Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection

Abstract

Background and aims Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). Design A cross‐sectional qualitative study, including telephone and face‐to‐face in‐depth interviews. Setting Baltimore City, MD, USA. Participants Twenty‐seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April–September 2021). Measurements Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. Findings Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone (‘spotting’) and using drugs in public spaces. Conclusions WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Commentary on Rosen et al.: Attending to the unique needs of pregnant and parenting women at risk for overdose

“…To our knowledge, this protection is not included in any state's 911 Good Samaritan Law. Similar to our findings in the later years of the HIV epidemic [6], in which we identified a host of competing priorities that challenged women's ability to negotiate HIV prevention behavior, Rosen et al's research [7] highlights issues that challenge women's ability to reduce their risk for fatal overdose. Harris et al [14], too, recently found that women worry much more about their personal safety and care-giving responsibilities than the 'inevitability' of overdose.…”

“…Rosen et al . [7] bring this scholarship into the current era by addressing the nature of and reasons for solitary drug use (a risk factor for overdose death [8]) among WWUD. They identify three motivations for solitary drug use among women in their sample: (i) the need to alleviate opioid withdrawal symptoms, (ii) a desire to avoid anticipated and experienced substance use stigma and (iii) an attempt to reduce vulnerability to violence while intoxicated.…”

“…Similar to our findings in the later years of the HIV epidemic [6], in which we identified a host of competing priorities that challenged women's ability to negotiate HIV prevention behavior, Rosen et al . 's research [7] highlights issues that challenge women's ability to reduce their risk for fatal overdose. Harris et al .…”

“…Much of this research has been concerned with the social dynamics of drug use and how women's intimate relationships influence harm through patterns of drug use initiation, control over drug use and sexual and injection-related risk for HIV and HCV acquisition [1][2][3][4][5][6]. Rosen et al [7] bring this scholarship into the current era by addressing the nature of and reasons for solitary drug use (a risk factor for overdose death [8]) among WWUD. They identify three motivations for solitary drug use among women in their sample: (i) the need to alleviate opioid withdrawal symptoms, (ii) a desire to avoid anticipated and experienced substance use stigma and (iii) an attempt to reduce vulnerability to violence while intoxicated.…”

Overdose Detection Technologies—A New Frontier in Preventing Solitary Drug Overdose Deaths

“…Solitary drug use is an underaddressed issue. At least 50% of people who use illicit opioids do so when they are alone, which can protect against stigmatization, theft, violence, and external distractions during drug use episodes but can also increase the risk of death . From May 2020 through April 2021, two-thirds of overdose deaths monitored by the Centers for Disease Control and Prevention did not include evidence of a bystander, and only 9% of drug use episodes leading to death were directly witnessed.…”