Ingenuity and resiliency of syringe service programs on the front lines of the opioid overdose and COVID-19 crises.

As COVID-19 accelerated throughout 2020, syringe service programs (SSPs) faced challenges necessitating programmatic adaptations to prevent overdose deaths while simultaneously keeping workers and participants safe from COVID-19. We used qualitative methods to gain an understanding of the social context within which SSPs are operating during the COVID-19 pandemic. We conducted 36 in-depth interviews with program representatives from 18 programs and used the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation framework to guide data analysis. We focused on 3 of the 4 EPIS constructs: Outer context, inner context, and innovation factors. Our data indicate that responding to the pandemic led to innovations in service delivery such as secondary and mail-based distribution, adoption of telemedicine for enrolling participants in medications for opioid use disorder (MOUD) and use of virtual training platforms for overdose prevention. We found high levels of staff and volunteer commitment, which was a cornerstone to the success of these innovations. We observed that many SSPs were short-staffed because of their commitment to safety, and some lost current funding as well as opportunities for future funding. Despite minimal staffing and diminished funding, SSPs innovated at an accelerated pace. To ensure the sustainability of these new approaches, a supportive external context (federal, state, and local policies and funding) is needed to support the development of SSPs' inner contexts (organizational characteristics, characteristics of individuals) and sustainment of the innovations achieved regarding delivery of naloxone and MOUD.