Traci C Green

The use of public health vending machines (PHVMs) is an emerging strategy implemented to mitigate drug-related harms via the dispensation of supplies like naloxone and sterile syringes from vending machines that have been documented to reduce transmission of blood borne viruses, support hygiene and basic personal health needs, and prevent overdose. To inform future applications of this technology and performed initially as part of a technical assistance request, we sought to examine PHVM adoption and implementation by conducting semi-structured interviews with 26 individuals from diverse roles and organizations/agencies across the United States in March 2023 about their experiences launching and optimizing PHVMs. We engaged in a secondary thematic analysis of the interview data using both deduction and induction. Using the interview guide as the frame, we broadly organized our findings into themes that are pertinent to consider prior to PHVM implementation (“Pre-implementation”) and those that are relevant during implementation (“Implementation and maintenance”). Pre-implementation themes included (1) Motivating factors influencing implementation, (2) Intended PHVM uptake population, (3) Partnership cultivation, (4) Responsiveness to community needs and concerns, and (5) Factors influencing placement of PHVMs. Implementation and maintenance themes included: (1) Operational components of implementation and (2) Tracking consumer use of machines and supply flow. We found that PHVMs have emerged as versatile and central tools to expand and extend critical, life-saving supplies and services to PWUD and other groups within communities throughout the United States, especially to underserved and high-risk populations, such as people of color, young people, rural residents, individuals leaving incarceration, and veterans. We also found that the planning phases of implementation were shaped by local needs, funding opportunities, collaboration, and community engagement, with PHVM placement most often determined by feasibility and willingness of host sites, as well as the perceptions and needs of the community. Operational challenges included unanticipated costs related to maintenance and supply stocking of the PHVMs. Our findings elucidate the local, ground-up, and bold approaches and innovations undertaken by many organizations, agencies, and programs throughout the country in PHVM implementation. Policymakers and government officials should consider passing local ordinances or granting permissions in support of placing PHVMs and securing access to life saving materials. •Public health vending machines (PHVMs) are tools for expanding lifesaving materials.•PHVMs extend lifesaving materials to underserved and high-risk populations.•Planning for PHVMs includes considering local needs, funding, and the environment.•Feasibility and willingness of host sites and community needs determine placement.•Unanticipated costs related to maintenance and stocking are operational challenges.

Methadone, a medication for opioid use disorder, is underused in the US response to the opioid overdose crisis. Under federal law, methadone can be offered in pharmacies via medication units, although a change to federal statutes or regulations could allow more options for pharmacists to dispense methadone.
To analyze innovative return on investment (ROI) for 2 pharmacy-based models: (1) pharmacy-based medication unit and (2) pharmacist-dispensed methadone.
This cross-sectional economic evaluation, conducted from March 13, 2024, to August 22, 2025, created 2 models for pharmacy-based methadone dispensed at community-based pharmacies in the US to people who are stable on methadone maintenance treatment and who were referred by the opioid treatment program (OTP) or who recently initiated treatment due to the new option for pharmacy dispensing: (1) an OTP and a pharmacy partner to operate a medication unit in the pharmacy wherein OTP clinicians prescribe and pharmacists dispense methadone and (2) regulatory changes that allow medical professionals to prescribe methadone and pharmacists to dispense the medication. Each model included startup costs plus 3 years of operational costs and revenue. Input data were extracted from key informant interviews, a time-motion study, and the literature. Data were analyzed from June 2024 to July 2025.
Models addressed clinical services, anticipated consumers, potential competitors, key differentiators, and critical success factors. Input data were combined with microcosting methodology and enumerated minimum, best, and maximum values (PertBeta distributions) for 121 key inputs. A total of 10 000 Monte Carlo simulations were conducted to obtain 95% uncertainty intervals (UIs). Values are presented in 2024 US dollars.
The primary study outcomes were ROI ratios and net profits after 3 years in operation.
The medication unit model (model 1) assumed a total of 3429 (95% UI, 1385-6244) client visits over the 3 years, indicating a mean (SD) of 95 (36) visits per month. For the pharmacist-dispensed model (model 2), the total number of client visits was estimated as 793 (95% UI, 531-1167), indicating a mean (SD) of 22 (5) visits per month. For model 1, over 3 years, a pharmacy would net $3.53 (95% UI, $1.14-$6.99) for every $1.00 spent, yielding a profit of $96 904 (95% UI, $5365-$267 451), including a 93.8% likelihood of netting $15 000 by year 3. For model 2, over 3 years, a pharmacy would net $2.64 (95% UI, $2.04-$3.41) for every $1.00, yielding a profit of $23 844 (95% UI, $15 045-$36 546), including a 97.6% likelihood of netting $15 000 or more by year 3.
In this economic evaluation of 2 pharmacy-based methadone business models, both models demonstrated positive ROI over 3 years. This finding suggests that increased access to methadone-a key step in reducing overdose deaths-can be profitable for community pharmacies. Changes to federal statutes or regulations may be needed, depending on the preferred model.

As the intersecting opioid and housing crises continue to compound, it is important to explore the ways that unhoused people who use drugs utilize the resources available to them to assert their rights and identities. As members of communities which are often construed as outside threats to the greater community, unhoused people who use drugs must contend with many forces that reject their rights to permanency (e.g., housing). This research focuses on people residing in Boston's low-threshold transitional housing (LTTH) programs, which co-located harm reduction services and other health and social supports, and where abstinence is not a requirement for entry. In our study, we aimed to capture resident experiences within LTTH environments. Through field observations and photo-ethnography, we observed the ways in which LTTH residents engaged in placemaking, a process through which individuals shape public or private space to reflect their desires, identities, and values. Analyses indicated that residents modified the existing infrastructure of the site to maximize their privacy and construct their own security systems. Residents leveraged their placement in these transitional sites as opportunities to personalize their space and develop independent living skills, demonstrating their individual identities. Residents also engaged in practices of resistance towards establishing a right to permanency and legitimacy within the context of these housing spaces. The way in which residents at LTTH sites engaged with site infrastructure facilitates the development of community and identity asserts its importance as a valuable and stabilizing resource for people experiencing homelessness.

In recent years, Boston has attempted to increase housing options and reduce overdose risk through the implementation of harm reduction housing (HRH) sites. Despite numerous harm reduction resources available to HRH residents, drug checking services are absent. Studies suggest that drug checking may prevent negative experiences associated with unexpected adulterants. Drug checking offers a window into concerning supply shiftsand helps monitor disruptions in the supply due to environmental changes, such as encampment clearings. Few studies have explored drug checking's application in housing programs. The establishment of the Massachusetts Drug Supply Data Stream, a statewide community drug checking program, allowed us to pilot real-time drug checking at HRH sites.
From September 2023 to February 2024, we administered surveys to 106 HRH residents. From September 2023 to March 2025, we conducted longitudinal interviews (baseline, 3-month, 6-month) with a subset of 28 survey respondents. In response to drug supply shifts and resident demand, starting on May 20, 2024, we implemented real-time drug checking services at three HRH sites located in Boston. Residents were asked to provide approximately 5 mg of their remnant substance in order to receive immediate test results using FTIR spectroscopy and immunoassay test strips. Survey responses pertaining to drug checking provision and real-time, on-site drug checking sample results were analyzed using descriptive and bivariate statistics. Longitudinal interviews and field notes collected during real-time, on-site service provision were analyzed to further contextualize resident experiences.
Resident engagement with drug checking services was considerable, with fifty-five drug samples collected across nine site visits over three months. The services generated an increase in xylazine awareness among residents and provided chances to address concerns about the changing drug market amid heavy policing. Engagement with residents confirmed the need for on-site drug checking alongside other provided harm reduction services, and a consensus vocalized concerns with the local drug supply.
Real-time, on-site drug checking in low-barrier housing programs is a promising harm reduction approach for detecting shifts in the drug supply and can complement transitional housing interventions. Residents engage with these services with the intention of intervening upon personal, community, and market-level norms.

Massachusetts law permits involuntary civil commitment (ICC) of people who use drugs (PWUD) into drug treatment. We sought to characterize experiences of PWUD with and without ICC histories by exploring the associations of one or more ICC experiences by sociodemographics, substance use, and subsequent health outcomes. We analyzed survey data of 714 PWUD, collected from multiple mixed-methods rapid assessments conducted between 2017 and 2022, with further examination of the 209 (29.3 %) participants who reported experiencing ICC and have since returned to use. We computed univariate and bivariate statistics by ICC experience—none versus at least one ICC experience and one versus multiple ICC experiences. Putative associations were also explored between recent ICC experience and subsequent overdose risk, response, and preventive behaviors. Among participants who reported ICC experience(s), most identified as male, White, housed, co-using opioids and stimulants, having been civilly committed by a family member and most recently in 2015 or beyond. Overdose experiences, both personal (χ2 = 16.2, p < .001) and witnessed (χ2 = 6.7, p < .01), were more common among participants reporting one or more ICC experiences than those with no ICC. 35.1 % of participants with ICC experience(s) in the past year had subsequently experienced an overdose, while 20.3 % experienced incarceration following their ICC. Naloxone administration at last witnessed overdose was higher with versus without a history of ICC (χ2 = 6.45, p < .05). To mitigate future health and social harms among PWUD, the current study's findings underscore the need for consideration of the aforementioned risk factors when tailoring future ICC policy. •Involuntary civil commitment (ICC) is common in people who use drugs in Massachusetts.•Lifetime ICC is associated with being male, white, housed, and stimulant-opioid co-use.•Recent ICC is associated with overdose and incarceration.

Since 1999, drug overdose deaths have surged in the United States. There is considerable geographic variability in overdose patterns, state laws, overdose prevention infrastructure, and opioid settlement amounts and investments. To guide localized overdose prevention, it is important to analyze these data and understand heterogeneity. In this descriptive analysis across six states-Massachusetts, Minnesota, Missouri, Nevada, New York, and Rhode Island, we compared five key domains essential to understanding overdose epidemics, prevention, and policy responses: (1) drug overdose mortality trends by substance and race/ethnicity (2018-2023); (2) state harm reduction laws; (3) availability and coverage of overdose prevention services; (4) opioid settlement funding and spending; and (5) availability and comprehensiveness of publicly available overdose-related data. Data were drawn from publicly available sources and legal information confirmed using Westlaw. All states experienced rising overdose death rates between 2018 and 2023, with significant racial/ethnic disparities. All states have enacted laws to increase access to naloxone. Naloxone distribution rates vary widely, but most states have high availability. Implementation of other harm reduction services differed across states, as well as drug paraphernalia laws. Opioid settlement funding per capita and transparency in spending and planning also differed across states. Some dashboards provided detailed fatal and nonfatal overdose and intervention data stratified by sociodemographics. State-specific differences in overdose patterns, harm reduction laws, prevention infrastructure, and settlement spending underscore the need for localized, tailored strategies. This study's state-specific profiles lay the groundwork for more advanced decision-support tools to guide effective overdose prevention.

The emergence of fentanyl in the street market for opioids has limited the benefits of some interventions to manage opioid overdose; thus, preventing the occurrence of opioid overdose is essential. We tested a behavioral intervention shown to prevent heroin overdose in a pilot study, in two United States cities with prevalent fentanyl. Phase III two-site single-blinded randomized controlled trial of a repeated dose motivational interviewing intervention to reduce overdose (REBOOT) versus attention control, over 16 months from 2019 to 2023. San Francisco, California, and Boston, Massachusetts, USA. 18-65 years of age, with opioid use disorder (OUD), active non-prescribed opioid use, opioid overdose within 3 years and prior receipt of take-home naloxone. A total of 268 participants were randomized (50% intervention, 50% control), 62% of whom were male, 15% Latine, 65% White and 14% Black/African American; 95% had used fentanyl. Motivational interviewing review of experienced and witnessed overdose and development of personal prevention plan, administered at months 0, 4, 8 and 12. TimeLine FollowBack of interval overdose events and covariates, administered prior to the intervention at months 0, 4, 8, 12 and 16. Primary outcome was occurrence of any nonfatal or fatal overdose event. There were no significant effects of REBOOT compared with control on the primary outcome of occurrence of any overdose [relative risk (RR) = 0.94, 95% confidence interval (CI) = 0.79-1.11, P = 0.45] or secondary outcome of the number of overdose events (RR = 0.80, 95% CI = 0.6-1.06, P = 0.12). Results did not differ when excluding data collected during the first 12 months of the COVID-19 pandemic. Compared with control, REBOOT was not associated with days in OUD treatment and not using opioids (RR = 0.94, 95% CI = 0.88-1.00, P = 0.06). In post-hoc analysis, REBOOT was associated with fewer overdose events among participants with no past 4-month overdose at baseline (RR = 0.70, 95% CI = 0.51-0.97, P = 0.03). A repeated dose motivational interviewing intervention to reduce overdose had no statistically significant effect on opioid overdose in two US cities where fentanyl was the dominant street opioid.

Most US drug use events that lead to a fatal overdose are unwitnessed. Given the scale of the overdose crisis, interventions to help detect and respond to overdoses in community settings are urgently needed. Overdose detection technologies (ODT), including reverse-motion restroom sensors, are a promising set of interventions that are underutilized. This study explored the perspectives of frontline harm reduction workers, clinicians, housing shelter staff, and their clients on restroom sensors. Staff and program client focus groups conducted between December 2022 and January 2024 discussed prior experiences of responding to overdoses and existing organizational overdose policies and procedures. A verbal and visual description of restroom sensors was given and supplemented with brief captioned educational videos to assess the feasibility and acceptability of restroom sensor implementation. We conducted N = 8 discussions (n = 40 participants total). Staff described the anxiety and cognitive burden of monitoring client restrooms and the trauma of witnessing and responding to overdoses. Sites varied in their safety procedures, ranging from manual door knocks every 5 minutes to every 24 hours. Participants embraced the prospect of restroom sensor implementation in community drop-in centers, housing programs, and public restrooms (eg, food service). Perceived benefits of restroom sensors, in addition to saving lives, included the low-threshold and automated nature of the technologies and potential reductions in stress, anxiety, and trauma. However, participants shared concerns surrounding data confidentiality, potential legal repercussions of being found onsite after overdosing (eg, loss of housing, job, children, freedom), stigmatizing attitudes among first responders, reactions to ODTs among clients who mistrust technologies, corporations, and the government, staff fatigue, and technology maintenance. Our findings demonstrated high acceptability of ODTs among staff and patients but revealed several programmatic and policy considerations that could support future implementation efforts.

Sweeping of encampments is one policy approach to the growing visibility of homelessness and substance use in U.S. cities but is associated with increased overdose deaths. In 2022, to mitigate the impacts of a sweep, the City of Boston created seven harm reduction housing (HRH) sites to accommodate displaced individuals. HRH sites offered on-site or off-site medications for opioid use disorder (MOUD). As part of a broader parent study, we recruited 28 residents from HRH sites previously enrolled in a survey for semi-structured interviews, exploring their experiences with housing, the current HRH site, substance use, service access, overdose, MOUD, and more. We engaged in an inductive thematic analysis of the MOUD interview data. Four themes emerged from thematic analysis: (1) HRH sites afforded participants on-site access and linkages that facilitated MOUD initiation and retention; (2) when off-site, location, transportation and accessibility issues limited MOUD access; (3) MOUD prescribing policies at HRH sites were uniquely low-threshold; and (4) HRH-related MOUD engagement shaped health-related outcomes. Participants reported that HRH facilitated ease of access and delivery of MOUD both on and off site, raised considerations about how MOUD is accessed through HRH, and described how MOUD through HRH changed their substance use behaviors, health, and quality of life. Government entities that opt to clear encampments as a policy approach to address homelessness and substance use should also implement HRH interventions that facilitate MOUD access in conjunction. Such an approach would mitigate known harms associated with sweeps.