The opioid overdose epidemic continues unabated, further exacerbated by the rise of synthetic opioids and the COVID-19 pandemic (Humphreys et al., 2022). Fatal overdoses rose by nearly 40% in the United States from 2019 to 2020, and disproportionately among Black individuals (Friedman and Hansen, 2022; Humphreys et al., 2022). In response to pandemic-related disruptions, many countries relaxed regulations on opioid use disorder treatment. These policy changes paved the way for a variety of low-barrier treatment options, such as telehealth, home delivery, and mobile outreach units, strategies that continue to engage individuals into care three years into the pandemic (Krawczyk et al., 2021).
Harm reduction is an important approach for responding to the latest surge in opioid use-related morbidity and mortality (Karamouzian et al., 2020). Harm reduction for substance use disorder includes evidence-based, pragmatic strategies to help individuals manage and mitigate the risk associated with their substance use and, for some, increase their readiness for treatment (Marlatt et al., 2012). These strategies include education about safe drug use, providing safe injection and safe sex supplies, syringe exchange programs, and supervised injection facilities (Ayon et al., 2018; Ritter and Cameron, 2006). Harm reduction strategies improve healthcare access for people who use drugs, reduce fatal drug overdoses, and mitigate the transmission of diseases such as human immunodeficiency virus (HIV) and hepatitis C (Dutta et al., 2012; Ritter and Cameron, 2006). In the United States, state and local public health agencies are increasingly supporting harm reduction programs. For example, as part of their initiative to reduce new HIV infections by 90 percent by the year 2030, the City of Philadelphia Department of Public Health provides harm reduction services and ensures access to syringe service programs (“Ending-the-HIV-Epidemic-in-Philadelphia-A-Community-Plan.pdf,” n.d.).
A promising and innovative harm reduction strategy that has emerged in the last fifteen years is the vending machine for harm reduction (VMHR). VMHR is an umbrella term for a range of mechanized devices that deliver materials, information, and treatment for historically excluded populations, particularly for people who inject drugs (McDonald, 2009; Strike and Miskovic, 2018). Although the earliest forms of VMHR were designed to collect and distribute syringes, some machines also dispense other harm reduction materials, such as emergency medications to reverse opioid overdoses (naloxone), fentanyl test strips, medications for opioid use disorder (MOUD; buprenorphine, methadone, naltrexone) and safe supplies of pharmaceutical opioids (Grullón Paz, 2022; Joseph, n.d.; Obadia et al., 1999; Tyndall, 2020). VMHR that dispense sterile and clean injecting supplies have been implemented in Australia, Taiwan, Mexico, Canada, and a number of European countries, (Huang et al., 2014; Islam and Conigrave, 2007; Obadia et al., 1999; Otiashvili et al., 2019; Philbin et al., 2008). Evaluations find that people who inject drugs appreciate that these machines conveniently and anonymously provide supplies at all hours (Islam and Conigrave, 2007). A review of syringe dispensing machines in Europe and Australia find that they commonly reached high-risk and marginzalized injecting drug using populations (Islam and Conigrave, 2007). Syringe vending machines also increase access to sterile injecting equipment for incarcerated individuals in Switzerland and Germany (Islam et al., 2007). The machines did not increase drug use frequency in this population and were most accepted when anonymity was maintained (Islam et al., 2007). These machines benefited other marginalized groups, including people experiencing homelessness, women, and disenfranchised racial and ethnic groups (Islam et al., 2007).
Despite their promise, some facets of VMHR can introduce many multi-faceted and sometimes contradictory feasibility and acceptability concerns. Qualitative studies among those that use VMHR identify practical concerns, such as where the machines would be stored, how to keep the machines stocked, and what supplies the machines would dispense (Deimel et al., 2020; Islam et al., 2008; Islam, Wodak et al., 2008; Obadia, 1999). Other stakeholders have raised questions about cost and frequency of use. A survey of people who inject drugs not currently receiving treatment in Tbilisi, Georgia found that 42% of those who would be willing to use a VMHR rated the availability of free supplies as the most important reason to use the machine (Otiashvili et al., 2019). Other stakeholders have raised concerns over the abuse and vandalism of machines (Islam et al., 2008). Although these concerns could be remedied through increased security, monitoring, and time restrictions, these stipulations may take away from the anonymous accessibility that makes VMHR attractive to people who inject drugs (Islam et al., 2008; Islam and Conigrave, 2007).
Separate from the feasibility of implementing VMHR, the lack of acceptability in different communities may obstruct initial or sustained implementation. Perceptions of VHMR vary widely across stakeholder groups. Those who use VMHR and syringe exchange machines generally have a positive perception of VMHR, whereas they are more controversial among those living in the surrounding neighborhood (Islam et al., 2008; Otiashvili et al., 2019; Philbin et al., 2009, 2008). For example, community members in Tijuana, Mexico, where starting a VMHR was being considered, were split between those that saw it as an important means of harm reduction and those who opposed it based on beliefs that the supplies provided in VMHR would enable drug use (Philbin et al., 2008). Those who argue against VMHR have emphasized the potential for VMHR to promote drug use, increase crime, and spread drug related litter (Islam et al., 2008; Otiashvili et al., 2019; Philbin et al., 2009, 2008), though evidence does not support these claims. Regarding the placement of machines in clinical settings, providers share concerns that VMHR would reduce staff contact and linkage to care (Islam et al., 2008). Some providers, however, argue that more staff contact is not associated with less needle sharing and that VMHR could reach populations historically excluded from the health system, such as people experiencing homelessnes and without health insurance (Islam et al., 2008). Furthermore, some VMHR advocates have sought to mitigate staff contact concerns by dispensing printed harm reduction and service referral information along with the harm reduction materials, which may be associated with increased attendance at proximate needle syringe programs (Islam et al., 2008).
Published evaluations of VMHR have almost exclusively assessed VMHR sites outside the United States, even as VMHR are increasingly implemented in the US. To date, there are only two published evaluations of VMHR in the United States.
In Cincinnati, Ohio, a nonprofit harm reduction organization offers a number of supplies, including safe injection kits (which notably exclude syringes), safer smoking kits, nasal and intramuscular opioid overdose reversal agents (i.e., naloxone), and personal protective equipment, through an outdoor VMHR that can be accessed 24/7 with a personal code (“Safer-Use Supplies,” n.d.). This machine is located outside a syringe service program. A recent evalution of this implementation suggests that this VMHR dramatically increased the accessability of harm reduction products and services, even among those who had never reportedly used harm reduction services. The machine was also associated with a decrease in countywide overdoses (Arendt, 2022).The public health department of Las Vegas, Nevada deployed six VMHR in 2019, which hold syringes, injectable and nasal naloxone, pregnancy tests, safe sex kits, hygiene kits, first-aid kits, and sharps containers. Similar to the Ohio implementation, preliminary evidence from this evaluation shows that providing naloxone in Las Vegas is associated with immediate reductions in overdose fatalities (Allen et al., 2022). In 2022, Philadelphia introduced “Narcan Near Me” towers, which dispense free naloxone. Naloxone dispensing machines have also been deployed in other areas of Pennsylvania, Wisconsin, Kentucky, and Rhode Island, due in part to the recent relaxing of naloxone access laws.
The objective of the present study was to ascertain the acceptability and feasibility, among different stakeholder groups, of placing a VMHR in Philadelphia. We endeavored to identify barriers that would inform where VMHR were placed and what harm reduction content they would contain. This exploratory, multi-stakeholder qualitative inquiry serves as a step towards establishing additional and expanded VMHR in Philadelphia. The study also focuses on contributing to the scientific literature on VMHR and gaining rapid and actionable knowledge about their use, providing a valuable service to our community partners.