Rural and Urban Differences in Overdose Response and Prevention Among Persons Who Inject Drugs

Abstract

BackgroundOverdose is a leading cause of morbidity and mortality among people who inject drugs (PWID). Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths. This analysis explores rural-urban differences in overdose experiences among PWID. We focus on perceptions of fentanyl and overdose prevention and reversal strategies.MethodsSemi-structured interviews were conducted with 59 participants who injected drugs, 19 from rural southern Illinois and 40 from New York City (NYC). Seven key informants were also interviewed (three from Illinois and four from NYC) to provide additional perspectives. Data were analyzed using constant comparison and theoretical sampling methods.ResultsParticipants in urban NYC described most commonly injecting heroin and fentanyl, which differed from the rural Illinois drug market that was dominated by methamphetamines. Despite these geographic differences, participants from both locations were concerned about the growing presence of fentanyl in their drug supply and many disclosed overdose experiences. Strategies to lower overdose risk included purchasing drugs from trusted network members and partial drug injection, however, fentanyl test strip use was low in both locations. A key difference emerged related to the use of naloxone; NYC participants commonly described using naloxone as a primary overdose response, but participants in rural Illinois did not. Low naloxone use in Illinois was attributed to perceived risks of its use, such as fear of arrest and opioid withdrawal symptoms the naloxone receiver may experience. ConclusionsDespite similarities in fentanyl awareness and concern, important rural-urban differences emerged related to access to overdose prevention and reversal resources. Findings can inform regional-specific interventions to reduce overdose risk among PWID.