Data-Driven Syringe Services and Naloxone Distribution Programming

Hennepin County Public Health is the largest local public health department in Minnesota.

Minneapolis, Minnesota's largest city, is located in Hennepin County. Hennepin County, the most populous in the state, comprises 22% (1,266,000/5,640,000) of Minnesota's population. The county is situated in the Minneapolis-St. Paul-Bloomington Metropolitan Statistical Area (MSA), which has a population of 3,657,477 as of 2020. It is the second largest MSA in the upper Mid-West.

According to the 2020 census, Hennepin County's population is 66% White (Not Hispanic), 13% Black/African American, 7.6% Asian/Pacific Islander (API), 7.6% Latinx, 5.0% multi-racial, 0.6% Native American, and 0.47% other. The greatest concentrations of Black, Latinx, API, and men who have sex with men (MSM) in Minnesota reside in Hennepin County, and Minneapolis has the third largest urban population of Native Americans in the U.S. An Emory University study estimates the MSM population in Hennepin County to be 8.5% of the male population. In addition, despite having 22% of the state's population, 51% of Minnesota's HIV cases are in Hennepin County. An HIV outbreak among people who inject drugs and/or experiencing unsheltered homelessness began in December 2018 in Hennepin and neighboring Ramsey (St. Paul) Counties and was recently expanded to include MSM who inject drugs.

Hennepin County's Public Health Clinic which houses the Red Door Clinic (RDC), offers a variety of services including refugee health screenings, tuberculosis testing and treatment, sexual health checkups, PrEP administration, and a syringe services program (SSP). The RDC diagnoses 20-25% of Minnesota's annual HIV cases.

In addition to providing competent, culturally informed services, the RDC is uniquely positioned to deliver exceptional care coordination, wrap-around services, syringe services and naloxone distribution because of its proximity, relationship, and integration with other county-based services. Relationships with Hennepin Healthcare (Hennepin County's safety-net hospital), and county services including Healthcare for the Homeless, Child Protection, and Adult Behavioral Health provide leverage to strategically deliver care coordination, wrap-around services, naloxone trainings, supplies, and support outside of the clinic. According to the CDC, SSPs are considered effective public health programming for preventing infectious disease, public safety, and linkage to substance use treatment, naloxone, and other healthcare services. RDC's SSP data collection provides evidence of its effectiveness in these areas as well.

The RDC's SSP operates out of the RDC in downtown Minneapolis. Service hours are Monday-Wed 8am-4pm, Thursday 10am-4pm, and Friday 8am-4pm. A range of syringe sizes, including tips and barrels, as well as safer injection supplies (alcohol pads, cookers, tourniquets, cottons, band aids, antibiotic ointment) are offered. In addition, participants can access hygiene kits, wound care kits, protein-based snacks, bottled water, condoms, lubricant, and other basic needs items as available.

In addition to serving clients at the clinic, the SSP serves Native American community members through established partnerships with the Minneapolis-based Little Earth Residents Association (the only Native American preference Section 8 rental assistance community in the U.S.) and families receiving services through Hennepin County Indian Child Welfare (ICWA). Because the opioid epidemic disproportionately affects the Native American community, it is imperative to have a seamless continuum of care for clients through these partnerships.

Syringe service programs entail the safe collection and disposal of used needles and syringes to ensure the health and safety of the larger community. According to the CDC, in 2020, 7% (2,055) of the 30,635 HIV diagnoses in the United States were attributed to intravenous drug use. CDC also reports the majority of new hepatitis C (HCV) infections have been associated with injection drug use. People who inject drugs are at higher risk for HIV and HCV due to sharing injection drug equipment and increased incidents of unprotected sexual encounters. Proper distribution and disposal create safer and healthier communities.  A 2014 study published in the International Journal of Epidemiology and several replicated studies have shown that communities with syringe service programs have lower rates of HIV infection in persons who inject drugs. RDC offers syringe disposal services and access to new syringes and injection equipment to clients who either request supplies or have been identified by staff to have risk.

A unique aspect of this program is its data and tracking practices. When an individual arrives at the clinic for syringe services, naloxone, or has been identified by staff to have risk, they will complete a standard questionnaire and receive an anonymous participant ID. The standard questionnaire collects demographic information, data on syringe and naloxone distribution, client reported overdose reversals, and referrals to clinical services such as sexual health testing and vaccination. The questionnaire is updated to respond to emerging community concerns, such as whether clients follow up with emergency services after administering naloxone in the community or if they experience homelessness. Staff enter this information into a Sharepoint form, tracking data dating back to 2018, which automatically populates to a Power BI dashboard. This dashboard displays up-to-date information, refreshing every day at midnight. This year, we have given over 167,000 syringes, disposed of 87,000 syringes, and distributed over 3,000 Narcan kits which have contributed to over 900 overdose reversals. We also expanded the reach of the program, with 583 individual participants in 2021 and 861 in 2022, a 48% increase.

The public health impact of the RDC SSP is vast as the county and state continue to respond to one of the largest HIV outbreaks in the nation. Stopping transmission of HIV is essential to ending the outbreak and ultimately the epidemic. RDC programming, including the SSP, commits serving disproportionately affected communities in a setting that is welcoming, client-centered, harm reduction-focused, and nonjudgmental. The success and innovation of this program is its merging of harm reduction interventions and practices with clinical services and resources.

In February 2020, the MN Department of Health (MDH) announced an HIV outbreak among people who inject drugs (PWID) in Hennepin and Ramsey Counties. This ongoing outbreak, as defined by CDC surveillance cluster detection methodology, began in December 2018. As of November 9, 2022, there were 149 cases identified in this outbreak. The outbreak disproportionally affects individuals who are Native American (24%), and people who have experienced unsheltered homelessness (46%). With increasing rates of homelessness in the Minneapolis St. Paul (MSP) area due to the COVID-19 pandemic and the related economic downturn, a significant proportion of the MSP's homeless population remains at high risk for HIV infection.

The emergence of large homeless encampments in the MSP area during the summer of 2018 is correlated with the outbreak, creating relatively closed networks of people participating in risk activities and creating the perfect storm for bloodborne disease transmission. The target population for our SSP are PWID, particularly those most disproportionately affected by homelessness and Opioid Use Disorder (OUD). Native Americans represent 26% of HIV outbreak cases while only making up 0.5% of MSP's total population.

PWID who come to the RDC for naloxone and syringe exchange services experience barriers to wellness as their social determinants of health are influenced by poverty, homelessness, limited access to health services, and structural racism, resulting in overdose death disparities. Our client demographics from calendar year 2021 reflect the disproportionate rates of OUD and overdose. Specifically, the demographics of the 583 participants making 1,358 visits to the SSP were as follows: 23.26% Native American/Alaskan Native, 13.49% Black/African American, and 53.18% White. The demographics of this year's 855 participants making 2,191 visits to the SSP are as follows: 25.21% Native American/Alaska Native, 16.35% Black/African American, and 47.19% White. In 2021, RDC's SSP's Native American clients accounted for 45% (n=188) of all self-reported opioid reversals (n=417). In 2022, RDC's SSP's Native American clients accounted for 55% (n=470) of all reported overdose reversals (n=849), a 10% increase from the previous year. These overdose rates as well as participant zip code reporting support anecdotal evidence from clients that fentanyl disproportionately impacts Native American clients and clients in economically disadvantaged neighborhoods. Our program focuses on serving clients impacted by poverty, homelessness, limited access to health services, and structural racism living in Minneapolis and other areas of Hennepin County. In closely tracking demographic data we can see that we are increasingly reaching the intended communities each year.

Our SSP is committed to serving disproportionately affected communities in a setting that is welcoming, client-centered, harm reduction-focused, and nonjudgmental. What makes our SSP unique is that it is housed in a sexual health clinic. We provide complementary services including testing for Hepatitis A, B, and C; Hepatitis A and B vaccinations; rapid HIV testing; PrEP services; comprehensive testing and treatment for sexually transmitted infections; and family planning services. We have a knowledgeable staff of nurse practitioners who can answer questions and administer treatment. Ryan White funded HIV care linkage and coordination staff can link clients newly diagnosed or living with HIV to core medical care and support services. In 2023 we plan to expand clinic services to include medication for opioid use disorder (MOUD). All clients are seen for clinical services regardless of their insurance status or ability to pay. By providing this coverage and walk-in availability, the RDC provides the lowest barrier medical care. We remained open throughout the COVID-19 pandemic and adapted its services to ensure clients receive high-quality care while staying as safe as possible. Providing RDC's SSP participants linkage to healthcare within the same setting is part of what makes the program uniquely successful.

RDC is home to one of seven syringe service programs in Minneapolis, but it is the only one of its kind with the ability to provide our clients with other clinical services in the same place. We can build and maintain trusting relationships with participants who are then more likely to use other services that the RDC offers, as well as other county services that may be in the same building or housed nearby including insurance navigation, chemical health assessments, and government assistance. In 2022 we have connected over 400 participants to safer using resources and HIV testing, over 300 participants to Narcan education and STI testing, and many others with things like vaccines, chemical health assessments, (re)connecting to HIV care, medication for OUD, and substance use treatment.

Our SSP and robust data collection technology allows us to respond in real-time to emerging data trends. As we notice shifts in data, such as the number of vials being used to reverse an overdose rising, we can make shifts in our programming to include more vials in each naloxone kit. Similarly, we can analyze trends in client zip codes to inform outreach strategy. We utilize data on types of supplies used, such as gauges of syringes, to inform our inventory and ordering. Clients regularly share with us their needs and requests, which can help us implement new aspects to our programming. We received regular requests for wound care support and responded with creating wound care kits and a clinic-wide training from a wound care specialist. Our provider networks have been reporting xylazine contamination in the local drug supply and we are soon going to stock test strips. Our team is constantly trying to innovate and find ways to respond to the emerging and evolving needs of our clients and have a strong commitment to constant quality improvement of the services that we provide.

Our syringe service program's goal is to connect people who inject drugs, particularly disproportionately affected communities, to necessary resources to reduce the risk involved with injection drug use in a setting that is welcoming, client-centered, harm reduction-focused, and nonjudgmental and in a way that reflects the needs of the community.

The RDC, part of Hennepin County's Public Health Clinical Services department, has been providing sexually affirming medical services since 1970. The clinic is in downtown Minneapolis and is on the light rail system and several bus lines and is in the epicenter of the HIV outbreak. The RDC is a multilingual, multicultural sexual health clinic which also includes Tuberculosis Control and Refugee Health Screening Services. Since 2013, the RDC has served an average of 11,314 clients a year providing an annual average of 20,560 clinic visits. RDC has approximately 50 diverse staff, including 11 nurse practitioners, 8 registered nurses, as well as various medical assistants and support staff. In addition to naloxone distribution and syringe services, RDC services include screening and treatment for sexually transmitted infections, partner notification/disease intervention services, HIV testing outreach services, HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), and family planning services.  Additionally, the clinic has Ryan White funded support services with specific focus on Black MSM, Latinx MSM, Transgender individuals, individuals who inject substances, as well as those living with HIV but not currently in care. To ensure cultural sensitivity and appropriateness, these services are supported by a team of community health specialists who are reflective of the priority populations served.

The variety of services offered in and around the RDC puts us in a unique and effective position to provide intersectional harm reduction services to the participants of our SSP. At RDC, we recognize that people who use drugs also have sex, and this can bring additional risk of infection. Our intake questionnaire lists additional services, including sexual health testing and treatment, incentivized HIV testing, vaccines, free condoms and lube, etc. with the intention of reducing barriers to receiving these additional services that the clinic offers. In 2022 we have connected over 400 participants to safer using resources and HIV testing, over 300 participants to Narcan education and STI testing, and many others with things like vaccines, chemical health assessments, (re)connecting to HIV care, MOUD, and substance use treatment.

The ability to serve diverse populations, regardless of physical ability, sexual orientation, gender identity, race, ethnicity, legal status, economic status, or native language is ingrained into the clinic culture and service delivery model. In line with ADA requirements, the RDC has accessible services for individuals with physical disabilities and provision of ASL interpreters. The clinic staff includes individuals who are fluent in Spanish, Somali, Hmong, and Oromo languages. Additionally, the RDC contracts with Language Line Solutions that can interpret over 100 languages.

We recognize and acknowledge that Hennepin County, as a government institution, has a traumatic history with local marginalized communities, including the Native American community. Staff and leadership at the RDC are committed to improving relationships with our target populations and community partners. We provide targeted nasal naloxone education and distribution at Little Earth, with an emphasis on families. The opioid epidemic, specifically the ubiquity of fentanyl, has severely affected Native American families in Little Earth, who report performing multiple overdose reversals in the community each week. To date we have distributed over 750 nasal naloxone kits to families living in Little Earth.

In our partnership with ICWA, we provide targeted nasal naloxone education and distribution to consenting ICWA clients with OUD. These clients include parents living with young children, parents whose children are in the foster care system, and youth experiencing risks related to chemical dependency and sexual exploitation whose families have open child protection cases. In Minnesota, opioid and methamphetamine use in families affects the disproportionate number of Native American youth in the foster care system. We know it is important that we provide age-appropriate education and distribute nasal naloxone to Native American families. Community members tell us that youth and elders increasingly need training to revive adults and that they are uncomfortable using syringes for intermuscular naloxone.

We continue to strengthen our relationships with Little Earth and ICWA and serve Native American families in Hennepin County by offering culturally specific care coordination and wrap-around services. Starting in March 2020, the RDC SSP assisted Health Care for the Homeless (HCH) nurses with distributing naloxone at encampments and drop-in shelters for Native American residents.  Additional referrals are made via our long-term relationships with other state and community-based organizations, including Southside Harm Reduction, AGATE, Rainbow Health, the Native American Community Clinic (NACC), Indigenous People's Task Force, and the Aliveness Project.

In addition to the internal county connections of the RDC, staff members are embedded in the community and actively participate in local pop-up events and meetings, furthering our reach and creating meaningful partnerships. 

The RDC SSP is committed to keeping our surrounding communities safe by collecting used syringes and making syringe disposal accessible for residents. Our SSP has three primary venues through which individuals can dispose of syringes: the RDC located in downtown Minneapolis, on site at Little Earth, and at community pop-up events.   

·         Public Health Clinic: Clients bring their used syringes into the clinic in safe disposal containers (either those we provide or a makeshift container such as laundry detergent or another thick plastic bottle). We also provide biohazard stickers for clients to take with them, should they decide to use a makeshift container for their syringe disposal. The biohazard stickers can provide an extra level of security to discourage the containers from being opened by anyone who may find it (either law enforcement personnel or other unintended recipients). Clients place these disposal containers into a red biohazard bin located inside of the SSP exam room to increase privacy and discretion. Clients self-report the number of the syringes that they bring in, which is recorded in our data collection for each encounter.  

·         Little Earth: We also have a disposal program operating with Little Earth, where we distribute and collect sharps containers on site. We have a long-standing relationship with Little Earth to provide HIV testing, naloxone distribution, Narcan/naloxone trainings, syringe disposal containers/pick-up, and linkage to services. We safely disposed of 1,500 used syringes for the Little Earth community in 2022.

·         Community Outreach Events: When doing outreach or attending a pop-up event, our staff routinely bring syringe disposal containers, grabbers, and gloves.

Other partnerships include:

·         Healthcare for the Homeless: Our outreach team works in coordination with Healthcare for the Homeless. This valuable collaboration helps us coordinate care for individuals experiencing homelessness that have extenuating circumstances and barriers to traditional medical care. We rely on the long-standing rapport and expertise of staff that have been embedded in the community for years and allows us to reach clients with harm reduction supplies, education, and overdose prevention kits. 

·         Twin Cities Recovery Project: We have an informal relationship with Twin Cities Recovery Project, a local non-profit that focuses on sober programming and events to enhance the recovery community. They come to our program to receive naloxone, which they distribute throughout the community in creative ways, such as training and distributing naloxone to gas station workers. Their Minneapolis Lake Street location is ideally placed amid high activity areas for drug use, overdoses, and homelessness. 

·         Minneapolis homeless shelters: Our SSP staff continue to strengthen partnerships with shelters and organizations that use a variety of models to serve the homeless population, such as AVIVO (harm reduction based tiny village program), First Covenant Church (shelter for couples), MN Indian Women's Resource Center (drop-in shelter for Native American women), and Sanctuary Supply Depot (outreach organization providing tent and supplies directly to homeless encampments). SSP staff provide virtual and in-person harm reduction and overdose prevention training, as well as Narcan kits, for frontline shelter staff and outreach workers.

·         Miscellaneous Partners: Our organization provides PrEP, PEP, and naloxone distribution. We collaborate with the SSP Network and attend some of the local pop-ups hosted by community-based organizations, such as Southside Harm Reduction. We provide education internally to ICWA. Additional referrals are made via our long-term relationships with other state and community-based organizations, including the Native American Community Clinic, Southside Harm Reduction, St. Stephen's, Rainbow Health, and the Aliveness Project.

In collaboration with Hennepin County's data and assessment team, we have been able to create a real-time data monitoring system to easily view trends as they are happening and modify our practices to best serve our participants and meet our goals. Any time a participant utilizes our SSP, they complete a standard questionnaire as described in the overview section. Staff enter the information from the questionnaire to the program's online Sharepoint form which tracks data dating back to 2018 which then gets displayed to our Power BI dashboard. This dashboard displays up-to-date information, refreshing every day at midnight. Currently, we can see that we have given over 1,300 Narcan kits this year which have contributed to over 840 overdose reversals and given roughly 167,000 syringes and safely disposed of 87,000 this year. We are also able to see the expanded reach of our program over the last year, with 583 individual participants in 2021 and 853 in 2022. Our focused efforts on reaching the Native American community have proven successful. In 2021 23.26% of participants identified as Native American and 25.21% in 2022, an almost 2% increase.

Our SSP has historically served Native American people and hard-to-reach populations, including those experiencing unsheltered homelessness. Since we began collecting data on unsheltered homelessness in October of 2021, over 40% of our clients report sleeping outside in the last 30 days. The HIV outbreak, which began in December 2018 disproportionately impacts the Native American population, as well as those experiencing homelessness. People who use drugs commonly experience various forms of stigma and discrimination, which can make it difficult for people to get competent and nonjudgmental healthcare in mainstream settings, further disenfranchising individuals and causing increasingly complicated health needs. RDC is a safe space for people who use drugs to access testing & treatment for HIV & other STIs; pregnancy testing & contraceptive care; vaccinations including MPOX, COVID, hepatitis A/B; and referrals to other supportive resources as needed including housing and treatment. 

Clients who use drugs or utilize safer injection supplies who come to the RDC for naloxone and syringe services experience multifaceted barriers to holistic wellness including poverty, homelessness, and limited access to health services. Their social determinants of health are additionally influenced by poverty and structural racism, which results in overdose death disparities and disproportionate rates of HIV and other bloodborne pathogens. Our data on overdose reversals indicate that we are reaching communities that are disproportionately affected by fentanyl and the overdose crises; with reports of over 40% (1,194/2,951) of Narcan kits given and over 51% (436/846) of overdose reversals this year being from participants who self-identify as being Native American.

The RDC began syringe services and naloxone distribution in August 2015 to complement existing clinical services. All clinic clients who seek care for sexual health and STIs are also assessed for injection drug use as it relates to risk for HIV and hepatitis. In response to the growing prevalence of OUD identified among the client population, RDC leadership felt it was a natural extension to offer syringe services and naloxone education and distribution for those individuals who seek HIV/STI services and report injection drug use. We currently have two full-time staff that operate the SSP.

Demand for syringe services grew rapidly and soon became the sole purpose of many participants' clinic visits. From August through December 2015 (the program's first calendar year), 2,773 sterile syringes were distributed, along with 57 naloxone kits (2 doses per kit), and 1,603 used syringes were collected and disposed, all without external funding. By 2021, the RDC SSP had 1,358 clinical encounters with 583 unique clients. Over 40% of clients reported sleeping outside within the last month. In 2021 the program distributed 98,000 syringes, disposed of over 70,000 used syringes, and distributed 1,669 naloxone kits, which were used to reverse 417 opioid overdoses as reported by clients. As of December 14, 2022, the RDC SSP cumulatively distributed 8,208 naloxone kits, 484,000 sterile syringes, and assisted in 2,117 opioid overdose reversals as reported by clients.

When clients use the SSP, either on outreach or in the clinic, they are issued a code that allows us to collect and analyze data without revealing identity. Clients complete a brief survey where they are asked about naloxone use (including overdose reversals), chemical dependency treatment interest, vaccinations, and need for STI screening. We have strong referral networks with culturally competent SUD and OUD treatment providers, and we routinely use the SUD Fast-Tracker (a Minnesota-wide database for treatment options) to find appropriate services for clients with OUD. To address the current HIV outbreak in Hennepin County that has largely stemmed from the opioid epidemic, our service design includes sterile syringe distribution and provision of appropriate harm reduction and preventive health services to syringe service participants as well as individuals living in the homeless encampments surrounding Little Earth.  

The survey information, including the client's unique code, demographic information, Narcan use, supplies received, and any referrals from the visit are recorded on an online Sharepoint form and is then pushed to a Power BI dashboard. The use of Sharepoint and Power BI allows us to view and evaluate trends in real time. Our data reports refreshing every night at midnight means any given day we are viewing the most current data possible along with all the data we have collected since we began collecting it in 2018. This has proven to be effective for our program, giving us the ability to modify our practices for immediate community need.

Our data collection through our online Sharepoint form and Power BI dashboard shows that we are reaching a large portion of our intended population and we are getting them the resources that they need. As stated in section one, the demographics of participants in 2022 has become more closely aligned with our target population. Total participants who identify as Native American increased by 1.95 % and Black by 2.86% from 2021 to 2022. Further, of the 97,718 syringes given in the calendar year of 2021, 26.71% (26,099) have been to those identified as Native American/Alaskan Native, 10.57% (10,329) to those identified as Black/African American, and 63.49% (62,037) to those identified as White. Of the 169,382 syringes given so far in 2022, 37.8% (64,019) have been to those identified as Native American/Alaskan Native, 13.43% (22,747) to those identified as Black/African American, and 50.04% (84,761) to those identified as White. In 2022 we have connected over 400 participants to safer using resources and HIV testing, over 300 participants to Narcan education and STI testing, and many others with things like vaccines, chemical health assessments, (re)connecting to HIV care, MOUD, and substance use treatment. All this information, as well as many other combinations of demographic information with services provided can be easily viewed and monitored in real time on the Power BI dashboard.

We pride ourselves on meeting people where they are at and giving participants the amount of supplies that they need to be able to not reuse injection supplies. We run on a flexible model of handing out up to 50 syringes or the number that they bring in to dispose plus an additional ten. Folks experience barriers to accessing safe disposal and using our discretion to determine whether that model is reasonable for each individual interaction is vital.

The ability to view trends in real time has proven to be extremely valuable to the success of our program. In 2020, we noticed that participants were reporting an increased number of vials of Narcan being used to reverse a single overdose. Recognizing this in real time allowed us to increase the number of vials we put in a single Narcan kit from two vials to three to ensure that folks had sufficient supplies to effectively reverse an overdose. Further, in August of 2022, Minnesota Department of Health (MDH) was reporting an increase in fatal overdoses and a decrease of non-fatal overdoses in the area. This sparked curiosity at our program because we were seeing an upward trend in participant-reported overdoses. Because MDH data is collected from emergency response personnel, we modified our questionnaire to not only ask how many overdoses participants reversed and how many vials of Narcan were used, but also to ask if folks followed up with emergency services after reversing an overdose. In doing this, we have been able to track additional overdose reversals in the community that would not have been recorded otherwise While client-reported, anecdotal  data cannot be used on its own to determine trends, is extremely valuable to the success of our program. We are given the opportunity to provide a true client-centered approach by responding to the needs of participants as they emerge.

Our SSP data also shows that the most common substance injected for our participants is methamphetamine, which is a trend that illustrates our ability to reach a very specific population. Methamphetamine is a culturally significant substance for MSM and has close ties to chem-sex behavior, where individuals use substances to elevate or enhance their sexual experience. This data is in line with the current HIV outbreak we are experiencing with 2 particularly impacted populations: (1) folks who inject drugs and sleep outside and (2) MSM who inject drugs. Our data would support that we are successfully reaching both groups, with the high rates of folks using methamphetamine as well as over 40% of our clients having slept outside within the last 30 days.

Our SSP is funded by several diverse funding streams, including sole-sourced funds from Minnesota's Department of Human Services and a NACCHO Implementing Overdose Response Strategies at the Local Level (IOPSLL) grant to expand our services and implement a MOUD program. Our demonstrated ability to use funds to address the opioid crisis effectively and collaboratively has led to sustainable relationships with DHS and MDH. Administrators at the state level alert us to funding opportunities, provide technical assistance, and support the RDC SSP with surplus harm reduction supplies and naloxone when we are in between funding or experiencing supply chain issues. In addition, we have internal support from the leadership of Hennepin County's Public Health Department to continue our programming. All resources combined have led to a sustainable model for providing these services to our community.

The policies and procedures specific to the SSP are integrated into the clinic. Program staff cross train clinical staff in naloxone, overdose reversals, harm reduction, and safe injection practices. This allows staff to feel competent when caring for an individual who may be high or may report injecting drugs. Many clinic staff have been trained to help a SSP participant receive supplies in the absence of regular SSP staff members. We have also developed referral protocols between the SSP and other clinical services, including assessing all sexual health appointments for injection drug use and incentivizing SSP participants to receive a rapid HIV test for a gift card.  Integrating the SSP with the RDC provides structure and support in case of staff turnover.

We have complementary systems within Hennepin County, such as an overdose response alert listserv that details specific areas of the county that are experiencing a spike in overdoses and fatalities to alert community partners and give general zip code locations to inform outreach response. Additionally, we work in coordination with an Opioid Response Coordinator that can focus on systems change and policy advocacy. Another clinic in Hennepin County focuses on the northern part of the county and operates an SSP as well. We learned through implementing our programming that it is not possible to single-handedly solve issues around substance use and harm reduction programming and instead, we focus on filling community gaps in programming (MOUD treatment with walk-in availability coming in 2023, full time hours to access our SSP, offering professional wound care, etc).

RDC's SSP is also part of the Hennepin County Opioid Response Plan. The Opioid Response Coordinator and County Commissioners are invested in the program as a crucial response to the opioid epidemic locally. While this does not guarantee monetary support, it speaks to the sustainability of the program as a county sanctioned public health intervention.