(5) Models for Accessing Harm Reduction Vending Machines: An Interrupted Time Series Design

Background & Introduction: Over one in ten fatal drug overdoses transpired in California in 2021.(1) In 2021, Kern County ranked ninth out of the 58 counties in California with an opioid-related-overdose death rate of 31.02 per 100,000.(2) While fatal drug overdose rates reached historic highs for all racial and ethnic groups in the United States, Black Americans experienced the steepest increase of drug overdose death rates of any group since 2015,(3) and drug mortality rates have tripled among the Latine population since 2011.(4) Similarly, persons experiencing homelessness (PEH) are at elevated risk for fatal drug overdoses.(5) Furthermore, the increase in illicit heroin and synthetic opiate use and injection drug use (IDU) has been accompanied by attendant public health issues, such as increases in Hepatitis C (HCV) and HIV, which also disproportionately affect Black and Latine communities and PEH.(6) While several studies have explored the impact of domestic harm reduction vending machines (HRVMs) on the availability and distribution of harm reduction supplies, including naloxone (7,8), no study to date has compared models of accessing HRVMs on the accessibility of harm reduction supplies, including safer sex, safer injection, naloxone, wound care, sharps disposal, hygiene, and feminine hygiene kits.

Methods: In June 2023, an outdoor HRVM (Project HOPE) became operational in Bakersfield, California in a geographic area with low naloxone kit saturation rate (2.76 kits per 1,000 residents) and medium fatality rate (62.6 per 100,000 residents). Between June and August 2023, only registered participants could access the HRVM with a personal ID number. Furthermore, registered participants were subject to daily and weekly product limits for each type of harm reduction kit. From August 2023 through October 2023, participants were no longer required to register and obtain a personal ID number to access harm reduction supplies from the HRVM, and the product limits were discontinued as well. Using an interrupted time series design, the number of harm reduction kits distributed by the HRVM were compared pre- and post-implementation of the unrestricted access model.

Results: During the first two month period of operation (June - August 2023), Project HOPE registered participants used 11 naloxone kits, 28 safer sex kits, 35 safer injection kits, 19 wound care kits, 20 sharps disposal kits, 22 hygiene kits, and 27 feminine hygiene kits, respectively. In the subsequent two month period (August - October 2023), Project HOPE participants used 24 naloxone kits, 117 safer sex kits, 183 safer injection kits, 185 wound care kits, 72 sharps disposal kits, 98 hygiene kits, and 154 feminine hygiene kits, respectively. The shift from restricted access for only registered users with daily supply limits to unrestricted access with no supply limits for the outdoor community-based HRVM was associated with significant increases in distribution for all the harm reduction kits, including 17.6% increase in safer sex kit utilization ( p < .001), 28.12% increase in safer injection kit utilization (p < .001), 29.47% increase in wound care kit utilization (p < .001), 9.73% increase in sharps disposal kit utilization (p = .022), 24.06% increase in feminine hygiene kit utilization (p < .001), 14.22% increase in hygiene kit utilization (p < .001), and 6.69% increase in naloxone kit utilization (p < .001), respectively.

Conclusion & Discussion: Given the high level of stigma and shame experienced by people who use drugs (PWUD) and persons experiencing homelessness (PEH), the lowest barrier harm reduction services should be adopted to promote equitable access to harm reduction supplies. Even though the outdoor HRVM was accessible to registered participants 24/7/365, utilization remained low, especially for the naloxone kits. The discontinuation of the registration process and product limits resulted in a significant increase in utilization for all harm reduction kits, including naloxone. Unrestricted access models for HRVMs stand to increase naloxone saturation, enhance health equity, and decrease fatal opioid ODs among PWUDs and PEH. With the high potency of fentanyl, HRVMs with unrestricted access models provide the lowest barrier approach to naloxone engagement and re-engagement. For programs distributing sterile syringes through HRVMs, HRVM software settings should allow unrestricted access to all other harm reduction supplies except the sterile syringes, as only registered users of SSPs are legally permitted to access sterile syringes through HRVMs and will require a participant ID number to do so.

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combined stimulant/opioid overdoses, 2007-2019. American Journal of Epidemiology. 2022; 191(4): 599-612.
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deaths, traffic deaths, and homicides. Public Health County of Los Angeles. Updated on May 23, 2023. Accessed June 14, 2023.
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