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Injections and infections: understanding syringe service program utilization in a rural state



Increasing rates of injection drug use (IDU) associated-infections suggest significant syringe service program (SSP) underutilization. Our study objective was to assess practices of safe injection techniques and to determine predictors of SSP utilization in a rural state.

Patients and methods

This was a fifteen-month cross-sectional study of participants hospitalized with IDU-associated infections in Maine. Data were collected through Audio Computer-Assisted Self-Interview survey and medical record review. Descriptive analyses were performed to characterize demographics, health characteristics, and injection practices. The primary outcome was SSP utilization, and the main independent variable was self-reported distance to SSP. Logistic regression analyses were performed to identify factors associated SSP utilization, controlling for gender, homelessness, history of overdose, having a primary care physician and distance to SSP.


Of the 101 study participants, 65 participants (64%) reported past 3 month SSP utilization, though only 33% used SSPs frequently. Many participants (57%) lived more than 10 miles from an SSP. Participants who lived less than 10 miles of an SSP were more likely to use an SSP (adjusted odds ratio 5.4; 95% CI 1.9–15.7).


Our study highlights unsafe injection practices and lack of frequent SSP utilization among people admitted with IDU-associated infections in a rural state. Especially given increasing stimulant use, these results also highlight the need for SSP access. Particularly in rural areas where patients may live more than 10 miles from an SSP, expansion of harm reduction services, including mobile units, should be a priority.


The increasing prevalence of substance use disorders in the United States has highlighted the need to examine approaches to reduce injection drug use (IDU)-associated infections [24]. Unsafe injection practices among people who inject drugs (PWID) have led to rising rates of HIV, viral hepatitis, and serious bacterial and fungal infections, such as infective endocarditis [10, 22, 31, 32]. From 2014 to 2018, new HIV diagnoses among PWID in the United States increased by 9% [21] and acute hepatitis C also increased, particularly among people ages 20–39 years old. The number of estimated acute hepatitis C cases in 2018 was 50,300, compared to 17,100 in 2011, with 72% of reported cases attributable to IDU [19]. In a recent study using national commercial and Medicaid databases, the incidence of infective endocarditis among people with opioid use disorder increased from 156.4/100,000 to 642.9/100,000 in 2017 [31]. Harm reduction services, specifically syringe services programs (SSPs), have been shown to effectively counsel clients about safe injection techniques, reduce the transmission of infections like HIV, deliver overdose prevention/education, administer vaccinations, and also facilitate referrals for medication for opioid use disorder (MOUD) [7, 8, 16].

Nationally, outbreaks of HIV and viral hepatitis, such as those in Scott County, Indiana, and the rise of other serious complications such as infective endocarditis, have raised concern about access to preventive and treatment services for PWID in rural areas [5, 14, 15, 33]. Additionally, some factors such as drug availability, close social networks, and economic hardship may play role in the increasing incidence of IDU-associated infections in rural areas [12]. In Maine, a predominantly rural state, the incidence of viral hepatitis and IDU-associated infective endocarditis have increased over recent years. Maine currently has the second highest rate of acute hepatitis B in the United States, with an 11.5% increase in cases from 2018 to 2019. Acute hepatitis C cases in Maine increased by 51.8% from 2018 to 2019, while IDU-associated infective endocarditis cases increased by 25% from 2013 to 2016 [4, 20, 29]. These trends have led to concerns that PWID underutilize SSP services and that SSPs may be less accessible, particularly to rural residents. A recent study showed that a majority of young people with acute hepatitis C in Maine lived ≥ 10 miles from an SSP [5]. The fact that IDU-associated infections have been reported at hospitals both near and far from SSPs suggests that geographic dispersion however may not be the only factor influencing utilization and that other barriers need to be identified. Thus, the goal of our study was to provide a more detailed understanding of factors that influence SSP utilization in Maine and also help inform future interventions to improve access to SSP services, particularly in rural states. Our hypothesis was that distance from SSP would be a significant predictor of SSP utilization, and that other social determinants of health, such as homelessness, insurance and employment status, would play a role as well. Our study objectives were to (1) examine practices around safe injection techniques and (2) determine factors predicting utilization of SSPs.


Study Design

This is a cross-sectional study of participants hospitalized with IDU-associated infections at four hospitals in Maine in counties deemed high risk for HIV/hepatitis outbreaks [30]. A convenience sample of n = 101 participants was prospectively recruited from January 1, 2019 through March 18, 2020. Study enrollment was halted due the COVID-19 pandemic.

Inclusion and exclusion criteria

Criteria for study enrollment included: (1) inpatient infectious disease consultation for a diagnosis of an IDU-associated infection such as infective endocarditis, skin/soft tissue infection, osteomyelitis, HIV or viral hepatitis, or whose chart has been reviewed by the ID antibiotic stewardship team and found to have an IDU-associated infection; (2) age 18–65; (3) EHR-reported or self-reported injection drug use and/or recent stigmata (e.g., injection sites on physical exam); (4) English speaking; and (5) ability to provide informed consent. Exclusion criteria included intubation, suicidal/homicidal ideation, or if the individual showed signs of psychotic symptoms. Data were collected through Audio Computer-Assisted Self-Interview (ACASI) [1] survey and medical record review. Of 120 individuals eligible for the study based on the inclusion criteria, n = 19 individuals declined to participate. No individuals met exclusion criteria. Upon completion of the survey, which took approximately 30–60 min, study participants were compensated with a $25 gift card for their time and expertise.



The primary outcome was SSP utilization which was defined as (1) having reported using an SSP in the past 3 months or (2) responding to the question about most common ways the participant accessed an SSP in the past 3 months.


Independent variable

The main independent variable was distance to closest SSP. Distance from the closest SSP to the participant's address was calculated in miles with an online map tool. If the participant was experiencing homelessness or if the participant's address was not available in electronic health record (EHR), distance in mileage was calculated between the closest SSP and the self-reported place/zip code where the participant most frequently lived or slept in the past 90 days.


Some variables were collected through self-report. Self-report demographic and health variables included gender, history of incarceration, willingness to take pre-exposure prophylaxis for HIV/discussed pre-exposure prophylaxis with provider, condomless sex, and homelessness. Self-report variables regarding substance use included overdose history and injectable and non-injectable drug(s) of choice. Severity of opioid use disorder was measured using the Short-inventory of Problems-Modified for Drug Use (SIP-DU) [3]. The Bacterial Skin Index Risk Score (BIRSI) score, which includes questions about alcohol pad and sterile water use, handwashing, rotating injection sites, injecting subcutaneously or in the muscle (“skin/muscle popping”), and clean needle use, was used as a continuous score to measure risk of skin and soft tissue infections [17]. Syringe acquisition and disposal variables (i.e. peer exchange, disposal of needle/syringes in SSPs, public places, etc.) were also collected through self-report. Unhealthy alcohol use was categorized using the AUDIT-C score [25]. Naloxone uptake was defined by self-report use of naloxone on another person, or having naloxone used on themselves. Self-report variables around SSP utilization included barriers to access, reasons for re-use of needles/syringes and other drug injection equipment.

Additional variables such as having a primary care provider (PCP), prior infectious complications, history of sexually transmitted infections and viral hepatitis were collected by a combination of self-report and EHR data. Hepatitis C (HCV) exposure was defined as positive if the participant self-reported history of HCV, HCV found in EHR, HCV antibody positive with or without HCV RNA. Hepatitis B (HBV) infection was defined as self-reported HBV, HBV listed in EHR, positive hepatitis B surface Ag, or positive HBV DNA. HIV infection was defined as self-reported HIV infection, positive HIV antigen/antibody or HIV noted in EHR. Vaccinations for Hepatitis A, HBV, and Tdap were collected via self-report and EHR. Rurality was categorized as either rural (small or isolated rural) or urban (large rural or metropolitan) using the Rural–urban commuting area (RUCA) codes [2]. Other variables were collected through EHR review exclusively. Such variables included insurance status, infectious disease diagnosis, Charlson co-morbidity index [6], prescribed MOUD prior to admission. MOUD prior to admission was defined as buprenorphine, buprenorphine/naloxone, naltrexone, or methadone on the pre-admission medication list.

Statistical analyses

Descriptive analyses were performed to characterize injection knowledge, attitudes and practices. The primary outcome was past 3-month SSP utilization, and the main independent variable was distance to closest SSP. Data were compared between subgroups using t-tests for continuous data; Pearson’s Chi square tests or Fisher’s exact tests were used as appropriate for categorical data. Logistic regression analyses were performed to identify factors associated with SSP utilization. Potential covariates were chosen a priori based on clinical knowledge and literature review. Bivariate unadjusted odds analyses were performed testing the following variables: gender, insurance, employment status, homelessness, overdose history, PCP, insurance, condomless sex, distance, MOUD, trouble accessing SSP, HIV, HBV, HCV, SIP-DU and BIRSI scores. SAS Enterprise Guide version 7.1 was used for the analysis.


Descriptive analysis

There were 101 study participants enrolled in the study, of whom n = 65 (64%) reported SSP utilization (Table 1). Fifty-six percent (n = 57) of participants had a distance of ≥ 10 miles to the closest SSP. Few participants used engaged in safe practices each time they injected (Table 2). Ninety-four percent of participants reported licking the tip of their needle prior to injecting.

Table 1 Demographics and health characteristics among the study population, stratified by syringe service program use
Table 2 Substance use characteristics and syringe acquisition/disposal in study participants, stratified by syringe service program use

Differences in demographics in participants with SSP utilization versus no SSP utilization include homelessness (55% versus 28%, p = 0.01), distance ≥ 10 miles (43% versus 81%, p < 0.01), and rurality (8% versus 36%, p < 0.01). There were no significant differences in SSP utilization by race, gender, sexual preference, or insurance status.

In terms of health differences, participants with a mental health condition were more like to report SSP utilization compared to those who did not use SSPs (95% versus 81%, p = 0.03). History of overdose was more common among participants who reported SSP utilization (65% versus 33%, p < 0.01). Overall, most participants reported opioids as injection drugs of choice; notably, 30% of participants reported stimulants (amphetamine, cocaine, cocaine plus heroin) as their drugs of choice. There were significant differences in injection drugs of choice among participants with SSP utilization (notably more methamphetamine and heroin use) compared to participants who did not use SSPs (Table 2). Certain infectious complications, such as epidural abscesses, were less common among participants with SSP utilization. Naloxone uptake was more prevalent among participants with SSP utilization (55% versus 33%, p = 0.03). Preventive and treatment services such as Tdap, hepatitis A and B vaccination and MOUD treatment were higher among participants who reported SSP utilization. There were no statistically significant differences in other health characteristics or substance use characteristics between the two groups (HCV, HIV, pre-exposure prophylaxis awareness, skin and soft tissue infection risk (BIRSI-7 score), drug use severity (SIP-DU), or unhealthy alcohol use (AUDIT-C) (Table 2).

There were several differences in syringe acquisition and disposal between the two groups. People who reported SSP utilization were more likely to use clean “works” (i.e. cookers and filters; (31% versus 11%, p = 0.04) and clean needles (52% versus 22%, p = 0.05) all or most of the time in the past 3 months. They were also more likely neutral/interested in mobile syringe service program units or supervised injection facilities. There were no statistically significant differences in syringe disposal in public places (45% versus 37%, p = 0.6), re-use of needles (82% versus 78%, p = 0.8), or always using clean needles (12% versus 6%, p = 0.6) or always using clean works (5% versus 6%, p = 0.24). Participants who did not use SSPs were more likely to acquire their needle/syringes from pharmacies or peer exchange (Table 2).

Of those n = 65 participants who used an SSP, 33% used an SSP frequently (few times per week), whereas others used it sometimes (21%) or hardly ever (28%). Many reported using one because its free services (57%) or because of privacy (31%). Fifty-four percent of participants reported trouble accessing an SSP, largely due to distance (28%), lack of car (19%), or stigma (14%).

Multivariable analysis

Gender, homelessness, history of overdose, having primary care physician and distance to SSP were included in the final multivariable regression model based on statistical significance of p < 0.05 in the bivariate, unadjusted odds analyses. Participants who lived ≤ 10 miles from an SSP were more likely to use an SSP (OR 5.4, 95% CI 1.9–15.7), controlling for female gender, homelessness, history of overdose, and having a PCP (Table 3). Notably, participants with history of overdose (OR 3.0, 95% CI 1.1–8.1) and with a PCP (3.1, 95% CI 1.1–8.7) were also more likely to use an SSP.

Table 3 Unadjusted and adjusted analyses of predictors of syringe service program use


Prior studies have documented the health benefits of access to SSPs, particularly when combined with access to MOUD treatment [7, 18]. Given the unsafe injection practices in this study population and geographic distribution of PWID in rural Maine, expansion of SSPs, including mobile units, could improve SSP utilization [28] and potentially prevent IDU-associated infections [8]. Thus far, behavioral interventions that include harm reduction counseling in the hospital have not yet been shown to reduce future hospitalizations [27], leading to an emphasis on community strategies for harm reduction, such as access to SSPs. At the time of this study, there were only 6 SSPs in Maine, though in the setting of increasing overdoses and costly IDU-associated infections, additional SSPs opened upon study completion. It is noteworthy that living in rural settings can lead to barriers to access to SSPs due to both distance and to lack of public transportation. Our study results are consistent with prior research where geographic disparities in SSP access were noted, particularly among young people with acute HCV [5]. Modeling studies have shown that scaling up prevention (SSPs) and treatment efforts (MOUD) could decrease the burden of IDU-associated infections like HCV [9, 18]. In our study, 66% of the participants were being treated with MOUD, yet still developed IDU-associated infections. Given rising stimulant use [11] and lack FDA-approved pharmacotherapy for stimulant use disorder, our findings highlight the importance of preventive services like SSPs in addition to expanding treatment and recovery services. While a multipronged approach including Medicaid expansion, increasing treatment capacity, housing security, and access to pre-exposure prophylaxis for HIV, is certainly needed for infection prevention [26], increased access to SSPs is especially important given the disproportionate burden of IDU-associated infections in rural areas.

While SSPs help reduce infection transmission, they also play a large role in naloxone distribution and overdose reversals [23]. Our results also showed that participants with a history of overdose were more likely to use SSPs. Notably, 90% of our study population reported injecting alone in the 30 days prior to hospitalization, and 72% of the participants supported supervised injection facilities, which are safe places where people can inject pre-owned drugs. While increasing accessibility to SSPs is needed, particularly to people who may not perceive overdose risk, consideration of supervised injection facilities is also important given the overdose and infection risks in our study population. Sanctioned supervised injection facilities have not yet been adopted in the United States at the time of this study, but have been shown to reduce adverse outcomes, such as overdoses, elsewhere [13].

This study had some limitations. Nearly 20% of the study population came from small/isolated rural areas, and there was only one participant with HIV; our results may not be generalizable to more urban regions or regions with a higher prevalence of HIV. While reflective of our state’s demographics, a majority of our study population was white. Black, Indigenous, people of color may experience additional barriers to SSP utilization that were not captured by this study. Selection bias also likely explains our findings that participants with history of overdose were more likely to use SSPs. Also, the high rate of unsafe injection practices in our convenience sample is likely due, in part, to a selection bias implicit in our study population, whose practices around safe injection techniques may not represent non-hospitalized people who use SSPs.


In our study of people hospitalized with IDU-associated infections in a rural state, unsafe injection practices were common. Especially given increasing stimulant use, these results also highlight the need to improve SSP access even among individuals prescribed medication for opioid use disorder. Living ≤ 10 miles from an SSP was associated with increased SSP utilization. Expansion of SSPs into rural areas, including mobile units, could increase SSP utilization and potentially reduce morbidity and mortality.

Availability of data and materials

De-identified data can be made available upon request to corresponding author.


  1. ACASI: Audio Computer-Assisted Self-Interview Software. Retrieved from

  2. Agriculture USDo. Rural-Urban Commuting Area Codes. 2019; Retrieved from

  3. Alterman AI, Cacciola JS, Ivey MA, Habing B, Lynch KG. Reliability and validity of the alcohol short index of problems and a newly constructed drug short index of problems. J Stud Alcohol Drugs. 2009;70(2):304–7.

    Article  Google Scholar 

  4. Bosse T. Hepatitis B in Maine, 2015. 2016. Retrieved from

  5. Canary L, Hariri S, Campbell C, Young R, Whitcomb J, Kaufman H, Vellozzi C. Geographic disparities in access to syringe services programs among young persons with hepatitis C virus infection in the United States. Clin Infect Dis. 2017;65(3):514–7.

    Article  PubMed  Google Scholar 

  6. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  Google Scholar 

  7. Des Jarlais DC, Feelemyer JP, Modi SN, Abdul-Quader A, Hagan H. High coverage needle/syringe programs for people who inject drugs in low and middle income countries: a systematic review. BMC Public Health. 2013;13:53.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Fernandes RM, Cary M, Duarte G, Jesus G, Alarcao J, Torre C, Costa S, Costa J, Carneiro AV. Effectiveness of needle and syringe Programmes in people who inject drugs—an overview of systematic reviews. BMC Public Health. 2017;17(1):309.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Fraser H, Vellozzi C, Hoerger TJ, Evans JL, Kral AH, Havens J, Young AM, Stone J, Handanagic S, Hariri S, Barbosa C, Hickman M, Leib A, Martin NK, Nerlander L, Raymond HF, Page K, Zibbell J, Ward JW, Vickerman P. Scaling up hepatitis C prevention and treatment interventions for achieving elimination in the United States: a rural and urban comparison. Am J Epidemiol. 2019;188(8):1539–51.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Gordon RJ, Lowy FD. Bacterial infections in drug users. N Engl J Med. 2005;353(18):1945–54.

    Article  CAS  PubMed  Google Scholar 

  11. Kariisa M, Scholl L, Wilson N, Seth P, Hoots B. Drug overdose deaths involving cocaine and psychostimulants with abuse potential—United States, 2003–2017. MMWR Morb Mortal Wkly Rep. 2019;68(17):388–95.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Keyes KM, Cerda M, Brady JE, Havens JR, Galea S. Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States. Am J Public Health. 2014;104(2):e52-59.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kilmer B, Taylor J, Caulkins JP, Mueller PA, Ober AJ, Pardo B, Smart R, Strang L, Reuter PH. Considering heroin-assisted treatment and supervised drug consumption sites in the United States. Santa Monica: RAND; 2018.

    Book  Google Scholar 

  14. Kishore S, Hayden M, Rich J. Lessons from Scott County—progress or paralysis on harm reduction? N Engl J Med. 2019;380(21):1988–90.

    Article  PubMed  Google Scholar 

  15. Nenninger EK, Carwile JL, Ahrens KA, Armstrong B, Thakarar K. Rural-urban differences in hospitalizations for opioid use-associated infective endocarditis in the United States, 2003–2016. Open Forum Infect Dis. 2020;7(2):ofaa045.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Patel MR, Foote C, Duwve J, Chapman E, Combs B, Fry A, Hall P, Roseberry JC, Brooks J, Broz D. Reduction of injection-related risk behaviors after emergency implementation of a syringe services program during an HIV outbreak. J Acquir Immune Defic Syndr. 2018;77(4):373–82.

    Article  PubMed  Google Scholar 

  17. Phillips KT, Stein MD. Risk practices associated with bacterial infections among injection drug users in Denver, Colorado. Am J Drug Alcohol Abuse. 2010;36(2):92–7.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, Jordan A, Degenhardt L, Hope V, Hutchinson S, Maher L, Palmateer N, Taylor A, Bruneau J, Hickman M. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9:CD012021.

    Article  PubMed  Google Scholar 

  19. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance Report 2018—Hepatitis C. Retrieved from

  20. Centers for Disease Control and Prevention. Acute Hepatitis B: Maine Surveillance Report 2017. 2017. Retrieved from

  21. Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated). 2020. Retrieved from

  22. Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002–12. Health Aff (Millwood). 2016;35(5):832–7.

    Article  Google Scholar 

  23. Rowe C, Santos GM, Vittinghoff E, Wheeler E, Davidson P, Coffin PO. Predictors of participant engagement and naloxone utilization in a community-based naloxone distribution program. Addiction. 2015;110(8):1301–10.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths-United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1378–82.

    Article  Google Scholar 

  25. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction. 1993;88(6):791–804.

    Article  CAS  Google Scholar 

  26. Schranz AJ, Barrett J, Hurt CB, Malvestutto C, Miller WC. Challenges facing a rural opioid epidemic: treatment and prevention of HIV and hepatitis C. Curr HIV/AIDS Rep. 2018;15(3):245–54.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Stein MD, Phillips KT, Herman DS, Keosaian J, Stewart C, Anderson BJ, Weinstein Z, Liebschutz J. Skin-cleaning among hospitalized people who inject drugs: a randomized controlled trial. Addiction. 2020.

    Article  PubMed  Google Scholar 

  28. Strike C, Miskovic M. Scoping out the literature on mobile needle and syringe programs-review of service delivery and client characteristics, operation, utilization, referrals, and impact. Harm Reduct J. 2018;15(1):6.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Thakarar K, Rokas K, Lucas F, et al. Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: the need to expand substance use disorder treatment and harm reduction services. PLoS ONE. 2019.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Van Handel MM, Rose CE, Hallisey EJ, Kolling JL, Zibbell JE, Lewis B, Bohm MK, Jones CM, Flanagan BE, Siddiqi A-E-A, Iqbal K, Dent AL, Mermin JH, McCray E, Ward JW, Brooks JT. County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr. 2016;73(3):323–31.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wong CY, Zhu W, Aurigemma GP, Furukawa N, Teshale EH, Huang YA, Peters PJ, Hoover KW. Infective endocarditis among persons aged 18–64 years living with human immunodeficiency virus, hepatitis C infection, or opioid use disorder, United States, 2007–2017. Clin Infect Dis. 2021;72(10):1767–81.

    Article  PubMed  Google Scholar 

  32. Wurcel AG, Anderson JE, Chui KK, Skinner S, Knox TA, Snydman DR, Stopka TJ. Increasing infectious endocarditis admissions among young people who inject drugs. Open Forum Infect Dis. 2016;3(3):157.

    Article  Google Scholar 

  33. Zibbell JE, Iqbal K, Patel RC, Suryaprasad A, Sanders KJ, Moore-Moravian L, Serrecchia J, Blankenship S, Ward JW, Holtzman D, Prevention. Increases in hepatitis C virus infection related to injection drug use among persons aged </=30 years - Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. MMWR Morb Mortal Wkly Rep. 2015;64(17):453–8.

    PubMed  PubMed Central  Google Scholar 

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The authors would like to thank the study participants for their time and expertise, as well as Katie Bessey NP, Caroline Knight RN, CCRP, Krysta Anderson BS, Terilee Gerry RN, Anna Cloutier RN, Jenny Carwile PhD, Scott Sughrue MS MEd, Denise Michaud BS CCRC CRCP, Alysse Wurcel MD, Kerri Nolte PhD, FNP-C, Stacey Sigmon PhD, Timothy Borelli DO, Robert Pinsky MD, and Cheryl Liechty MD MPH for their contributions to this study.


The research reported here was supported by Grant U54 GM115516 from the National Institutes of Health for the Northern New England Clinical and Translational Research network.

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Conceived and designed the study: KT, FL, DB, RS. Analyzed the data: KM. Wrote the manuscript: KT, NS, FL, DB, RS. All authors read and approved the final manuscript.

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Correspondence to Kinna Thakarar.

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The Maine Medical Center Institutional Review Board approved this study. Informed consent was obtained from study participants.

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Thakarar, K., Sankar, N., Murray, K. et al. Injections and infections: understanding syringe service program utilization in a rural state. Harm Reduct J 18, 74 (2021).

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