People who use drugs and live in rural communities may lack access to harm reduction services. Harm reduction vending machines that offer 24/7 access to resources may help address this need. This study examined who in particular may be more or less likely to use a harm reduction vending machine in a sample of people using drugs in Appalachia.
l
Harm reduction vending machines are a relatively novel approach to harm reduction. These machines are similar to traditional vending machines, but offer harm reduction supplies, such as sterile injection equipment, naloxone, and informational resources. These supplies can be accessed by a card, code, or payment. Harm reduction vending machines can help overcome some barriers to syringe service programs, including 24/7 access and not requiring contact with service providers for those who would prefer to remain anonymous. Implementation of these vending machines has been associated with decreases in syringe sharing and deaths from overdoses.
People who live in rural communities, such as Appalachia (a rural region spanning 13 states along the Appalachia Mountains in the eastern United States), may lack access to harm reduction services due to stigma, lack of easily accessible resources, and fear of legal consequences. Importantly, people who use drugs in rural communities have indicated that they would like to have greater access to a range of harm reduction services, particularly vending machines. Researchers in this study examined factors associated with anticipating the use of a harm reduction vending machine among people who use drugs in parts of Appalachia. Such research can help identify the needs and desires of people who use drugs in rural communities and who may be most likely to take advantage of harm reduction services.
The research team examined the likelihood of whether people who use drugs would use a harm reduction vending machine, their demographics, and their behavioral characteristics regarding drug use. This was done via a survey administered by an interviewer in field offices in 5 counties from Appalachian Kentucky.
Survey data were collected from February 2018 through March 2020. The survey asked “If a new needle or syringe exchange program was going to be created here, what kind of program would you be likely to use? This program would exchange syringes, offer referrals to drug treatment, and provide other health services. (check all that apply).” A variety of response options were provided. The main outcome of interest was checking likely use of “one that was operated out of a vending machine where I could turn in old needles and get new ones”.
The predictor variables of interest were also assessed via the survey and included the following: substance use in the past 6 months; injection drug use; syringe sharing (both when an individual uses a syringe previously used by another person, or receptive sharing, and when an individual passes a used syringe onto another person to be used, or distributive sharing); syringe reuse; access to treatment for substance use disorder; history of overdose; use of a syringe service program; demographic and socioeconomic indicators (e.g., age, gender, income, houselessness, and transportation access), and the extent to which participants felt shame related to their drug use, to which response options included not at all, just a little, somewhat, very much.
For the statistical analyses, the research team ran models to estimate the associations between the likelihood of using a harm reduction vending machine and demographic and behavioral characteristics regarding drug use. To isolate the independent effects between these variables and the likelihood of using a harm reduction vending machine from using harm reduction services more broadly, the researchers controlled for having ever used a syringe service program in all models. However, each factor and its association with anticipated use of a harm reduction vending machine was examined separately, making it difficult to tease apart the effects of each of these factors.
Participants were recruited by asking people who already participated in the study to help recruit others to participate (called “respondent-driven sampling”). Those who were 18 years old or older, resided in the geographic location of interest to the study (i.e., 5 counties in Appalachian Kentucky), and used opioids or injected any drug for recreational purposes in the last 30 days were eligible to participate.
A total of 338 participants were recruited into the overall study, of which 259 who reported injecting drugs in the past 6 months were included in the analyses for the current study. Of these, 60% were men and were on average 35 years old. A little over half (56%) reported an income level of $500 a month or less and 37% experienced homelessness.
More severe addiction histories associated with likelihood of using a harm reduction vending machine
Over half of participants (57%) reported being likely to use a harm reduction vending machine. Participants who engaged in riskier drug use practices were more likely to anticipate using a harm reduction vending machine (see graph below). Specifically, those who reported engaging in receptive and distributive syringe sharing were 76% and 42% more likely to use a vending machine, respectively, than those who did not engage in syringe sharing. Also, more overdoses were associated with a greater likelihood of vending machine use, with a 7% likelihood increase for each additional overdose reported.
Further, participants who experienced barriers to accessing treatment were more likely to anticipate using a harm reduction vending machine. Participants who reported a lack of consistent transportation for medical appointments were 54% more likely to use a vending machine than those who had or may have transportation. Similarly, those who reported an inability to access medications for opioid use disorder in the past 6 months were 31% more likely to use a vending machine than those who were able to access them.
Opioid use and shame associated with a lower likelihood of using of a harm reduction vending machine
Use of certain drugs was associated with a lower likelihood of anticipating use of a harm reduction vending machine. Participants who reported using heroin and prescription opioids for non-medical purposes in the past 30 days were 26% and 17% less likely to use a harm reduction vending machine, respectively, than those who did not report using these drugs.
Additionally, experiencing shame about using drugs was associated with a lower likelihood of anticipating use of a harm reduction vending machine. Participants who reported experiencing “just a little” shame around their drug use were 29% less likely to use a vending machine than those who reported no shame. Likewise, those who reported that they were somewhat or very much ashamed about their drug use were both 32% less likely to use a vending machine than those who reported no shame.
This study examining the likelihood of whether people who use drugs in Appalachian Kentucky would use a harm reduction vending machine showed that over half of participants would be willing to use such as resource. Further, participants who shared syringes, experienced more overdoses, lacked transportation, and were not able to access medications for opioid use disorder were more likely to anticipate use of a harm reduction vending machine, while those who reported using heroin and prescription opioids and experiencing shame were less likely. These findings highlight an unmet need for harm reduction services in rural communities, particularly among people who engage in riskier drug use or have faced barriers to treatment.
The findings showing that those who are at a higher risk of contracting blood-borne diseases through syringe sharing and are at a greater risk of overdose based on their history of prior overdoses reported a greater likelihood of willingness to use a harm reduction vending machine than people without these risks suggest that people who are at higher risk of adverse health consequences may be most likely to benefit from the implementation of a vending machine. At the same time, recent use of heroin and more shame regarding one’s drug use were associated with lower likelihood of using a harm reduction vending machine.
These facilitators and barriers would seem to be in opposition, suggesting certain individuals for whom these resources would be helpful (e.g., people using heroin with higher levels of shame) may be less inclined to use them. One explanation is that the vending machines were located in public places, where others can see who is using them. Use of heroin, for example, may be associated with more perceived stigma and fears of legal consequences. Because all of these variables were examined on their own, it is difficult to say why injection drug use makes vending machine use more likely but recent heroin use makes it less likely. Future work should help clarify the direction of these effects to understand who is likely to use these harm reduction resources and who may benefit from a “nudge” to do so. Irrespective of what explains these counterintuitive results, implementation efforts that identify ways to improve privacy may increase access to those experiencing shame and do not want to be seen in public using the machine.
Many people living in Appalachia who use drugs appear to be willing to use a harm reduction vending machine, especially those who shared syringes, experienced more overdoses, lacked transportation, and were not able to access medications for opioid use disorder. Somewhat counterintuitively, those who reported using heroin and prescription opioids were less likely to use a vending machine. Also, perhaps expectedly, those who reported experiencing shame about their drug use were less likely to use them. While more rigorous analyses can help tease apart what makes someone more or less likely to use these harm reduction resources, the findings highlight an unmet need for harm reduction services in rural communities, particularly among people who engage in riskier drug use or have faced barriers to treatment, and suggest the need for more privacy when implementing machines.
Young, A. M., Jahangir, T., Belton, I., Freeman, E., & Livingston, M. D. (2025). Likelihood of using a harm reduction vending machine among rural people who inject drugs in Appalachian Kentucky. International Journal of Drug Policy, 137. doi: 10.1016/j.drugpo.2025.104709.
l
Harm reduction vending machines are a relatively novel approach to harm reduction. These machines are similar to traditional vending machines, but offer harm reduction supplies, such as sterile injection equipment, naloxone, and informational resources. These supplies can be accessed by a card, code, or payment. Harm reduction vending machines can help overcome some barriers to syringe service programs, including 24/7 access and not requiring contact with service providers for those who would prefer to remain anonymous. Implementation of these vending machines has been associated with decreases in syringe sharing and deaths from overdoses.
People who live in rural communities, such as Appalachia (a rural region spanning 13 states along the Appalachia Mountains in the eastern United States), may lack access to harm reduction services due to stigma, lack of easily accessible resources, and fear of legal consequences. Importantly, people who use drugs in rural communities have indicated that they would like to have greater access to a range of harm reduction services, particularly vending machines. Researchers in this study examined factors associated with anticipating the use of a harm reduction vending machine among people who use drugs in parts of Appalachia. Such research can help identify the needs and desires of people who use drugs in rural communities and who may be most likely to take advantage of harm reduction services.
The research team examined the likelihood of whether people who use drugs would use a harm reduction vending machine, their demographics, and their behavioral characteristics regarding drug use. This was done via a survey administered by an interviewer in field offices in 5 counties from Appalachian Kentucky.
Survey data were collected from February 2018 through March 2020. The survey asked “If a new needle or syringe exchange program was going to be created here, what kind of program would you be likely to use? This program would exchange syringes, offer referrals to drug treatment, and provide other health services. (check all that apply).” A variety of response options were provided. The main outcome of interest was checking likely use of “one that was operated out of a vending machine where I could turn in old needles and get new ones”.
The predictor variables of interest were also assessed via the survey and included the following: substance use in the past 6 months; injection drug use; syringe sharing (both when an individual uses a syringe previously used by another person, or receptive sharing, and when an individual passes a used syringe onto another person to be used, or distributive sharing); syringe reuse; access to treatment for substance use disorder; history of overdose; use of a syringe service program; demographic and socioeconomic indicators (e.g., age, gender, income, houselessness, and transportation access), and the extent to which participants felt shame related to their drug use, to which response options included not at all, just a little, somewhat, very much.
For the statistical analyses, the research team ran models to estimate the associations between the likelihood of using a harm reduction vending machine and demographic and behavioral characteristics regarding drug use. To isolate the independent effects between these variables and the likelihood of using a harm reduction vending machine from using harm reduction services more broadly, the researchers controlled for having ever used a syringe service program in all models. However, each factor and its association with anticipated use of a harm reduction vending machine was examined separately, making it difficult to tease apart the effects of each of these factors.
Participants were recruited by asking people who already participated in the study to help recruit others to participate (called “respondent-driven sampling”). Those who were 18 years old or older, resided in the geographic location of interest to the study (i.e., 5 counties in Appalachian Kentucky), and used opioids or injected any drug for recreational purposes in the last 30 days were eligible to participate.
A total of 338 participants were recruited into the overall study, of which 259 who reported injecting drugs in the past 6 months were included in the analyses for the current study. Of these, 60% were men and were on average 35 years old. A little over half (56%) reported an income level of $500 a month or less and 37% experienced homelessness.
More severe addiction histories associated with likelihood of using a harm reduction vending machine
Over half of participants (57%) reported being likely to use a harm reduction vending machine. Participants who engaged in riskier drug use practices were more likely to anticipate using a harm reduction vending machine (see graph below). Specifically, those who reported engaging in receptive and distributive syringe sharing were 76% and 42% more likely to use a vending machine, respectively, than those who did not engage in syringe sharing. Also, more overdoses were associated with a greater likelihood of vending machine use, with a 7% likelihood increase for each additional overdose reported.
Further, participants who experienced barriers to accessing treatment were more likely to anticipate using a harm reduction vending machine. Participants who reported a lack of consistent transportation for medical appointments were 54% more likely to use a vending machine than those who had or may have transportation. Similarly, those who reported an inability to access medications for opioid use disorder in the past 6 months were 31% more likely to use a vending machine than those who were able to access them.
Opioid use and shame associated with a lower likelihood of using of a harm reduction vending machine
Use of certain drugs was associated with a lower likelihood of anticipating use of a harm reduction vending machine. Participants who reported using heroin and prescription opioids for non-medical purposes in the past 30 days were 26% and 17% less likely to use a harm reduction vending machine, respectively, than those who did not report using these drugs.
Additionally, experiencing shame about using drugs was associated with a lower likelihood of anticipating use of a harm reduction vending machine. Participants who reported experiencing “just a little” shame around their drug use were 29% less likely to use a vending machine than those who reported no shame. Likewise, those who reported that they were somewhat or very much ashamed about their drug use were both 32% less likely to use a vending machine than those who reported no shame.
This study examining the likelihood of whether people who use drugs in Appalachian Kentucky would use a harm reduction vending machine showed that over half of participants would be willing to use such as resource. Further, participants who shared syringes, experienced more overdoses, lacked transportation, and were not able to access medications for opioid use disorder were more likely to anticipate use of a harm reduction vending machine, while those who reported using heroin and prescription opioids and experiencing shame were less likely. These findings highlight an unmet need for harm reduction services in rural communities, particularly among people who engage in riskier drug use or have faced barriers to treatment.
The findings showing that those who are at a higher risk of contracting blood-borne diseases through syringe sharing and are at a greater risk of overdose based on their history of prior overdoses reported a greater likelihood of willingness to use a harm reduction vending machine than people without these risks suggest that people who are at higher risk of adverse health consequences may be most likely to benefit from the implementation of a vending machine. At the same time, recent use of heroin and more shame regarding one’s drug use were associated with lower likelihood of using a harm reduction vending machine.
These facilitators and barriers would seem to be in opposition, suggesting certain individuals for whom these resources would be helpful (e.g., people using heroin with higher levels of shame) may be less inclined to use them. One explanation is that the vending machines were located in public places, where others can see who is using them. Use of heroin, for example, may be associated with more perceived stigma and fears of legal consequences. Because all of these variables were examined on their own, it is difficult to say why injection drug use makes vending machine use more likely but recent heroin use makes it less likely. Future work should help clarify the direction of these effects to understand who is likely to use these harm reduction resources and who may benefit from a “nudge” to do so. Irrespective of what explains these counterintuitive results, implementation efforts that identify ways to improve privacy may increase access to those experiencing shame and do not want to be seen in public using the machine.
Many people living in Appalachia who use drugs appear to be willing to use a harm reduction vending machine, especially those who shared syringes, experienced more overdoses, lacked transportation, and were not able to access medications for opioid use disorder. Somewhat counterintuitively, those who reported using heroin and prescription opioids were less likely to use a vending machine. Also, perhaps expectedly, those who reported experiencing shame about their drug use were less likely to use them. While more rigorous analyses can help tease apart what makes someone more or less likely to use these harm reduction resources, the findings highlight an unmet need for harm reduction services in rural communities, particularly among people who engage in riskier drug use or have faced barriers to treatment, and suggest the need for more privacy when implementing machines.
Young, A. M., Jahangir, T., Belton, I., Freeman, E., & Livingston, M. D. (2025). Likelihood of using a harm reduction vending machine among rural people who inject drugs in Appalachian Kentucky. International Journal of Drug Policy, 137. doi: 10.1016/j.drugpo.2025.104709.
l
Harm reduction vending machines are a relatively novel approach to harm reduction. These machines are similar to traditional vending machines, but offer harm reduction supplies, such as sterile injection equipment, naloxone, and informational resources. These supplies can be accessed by a card, code, or payment. Harm reduction vending machines can help overcome some barriers to syringe service programs, including 24/7 access and not requiring contact with service providers for those who would prefer to remain anonymous. Implementation of these vending machines has been associated with decreases in syringe sharing and deaths from overdoses.
People who live in rural communities, such as Appalachia (a rural region spanning 13 states along the Appalachia Mountains in the eastern United States), may lack access to harm reduction services due to stigma, lack of easily accessible resources, and fear of legal consequences. Importantly, people who use drugs in rural communities have indicated that they would like to have greater access to a range of harm reduction services, particularly vending machines. Researchers in this study examined factors associated with anticipating the use of a harm reduction vending machine among people who use drugs in parts of Appalachia. Such research can help identify the needs and desires of people who use drugs in rural communities and who may be most likely to take advantage of harm reduction services.
The research team examined the likelihood of whether people who use drugs would use a harm reduction vending machine, their demographics, and their behavioral characteristics regarding drug use. This was done via a survey administered by an interviewer in field offices in 5 counties from Appalachian Kentucky.
Survey data were collected from February 2018 through March 2020. The survey asked “If a new needle or syringe exchange program was going to be created here, what kind of program would you be likely to use? This program would exchange syringes, offer referrals to drug treatment, and provide other health services. (check all that apply).” A variety of response options were provided. The main outcome of interest was checking likely use of “one that was operated out of a vending machine where I could turn in old needles and get new ones”.
The predictor variables of interest were also assessed via the survey and included the following: substance use in the past 6 months; injection drug use; syringe sharing (both when an individual uses a syringe previously used by another person, or receptive sharing, and when an individual passes a used syringe onto another person to be used, or distributive sharing); syringe reuse; access to treatment for substance use disorder; history of overdose; use of a syringe service program; demographic and socioeconomic indicators (e.g., age, gender, income, houselessness, and transportation access), and the extent to which participants felt shame related to their drug use, to which response options included not at all, just a little, somewhat, very much.
For the statistical analyses, the research team ran models to estimate the associations between the likelihood of using a harm reduction vending machine and demographic and behavioral characteristics regarding drug use. To isolate the independent effects between these variables and the likelihood of using a harm reduction vending machine from using harm reduction services more broadly, the researchers controlled for having ever used a syringe service program in all models. However, each factor and its association with anticipated use of a harm reduction vending machine was examined separately, making it difficult to tease apart the effects of each of these factors.
Participants were recruited by asking people who already participated in the study to help recruit others to participate (called “respondent-driven sampling”). Those who were 18 years old or older, resided in the geographic location of interest to the study (i.e., 5 counties in Appalachian Kentucky), and used opioids or injected any drug for recreational purposes in the last 30 days were eligible to participate.
A total of 338 participants were recruited into the overall study, of which 259 who reported injecting drugs in the past 6 months were included in the analyses for the current study. Of these, 60% were men and were on average 35 years old. A little over half (56%) reported an income level of $500 a month or less and 37% experienced homelessness.
More severe addiction histories associated with likelihood of using a harm reduction vending machine
Over half of participants (57%) reported being likely to use a harm reduction vending machine. Participants who engaged in riskier drug use practices were more likely to anticipate using a harm reduction vending machine (see graph below). Specifically, those who reported engaging in receptive and distributive syringe sharing were 76% and 42% more likely to use a vending machine, respectively, than those who did not engage in syringe sharing. Also, more overdoses were associated with a greater likelihood of vending machine use, with a 7% likelihood increase for each additional overdose reported.
Further, participants who experienced barriers to accessing treatment were more likely to anticipate using a harm reduction vending machine. Participants who reported a lack of consistent transportation for medical appointments were 54% more likely to use a vending machine than those who had or may have transportation. Similarly, those who reported an inability to access medications for opioid use disorder in the past 6 months were 31% more likely to use a vending machine than those who were able to access them.
Opioid use and shame associated with a lower likelihood of using of a harm reduction vending machine
Use of certain drugs was associated with a lower likelihood of anticipating use of a harm reduction vending machine. Participants who reported using heroin and prescription opioids for non-medical purposes in the past 30 days were 26% and 17% less likely to use a harm reduction vending machine, respectively, than those who did not report using these drugs.
Additionally, experiencing shame about using drugs was associated with a lower likelihood of anticipating use of a harm reduction vending machine. Participants who reported experiencing “just a little” shame around their drug use were 29% less likely to use a vending machine than those who reported no shame. Likewise, those who reported that they were somewhat or very much ashamed about their drug use were both 32% less likely to use a vending machine than those who reported no shame.
This study examining the likelihood of whether people who use drugs in Appalachian Kentucky would use a harm reduction vending machine showed that over half of participants would be willing to use such as resource. Further, participants who shared syringes, experienced more overdoses, lacked transportation, and were not able to access medications for opioid use disorder were more likely to anticipate use of a harm reduction vending machine, while those who reported using heroin and prescription opioids and experiencing shame were less likely. These findings highlight an unmet need for harm reduction services in rural communities, particularly among people who engage in riskier drug use or have faced barriers to treatment.
The findings showing that those who are at a higher risk of contracting blood-borne diseases through syringe sharing and are at a greater risk of overdose based on their history of prior overdoses reported a greater likelihood of willingness to use a harm reduction vending machine than people without these risks suggest that people who are at higher risk of adverse health consequences may be most likely to benefit from the implementation of a vending machine. At the same time, recent use of heroin and more shame regarding one’s drug use were associated with lower likelihood of using a harm reduction vending machine.
These facilitators and barriers would seem to be in opposition, suggesting certain individuals for whom these resources would be helpful (e.g., people using heroin with higher levels of shame) may be less inclined to use them. One explanation is that the vending machines were located in public places, where others can see who is using them. Use of heroin, for example, may be associated with more perceived stigma and fears of legal consequences. Because all of these variables were examined on their own, it is difficult to say why injection drug use makes vending machine use more likely but recent heroin use makes it less likely. Future work should help clarify the direction of these effects to understand who is likely to use these harm reduction resources and who may benefit from a “nudge” to do so. Irrespective of what explains these counterintuitive results, implementation efforts that identify ways to improve privacy may increase access to those experiencing shame and do not want to be seen in public using the machine.
Many people living in Appalachia who use drugs appear to be willing to use a harm reduction vending machine, especially those who shared syringes, experienced more overdoses, lacked transportation, and were not able to access medications for opioid use disorder. Somewhat counterintuitively, those who reported using heroin and prescription opioids were less likely to use a vending machine. Also, perhaps expectedly, those who reported experiencing shame about their drug use were less likely to use them. While more rigorous analyses can help tease apart what makes someone more or less likely to use these harm reduction resources, the findings highlight an unmet need for harm reduction services in rural communities, particularly among people who engage in riskier drug use or have faced barriers to treatment, and suggest the need for more privacy when implementing machines.
Young, A. M., Jahangir, T., Belton, I., Freeman, E., & Livingston, M. D. (2025). Likelihood of using a harm reduction vending machine among rural people who inject drugs in Appalachian Kentucky. International Journal of Drug Policy, 137. doi: 10.1016/j.drugpo.2025.104709.
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