Mobile services are particularly important in Appalachia, where overdose rates remain far higher than the national average and structural disadvantage amplifies barriers to care.

A new study in Harm Reduction Journal surveyed over 250 people living in rural Kentucky counties who inject drugs, asking about their preferences for service delivery.

“Given the geographic barriers and transportation barriers in rural Appalachia, we wanted to look at the willingness among rural Appalachian people who use drugs to engage with mobile syringe service programs,” lead author Dr. Alexander Elswick, of the University of Kentucky, told Filter.

Nearly 60 percent were willing to use a mobile SSP, with interest concentrated among the most disadvantaged populations. Participants preferred clinical, discreet vehicles with evening hours of operation.

The survey is part of the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic project (CARE2HOPE), founded in 2019 by Elswick’s colleague Dr. April Young. The research team recruited 259 adults across five counties who had used opioids or injected drugs to get high in the previous 30 days.

All participants completed a baseline survey that assessed their willingness to use a mobile SSP, and 135 returned six months later for a follow-up survey which gathered their feedback on how best to design mobile programs.

Overall, 59.9 percent of participants said they would be likely to use an SSP “that operated out of a mobile van that made visits throughout the community.” Importantly, mobile SSP were especially popular among many of the people they are designed to reach.

“It’s the more vulnerable population—those who experienced geographic and transportation barriers—who would be more likely to use the SSP,” Elswick said.

“Everybody knows everybody, and anonymity is so much more of a concern.”

People unable to access transportation were significantly more willing to use a mobile SSP, as were people earning less than $500 per month. Acceptance was also higher among people who tended to reuse their own syringes or share with others.

While a 60 percent acceptance rate might seem low, Elswick found these results encouraging.

“I took it generally as a positive,” he said. “Particularly in communities where there’s so much stigma … even moderate willingness is probably a good thing.”

However, one subset of participants was unenthusiastic about mobile services: people who reported feeling shame about their substance use. Elswick suspects that the tight-knit nature of some rural communities, which makes privacy difficult, might exacerbate fear of receiving services.

“There’s something unique about some of these rural Appalachian communities that are very small,” he said. “Everybody knows everybody, and anonymity is so much more of a concern.”

A desire for anonymity seems to have influenced participants’ stated preferences for mobile SSP deployment and design. Most participants endorsed parking mobile units at hospitals or clinics, but more general public locations—like large retail parking lots, gas stations and churches—were substantially less popular.

Participants also preferred vehicles to be smaller, and with more discreet markings—such as a research study logo, rather than health department branding.

“Appalachia has experienced a disproportionate burden … yet it’s underrepresented in research.”

“Another thing that surprised me was that there was low desire to engage with a peer who uses drugs,” Elswick said. “What participants preferred in terms of setting and provider were both more clinical in nature.”

That preference differs from those expressed by service users in other places—which underscores the importance of designing harm reduction services in conversation with their intended users, to reflect specific local circumstances and needs.

Syringe service programs have been legal in Kentucky since 2015, and their coverage has dramatically increased in recent years. But they’re only effective if people feel comfortable using them.

“Acceptability of the services really matters,” Elswick emphasized. “Design preferences have to be taken into consideration in order to increase engagement.”

While their findings suggest that rural Kentuckians prefer discreet, clinical mobile outreach services, the researchers are cautious about extrapolating these conclusions to other rural communities. Instead, they hope to shed light on Appalachians’ unique harm reduction needs and desires.

“Appalachia has experienced a disproportionate burden and consequences from the opioid epidemic and drug-related harms in general,” Elswick said. “Yet it’s underrepresented in research.”

Elswick’s stake in the work is not only academic. He is a Kentuckian in recovery himself, and a co-founder of Voices of Hope, which operates its own mobile outreach program. His research has left him feeling cautiously optimistic about the future of harm reduction efforts in his home state.

“This is a positive sign, but there’s still the need to reduce stigma and shame so that more people can get on board,” he concluded.

Image via County of Los Angeles Public Health

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Though the new regulations don’t explicitly targeting harm reduction services, that is the focus. Bill 240665-AA was filed in September 2024 by Councilmember Quetcy Lozada (D), whose district includes Kensington. It creates a permit system that applies specifically to mobile services addressing overdose, blood-borne disease transmission, and other medical and non-medical services. But it exempts EMTs and a number of other outreach services that would otherwise fit the description, like mobile vaccines and mammograms.

Mobile medical services such as HIV and hepatitis C testing can now only operate in two locations. One is off-limits between 11 pm and 6 am. The other is in front of a local law enforcement-assisted diversion program. Adam Geer, the city’s chief public safety director, has described this as “creating a natural synergy to co-locate important resources and meet people where they are in a safe environment.”

Non-medical services, meanwhile, cannot remain in the same location for more than 45 minutes at a time. For all providers, violations are punishable with a $1,000 fine.

“Moving every 45 minutes is extremely destabilizing,” Liddy Rechenberg, communications director for Savage Sisters Recovery, told Filter. “Outreach is built on trust and presence, not speed. Constantly relocating wastes time and causes confusion.”

Many participants have limited mobility, or other barriers that will prevent them from connecting to outreach under the new law. Rechenberg said the permitting process is also “slow and unclear,” and that city officials caused lot of confusion by failing to sufficiently involve providers in the process.

“We weren’t consulted before the law passed, and there’s been little guidance since,” she said. “The lack of collaboration with community orgs actually doing this work is extremely disappointing.”

“The majority of our mobile outreach will be impacted.”

The City Council is purporting to address complaints from Kensington residents.

“Among other things, residents living near where vehicular mobile service providers operate in the Seventh Councilmanic District have experienced increases in: The accumulation of plastic waste, human waste, discarded drug paraphernalia, discarded pills, medical supplies and various other items on residential streets, which pose a danger to children, the environment, public health and the dignity of our communities,” the law states. “Increased social conflict and confrontation [are] caused by some recipients of mobile services who engage in nuisance and criminal activity.”

Savage Sisters has not received any updates about next steps. Rechenberg and her colleagues have preemptively rescheduled outreach hours to the evenings, but she noted that a lot of other providers can’t necessarily do the same.

“The majority of our mobile outreach will be impacted,” Rechenberg said. “Our services rely on being present in high-need areas for consistent periods.”

Kensington, often vilified as one of the nation’s largest so-called “open-air drug markets,” has long been a flashpoint for housing and harm reduction. But in 2024, the neighborhood saw a 23-percent increase in unsheltered homelessness compared to 2023. In recent years, city officials have steadily defunded syringe service programs in favor of “community policing” and crackdowns public drug use, while Kensington’s affordable housing crisis continues to worsen.

Mayor Cherelle Parker (D) was elected in 2024 on a “tough-on-crime” platform, and shortly after taking office declared a public state of emergency in Kensington. This involved mobilizing law enforcement with an executive order to “permanently shut down all pervasive open-air drug markets, including but not limited to the open-air drug markets in the Kensington neighborhood.” Parker has expressed support for practices like “stop and frisk,” while opposing public-health strategies like overdose prevention centers (OPC).

In an appeals court hearing in April, nonprofit Safehouse Philly continued a years-long battle against the Department of Justice and the federal “crack-house statute” that criminalizes OPC. The DOJ first sued Safehouse in 2019 during President Donald Trump’s first term. During the April hearing, a federal judge suggested that Safehouse may have an avenue toward legal operations under religious freedom exemptions in the Controlled Substances Act.

“I think it probably cuts in favor of Safehouse, because it’s a prohibitive activity, or it’s a controlled substance like peyote was, but they want to either take it or enable others to take it safely for religious purposes,” United States Circuit Judge David J. Porter, who was appointed during Trump’s first term, said according to Courthouse News. “And if that interest is burdened, and if the government’s not prosecuting everyone the same way for doing that, then they have a pretty good case.”

Top image (cropped) and inset graphic via City of Philadelphia

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