Harm reduction vending machines: Exploring and improving acceptability of a low barrier approach to reducing drug related harms
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Authors
Kirk, Mia Rae
Issue Date
2025
Type
Dissertation
Language
en_US
Keywords
Alternative Title
Abstract
Background: The opioid overdose crisis remains a major public health issue in the United States. The National Academy of Sciences (NAS) prevention framework categorizes interventions into three levels: universal, selective, or indicated. Naloxone is central to overdose prevention and has traditionally focused on individuals at highest risk of experiencing an overdose (i.e., indicated interventions). However, in recent years, efforts have expanded to include broader strategies targeting at-risk subgroups (selective interventions) and the general public (universal interventions). This shift reflects a growing interest in expanding naloxone access through novel, low-barrier approaches. Harm reduction vending machines (HRVMs) represent a novel approach that may support this broader distribution landscape. While international evidence supports HRVMs, limited research has explored their use and perception in the United States context.Purpose: The three aims of this dissertation were to: 1) Summarize universal and selective naloxone distribution models in the United States, 2) Characterize the reach and acceptability of HRVMs among PWUD in Nevada using survey data, 3) Identify factors that influence HRVM use in Nevada through qualitative research.
Methods: In manuscript one, a scoping review of peer-reviewed U.S.-based studies (2005–2025) was conducted to characterize universal and selective naloxone distribution models. Studies were categorized by intervention type (universal vs. selective), setting, target population, and most common outcomes reported. In manuscript two, survey data from 213 people who used drugs in Nevada (2022–2023) were analyzed to assess HRVM awareness, intent, and perceived barriers, and facilitators. Descriptive statistics and regression models were used to identify correlates of intent to use. In manuscript three, a rapid ethnographic approach was employed, including 43 interviews, 44 hours of observation, and audits of eight HRVM sites. Thematic analysis focused on enabling and impeding factors that shape HRVM access and use.
Results: The scoping review identified 16 relevant studies (3 universal, 13 selective). The most commonly reported outcomes were number of naloxone doses distributed and improvements in overdose knowledge and attitudes. Manuscript 2 survey results showed low HRVM awareness (30%) but high intent to use (69%) among non-users. Facilitators included free supplies and 24/7 access; barriers included transportation, location awareness, and surveillance concerns. Paper 3 qualitative data highlighted HRVMs as preferred for their convenience, anonymity, and non-judgmental access. Impeding factors included limited hours, too much visibility, and unclear information. Participants recommended locating machines outside, near public transportation, and increasing supply limits.
Conclusions: There is not sufficient evidence to support implementation of universal or selective naloxone distribution interventions. However, the NAS framework could be used to guide naloxone distribution plans, including HRVM implementation efforts. HRVMs show promise in expanding supply distribution. HRVMs are acceptable and valued by PWUD but programmatic barriers exist. Centering user perspectives is critical for improving reach, equity, and effectiveness of future HRVM implementation efforts.