From Emergency Declaration to District-Level Delivery: A Theory-Guided Mixed-Methods Evaluation of Sierra Leone’s National KUSH Response (2024–2025)

Background In April 2024, the President of Sierra Leone declared a national emergency over the synthetic street drug “KUSH,” linked primarily to nitazene-class synthetic opioids. In response, the government established a five-pillar national strategy coordinated by the newly formed National Task Force on Drug and Substance Abuse (NaTFDSA), modeled on the country’s prior COVID-19 coordination platform. This evaluation examines how the strategy transitioned from policy to practice during its first 18 months, what scaled, where implementation lagged, and what adaptations emerged under constraint. Methods We conducted a convergent mixed-methods implementation evaluation in four districts (Western Area Urban, Bo, Kenema, and Port Loko) between June and September 2025. Data sources included 52 in-depth interviews, eight focus group discussions with 67 participants, 18 facility observations, 127 strategy and monitoring documents, and routine implementation indicators. Qualitative data were analyzed using the Consolidated Framework for Implementation Research (CFIR). Quantitative indicators aligned with Proctor’s implementation outcomes. Triangulation matrices integrated data across sources. Ethical approval was obtained from the national research ethics committee. Findings: Treatment bed capacity expanded from 50 to 212 beds across six centers (4.24-fold increase; ±324%), surpassing the 180-bed national target. The Sierra Leone Psychiatric Teaching Hospital (SLPTH) expanded to 60 beds, and three regional centers opened. A total of 847 healthcare workers were trained, and 1,289 admissions occurred over the 18 months. Prevention efforts reached 1,186 communities (62% of the target). Reintegration services reached 678 discharged patients; among those with six-month follow-up data, 43% had returned to work or school. Law enforcement recorded 891 arrests and 189.7 kg of drug confiscations, while a perception survey (n = 220) estimated a 35% reduction in street-level availability. The Task Force held all 18 planned coordination meetings and mobilized US$2.23 million, with 78% budget execution. Reintegration received the lowest funding allocation. Interpretation: Sierra Leone achieved a rapid, multi-sectoral scale-up of substance use services under emergency conditions. This experience shows how crisis coordination architecture can accelerate implementation in low-resource settings. However, gaps in reintegration fidelity, rural equity, and sustainability highlight the need for institutionalization, routine financing, integration of indicators into health information systems, and expanded harm reduction. The next phase should prioritize peer-led recovery, gender-responsive reintegration, and diversion-to-treatment protocols to ensure enduring, equitable impact.