Service Delivery in a Dynamic Drug Market: Building on Successes of SSP Service Delivery in North Carolina

In 2023, I traversed North Carolina, listening to the stories, work, challenges, and triumphs of people who use drugs, work at syringe service programs, and provide treatment (namely medications for opioid use disorder) for folks looking to stop or reduce their substance use.  The goal, tied to a larger, mixed-methods grant funded by CDC, was to improve our understanding for polysubstance use. 

Some of the research questions we sought to understand:

What types of drugs are people using together and why? 
What are the perceived risks of using different types of drugs together, and how do people mitigate risk? 
How do people come to transition from one type of drug to another, or away from a specific type of drug? 
How do syringe service programs and treatment providers offer care for people who intentionally or unintentionally use multiple types of drugs in the wake of a dynamic drug market, and why do they take that approach?

Recent studies using our qualitative data

The effort and thoughtfulness provided by folks across the state were integral to data collection and the ensuing findings on drug transitions and navigating competing risks in an era characterized by increasing deaths with polysubstance involvement.   The third study, ““No judgment, no preaching”: approaches to harm reduction service provision for people who use drugs in North Carolina”, is the primary focus of this post.

Study Design: In this study, I conducted a thematic analysis of in-person, semi-structured interviews with SSP providers (n=10) and people who use drugs in NC (n=30). This specific study topic arose through iterative analysis, probing more frequently on participants’ differing preferences toward approaches for service delivery in a dynamic drug market. Data were collected between June and November of 2023. All participants had to be 18 years or older. SSP staff had to work directly with people in active use, and people who use drugs had to report use of some type of opioid not as prescribed in the past 30 days (hereafter referred to as people who use opioids, or PWUO). Participants were reimbursed with a $30 gift card for their time. 

Study Findings
We found that, despite some heterogeneity, SSP providers often defaulted to letting folks attending the SSP lead interactions --- keeping the questions they asked and unsolicited information they offered to a minimum. 

Tom (Pseudonym to protect identity), a 30-year old man likened the interaction to going to Chipotle. 

“It's like a Chipotle, man. You go down the line and they're like, you know, "Do you need any of this?" "No." And, "This?" "No." And then you're like, "That, that, that, that." And they ask you how much you need. … Um, and then, you know, everything else is pretty much just watcha need, on the basis, and then we get some food and we're good.” (Tom, Male PWUO, 30)”

Rationale for having PWUO lead interaction
SSP providers that took this approach explained that they did so to avoid enacting stigma onto people that are already marginalized; that people who use drugs understand what they are doing carries risk and offering information or asking questions to identify what someone uses can be unnecessary, paternalistic, and invasive; that services provided — from intangible social support to addressing basic physiological needs and harm reduction tools/tips — had applicability across the types of drugs people may use; and finally, that they are forced to triage simply due to resource constraints. 

Divergence in PWUO preferences for approach to service delivery 
PWUO preferences toward service delivery approaches varied considerably, with some preferring less interaction about what and how someone uses drugs, while other PWUO demonstrating an openness to staff questions or information about their use to better inform care. Ultimately, it boiled down to the individual — their relationship with the SSP provider, many of which had developed extensive trust — and how sick they might have been.  While others were open to SSP staff asking about their use or providing unsolicited information, as it could lead to more tailored care:

“Yeah, I would take any information that they had. Actually, if there's resources out there that I'm not aware of and they are, I would absolutely, um, be—I'm…approachable anyway. I'm a people person… especially going into the needle exchange. They already know that you're an addict. So you don't have that stigmatism on you. And most of them are addicts, also, you know… or were addicts and whatever. Um, and they're really cool, those people, heh. They're really nice…and they understand. They… totally get it, you know. and that's nice to have somebody that understands instead of judging you…I would definitely be open to any kind of information that was out there…” (Nadia, Female PWUO, 51)

This attitude is largely the result of the care and compassion SSP staff treat folks who come in for service delivery. 

When SSPs take a different approach to service delivery

SSP staff explained that there were several instances in which they took a more direct approach to service delivery: if there was a ‘red flag’ in the interaction (e.g., participant demonstrated inaccurate and potentially dangerous knowledge toward a drug or harm reduction practice); if there was something pertinent to share – changes in the drug supply, a new service being offered, or an upcoming event; or if they seemed open to a conversation. 

“I think it’s on a case by case, right? Like, if someone comes in with a hat down, eyes averted, very closed off, we will stick to the bare minimum, no—rare—few questions. “What do you need? We’ll send you on your way.” Um, but those people are becoming less and less. And so, we—I think we just read the room, and we let the participant kinda guide the way. If I’ve—first time, I probably won’t just come right out and—I don't know, maybe I will. I don't know. I think it’s just case by case, really.” (Krista, Female Provider, 36)

So what does it all mean? Two points to highlight: 

We have known this, but it bears repeating – especially when the already sparse budget is being threatened, and there is talk on restricting what types of services can and can’t be provided using federal dollars. Of course, SSPs provide a range of services: tools like unused syringes and naloxone; linkages to housing/treatment facilities; and basic essentials like water, food, clothes, and a place to cool off when the North Carolina sun gets to be too sweltering – all of which make substance use safer and address structural needs that may disproportionately be felt by folks in active substance use and recovery. This study further illuminates the importance of intangible aspects of care, including social support that extends well beyond substance use, having staff with lived substance use experience, and taking an approach that doesn’t further stigmatize people visiting the SSP.  The North Carolina SSP staff included in this study epitomized these values – evident in the perceptions and interactions reported by PWUO.  

The successes of North Carolina SSPs in this space – despite budgetary constraints and increases in demand – meant not only a more enjoyable experience, but trust – and an opportunity to provide more extensive or tailored care for people who might be interested. This established trust also meant that SSP staff could correct misconceptions that program participants might have had; or share more information about new tools, trends, or upcoming events. For some, these relationships meant an outlet where someone in active use could go if they wanted to seek treatment (which can be a narrow window). For others, it meant wanting to hear more about shifts in the drug supply or answering questions about their use so they could receive targeted information about how to be as safe as possible. SSPs that have the bandwidth might consider simply asking participants how they’d like to engage, especially if they are unsure and have established some rapport. Regardless, it serves as a foundation for all interactions, and an opportunity to even be more hands-on in certain instances. 

On a personal note

I will end this post with a simple, but genuine thank you to everyone I met when collecting data for this study. The SSP staff, treatment providers (not captured in this specific manuscript), and most importantly, people in active substance use that trusted me with their stories emphasize the through-line of care and mutual support – some of the most beautiful aspects of humanity – that we see time and time again in communities of people that use drugs. 

This work was supported by the Centers for Disease Control & Prevention (R01CE003471, Pence & Ranapurwala). David Colston was also supported by NICHD of the National Institutes of Health under award number T32 HD091058 and the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention under award number R49CE003568. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.