The illicit drug overdose crisis is an ongoing epidemic that continues to take lives at unprecedented rates and British Columbia, Canada has been identified as the epicenter in Canada, where approximately five deaths per day are linked to unregulated substances most often including fentanyl (Service, 2022). In Victoria, British Columbia, community drug checking sites have been implemented as a public health response to the ongoing overdose crisis and the unregulated illicit drug market through a community-based research project called the Vancouver Island Drug Checking Project. In addition to providing anonymous, confidential, and non-judgmental drug checking services with rapid results, the project has conducted qualitative research aimed to better understand drug checking as a potential harm reduction response to the illicit drug overdose crisis and the unregulated illicit drug market (Wallace et al., 2021; Wallace et al., 2020). An analytical framework was utilized to understand the impact substance use stigma has on those accessing drug checking services, as well as those who avoid accessing these services as a direct result of substance use stigma. This study found that the risk of criminalization and the anticipation of being poorly treated appear to be the most significant barriers related to stigma, rather than actually experiencing stigma. Further, it appears the implementation of community drug checking creates tensions that need to be navigated as sites and services balance a hierarchy of substances and stigma; differing definitions of peers; public yet private locations; and, normalization within criminalization. The findings suggest the solution to substance use stigma and drug checking will not come from continuing as we are, but through making changes at all levels (individual, interpersonal, and structural) and thus for all people who access community drug checking. / Graduate

Introduction: The entire United States has felt the effects of the overdose epidemic, but rural Appalachia has experienced disproportionate overdose deaths. This variation in overdose mortality can be attributed to the risk environment for overdose in rural Appalachia. Overdose prevention behaviors are individual level behaviors that people who inject drugs can implement that may have the potential to reduce their risk of overdose, however limited research exists regarding the utilization of those behaviors. It is important to consider how the risk environment can influence the utilization of overdose prevention behaviors among people who inject drugs. Therefore, the purpose of this research was to identify overdose prevention behaviors among people who inject drugs in rural Appalachia and better understand the relationship between those behaviors and the rural risk environment for overdose. Methods: This research was conducted using a mixed methods approach, including a scoping review, qualitative, and quantitative study. A scoping review was used to identify overdose prevention strategies and behaviors in rural America. Semi-structured interviews were used to identify overdose prevention behaviors among people who inject drugs in rural Appalachia. A quantitative survey was used to examine the relationship between risk environment determinants and overdose prevention behaviors utilization among people who inject drugs in rural Appalachia. Results: Results of primary data collection showed that people who inject drugs in rural Appalachia do utilize overdose prevention behaviors, including several drug checking methods and safe use behaviors. However, environmental barriers and disparities among people who inject drugs in rural Appalachia were highlighted in this research. Potential relationships exist between environmental determinants and the utilization of some overdose prevention behaviors. Conclusion: This research found the need for several policy and community program implications which all stem from the War on Drugs. Results highlighted the need for systems level change regarding the care for people who inject drugs, which includes the necessity for policy makers to consider harm reduction methods to reduce overdose mortality among people who live in rural Appalachia.