"If Everyone Knew about This, How Many Lives Could We Save?": Recognizing Drug Suppliers' Role in Reducing Overdose Risk

Background and Purpose: A major driver of overdose and other harms among people who use drugs in the U.S., is the variability and unpredictability of the unregulated drug supply (Jalal et al., 2018; Jones et al., 2018; Scholl, 2019). While some are able to discern certain changes in the composition or contamination of the illicit drug supply (Duhart Clarke et al., 2022), many face general uncertainty about the content of the substances they use, rendering them unable to estimate dose or potency and increasing the likelihood of overdose, especially after a period of abstinence (Amlani et al., 2015; Hayashi et al., 2018; Klar et al., 2016; McCrae et al., 2019; McKnight & Des Jarlais, 2018; Nolan et al., 2019; Tomassoni et al., 2017). While a safer, well-regulated drug supply remains inaccessible, many people who use drugs rely on trusted individuals who supply drugs to support access to a more predictable supply, developing shared understandings of supply changes, and, when possible, communicating openly in order to reduce the risk of overdose (Bardwell et al., 2019; Carroll, 2021; Carroll et al., 2020; Measham, 2020). As such, people who supply drugs are often well-positioned to have an outsized impact on drug use-related health outcomes and behaviors, as their role in drug use networks can shape the risk and protective environment for people who use drugs (Carroll et al., 2017, 2020; Kolla & Strike, 2020; Palamar & Sönmez, 2022; Rhodes et al., 2019).

Methods: As part of a larger study, we conducted a total of 30 interviews with residents of Indianapolis, Indiana who used illicit opioids or stimulants within the past month. We thematically analyzed a subset of these interview data, all of whom were members of a social network that was targeted by a harm reduction education program designed specifically for people who supply drugs at various levels of distribution (n=6). The majority identified as members of the BIPOC community.

Results: Participants described a diverse array of harm reduction strategies, some gained through the targeted education program, which they regularly practiced as they consumed and/or supplied drugs. People who supply drugs were regularly identified as key actors capable of widely reducing risk across drug networks. Participants described being motivated by a moral imperative to protect community members, tying the previous loss of loved ones to overdose to their commitments to the safety of others.

Conclusions and Implications: Our findings highlight the importance of two-way information sharing in supplier-consumer relationships, in which trust may be critical. Building on that trust expands what types of social relations between drug use networks are possible so that we can mitigate the harms in a drug market marked by deadly variability. These efforts could be achieved by supporting people who use, sell, or share drugs in leading and developing these efforts, and by better enabling grassroots harm reduction organizations to provide people who supply drugs with harm reduction training and access to harm reduction resources.