African Americans (AAs) are dying from opioid overdoses faster than any racial/ethnic group in the
United States. Furthermore, the increased adulteration of cocaine with fentanyl may further exacerbate the risk
of opioid overdose among AAs. Over the past 10 years, peer-based overdose education and naloxone
distribution (OEND) has become a widely used opioid overdose harm reduction practice. OEND programs
seek to increase knowledge of overdose risk factors, symptoms, and efficacious first aid (e.g., rescue
breathing), dispel myths of ineffective treatments (e.g., salt shots), and increase access to the overdose-
reversal agent, naloxone. OEND programs largely target high-risk individuals who use opioids through
treatment or syringe exchange programs, and thus, ways to expand access to OEND are needed. AAs are
more likely to seek help for drug use from churches than formal drug treatment centers. Church-based
interventions are culturally acceptable, reduce access barriers, and can be brought to scale in under-resourced
communities. For OEND to be efficacious in Black churches, tailoring may be needed. For this audience,
standard OEND curricula may need to be adapted to their level of knowledge of substance use disorders
(SUDs), limited general mental health literacy, and to specifically address stigma related to SUDs and
medications for opioid use disorder (MOUD). Finally, a tailored implementation strategy may need to address
contextual variations (e.g., denomination and membership size) across churches. In a previous trial, the
research team developed a Comprehensive Overdose Education and Skills Training (COEST), targeting
experienced opioid users. COEST significantly increased knowledge of overdose risk factors and improved
attitudes about intervening in an overdose event. In a randomized controlled trial, COEST (vs basic OEND
training) increased naloxone utilization (in suspected cases of opioid overdose) by nearly 20%. The proposed
pilot study aims to identify the socio-cultural modifications that will be needed to adapt COEST to target Black
communities of faith. Phase 1 of the study will involve key stakeholder interviews with clergy, individuals with
OUD and stimulant use disorder, church members, and formerly incarcerated adults. Informed by qualitative
results, the study team’s Community Advisory Board will use “intervention mapping” to adapt COEST for AA
churches. Phase 2 will involve a pilot randomized controlled trial (RTC) of adapted COEST among three
target groups within the church who are most in need of OEND services: (1) Family and Friends of People with
OUD; (2) Prisoners Re-Entering Society; and (3) Drug Use Support / Health Ministry. The RTC will use a
stepped-wedge design to assess whether COEST increases naloxone utilization, reduces SUD stigma and
negative perceptions of MOUD, and increases mental health literacy. This pilot trial aims to generate data for a
large-scale R01 to conduct a Hybrid Type-2 Effectiveness-Implementation trial of the adapted intervention.
