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Background: Rural communities in the United States have been disproportionately affected by the opioid crisis. Little research has explored the relationship between polysubstance use and overdose experiences among people who inject drugs (PWID) in rural communities. We sought to identify classes of polysubstance drug use among rural PWID and evaluate the associations between polysubstance drug use classes, recent overdose experiences, and receipt of take-home naloxone (THN)., Methods: We surveyed 420 PWID (June-July 2018) who had injected drugs in the previous 6 months in Cabell County, West Virginia. Participants were recruited from the local syringe services program and through street-based recruitment. We conducted a latent class analysis using 9 measures of injection and non-injection drug use and tested for associations with having experienced an overdose in the past 6 months and having received THN in the past 6 months., Results: We identified four substance use classes in our sample: polydrug/polyroute use (35.0% of the sample), polyroute stimulant/injection opioid use (33.3%), polyroute stimulant use (20.3%), and injection opioid use (11.3%). Overall, 42.6% of the sample had experienced an overdose in the past 6 months. The classes differed in terms of overdose (χ=91.53, p<0.001), with the polydrug/polyroute use class having the highest probability of overdose and the polyroute stimulants class having the lowest. Only 46.5% of participants had received THN, and probabilities differed between classes (χ=21.93, p<0.001). The polyroute stimulants/injection opioid use and polydrug/polyroute use classes had the highest levels of THN receipt while the polyroute stimulants use class had the least., Conclusion: Among rural PWID in West Virginia, polysubstance use was prevalent and associated with overdose and THN acquisition. These analyses demonstrate the importance of scaling up naloxone distribution in rural settings. Overdose prevention initiatives are reaching persons at high risk of overdose, but expansion of services is needed., Competing Interests: Declaration of Competing Interest Dr. Susan G. Sherman is an expert witness for plaintiffs in opioid litigation. No other authors have competing interests to disclose., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Overdose fatality rates in rural areas surpass those in urban areas with the state of West Virginia (WV) reporting the highest drug overdose death rate in 2017. There is a gap in understanding fentanyl preference among rural people who inject drugs (PWID). The aim of this study is to investigate factors associated with fentanyl preference among rural PWID in WV. Methods: This analysis uses data from a PWID population estimation study conducted in Cabell County, WV in June-July 2018. Factors associated with fentanyl preference were assessed using multivariable Poisson regression with a robust variance estimate. Results: Among PWID who reported having ever used fentanyl ( n  = 311), 43.4% reported preferring drugs containing fentanyl. Participants reported high levels of socioeconomic vulnerability, including homelessness (57.9%) and food insecurity (66.9%). Recent increases in drug use and injecting more than one drug in the past 6 months were reported by 27.0% and 84.2% of participants, respectively. In adjusted analyses, fentanyl preference was associated with being younger (PrR:0.98, 95% CI: 0.97-1.00), being female (PrR:1.45, 95% CI:1.14-1.83), being a Cabell county resident (PrR:0.60, 95% CI: 0.45-0.81), increased drug use in the past 6 months (PrR:1.28, 95% CI: 1.01-1.63), and injecting fentanyl in the past 6 months (PrR:1.89, 95% CI: 1.29-2.75). Conclusion: Fentanyl preference is highly prevalent among rural PWID in WV and associated with factors that may exacerbate overdose risks. There is an urgent need for increased access to tailored harm reduction services that address risks associated with fentanyl preference.

Aim: Safe consumption spaces (SCS) are indoor environments in which people can use drugs with trained personnel on site to provide overdose reversal and risk reduction services. SCS have been shown to reduce fatal overdoses, decrease public syringe disposal, and reduce public drug consumption. Existing SCS research in the USA has explored acceptability for the hypothetical use of SCS, but primarily among urban populations of people who inject drugs (PWID). Given the disproportionate impact of the opioid crisis in rural communities, this research examines hypothetical SCS acceptability among a rural sample of PWID in West Virginia., Methods: Data were drawn from a 2018 cross-sectional survey of PWID (n = 373) who reported injection drug use in the previous 6 months and residence in Cabell County, West Virginia. Participants were asked about their hypothetical use of a SCS with responses dichotomized into two groups, likely and unlikely SCS users. Chi-square and t tests were conducted to identify differences between likely and unlikely SCS users across demographic, substance use, and health measures., Results: Survey participants were 59.5% male, 83.4% non-Hispanic White, and 79.1% reported likely hypothetical SCS use. Hypothetical SCS users were significantly (p < .05) more likely to have recently (past 6 months) injected cocaine (38.3% vs. 25.7%), speedball (41.0% vs. 24.3%), and to report preferring drugs containing fentanyl (32.5% vs. 20.3%). Additionally, likely SCS users were significantly more likely to have recently experienced an overdose (46.8% vs. 32.4%), witnessed an overdose (78.3% vs. 60.8%), and received naloxone (51.2% vs. 37.8%). Likely SCS users were less likely to have borrowed a syringe from a friend (34.6% vs. 48.7%)., Conclusions: Rural PWID engaging in high-risk behaviors perceive SCS as an acceptable harm reduction strategy. SCS may be a viable option to reduce overdose fatalities in rural communities.