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People who use drugs (PWUD) are internationally understood to be at higher risk of adverse health outcomes and overdose. Multiple theoretical frameworks have emerged to understand the degree to which social and structural factors contribute to health risks for PWUD. Studies applying these frameworks reveal important local factors that uniquely contribute to overdose risk or mitigation. While some research has critically analyzed naloxone distribution in the context of local risk environment, no work has 1) specifically examined the risk environment in urban New Jersey or 2) or imagined interventions for harm reduction practitioners grounded in a local application of the framework. The goal of this study was to elucidate the overdose risk environment in two urban areas in New Jersey and provide specific actionable steps for practitioners to take in order to address these risks.
Methods
In collaboration with a local harm reduction organization and with advising from community members who use drugs, we conducted semi-structured in-depth interviews with people who use drugs and naloxone distributors (n = 30) in New Brunswick and Newark, New Jersey between February and November of 2022. We used a community-based participatory research model to elucidate PWUD and naloxone distributor perceptions of the local overdose risk environments. Interviews used a pragmatic approach to ask aspects of local risk environment and were analyzed using thematic analysis. Participants were appropriately compensated for their time, drove network-based sampling, and were asked to review study results.
Results
Robust themes emerged in line with the understandings of macro and micro risk environments, with many factors overlapping between the two interpretations. Macro factors included structural barriers like capitalism, government austerity and white supremacy, along with institutional barriers such as the criminal legal system, lack of community support and resources, and inadequate access to treatment and recovery for both mental health and substance use. Many individuals referenced the stigma associated with drug use, and almost all highlighted the unregulated drug supply and fentanyl contributing to overdose risk.
Micro risk environment factors contributing to overdose included detrimental interpersonal interactions with the criminal legal system, inability to access housing, missed opportunities for overdose education, and how drug use behaviors change in the context of fentanyl. Many also highlighted individual challenges with mental health, modulating one’s own substance use behavior, and struggles with treatment and recovery.
Conclusions & Implications
Participants elucidated many factors that contribute to their own local overdose risk, which included both systemic factors and individual risk behaviors. Our findings indicate that harm reduction programs or practitioners in the substance use treatment care continuum should provide specific, individual-level interventions that support participant-led wellness (which could include substance use treatment or harm reduction strategies to mitigate the negative consequences of drug use in addition to comprehensive support regarding related risks such as criminal legal system involvement or housing status). Additionally, our findings necessitate policy and advocacy level action around housing access, criminal-legal system reform, and stigma reduction to reduce the negative effects of the War on Drugs.