The Drug Market's Impact on the Overdose Risk Environment for Women Who Use Drugs During the COVID-19 Pandemic

The volatility of the illicit drug market increased during the COVID-19 pandemic, contributing significantly to increased rates of overdose mortality in the United States. Given this unprecedented period and its associated impacts, we examined how various macro and micro-environmental factors, namely disruptions of the drug market, impacted the overdose risk of women who use drugs (WWUDs) during the pandemic. Grounded in the COVID Action Research Engagement (CARE) study among WWUD (N = 227 in Baltimore, Maryland) (August 2021 to December 2022), this analysis investigated the influence of drug market factors on nonfatal overdose risk during the first two years of the COVID-19 pandemic among study participants. We used a multivariable GEE Poisson regression clustered by enrollment location to examine environmental risk factors associated with nonfatal overdose among WWUD during the pandemic. In the clustered adjusted regression, WWUD who overdosed during the pandemic compared to those that did not were significantly more likely to report drug market changes in accessing drugs (aRR = 1.22; 95% CI = 1.04, 1.43) and in drug prices (aRR = 1.30; 95% CI = 1.26, 1.35), as well as increased drug purchasing frequency (aRR = 1.42; 95% CI = 1.03, 1.98). During the pandemic in Baltimore, WWUD's overdose risk was significantly elevated by disruptions to local drug markets. Drug checking and safer supply interventions are necessary to mitigate drug market-related risks. Future research warrants further investigation of the impact of drug market changes post-pandemic to better understand how to reach a diversity of women and assess overdose interventions among WWUD.