Vending machines for reducing harm associated with substance use and use disorders, and co-occurring conditions: a systematic review

Alice Zhang; Matthew Carrillo; Ryan Liu; Sarah M Ballard; Alexis Reedy-Cooper; Aleksandra E Zgierska

doi:10.1186/s12954-025-01236-6

. 2025 May 28;22:89. doi: 10.1186/s12954-025-01236-6

Vending machines for reducing harm associated with substance use and use disorders, and co-occurring conditions: a systematic review

Alice Zhang ^1,^2,^✉, Matthew Carrillo ², Ryan Liu ¹, Sarah M Ballard ^3,⁴, Alexis Reedy-Cooper ¹, Aleksandra E Zgierska ^1,^2,^4,⁵

PMCID: PMC12121115 PMID: 40437578

Abstract

Background

To stem rising fatal overdoses and other substance use/use disorder (SUD)-related harms, communities are turning to low-barrier harm reduction strategies, such as harm reduction-focused vending machines (VMs) that distribute naloxone, fentanyl test strips, and other harm reduction-related items. This systematic review aims to synthesize literature on VMs for SUD-related harm reduction.

Methods

Four databases (Embase, Cochrane, PubMed, MEDLINE) were searched from their inception through November 29, 2023. References of identified eligible articles and pertinent prior reviews were also searched for relevant eligible research articles describing VM’s feasibility, acceptability, reach, and/or impact when used for SUD-related harm reduction. Data from eligible articles were systematically extracted and summarized.

Results

The search found 45 eligible articles covering 30 separate studies involving 191,242 participants (190,576 VM users; 666 non-users). Most studies were conducted outside of the U.S. (n = 20), focused on individuals who injected drugs (n = 18), and evaluated syringe-dispensing VMs (n = 12). Of the 45 articles, the majority evaluated feasibility (n = 35), followed by acceptability (n = 21), impact (n = 17), and reach (n = 14). The feasibility-assessing articles noted high demand for VM-dispensed items, with usage mostly occurring outside of traditional business hours, and more syringes and HIV self-tests being dispensed compared to some in-person programs. The VMs were generally accepted by target populations, regardless of the items dispensed, and reached high-risk populations. Impact evaluation was limited and based on item dispensed. Seven articles examined the impact of syringe-dispensing VMs and described reductions in syringe sharing (n = 4) and drug use (n = 2), as well as stable or declining rates in drug use-related crime (n = 1). Articles evaluating the impact of HIV self-test-dispensing VMs (n = 3) described HIV detection rates ranging from 1.9% to 17.7%. Two articles reported reduced fatal overdoses after naloxone-dispensing VMs were implemented.

Discussion

VMs show promise as a low-barrier method for reducing SUD-related harm, decreasing health disparities, and engaging hard-to-reach populations. Future implementation science-based research is needed to assess VMs’ impact on individual and community health outcomes, including overdose.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-025-01236-6.

Keywords: Vending machine, Harm reduction, Substance use, Substance use disorder, Addiction, HIV prevention, Condoms, Syringes, Dispensing machine, Overdose prevention

Background

Harms associated with substance use and use disorder (SUD) represent a significant public health threat, with over 100,000 deaths due to drug overdose in the U.S. in 2023 [1]. Furthermore, the scope of SUD and overdose-related harm has been paralleled by increases in conditions frequently co-occurring with SUD. For example, the rate of human immunodeficiency virus (HIV) infection among people who inject drugs (PWID) increased by 11% from 2016 to 2018, particularly among younger adults [2]. During the 2019 coronavirus disease (COVID-19) pandemic, the U.S. experienced significant increases in fatal overdoses [1, 3].

In response to this ongoing crisis, early treatment and prevention strategies aimed at reducing substance use, associated high-risk behaviors (such as higher-risk sexual behaviors), and related harms have been introduced throughout the U.S. However, some people may be unable to access treatment [4] due to inadequate health plan coverage, lack of health insurance, or stigma [5–7]. In addition, not everyone who use substances may be interested in substance use cessation or reduction [8]. For those individuals, harm reduction approaches can be beneficial in reducing the harms of substance use and associated higher-risk behaviors, which include HIV, hepatitis C (HCV) and B (HBV) virus infection [9] or overdose. Examples of harm reduction practices include distribution of naloxone and/or “clean” equipment (e.g., sterile water, cookers, filters), drug checking items (e.g., fentanyl test strips), needle and syringe programs, overdose prevention or supervised consumption sites, and even a provision of opioids (as a safer supply compared to illicitly-obtained opioids) [10–14]. Harm reduction can increase engagement in safer practices, offer a bridge toward treatment, and reduce fatal overdoses [15–17].

In the U.S., many emerging harm reduction strategies [18], including vending machines (VMs) for naloxone distribution, have been implemented [19–24]. VMs dispensing harm reduction items, mostly sterile needles and syringes, have been present in Europe and Australia since the 1990s [14]. These early experiences show that these VMs can supplement other harm reduction programs, especially those requiring in-person participation, by offering relative anonymity, reducing stigma associated with in-person attendance, and increasing harm reduction reach within underserved populations and uptake of services due to increased accessibility [14, 25, 26]. For example, VMs can be accessible when traditional services are closed, e.g., during evenings and weekends [14]. VMs can allow individuals to obtain clean injection supplies who otherwise would be unable to do so, due to limited hours of syringe exchange programs [27]. As a result, many communities in the U.S. have been increasingly turning to VMs as a means to address harm reduction needs. However, despite VMs’ growing popularity, there is limited research on them as a vehicle for harm reduction, including their impact on health outcomes.

Given that VM-delivered harm reduction are increasingly used and represents a promising alternative to traditionally-implemented initiatives, which rely on in-person or face-to-face contact, there is an urgent need to rigorously assess existing evidence on harm reduction-focused VMs and their impact. Therefore, we conducted a systematic review of literature to evaluate the feasibility, acceptability, reach, and impact of VMs as an innovative method for delivering SUD-related harm reduction items and services.

Methods

We followed the PRISMA Extension for Systematic Reviews to conduct this systematic review and summarize its findings [28].

Eligibility criteria

Eligible articles were full-text articles published in English in a peer-reviewed scientific journal that described findings from original research directly examining the feasibility, acceptability, reach, and/or impact of VMs (or similar automated dispensing machines) for SUD-related harm reduction. The eligible article could describe research centered on individuals with SUD, populations with conditions or behaviors frequently co-occurring with substance use or SUD (including higher-risk sexual behaviors), or if the VM-dispensed items were relevant to substance use-related harm reduction. Examples of such VM-dispensed items included, but were not limited to, substance or sexually-transmitted disease (STD) test kits, safer sex supplies, syringes, or sharps disposal.

Information sources, search strategy, and selection process

A librarian conducted the literature search across four databases (Embase, Cochrane, PubMed, and MEDLINE) from their inception through November 29, 2023, using pre-defined MeSH terms, which are commonly used to index articles in these databases (Table 1). References of identified eligible articles and pertinent prior reviews were also reviewed, as were articles solicited from organizations and colleagues whose work focused on SUD-related harm reduction. The entire search process was completed on December 15, 2023 (Fig. 1).

Table 1.

Database Search Strategy

Step	Search terms	Filters
1	("Substance Abuse, Intravenous"[Mesh]) OR "HIV Infections"[Mesh]	N/A
2	((("Needles"[Mesh]) OR "Needle Sharing"[Mesh]) OR "Needle-Exchange Programs"[Mesh]) OR "Syringes"[Mesh]	N/A
3	"Needle Sharing"[Mesh]	N/A
4	"Automation"[Mesh]	N/A
5	vending[Title/Abstract] OR syringe[Title/Abstract] OR test-kit[Title/Abstract] OR "mobile needle"[Title/Abstract] OR Needle[Title/Abstract] OR self-test[Title/Abstract] OR syringe-dispensing[Title/Abstract]	N/A
6	(("Automation"[Mesh]) OR (((("Needles"[Mesh]) OR "Needle Sharing"[Mesh]) OR "Needle-Exchange Programs"[Mesh]) OR "Syringes"[Mesh])) OR (vending[Title/Abstract] OR syringe[Title/Abstract] OR test-kit[Title/Abstract] OR Needle[Title/Abstract] OR self-test[Title/Abstract] OR syringe-dispensing[Title/Abstract])	N/A
7	"Harm Reduction"[Mesh]	N/A
8	(Harm Reduction[Title/Abstract]) OR ("Harm Reduction"[Mesh])	N/A
9	((("Substance Abuse, Intravenous"[Mesh]) OR "HIV Infections"[Mesh]) AND ((("Automation"[Mesh]) OR (((("Needles"[Mesh]) OR "Needle Sharing"[Mesh]) OR "Needle-Exchange Programs"[Mesh]) OR "Syringes"[Mesh])) OR (vending[Title/Abstract] OR syringe[Title/Abstract] OR test-kit[Title/Abstract] OR Needle[Title/Abstract] OR self-test[Title/Abstract] OR syringe-dispensing[Title/Abstract]) AND ((Harm Reduction[Title/Abstract]) OR ("Harm Reduction"[Mesh]))	N/A
10	((("Substance Abuse, Intravenous"[Mesh]) OR "HIV Infections"[Mesh]) AND ((("Automation"[Mesh]) OR (((("Needles"[Mesh]) OR "Needle Sharing"[Mesh]) OR "Needle-Exchange Programs"[Mesh]) OR "Syringes"[Mesh])) OR (vending[Title/Abstract] OR syringe[Title/Abstract] OR test-kit[Title/Abstract] OR Needle[Title/Abstract] OR self-test[Title/Abstract] OR syringe-dispensing[Title/Abstract]) AND ((Harm Reduction[Title/Abstract]) OR ("Harm Reduction"[Mesh]))	English

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Two authors (AZ, MC) assessed the search-identified articles for eligibility using their titles/abstracts; ineligible articles were removed. The full texts of the remaining, potentially eligible articles were then reviewed by all authors; a consensus approach was used to determine eligibility and resolve any disagreements, with the senior author (AEZ) consulted for final determination as needed.

Data collection process

Two reviewers (AZ, MC) manually and systematically extracted and summarized information on study design, goals, VM description, setting, location, target population, sample, results, and limitations from each included article (see Additional file 1). All authors reviewed and assessed the evidence and limitations of the included articles, including strength of evidence for each included article [29]. Heterogeneity of the study designs and methods precluded data pooling and meta-analysis.

Outcome measures

Outcomes of primary interest fell into four main categories: (1) feasibility, (2) acceptability, (3) reach, and (4) impact. Feasibility was conceptualized as the potential for the VM to be effective within a given setting, with subconstructs of demand (number of items dispensed from the VM and patterns in VM usage), implementation (considerations for VM placement and/or the extent the proposed plan was carried through), and practicality (associated time, resources, and/or costs in implementing and/or maintaining the VM) [30]. Acceptability was defined as the attitudes and perceptions among VM users and/or stakeholders toward agreeability of VMs within a given setting, and the potential barriers and facilitators to VM-related use satisfaction [31]. Reach was assessed by the representativeness of the VM users in relation to the target population [32]. Impact was defined as the influence of the VM on community or individual-level outcomes relevant to the specific VM’s target population and/or intention [32].

Results

Eligible articles-identification

The multi-database search identified 2946 articles. After removing duplicates, 2461 unique articles remained, and their titles/abstracts were screened, leading to the identification of 80 potentially-eligible articles. Full text review of these 80 articles led to the exclusion of 44 articles (including one not published in English [33]), and the inclusion of 36 eligible articles. The search of references listed within these eligible articles and from prior pertinent reviews [14, 25, 26, 34–36] yielded additional 80 original research articles. In addition, four articles [37–40] were identified through personal connections with harm reduction organizations. Among these additional 84 potentially-eligible articles, the screening process identified 42 duplicates, and the remaining 42 titles/abstracts were screened; of those, nine full-text articles were reviewed, and all were deemed eligible (Fig. 1). Overall, these above pathways yielded a total of 45 eligible articles included in this systematic review (Table 2).

Table 2.

Overview of included articles (n = 45)

Primary Item dispensed from VM	Article name	Study design	Location	Target population (Sample)	Outcome measures evaluated				Review authors’ comments	Strength of evidence
Primary Item dispensed from VM	Article name	Study design	Location	Target population (Sample)	Feasibility	Acceptability	Reach	Impact	Review authors’ comments	Strength of evidence
Syringes	Cama et al., 2014 [61]	Cross-sectional survey	Sydney, Australia	PWID (n = 91)	Y	Y	Y	N	Describes user characteristics of syringe exchange programs generally, but also includes data on those using a syringe VM	Low^a
	Coupland et al. 2022 [95]	Cross-sectional mixed methods survey	Sydney, Australia	PWID (n = 70)	N	Y	Y	N	Unique mixed methods approach using closed-circuit television, footage, fieldwork observations; only study to evaluate feasibility of incorporating Hepatitis C testing into a VM	Very low due to imprecise results
	Day et al., 2016 [65]	Cross-sectional survey	Sydney, Australia	PWID (n = 274)	Y	N	Y	Y	Only study to evaluate VM’s impact on local drug-related crime rates	Low^a
	Deimel et al. 2000 [41]	Cross-sectional survey	North Rhine-Westphalia, Germany	PWID (n = 36 VM operators)	Y	Y	Y	N	Evaluates 110 VMs regionally in Germany, with a specific focus on VM operations logistics	Low^a
	Dodding & Gaughwin 1995 [67]	Cross-sectional qualitative interviews	Perth, Australia and Adelaide, Australia	PWID (n = 24)	Y	Y	N	N	One of the older studies included in literature review; qualitative interviews with PWID	Low^a
	Duplessy & Raynaud 2014 [60]	Retrospective observational	Paris, France	PWID	Y	N	N	N	VM data collected over a 12-year time span	Very low due to heterogeneity of VM operations over time and across different sites
	Islam et al. 2008 [62]	Cross-sectional survey	New South Wales, Australia	PWID (n = 167)	Y	Y	Y	N	Study includes multiple (n = 9) syringe-dispensing VMs	Low^a
	Islam et al. 2009 [80]	Cross-sectional survey	New South Wales, Australia	PWID (n = 94 employees and staff)	N	N	N	Y	Identifies perceptions of VMs from staff members of needle syringe programs, drug treatment centers, local health centers	Low^a
	Jacob & Stover 2000 [42]	Prospective cohort	Lower Saxony, Germany	PWID, Prisoners (n = 169)	Y	Y	N	Y	Impact evaluation found complete elimination of syringe sharing among prisoners and of drug overdoses in the prison	Low^a
	Kerr et al. 2022 [49]	Prospective observational	Melbourne, Australia	PWID (n = 90,488)	Y	N	Y	N	More recent study with one of the largest study sizes; includes reporting by non-binary gender	Low^a
	McDonald 2009 [43]	Prospective observational	Canberra, Australia	PWID (n = 147)	Y	Y	Y	Y	Syringe-dispensing VMs were placed outside of community health centers as opposed to harm reduction organizations	Low^a
	Moatti et al. 2001 [79]	Cross-sectional survey	Marseille, France	PWID (n = 88)	N	N	Y	N	Includes other forms of syringe services in their study, including pharmacies, in addition to the VM	Low^a
	Nelles et al. 1998 [44]	Prospective cohort	Hindelbank, Switzerland	PWID, Prisoners (n = 137)	Y	N	N	Y	Promising impact evaluation with decreased number of prisoners using drugs and sharing syringes, however prison-based VM with small sample size	Low^a
	Nelles et al. 1999 [45]	Prospective cohort	Hindelbank, Switzerland	PWID, Prisoners (n = 137)	Y	N	N	Y	Builds upon Nelles et al. (1998) article with data collected over 2 years; positive impact noted on number of prisoners using drugs	Moderate due to large effects
	Obadia et al. 1999 [64]	Cross-sectional survey	Marseille, France	PWID (n = 88)	Y	Y	Y	N	Syringe-dispensing VMs were placed during HIV epidemic in France	Low^a
	O’Keefe et al. 2022 [47]	Retrospective observational	Melbourne, Australia	PWID (n = 85,851)	Y	N	N	N	Evaluates COVID pandemic’s influence on VM usage, particularly on unique visits	Low^a
	Otiashvili et al. 2019 [69]	Cross-sectional survey	Tbilisi, Georgia	PWID (n = 149)	Y	Y	N	N	A more recently published article soliciting feedback from people who use drugs and not connected to care/treatment	Low^a
	Philbin et al. 2009 [72]	Cross-sectional qualitative interviews	Tijuana, Mexico	PWID (n = 40 stakeholders)	N	Y	N	N	Only study conducted in Mexico; highlights barriers and concerns over a syringe-dispensing VMs	Low^a
	Stark et al. 1994 [51]	Cross-sectional survey	Berlin, Germany	PWID (n = 313)	Y	N	Y	N	Oldest article included in review	Low^a
	Uthurralt et al. 2022 [48]	Retrospective observational	Sydney, Australia	PWID	Y	N	N	Y	Focuses on changes to face-to-face contact with services, including with primary care, after 24-h VM access is implemented	Moderate due to large effects
	White et al. 2016 [77]	Cross-sectional survey	Sydney, Australia	PWID (n = 153)	N	Y	N	N	Evaluates community perceptions on implemented VMs	Low^a
Condoms	Demaria et al. 2020 [73]	Cross-sectional qualitative interviews	Florence, Italy	Women (n = 26)	Y	Y	N	N	Focuses on female attitudes towards condom VMs; complements Ramos-Ortiz et al., 2020 article	Low^a
	Kirby et al. 1999 [66]	Prospective observational	Seattle, USA	Adolescents (n = 6636)	Y	N	N	Y	Large sample size; study found baskets with condoms had higher demand compared to VMs	Low^a
	Lucas et al. 2014 [54]	Prospective observational	California, USA	Prisoners (n = 26)	Y	Y	N	Y	One of the few studies evaluating prison-based condom-dispensing VMs	Low^a
	Ramos-Ortiz et al. 2020 [74]	Cross-sectional qualitative interviews	Florence, Italy	Sexually active adults (n = 42)	Y	Y	N	N	Focuses on attitudes towards condom VMs from both males and females; complements Demaria et al., 2020 article	Low^a
	Sylla & Harawa 2010 [53]	Prospective cohort	San Francisco, USA	Prisoners	Y	Y	Y	Y	One of the few studies evaluating prison-based condom-dispensing VMs; main study goal is to evaluate feasibility, however other outcome measures were also studied (acceptability, reach, impact)	Low^a
	Tomnay & Hatch 2013 [52]	Prospective observational	Victoria, Australia	Adolescents	Y	Y	N	N	Condoms were dispensed for a fee; VMs were placed in a rural location	Low^a
HIV self-tests	He et al. 2019 [56]	Prospective observational	China	Students	Y	N	N	Y	University-based VM dispensing urine HIV self-tests	Low^a
	Lee et al. 2020 [68]	Cross-sectional survey	London, United Kingdom	Minority communities	Y	Y	N	N	One of the few studies in review with explicit focus on reaching minority communities	Low^a
	Lv et al. 2021 [78]	Prospective observational	China	Students, MSM	Y	N	Y	Y	Large study with 146 VMs dispensing urine HIV self-tests across 73 universities in China	Low^a
	Raffe et al. 2020 [75]	Cross-sectional qualitative interviews	Brighton, United Kingdom	MSM (n = 23)	N	Y	Y	N	VM placed in the lobby of a licensed sex-on-premise sauna	Low^a
	Stafylis et al. 2018 [57]	Cross-sectional survey	Los Angeles, USA	MSM (n = 110)	Y	Y	N	Y	Out of included studies related to HIV self-test VMs, had most promising impact evaluation, with 17.7% reporting a first-time positive HIV test and 41% of those seeking care afterwards	Low^a
	Vera et al. 2019 [58]	Cross-sectional survey & qualitative interviews	Brighton, United Kingdom	MSM (n = 53)	Y	Y	Y	N	Found higher dispense rates of HIV self-tests compared to in-person outreach at the same location	Low^a
	Young et al. 2014a [76]	Case study	Los Angeles, USA	MSM	Y	N	N	N	Only case study included in the review; Young et al., 2014b provides follow-up results	Low^a
	Young et al. 2014b [70]	Cross-sectional qualitative interviews	Los Angeles, USA	MSM (n = 8)	Y	Y	N	N	One of the few studies in review with explicit focus on including minority populations	Low^a
Naloxone	Allen et al. 2022 [37]	Retrospective observational	Clark County, Nevada	PWID	N	N	N	Y	One of the few studies evaluating impact of naloxone-dispensing VMs; evaluation time period includes COVID pandemic	Low^a
	Arendt 2022 [55]	Prospective observational	Cincinnati, USA	PWID (n = 637)	Y	N	N	Y	One of the few studies evaluating impact of naloxone-dispensing VMs; evaluation time period includes COVID pandemic	Moderate due to large effects
	Wagner et al. 2022 [38]	Cross-sectional qualitative interviews	Colorado, USA	Young adults with history of opioid use disorder (n = 16)	Y	Y	N	N	Study population more accurately reflects current opioid crisis in the U.S. (compared to earlier studies focusing on PWID)	Low^a
Prescription Opioids (Safer Supply)	Bardwell et al. (2023) [39]	Cross-sectional	Vancouver, Canada	Individuals who regularly use opioids (including fentanyl) with history of overdose (n = 46)	N	Y	N	Y	These studies were unique in evaluating VMs dispensing prescription opioids for safer supply	Low^a
Prescription Opioids (Safer Supply)	Mansoor et al. (2023) [40]	Cross-sectional	Canada	Individuals who regularly use opioids (including fentanyl) with history of overdose (n = 17 community partners)	Y	N	N	N		Low^a
Nicotine Replacement Therapy	Giles & Bauer 2021 [59]	Prospective observational	New South Wales, Australia	Nicotine users	Y	N	N	Y	Only study to evaluate a VM dispensing nicotine replacement therapy; primary aim is to encourage compliance to hospital non-smoking policies	Low^a
Multiple Items (e.g., syringes, condoms, clean drug use supplies, pregnancy tests, naloxone)	Otiashvili et al. 2021 [46]	Prospective observational	Tbilisi, Georgia	PWID (n = 1605)	Y	N	N	N	Only study to focus on using “smart” VMs to enable research data collection, including Internet connectivity and interactive touchscreen	Low^a
	Otiashvili et al. 2022 [63]	Stepped-wedge cluster randomized trial	Tbilisi, Georgia	PWID (n = 1846)	Y	Y	Y	N	Unique study design (stepped-wedge cluster randomized trial) to implement and evaluate VMs	High
	Stewart et al. 2023 [71]	Cross-sectional qualitative interviews	Philadelphia, USA	PWID (n = 31 stakeholders)	Y	Y	N	N	One of the few studies focusing on multi-item VMs; includes on community recommendations to enhance acceptability	Low^a
	Walker et al. 2023 (50)	Prospective observational	Tbilisi, Georgia	PWID, MSM (n = 1358)	Y	Y	N	N	Includes VM operating costs	Low^a

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^aLow strength of evidence due to observational study design without significant limitations or strengths

Eligible articles-characteristics

The included 45 articles were published between 1994 and 2023, and described 30 separate studies. The majority of the articles (n = 35) focused on VMs in non-U.S. regions/countries: Europe (n = 17), Australia (n = 13), Asia (n = 2), Canada (n = 2) and Mexico (n = 1), and, altogether, encompassed 191,242 participants (190,576 VM users; 666 non-users). The target populations involved PWID or individuals using opioids (n = 29), followed by men who have sex with men (MSM; n = 7), prisoners (n = 5), adolescents/young adults (n = 5), or others (n = 4: sexually active adults, general community members, hospital visitors). Occasionally, articles (n = 6) had multiple target populations, such as PWID and prisoners. Fifteen articles described findings from interviews with VM users (n = 1,438), while 11 examined attitudes and behaviors of non-users (n = 666) who were either stakeholders (n = 218; i.e., harm reduction organization staff, prison staff, local community members) or representatives of target populations (n = 448). The remaining 20 articles primarily examined aggregate data surrounding VM characteristics and usage; of those, 11 articles reported on the number of users served by the VMs, totaling 189,138 users.

Among the 45 included articles, 37 examined VMs that had already been implemented, and 8 evaluated attitudes toward potential VMs. The already-implemented VMs were placed near harm reduction organizations (n = 9), healthcare settings (n = 7), public settings (n = 6; e.g., outside community organizations or train stations), prisons (n = 5), schools/universities (n = 3), commercial sex venues (n = 3), or other unspecified locations (n = 12). These VMs most frequently provided clean syringes (n = 21), followed by HIV self-tests (n = 6) and condoms (n = 6), with few VMs dispensing naloxone (n = 2), prescription opioids for safer supply (n = 1) or nicotine gums (n = 1). Of the 37 articles examining implemented VMs, the majority (n = 25) evaluated VMs dispensing only one type of item; however, 12 articles examined VMs dispensing syringes along with clean drug use supplies (e.g., alcohol swabs, sterile water, cookers). Four examined VMs dispensing multiple diverse items, ranging from those specifically focused on SUD-related harm reduction (e.g., naloxone, syringes, fentanyl test strips) to those addressing health needs in more general terms (e.g., pregnancy tests).

The majority of articles (n = 24) described results stemming from cross-sectional studies, with 13 of them utilizing surveys, 10 utilizing qualitative interviews, and 1 utilizing both survey and interview data. Approximately one-quarter of the articles (n = 11) described prospective observational studies, while four presented findings from retrospective cohort studies and four from prospective cohort studies. Only one article was based on a stepped-wedge cluster randomized trial and one on a case study.

Outcomes

Most articles evaluated outcomes spanning more than one of the four main outcome categories (n = 36), with 9 studies focusing on outcomes falling into one category only. Among the included 45 articles, the most common outcomes addressed feasibility (n = 35) and acceptability (n = 21), followed by impact (n = 17) and reach (n = 14).

Feasibility (n = 35 articles): For feasibility sub-measures, demand was the most commonly assessed outcome (n = 28), with few articles examining implementation (n = 9) or practicality (n = 7) of VM implementation.

Demand (n = 28 articles). Of the 28 articles describing the number of items dispensed by the VMs, syringe-dispensing VMs were reported to dispense a high number of items, averaging 2,899 syringes (range 44–16,740) per VM monthly [41–50]. One study in Berlin, Germany found many participants (77%; 241/313) were using syringe-dispensing VMs at least 4 times a week and that those who injected drugs on a daily basis used the VMs more frequently than others who injected less frequently (p < 0.001) [51]. Although not in the same geographic location, the monthly average for condom-dispensing VMs ranged from 48 to 356 male/external condoms [50, 52, 53], with one article reporting an average of 171 male/external condoms monthly across multiple dispensing machines [54]. Only 2 articles reported on VMs dispensing naloxone and/or fentanyl test strips, with the monthly averages of 156 naloxone doses (range 31–280) [50, 55] and 846 fentanyl test strips [55]. VMs with HIV self-tests dispensed an average of 26 tests/machine monthly (range 14–39) [56–58], while the numbers for the dispensed nicotine replacement therapy items was much lower, with a monthly average of 3.5 packets/machine [59].

Few articles examined long-term VM dispensing patterns. A prospective study of syringe-dispensing VMs in Paris, France found the number of syringes steadily increased by 202% over a 12-year follow-up, with two out of 34 VMs responsible for more than half of the dispensed syringes [60]. However, another study in a women’s prison in Switzerland saw a significant decrease in the number of syringes (from 5,335 down to 650; p < 0.01) dispensed over two years; the decrease correlated with fewer inmates reporting drug use [45].

Most VM activity occurred outside of traditional business hours [46, 49, 56, 57, 60–62]. During the COVID-19 pandemic when many in-person programs and businesses were closed, two studies found increased use of the VMs [46, 48], although one study found a small but significant decrease in the number of unique encounters [47]. In some instances, demand for VM-dispensed syringes, HIV self-tests, naloxone, and fentanyl test strips was higher than through in-person outreach and existing harm reduction programs (i.e., needle/syringe exchange; pharmacies) [55, 57, 58, 63, 64]. One VM dispensing HIV self-tests distributed six times as many tests compared to a local in-person outreach program [58]; one syringe-dispensing VM was responsible for 66% of all syringes distributed by that particular needle syringe program [49]. However, other articles noted that syringe-dispensing VMs were estimated to dispense around 2–14% of all syringes in their community [41, 43, 63, 65]. The included articles provided sparse evidence regarding the demand for services offered by condom-dispensing VMs versus in-person programs; one prospective cohort study in the state of Washington, U.S. found that high school students obtained fewer male condoms from school-based condom-dispensing VMs (n = 2,526 condoms) compared to the baskets placed in school-based health centers (n = 131,185 condoms) over two years [66].

Implementation (n = 9 articles). Most (n = 7) of these articles focused on ideal locations for potential future VMs. Privacy and safety were emphasized as key characteristics [38, 67–71], with particular consideration for avoiding police presence nearby for naloxone-dispensing VMs [38]. For VMs dispensing HIV self-tests, there was specific preference for healthcare-based locations [68, 70]. To reduce stigma, some emphasized providing a broad selection of items, particularly for community-based VMs [69–71], and informational materials to connect users to treatment and other resources [71]. Availability of nearby wrap-around services was highlighted for one proposed VM that would be dispensing hydromorphone tablets for safer supply [40]. One study evaluated VM intervention’s implementation fidelity, finding inconsistencies in its implementation across organizations, e.g., due to staff forgetting to offer VM access cards to clients [63].

Practicality (n = 7 articles). The main concern related to practicality was item restocking [41], the VM’s reliability, and need for repairs with regular use and due to occasional vandalism [41, 43, 52]. Implementation and maintenance costs varied. One article on a prison-based condom-dispensing VM noted a cost of below $2/year/inmate in the first year (due to the upfront VM cost in the first year), with a lower cost of around $0.72/year/inmate in subsequent years to maintain the VM [54]. Another article evaluating 10 VMs that dispensed a variety of harm reduction- and health-related items estimated a cost of €66/year per user; notably, 51% of the cost in this study was associated with staff salaries, of which 31% was for a data manager [50]. Similarly, the reported item costs varied; one article examining two VMs dispensing HIV self-tests found the majority of cost was incurred by the supplies [57], while another found that the item cost took up only 28% of their budget [50].

Acceptability (n = 21 articles). For both already-implemented and future VMs, there was high acceptability among target populations [38, 39, 67, 68, 72], associated staff members, and community and other partners [42, 43, 52–54, 58, 61–63, 71, 73–76] due to the VM’s convenience, minimal oversight, increased privacy, and accessibility outside of business hours [39, 43, 61, 73, 75]. Only one article specifically examined VM acceptability among minority populations and found the proposed HIV self-test-dispensing VM to be acceptable [68]. For male condom-dispensing VMs, acceptability was contingent upon condom quality, reliability, cost, and variety [73, 74]. Specific concerns related to HIV self-test-dispensing VMs pertained to the credibility of these tests, presence of counseling at the time of testing, access to immediate supports if testing positive, and availability of co-testing for other STDs [58, 75, 76]. Community members, local businesses, and those from government and religious sectors were more likely to be hesitant of syringe-dispensing VMs, with many believing such VMs could encourage drug use, attract individuals who use drugs, or result in a local increase in drug use-related crime [41, 71, 72, 77]. For one prison-based condom-dispensing VM in San Francisco, U.S., there had been initial hesitation among staff members, which dissipated after the VM’s implementation, with all staff endorsing it [53]. To enhance community acceptability, community and other partners in one study recommended holding small community meetings, and promoting the VM, which offered a needle disposal, as a way to connect individuals to SUD treatment and recovery resources [71].

Reach (n = 14 articles). Regardless of the type of items dispensed, most VMs were able to reach higher-risk populations, such as PWIDs (for syringe VMs), those less likely to be connected to healthcare, and those from socioeconomically disadvantaged backgrounds or engaging in riskier behaviors [51, 53, 58, 62, 64, 65, 78, 79]. VMs also attracted a younger population [58, 63, 64, 79], with stigma avoidance being an important factor influencing utilization of syringe-dispensing VMs among younger people [62]. Indeed, one article found that PWID aged < 25 years were more likely than older cohorts to access a VM dispensing syringes and other clean drug use supplies when other programs were closed [49]. Only one article examined the VM’s reach on a larger scale, finding that syringe-dispensing VMs in Germany had a greater reach in rural compared to urban areas [41].

Impact (n = 17 articles). For VMs dispensing syringes and HIV self-tests, a positive impact was generally noted, although only a limited number of articles evaluated such impact. For syringe-dispensing VMs, needle-sharing decreased [43–45, 80], drug use reduced in prison settings [44, 45], and face-to-face encounters with primary care increased [48]; there was little-to-no increase in drug-related crime in the community [65, 80]. One article found outright elimination of syringe-sharing and drug overdoses following the implementation of five syringe-dispensing VMs in a prison [42]. For VMs dispensing HIV self-tests, the detection rate of positive HIV tests ranged from 1.9% to 17.7% [56, 57, 78], with one article reporting that 41.2% of those with a positive HIV test sought care afterwards for confirmatory testing [57].

Impact evaluation for VMs dispensing items other than those described above was also limited. For condom-dispensing VMs, no increase in sexual activity rates [53, 66] or in penal code infractions for the prison-based VMs was noted [54]. The hospital-based VM dispensing nicotine replacement therapy geared toward visitors to eliminate smoking on campus did not see a difference in the visitor smoking rates [59]. For naloxone-dispensing VMs, opioid-related deaths were lower than predicted in the first 12 months after the VM implementation, but then rose in the following 10 months—a timeframe which included the COVID-19 pandemic [37]. In contrast, another article examining the impact of a naloxone-dispensing VM, which was operational during the COVID-19 pandemic, found the number of unintentional fatal overdoses in the county where the VM was located decreased by 10% over a year [55]. For one VM that dispensed hydromorphone tablets for safer supply, participants noted that they were using illicit drugs and overdosing less frequently, with subsequent positive effects on their health, well-being, and finances [39].

Discussion

This systematic review aimed to synthesize the current evidence on the VM-delivered items and services for harm reduction related to SUD. We found 45 articles, describing results from 30 separate studies, that provided limited yet promising evidence on feasibility, acceptability, reach and impact of VM-delivered harm reduction efforts. Although these findings call for further rigorous research in this area, they are encouraging, especially given the growing use of this approach across the U.S. [19–24].

This systematic review included studies evaluating VMs dispensing syringes, condoms, HIV self-tests, naloxone, fentanyl test strips, hydromorphone tablets, and/or nicotine gums; this is different from prior reviews, which focused only on syringe-dispensing VMs [25, 36]. Our review also applied an implementation science-driven approach to assess evidence across multiple domains essential to effective implementation [30–32]. This approach enabled us to note that the majority of included studies assessed two of these domains (feasibility and acceptability), with limited research evaluating impact or effectiveness. Many studies noted that VM-enabled expanded after-hours access to items was an important contributor to feasibility and acceptability. Demand for syringes and HIV self-tests dispensed by VMs was occasionally higher compared to some in-person outreach and existing harm reduction programs. Of note, some VMs did require tokens, access cards, payment, or in-person registration to obtain items from the VM [39, 41, 43, 49, 52, 56, 60, 62, 63], which may have an impact on VM accessibility.

The VMs were also able to mitigate some of the associated stigma and reach high-risk populations whose members may experience difficulties connecting to care (e.g., rural locations, lower socioeconomic status). Thus, VMs may represent an alternative or adjunctive strategy for existing public health and harm reduction programs, with significant implications for providing the tools to help improve health outcomes for those living in poverty, unhoused, at a lower education level, unemployed, or disabled who are at a higher risk of opioid overdoses [81]. It is important to note, however, that while the VMs’ relative anonymity and accessibility may be beneficial for certain populations, others may benefit more from in-person engagement with harm reduction workers and healthcare staff for education, linkage to treatment and services, and ongoing support. Potential ways to promote in-person connections to treatment and recovery services, while preserving VMs’ accessibility and anonymity, could include placing VMs outside healthcare or harm reduction organizations, having VMs act as an extension of existing services, or providing contact information of service organizations with the items dispensed. Individuals affected by SUDs are also at risk of having co-occurring conditions, such as HCV or sexually transmitted infections [82]. While there were very few studies on the VMs’ impact, particularly long-term, on SUD-related behaviors and co-occurring conditions and their findings on VMs’ effectiveness were limited, the VMs showed potential in improving some of the relevant public health outcomes, particularly related to needle sharing and drug use for syringe-dispensing VMs, and identification of HIV positivity for HIV self-test VMs.

Research gaps and considerations for future VM implementation

Future communities adapting VMs to address SUD and commonly co-occurring conditions should conduct early community outreach, given that reservations about VMs may come from community members, government and religious sectors, or local businesses [41, 53, 72]. A common belief about harm reduction-focused VMs is that their presence can encourage negative behaviors [71, 77], including public discarding of syringes or other drug use-related equipment; however, the limited evidence did not corroborate these worries [55, 65, 80]. In fact, early evidence showed drug use-related crime did not increase, while needle sharing, drug use, and overdoses decreased in some settings after the implementation of syringe-dispensing VMs [42–45, 80]. In addition, no perceived change or decrease in discarding of used syringes and associated equipment were observed [80]. Furthermore, some VMs provide sharps containers as part of their offerings to promote safe disposal of syringes [55] or exchange new syringes for used ones [45]. These early encouraging findings are consistent with those associated with overdose prevention sites [83, 84]. Future research on VM impact on individual- and community-level health indicators (both long- and short-term) is necessary to not only establish the VM efficacy, but also help sway potential negative community attitudes and misperceptions.

In addition, although recent studies have started to evaluate VMs offering multiple items, most of the research to date has focused on single-item dispensing VMs. The single-item VMs may also reflect organizational capacity and priorities, as organizations with a specific focus (e.g., needle exchange or HIV testing programs) have typically initiated harm reduction-focused VMs. However, having VMs that dispense multiple items (e.g., condoms, pregnancy tests, HIV self-tests) could enhance broader community acceptability, reduce associated stigma, and address more than one need, which is important, especially given that individuals with SUD are likely to have co-occurring health conditions [69, 70]. Cross collaboration with other organizations addressing public health needs could help promote effective implementation of VMs for harm reduction and addressing associated needs. Furthermore, while VMs have been used for harm reduction since the 1990s, technological advancements are now present (e.g., being able to connect individuals to care or recovery peer specialists, or biometric scanning [85]) that may lead to novel ways to provide wrap-around care for individuals with SUD.

There is also a scarcity of studies on VMs dispensing naloxone or fentanyl test strips despite their increasing use in the U.S. This partially reflects an evolving environment with legislative and policy changes aimed at increasing harm reduction accessibility, such as state-specific naloxone standing orders, the Food and Drug Administration’s (FDA) approval for naloxone’s over-the-counter designation, and harm reduction being included in programming planning of federal agencies [86–88]. Recently, some states have started to legalize drug testing supplies, such as fentanyl test strips, however these can still be considered to be “drug use paraphernalia” in some states and thus remain illegal [89, 90]. While it is likely that VMs dispensing naloxone or fentanyl test strips will share similarities in their feasibility, acceptability, reach, and other impact as “traditional” VMs dispensing syringes, condoms, or HIV self-tests, there is a need for more research evaluating these specific applications for the VM-delivered harm reduction. Further, almost all of the evidence on syringe dispensing VMs come from studies conducted in Europe and Australia, with no identified studies in the U.S., likely reflecting the sociopolitical climate around syringe exchange in the U.S.

With respect to the VM’s reach, while most studies focused on marginalized populations, the racial and ethnic breakdown of the study samples reflected largely white participants or was otherwise unspecified. A few studies focused on MSM, usually in relation to VMs dispensing HIV self-tests. Only one study explicitly focused on Black African and Caribbean, and Latin American communities [68], while two included a substantial proportion of Hispanic/Latino participants [57, 70]. Thus, future research and VM programming should incorporate greater racial/ethnic, sexual/gender and other diversity, given existing disparities in overdose and other health outcomes [91, 92]. Finally, there is limited research on the factors influencing VM implementation in various communities, with a specific lack of studies using implementation science frameworks. Future research should incorporate these theories and frameworks to rigorously assess the VMs and ensure they can be successfully implemented and disseminated in different communities.

Policy and practice implications

This systematic review has implications for the implementation of other initiatives beyond VMs to provide low-barrier access for harm reduction items and services. For example, Naloxbox, which contains an easy-to-use rescue kit with multiple nasal naloxone doses, has been introduced in several states in order to increase community access to naloxone [93]. Similar considerations related to VMs for harm reduction could likely be useful toward the implementation of these low-barrier initiatives to help address concerns over acceptability by community members, a need to reach diverse populations, and evaluating these initiatives’ impact on long-term health outcomes.

Limitations & strengths

Limitations include publication bias, as per our eligibility criteria, we excluded those not published in peer-reviewed journals (e.g., news releases or briefs, conference abstracts, poster presentations) or in a language other than English. Furthermore, the field of harm reduction-based VMs is rapidly evolving given the popularity of this approach in recent years and our review was limited to studies published before November 29, 2023. Additionally, almost all of the eligible studies we found were observational in nature, with only one being a randomized controlled trial [63]. While it may not always be feasible or ethical to conduct randomized controlled trials for public health interventions [94], having an adequate comparison arm is key to establishing the efficacy of any intervention; future studies should include, whenever possible, a comparison condition in VM evaluation studies.

The settings in which the harm reduction-focused VMs exist can also have a significant influence on the studied outcomes. The included studies assessed VMs located in a wide variety of locations, ranging from Europe to Australia to the U.S., in both community and institutional settings. While this variability ensured a diversity of articles, it also made it challenging to standardize outcomes among all of the studies. Generalizability was further limited by the vast heterogeneity of the study designs. Additionally, not all studies reported on demographics, precluding the summarization of common demographic characteristics (e.g., average age for VM users).

Despite these limitations, our systematic review provides a thorough review of eligible studies describing VMs dispensing items to address harms associated with SUD and its comorbidities, extending beyond typical SUD-related harm reduction items (i.e., syringes and naloxone) to include condoms, HIV self-tests, and nicotine replacement therapy. Thus, the findings of this systematic review can be applied to broader applications of the VM-based harm reduction and broader populations, as many individuals with SUD have additional health needs.

Conclusions

Over the past three decades, harm reduction-focused VMs have been used in a variety of settings to offer needed harm reduction items and services, ranging from syringes to HIV self-tests to condoms. There are many potential intrinsic advantages to using VMs as a low-barrier method to reach high-risk, hard-to-reach individuals, reduce the harms associated with SUD and address co-occurring conditions. This systematic review indicates high feasibility and acceptability of these VMs among their target populations. Harm reduction-focused VMs continue to grow in popularity, particularly in the U.S., and have evolved to reflect changing harm reduction needs (e.g., VMs are now dispensing naloxone and drug testing kits). Long-term impact evaluation of the VMs, and implementation science frameworks are needed in future VM-related research to rigorously evaluate the VMs and help ensure their effective implementation and sustainability within the community.

Supplementary Information

12954_2025_1236_MOESM1_ESM.docx^{(70.9KB, docx)}

Additional file1 (DOCX 70 kb) Additional files: Additional material is provided in “Additional file 1.docx.” The title of the data is: “Supplementary Table 1: Summary of Articles (n=45) Included in the Systematic Review.” This data includes additional details on the articles’ study design, goal, description of the vending machine, setting, location, target population, sample, results, and limitations as identified by article authors.

Acknowledgements

The authors would like to thank Amy Knehans, MLIS, Associate Librarian at the Penn State College of Medicine for her assistance in the literature search.

Abbreviations

COVID-19: Coronavirus disease 2019
HBV: HEPATITIS B virus
HCV: Hepatitis C virus
HIV: Human immunodeficiency virus
MSM: Men who have sex with men
PWID: People who inject drugs
SUD: Substance use disorder
VM: Vending machine

Author contributions

AZ was involved in conceptualization, data collection, analysis, and writing (original draft, reviewing and editing). MC, RL, SMB, and ARC contributed to data collection, analysis, and writing (reviewing and editing). AEZ was involved in conceptualization, data analysis, writing (reviewing and editing), supervision, and funding acquisition. All authors read and approved the final manuscript.

Funding

This project was supported by the Penn State Addiction Center for Translation, and the Penn State College of Medicine Department of Family and Community Medicine. AZ’s effort on this project was supported by the Penn State Family and Community Medicine Primary Care Research Fellowship, and by the National Center for Advancing Translational Sciences, Grant KL2 TR002015 and Grant UL1 TR002014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

12954_2025_1236_MOESM1_ESM.docx^{(70.9KB, docx)}

Data Availability Statement

No datasets were generated or analysed during the current study.

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PERMALINK

Vending machines for reducing harm associated with substance use and use disorders, and co-occurring conditions: a systematic review

Alice Zhang

Matthew Carrillo

Ryan Liu

Sarah M Ballard

Alexis Reedy-Cooper

Aleksandra E Zgierska

Abstract

Background

Methods

Results

Discussion

Supplementary Information

Background

Methods

Eligibility criteria

Information sources, search strategy, and selection process

Table 1.

Fig. 1.

Data collection process

Outcome measures

Results

Eligible articles-identification

Table 2.

Eligible articles-characteristics

Outcomes

Discussion

Research gaps and considerations for future VM implementation

Policy and practice implications

Limitations & strengths

Conclusions

Supplementary Information

Acknowledgements

Abbreviations

Author contributions

Funding

Availability of data and materials

Declarations

Competing interests

Ethics approval and consent to participate

Consent for publication

Footnotes

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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