINFO, Web of Science, and PubMed databases (April, 2024). Articles meeting inclusion criteria involved rural samples or conducted urban/rural comparisons with data collected post March, 2020, that describe a syringe service or naloxone distribution program, service, or intervention aimed at facilitating access to harm reduction services following the COVID-19 pandemic. Harm reduction programs of focus were syringe service programs and naloxone distribution programs as these are commonly implemented harm reduction approaches in rural areas with evidence-based effectiveness. Abstracts were screened by a team of reviewers. Relevant studies were read in full by three reviewers and those that met inclusion criteria underwent final data extraction and synthesis (n=7). We used a narrative synthesis approach to identify major themes around key harm reduction service modifications and innovations implemented for rural communities.

Results: Reviewed articles spanned settings in the rural US (Appalachia 2 [28%]; Southeast 1 [14%]; Pacific Northwest 1 [14%]; Northeast 1 [14%]; and Pacific Coast 1 [14%]) and a range of settings from syringe service programs to naloxone outreach programs. All articles (N=7) included noted that drug use increased during the pandemic and the associated risks were increased due to disruptions in the drug supply, drug use in isolation, and further saturation of fentanyl in unregulated rural drug markets. Innovative service naloxone distribution modifications to adapt to COVID-19 circumstances primarily involved expanded use of needs-based service delivery, embedding naloxone distribution efforts into the broader rural healthcare environment, and pairing naloxone distribution with non-stigmatizing health and policy information to consumer. Of the three articles exploring SSP operational impacts from the pandemic, two acknowledged that rapid implementation of COVID-19 policy and practice changes improved service delivery – such as, expanded syringe delivery services and secondary exchange of syringed among PWUDs. All three SSP studies noted the pandemic’s impacts on SSP participants, which included two articles highlighting participants’ struggles with isolation and loneliness, one referencing the fear of exposure to COVID-19, and two examining the overall negative psychological effects experienced during this time. Two studies mentioned that the use of applications of research evidence improved attitudes among providers and facilitated policy changes during COVID-19.

Conclusion: This study provides an overview of rural harm reduction service implementation and modification during and after the COVID-19 pandemic. The included articles provide rich information to guide rural health planning and intervention development and highlights the lack of available data specific to the rural context. Recommendations for practice, policy, and future research will be discussed.