Synthetic opioid response in a low-income country: policy and implementation lessons from Sierra Leone

Potent synthetic opioids are entering low-income settings where addiction-treatment, harm-reduction, overdose-surveillance, toxicology, and regulatory systems remain limited. In April 2024, Sierra Leone declared a national emergency after the rapid spread of Kush, later confirmed to contain nitazene-class opioids in 87% of tested samples.

To examine implementation determinants shaping Sierra Leone's national Kush response and draw policy lessons for low-resource settings confronting synthetic opioid markets.

We conducted a theory-driven document analysis using directed qualitative content analysis guided by the 2022 Consolidated Framework for Implementation Research (CFIR). Seventeen documents were coded across 39 CFIR constructs. Twenty-four Weekly Situation Reports were reviewed as one longitudinal programme-monitoring series. Evidence was triangulated across document categories and classified by valence; inter-rater agreement was κ = 0.87.

CFIR coding identified evidence across 29 constructs (74%): 16 determinant patterns operated primarily as facilitators and 13 as barriers. The most consistently documented facilitators were political leadership, >90% domestic financing, and repurposed COVID-19 emergency infrastructure. Within 18 months, six treatment centres were established, 547 health workers completed training in substance-use assessment and care, and 8247 patients were enrolled in care and treatment (82% of target). Three gaps persisted: no routine community naloxone distribution or opioid substitution therapy, services in 8 of 16 districts, and women accounted for 12% of care-and-treatment enrolment.

Sierra Leone shows rapid mobilisation is possible when governance, financing, and coordination align, but treatment scale-up without harm-reduction integration and equity-focused design leaves major gaps in overdose prevention and access to care.