"I wasn't scared of the dope I had anymore because I could test it myself:" A qualitative study among rural Appalachians who use drugs about experiences with a fentanyl test strip intervention.

Background: While fentanyl overdose rates are high in rural Appalachia, access to fentanyl test strips (FTS) and related research remains nascent in this region. Here, we explore the perspectives of rural Appalachian people who use drugs (PWUD) about an FTS education and distribution intervention. Methods: This qualitative study sampled PWUD participants in a harm reduction intervention located in six rural Appalachian Kentucky counties that included FTS education and distribution. During one-on-one semistructured interviews, interviewers queried participants' perceptions of risk environment features that shape their interest in FTS; their experience of the FTS intervention itself and their use of FTS; and their responses to positive test results. Constructivist thematic analysis methods were applied to transcripts. Results: PWUD reported that fentanyl saturated local drug markets and that fentanyl overdoses were pervasive and devastating features of these small rural risk environments. Just seven of the 29 participants had heard of FTS before participating in the intervention and only one had a current way to access them. Participants deemed FTS an essential intervention because (1) EMS response to overdoses was unreliable in these rural risk environments where PWUD often used in unmapped areas far from EMS stations; and (2) naloxone reversals, though essential, were physically and emotionally wrenching. Participants found FTS easy to use. Of the 11 participants who reported receiving a positive FTS result, all but one reported engaging in at least one behavior to reduce their overdose risk. Additionally, reflecting social support networks in this risk environment, 1/3 of the 29 participants reported disseminating FTS throughout their networks. Conclusions: This analysis found that specific features of the local rural Appalachian risk environment render FTS especially important. Unreliable EMS responses enhanced interest in this intervention. Strong social networks, a well-documented strength of rural Appalachian risk environments, permitted unanticipated diffusion of the intervention. Future interventional research should intentionally leverage these networks to extend reach.