Beyond Overdose: How People Who Use Drugs Navigate Competing Risks in the Polydrug Era

With increasing polydrug overdose deaths, public health messaging has centered around overdose prevention. However, it is important to contextualize overdose risk through the lived experience of people who use drugs (PWUD) and challenge the assumption that overdose is their primary salient risk. PWUD navigate multiple competing risk priorities daily and will adjust their behaviors in response to risks they prioritize.

Conduct in-depth interviews to explore the lived experience of PWUD in North Carolina, how they conceptualize the risks related to polydrug use, and what protective strategies they use to mitigate those risks.

Four major themes emerged from the qualitative interviews. First, overdose is ubiquitous, but not salient. Participants did not express distress regarding overdose because they thought they were careful or because they were not afraid of dying. Second, participants' primary concern was avoiding withdrawal. The immediate suffering of withdrawal outweighed the probabilistic risk of overdose. Third, participants strategically engaged in polydrug use to mitigate risks they prioritized. Fourth, despite not being significantly concerned about overdose, participants were knowledgeable and open to harm reduction strategies. PWUD employed a range of risk reduction practices aligned with their risk hierarchies.

Implications for these findings include the need for harm reduction providers and other public health stakeholders to target education, treatment, and interventions to align with the risks and considerations most salient and potentially persuasive to PWUD.