The Overdose Crisis and Using Alone: Perspectives of People Who Use Drugs in Rural and Semi-Urban Areas of British Columbia

Abstract

Background: A significant rise in the rate of overdose deaths in British Columbia (BC), driven by fentanyl contamination of the illicit drug supply, led to the declaration of a public health emergency in 2016. Those at greatest risk of death are people who use alone. This community-based participatory action research study based in the Fraser East region of BC study aimed to overview underlying factors that contribute to unwitnessed overdoses in semi-urban and rural settings. Methods: This descriptive study used a community-based participatory action research model with peer research associates (PRAs) involved at various research stages. In total, 22 interviews were conducted with participants aged 19 and over who used illicit drugs in the Fraser East since the start of the public health emergency in 2016. A collaborative data analysis approach was taken for data interpretation, and content analysis was performed to explore themes surrounding using alone. Results: Among people who use drugs (PWUD), using alone was found to be influenced by (a) the availability of drugs and personal funds, (b) personal safety, (c) stigma and shame, (d) protecting privacy, (e) mental health conditions and addiction, and (f) the lack of engagement with harm reduction services. At times, using alone was due to unforeseen, episode-specific situations. Conclusion: A multi-dimentional and context-specific approach is needed in overdose prevention and response for people who use drugs alone. There is need for enhanced approaches that address or include support services for families to reduce stigma and isolation of those at risk of an overdose.

Keywords:

• Using alone
• fentanyl crisis
• people who use drugs
• overdose

Introduction

In Canada, an increasingly toxic drug supply due to fentanyl and fentanyl analogue contamination has resulted in a rise of overdose fatalities across the country (Ivsins et al., 2020). A substantial proportion of overdose deaths due to fentanyl, a highly potent synthetic opioid with substantially cheaper production costs compared to heroin (Bardwell & Kerr, 2018; Frank & Pollack, 2017), along with its more potent analogues, has occurred in the province of British Columbia (BC). In April 2016, a sharp rise in the rate of opioid-related overdose deaths led to the declaration of a public health emergency in BC (Karamouzian et al., 2019; Young et al., 2015). Since 2016, BC health authorities have made significant efforts and investments to develop and implement diverse strategies to reduce fentanyl-related overdose deaths, including the rapid expansion of naloxone distribution programs, drug checking services, supervised consumption and overdose prevention sites, injectable opioid agonist treatment (Kerr et al., 2017; Strike & Watson, 2019), and overdose monitoring mobile applications (Tsang et al., 2019). These efforts led to a considerable reduction in overdose events, but since March 2020, BC has grappled with dual emergencies due to the spread of COVID-19 (Moe & Buxton, 2020). Despite previous gains from substantial public health interventions (Papamihali et al., 2020), the number of deaths since the onset of the pandemic has risen significantly (British Columbia Coroner’s Service, 2022). Between January 2020 and December 2021, there were a total of 4039 suspected illicit drug toxicity deaths in BC (British Columbia Coroner’s Service, 2022).

Consistent throughout the overdose crisis, many overdose deaths occurred in BC’s rural and semi-urban Fraser East region, with 652 recorded overdose deaths between 2016 and 2021, accounting for more than 7% of total overdose deaths in BC during this period. Between 2019 and 2022, 68.6% of overdose deaths in the Fraser Health Authority (FHA), a health service delivery region including the Fraser East, occurred in private residences. In comparison, the health service delivery region of Vancouver Coastal Health (VCH), servicing a highly urban area of BC, had 36.3% of overdose deaths occur in private residences in the same period (British Columbia Coroner’s Service, 2022). Rural and semi-urban populations, such as those in the Fraser East face particular challenges in public health overdose responses, specially related to unwitnessed overdoses in private residences.

There is a paucity of research and programming for populations in rural and semi-urban communities where the rates of unwitnessed overdose death are high, and barriers, both systemic and value-driven, to accessing recommended interventions are significant (Jozaghi & Samona, 2017; Mitra et al., 2017; Papamihali et al., 2020). Although rural and smaller urban communities have consistently high rates of overdose and fewer resources with which to address the emergency, much of the research supporting public health interventions has been generated in urban centers. These interventions, largely informed by urban social and geographic contexts, may not be appropriate for rural and semi-urban settings. In 2017, a review of opioid overdose hospitalizations in the U.S. concluded that public health research and interventions need to consider local and regional contexts (Unick & Ciccarone, 2017). Another study based in the US examining rural-urban differences in opioid use found that risk environments in rural and semi-urban environments are often characterized by economic vulnerability, the outflux of youth from rural communities, and complex social relationships (Keyes et al., 2014). Stigma and exclusion related to drug use may be amplified in smaller communities where members are more visible. Additionally, the effects of poverty combined with social and geographic isolation present in some rural communities can create a high-risk environment for death as a result of using alone (McLean, 2016). Practitioners and policy-makers must understand the local contexts within rural and semi-urban environments, examining factors such as social networks, neighborhood environments (Heavey, 2017; Tempalski & McQuie, 2009), and belief systems (Grim & Grim, 2019) in these regions.

The Fraser East is located within the Fraser Valley, colloquially considered the “Bible Belt of British Columbia” (Dart, 2012). Currently, there is no available literature uncovering attitudes related to harm reduction, or reasons for using alone in the Fraser East region. Available evidence regarding attitudes toward harm reduction and drug policies within religious communities in the United States (US) (Durantini et al., 2021) suggests that some religious communities oppose public health policies aimed to address the rural overdose crisis (Durantini et al., 2021). An illicit drug-policy survey (Durantini et al., 2021) capturing responses from 3,096 participants from 14 Appalachian and midwestern states impacted by the overdose crisis revealed: 36% supported syringe exchange services, while 52% supported punishment for illicit drug use, and 50% supported incarceration for people who use drugs (Durantini et al., 2021). Additionally, the frequency of religious service attendance was positively correlated with support for punitive policies (i.e. unfair criminalization), and negatively correlated with support for protective policies (i.e. harm reduction) (Durantini et al., 2021).

In the context of a fentanyl-contaminated drug supply, those at greatest risk of death are people who use alone, with the majority occurring in private residences (Papamihali et al., 2020). In a descriptive analysis of 827 completed illicit drug overdose investigations between 2016 and 2017, the BC Coroners Service found that 69% of decedents used their drugs alone (Coroners Service, 2017). There is a small, emerging body of qualitative research studies examining social and structural influences or mediators of using drugs alone (Bardwell et al., 2019). Available research suggests that reasons for using drugs alone include securing limited drug supply due to poverty (Bardwell et al., 2019; Moore, 2004; Winiker et al., 2020), the absence of trust among peers (Winiker et al., 2020), stigma and shame related to drug use (Bardwell et al., 2019; Bardwell & Kerr, 2018; Rhodes et al., 2007; Winiker et al., 2020), and the risk of interacting with police due to drug criminalization when using in public (Bardwell et al., 2019; Small et al., 2006).

Despite several years of emergency public health campaigns urging against the practice, why are so many people still using—and dying—alone? The current study explores participant perspectives based in the Fraser East region of BC. The study aimed to obtain a deeper understanding of the underlying risk factors that contribute to overdose deaths while using alone in the Fraser East and similar regions. While this study was conducted prior to the COVID-19 pandemic, insights gained into individual behaviors, situations and structures surrounding using alone pertain to conditions of isolation and despair further exacerbated by public health measures enacted to combat COVID-19.

Methods

The current study used a participatory action community-based research model (CB-PAR) for conducting research activities (Wilson, 2019). In 2017, our initial activities involved a community-led approach in identifying critical research priorities within the Fraser East region surrounding the overdose crisis. Alongside extensive community engagement efforts, our activities have built a strong foundation of meaningful, active, cross-sectoral peer, family, and stakeholder involvement that was crucial for understanding the practical and contextual factors that distinguish OD responses needed in smaller municipalities and surrounding rural communities. This research may also be used to contextualize administrative health data for the Fraser East region from BC’s Provincial Overdose Cohort, which contains records on all persons who have overdosed in BC, and is the largest linked database of non-fatal and fatal OD events in Canada (N = 23,181).

Members of the research team consisted of researchers from a large academic health center, peer research associates (PRAs) with lived experience of substance use, and professionals working in the Fraser East region, including municipal government and health authority staff, and frontline staff working in health and social services supporting people who use drugs. PRAs were involved at all stages of the current research study, starting with identifying the need for public health interventions to engage “hidden populations” impacted by the overdose crisis, and developing a CB-PAR oriented grant proposal with the research team. Ethics approval was provided by the UBC Providence Health Care Research Ethics Board (H18-02881).

Initially, we conducted community engagement sessions with key stakeholder groups to gain their perspectives on how best to conduct research on this topic, while consulting them on key questions to include in the research process and interview guide. The interview guide was developed by all members of the research team, including PRAs. The guide was semi-structured to capture broad themes as well as nuanced perspectives, with questions designed to elicit insights into environments and behaviors surrounding overdose and illicit drug use. We provided training to five PRAs in qualitative, semi-structured interviewing techniques and consent processes before conducting the qualitative interviews . Peer-led interviews are a well-established approach in substance use research and have been shown to create environments which are more comfortable for individuals being asked to speak about difficult and potentially stigmatizing topics (Closson et al., 2016). All five peers conducted interviews with the help of one research assistant based in the Fraser East (M.K.). Audio recordings were transcribed by an external transcription company using pseudonyms to protect the identity of participants.

Recruitment

The study employed purposive and respondent-driven sampling (Heckathorn & Cameron, 2017; Ober et al., 2016; Tuot et al., 2019) to identify and engage potential participants. Recruitment flyers were posted in service locations, cafes, bathrooms of local bars and gyms, as well as on social media platforms. Referrals were also made by community partners through word-of-mouth, and connections were established through social networks by PRAs and research team members. For participants who referred others (up to two PWUD) who fit the eligibility criteria, a $10 incentive was provided for each referral. To ensure diversity in the sample, this cap was placed on the number of indiviudals who could participate through referral from a single respondent. Eligible participants were aged 19 and over and currently using or had used illicit drugs in the rural and semi-urban Fraser East region since the beginning of the public health emergency in April 2016. Interviews were conducted at a safe location of the participant’s choice within their community, and participants were provided with $50 cash honoraria for participating in the interview. Employing the aforementioned methods yielded a total of 22 participants for data analysis.

Data collection

All interviews (n = 22) were conducted with PWUD at risk of overdose due to illicit substances. Twenty interviews were conducted by the PRAs, and two were conducted by an experienced research assistant (M.K). The interviews took place in the Fraser East region between May 2019 and November 2019. Specific locations included participant’s homes and public spaces (i.e. coffee shop, community centers). Prior to the interview, interviewers led participants through an informed consent process emphasizing privacy and confidentiality. They also collected self-reported information on participant demographics, patterns and habits of drug use, types of drugs used, and self-reported mental health histories. The hour-long interviews covered the following topics: experiences surrounding overdose occurrence, behaviors related to drug use, perceptions of risk surrounding overdose, privacy and hidden drug use, willingness to engage social networks, and experiences with and perspectives of local health services and support systems. Some questions directly asked about decisions and experiences around using alone, such as “what are some reasons for using alone?”, “what are some reasons for using alone? (i.e. personal privacy? risks? benefits?)”, and “What brought about the transition from using more socially to using primarily alone?”.

We also asked about decisions about or experiences of using alone, including social support systems, perceptions of risky use, access to and perceptions of harm reduction services (i.e. overdose prevention sites), and awareness of fentanyl in the drug supply. Interviews were audio-recorded, transcribed verbatim, and de-identified using pseudonyms.

Data analysis

Using NVivo 12, one qualitative researcher (S.F.) conducted an inductive open coding process to examine various experiences of PWUD at risk of an OD within the Fraser East. Following this initial exploratory step, three qualitative researchers (S.F., J.H., M.K.) conducted a descriptive content analysis based on a priori areas of interest surrounding using alone. These areas included reasons for using alone, harm reduction, and risky use. Queried terms included “using alone,” “perceptions of risk,” and “staying safe.” For the purpose of sense-making and presenting emerging trends to the research team, a data summary matrix inspired by framework analysis methods (Dixon-Woods, 2011) was used to visualize, organize, and consolidate data. A collaborative data analysis approach (Jennings et al., 2018) was used to engage PRAs in data interpretation, trend identification, and theme validation. Early analyses were then presented to the larger team, including PRAs, all of whom had reviewed the completed and de-identified interview transcripts, for further elaboration and refinement. This process occurred over several sense-making meetings with the research team to discuss trends emerging from the data.

Results

Participant demographics & drug use

In total, 22 participants from semi-urban and rural areas in the Fraser East were recruited into the current study (see Participant Demographics, Table 1). Ten participants were male, and 12 were female. No participants self-identified as transgender and/or non-binary. The mean participant age was 35.3 years old (range 26–54 years old) out of 18 participants who reported a birth date and age range. Most participants (n = 12) self-identified as White, and five self-identified as Indigenous. There was notable fluidity within semi-urban environments, with PWUD living in one region, and seeking services and supports in another. Participants reported using a variety of drugs including fentanyl, carfentanil, cocaine, heroin, and methamphetamines, with twelve participants reporting current use (past 6 months) of one or more of these drugs. Eighteen participants reported having experienced at least one past overdose event.

Table 1. Fraser East participant demographics.

Participants (n = 22)	Number of participants
Age
19–29	7
30–39	7
40–49	3
50–59	5
Gender
Female	12
Male	10
Ethnicity
Caucasian	12
Indigenous	5
Caucasian & indigenous	3
Other	2
Housing
Apartment	7
House	5
SRO	2
Homeless	1
Did not disclose	7
Living alone
Yes	4
No	18
Employment
Unemployed	14
Employed	8
Drug use
Current (6 months or less)	15
Last 3 Years	7

Reasons for using alone

Within varying contexts, reasons for using illicit drugs alone were often overlapping and intertwined. Notably, the quality and nature of social networks and personal relationships emerged as a particularly salient factor, appearing throughout all the themes pertaining to using alone. Drug using behaviors were based on diverse life histories and drug use trajectories, from some participants experiencing a history of homelessness in urban centers to those with a family and stable housing. As a 26-year old participant expressed:

“People need to be more supportive and open to each and every person because everybody’s addiction is different…It’s not one size fits all, everyone has a different glove.”

Overall, we found that using alone was impacted by (a) the availability of drugs and personal funds to buy them, (b) personal safety, (c) feelings of stigma and shame, (d) personal privacy, (e) mental health conditions and addiction, and (f) the lack of engagement with harm reduction services. In addition, we found that decision-making around drug use was also influenced by unforeseen and episode-specific situations.

Personal supply of drugs and funds

In several accounts, the decision to use alone was based on the availability of personal drug supply or money. Accounts highlighted the expectation to share drugs with peers when using with others and/or in public, thus using alone was more cost-effective given the high cost of drugs. When funds and/or drug supply were limited, participants who had expressed a willingness or desire to use with others chose to use alone:

“It’s really expensive for me, let alone around other people. That is true, actually it’s one of the reasons.” – 52-year old participant

Despite some accounts indicating the preference to use drugs in social settings, participants often explained that maintaining a consistent drug supply would override the desire to use with others. Having “enough” drugs or money increased the likelihood of using with peers, but this estimation varied with the intensity of addiction and one’s position within a cycle of need and fulfillment. Another factor in deciding to use with others was the complexity of intersecting with the needs of their peers, who were similarly experiencing their own “cycles” of addiction:

“Towards the end, it became, whether I had enough money. If I had enough money to share, it changed things. But as the cycle continued, and I jumped into the addiction cycle, spawning its own storms. As I’m in that cycle, I’m coming into other peoples and their own cycles.” – 30–39 year old participant

Personal safety

Decision-making surrounding drug use among peers or alone often resulted from weighing risks and benefits of each scenario. Though participants demonstrated a heightened awareness of the lethality of fentanyl-contaminated drugs, many considered the potential risk of overdose when using alone did not outweigh immediate personal safety risks when using with others. To improve their sense of safety when using alone, some participants possessed personal drug-use equipment, drug supply, and/or weapons:

“I used by myself. I always had my own personal little bag of needles, my own cookers, my own personal little injection kit. I always bought off of one person, so to me it was a safe supply. I always carried bear spray around with me, and weapons.” – 37-year old participant

Several participants expressed a notable lack of trust and strong sense of suspicion of other peers that influenced drug use behaviors. In some cases, the reliance on drugs to act as a “dependable” companion was considered safer than placing that trust in peers, despite a clear understanding of the connection between using alone and overdose fatalities. Additionally, suspicion of drug theft was often a reality as expressed by the following 50-year old participant, and identified as a potential reason for unwitnessed overdose deaths:

“You don’t form any relationships, lasting relationships, and you don’t get robbed. All your trust is that you’re going to get high. That drug really becomes your best friend. You’re always suspicious, but that just becomes a way of life. And I know so many people that were like that, and I think that’s a reason so many people die is because they’re using alone.”

Furthermore, one 51-year old participant highlighted that he felt “safer” at home compared to a community shelter where he was robbed. When he was precariously housed, there was no place to securely store personal effects:

“I’ve had my wallet stolen, well, other people have had things go missing. But I feel safe, safer than the homeless shelter. The homeless shelter I used to hide my shoes under the bed because I wasn’t sure they were going to be there in the morning when I woke up. Slept with everything under my pillow.”

Feeling shame and stigma

Shame and stigma drove several participants to use alone, as described by a 28-year old participant:

“Because I’m ashamed of it, yeah the stigma of it, people think when you’re using hard-core drugs that you’re just like, I don’t know, a piece of crap.”

Keeping drug use private mitigated the shame that was often present due to fear of judgment from others, particularly family members. Using alone helped separate drug use from other aspects of life, both public and private, keeping participants hidden in ways that felt safer. Notably, shame was often felt and expressed within a family system; several participants highlighted the active presence of family members in their lives who were considered support systems during times of struggle. In many cases, participants hid their drug use from immediate family members, some of whom were more attuned to behavioral changes from drug use:

“It was a shame factor. To me, addiction is a very shameful thing, so I wanted to keep it hidden. I wanted to use by myself so I could keep it hidden. Sometimes it was hard to tell people that I was high, sometimes it wasn’t. All depending on the drug or the person. Like my Dad, he could tell right away. I would use by myself because I didn’t want anyone to know. Who wants to watch someone tie themselves off and shoot dope in their arm?” – 37-year old participant

In rural and semi-urban contexts, community services are provided for PWUD living in small, close-knit communities. In some cases, shame would pose as a barrier to accessing such services due to the potential of exposure as a drug user that could result in a loss of standing in the community:

“Maybe felt shame, and didn’t want to be seen. I know people that know a lot of people that work in the community. The outreach community. I didn’t want to be around it or it getting back to people. I stayed away from it.” – 30-year old participant

Protection of privacy

In a context of shame and stigma, participants expressed the need to protect their privacy and personal vulnerability. Using alone was considered a more comfortable and perceivably safer option, particularly when coping with grief, trauma, or addiction itself:

“I didn’t like the feeling of being on display. I felt a bit like a zoo animal when I was homeless and going through my thing. You know, mourning my parents’ death, dealing with being homeless, dealing with drug use and just not having any space to go and have private thoughts or anything, it felt like when I was crying it was always on display or this, that. That lack of privacy has made me seek it out even more, you know, the privacy…” – 30-year old participant

Participants also described the need to hide behavioral changes surrounding drug use, where privacy protected their intense feelings of vulnerability:

“I just can’t stand myself… and I become very paranoid when I take cocaine as well. I take it to the point that I’m getting paranoid. I can’t be around people. Call it psychosis, call it what you want.” – 51-year old participant

Mental health & addiction

Depression and other mental health issues were significant factors contributing to addiction, which often became a leading driver of isolation. The absence of social support networks available, including peer networks using in semi-urban and rural settings, further contributed to the trajectory of depression, increased drug use, isolation, and using alone:

“I don’t know. I was extremely depressed and I wanted to, like, die, like I was suicidal, I think. I don’t know. I was alone and I was really lonely. I was isolated I think and I feel like if I had more support and people around me I probably wouldn’t have been in that dark headspace.” – 28-year old participant

Many participants became increasingly isolated as their addiction progressed, resulting in the erosion of relationships with family members and close friends:

“Loss of relationships, loss of personal friends. Becoming an outcast. Becoming an isolated person. I became isolated, I started using by myself. I’ve used by myself for 20 years. I don’t use around anybody now.”– 50–59 year old participant

In some cases, participants found relief from mental distress and drug dependence through establishing a stronger connection to faith. In the following account, “turning to God” helped the 37- year old participant establish a greater purpose in life:

“When I go through my trauma or crisis, losing a marriage or whatever, if I don’t turn to God, I turn to my substance. I can fairly say, and I can wholeheartedly say, if it wasn’t for God I wouldn’t have purpose and move forward in my steps.”

Lack of engagement in harm reduction services

Overall, participants did not report barriers to accessing harm reduction services (i.e. overdose prevention sites (OPS) and/or safe supplies) as a predominant reason to use alone, despite using in rural and semi-urban areas where fewer harm reduction services are available compared to urban areas. In a few cases, transportation issues and limited operating times were mentioned as explanations for not seeking harm reduction services. Though many participants recognized the value of harm reduction for reducing risks associated with drug use, for some, the need for privacy and feelings of shame were undercurrents for the lack of engagement in harm reduction services. As illustrated by a 25-year old participant, “[the] barrier is my own privacy…feeling like I was too above that.” In another case, when asked about accessing harm reduction services, a 26-year old participant responded: “I have not. Only for the simple fact that I don’t like people knowing I use.”

Unforeseen, Episode-Specific situations

Some participants were willing to use drugs with others, and their choices around how using was often unplanned. In these cases, using alone was less driven by intentional behavior compared to immediate and unplanned factors, such as the intensity of physical need or the happenstance nature of the social setting:

“It doesn’t really matter. It just depends on where I am and who has what. Like a couple days ago, I was at this guy’s house who I was seeing and everyone was smoking crack. I was like, okay, I’ll smoke crack. It all depends on who has money, and what it is.” – 27-year old participant

Among participants who preferred using with others, drug use was often described as more enjoyable in social situations, particularly in the company of friends, as indicated by a 30-year old participant:

“It depends on the quality of the people I’m around. If I have good friends who I really feel in touch with maybe I’d use with them or feel more kindred.”

The experience of craving and withdrawal also influenced drug use decisions. One participant highlighted the sense of urgency to consume drugs immediately after acquiring them as an important factor in his decision-making:

“My whole point of using was I wanted to get high, but I didn’t want to be sick. If I’m going to meet my drug dealer, I’m going to go off and use right away. I’m not going to wait, go find someone and ask them to watch me. The only thing you want is to get that stuff inside of you.” – 26-year old participant

Discussion

This study explored perspectives of individuals at risk of an overdose and situations giving rise to using drugs alone. The findings captured diverse accounts of those living in rural and semi-urban communities presenting with complex reasons for using drugs alone, occurring at various time points along a drug use trajectory. Reasons for using drugs alone reflected personal, social, and structural circumstances, as well as past and present experiences and beliefs, which in turn influenced how participants navigate risk environments (Boyd et al., 2018; Collins et al., 2019; Rhodes, 2009). At all points, social networks and relationships emerged as a particularly salient factor influencing drug use behaviors.

Despite a heightened awareness and knowledge of fentanyl contamination, many participants continued to use alone. This finding is accompanied by a rising incidence of PWUD in BC knowingly using fentanyl (Papamihali et al., 2020). How people choose to use drugs often becomes primarily a matter of personal resources (Bardwell et al., 2019; Moore, 2004; Winiker et al., 2020). Previous studies indicate that there is social expectation for PWUD to share drugs when used in the presence of others (Papamihali et al., 2020), and using alone is preferred among people who inject drugs (Winiker et al., 2020), particularly those experiencing homelessness with limited resources to conserve personal supply (Papamihali et al., 2020; Winiker et al., 2020). The current study found a similar attitude among participants, who reported that financial considerations would take precedence over other inducements to use with others. The high cost of drugs, as expressed by several participants, made it difficult for those experiencing addiction to maintain a consistent drug supply. This further highlights the urgency of developing adequate systems to facilitate the provision of accessible, safe supply. Ivsins et al. (2020) suggest that a safer alternative to the toxic drug supply would resolve the limitations of current overdose response measures and reduce the incidence of overdose events (Ivsins et al., 2020). In B.C., there has also been some, albeit limited, progress toward decriminalization: effective January 31^st, 2023, B.C. will decriminalize small-scale possession of illicit drugs (Paas-Lang, 2022).

However, it is necessary to consider the multiple barriers and difficulties involved with providing a safe supply, including opposition supporting efforts toward addiction treatment rather than harm reduction, and complex bureaucratic issues surrounding the regulation of controlled drugs and substances (Tyndall, 2020). Due to significant resource and capacity limitations, implementing and scaling up of harm reduction interventions is particularly challenging in rural settings (Ivsins et al., 2020).

The navigation of risks related to drug use behaviors also incorporated social risks involving threats to personal safety. A study of young people who inject drugs by Winiker et al. (2020) describes the social environment of drug use as often unpredictable and sometimes dangerous; social networks are often interrupted by entry into treatment or housing programs, incarceration, or overdose death, and participants described dangers and betrayals among peers (Winiker et al., 2020). Participants in this study described this risk environment in various capacities. While some participants spoke of social bonding that can occur upon shared use, many preferred to use alone, regardless of circumstances. Participants expressed a fear of theft or assault, and some considered the drug itself as a more comforting and reliable “companion.” Findings in this study reinforced the difficult public health quandary that, for various complex reasons, using alone often feels the safest for people who use drugs.

Stigma, shame, and embarrassment have been highlighted in the literature as contributing factors to solo drug use among PWUD (Bardwell et al., 2019; Papamihali et al., 2020; Winiker et al., 2020). This was a particularly salient reason for using alone among participants in the current study. Significantly, shame experienced within family and social systems led to using alone despite the heightened awareness of risks. While family members were sometimes described as important sources of support, participants often experienced shame in relation to their family members or loved ones. While multiple competing risks and risk environments are noted above, the interplay of shame and family support systems are perhaps the most prominent. When drug use behavior is driven by complex factors of shame, stigma, discrimination and criminalization, public health advice may be inadequate to prevent unwitnessed overdoses from PWUD using alone. While the harm reduction approach comes from a philosophical perspective of non-judgment (Carlberg-Racich, 2016) that should mitigate shame, family and loved ones are highly influential in this regard, and current efforts to address stigma and increase understanding may be insufficient. Recognizing the prominent role of stigma in contributing to the hiddenness of illicit substance use, BC’s Ministry of Mental Health and Addiction implemented a widespread anti-stigma campaign highlighting the presence of drug use across multiple demographics after the onset of the overdose public health emergency (Government of British Columbia, 2019). Little is known, however, about the efficacy of anti-stigma public health messaging with family members who themselves might be experiencing harms from their loved one’s substance use and whose approaches and responses most certainly impact their loved one’s drug use behaviors, particularly using alone.

In literature based across predominantly urban settings (Papamihali et al., 2020), privacy sought through choosing a hidden environment for drug use has been highlighted as a form of protection from law enforcement and potential street violence (Papamihali et al., 2020; Small et al., 2012). Among people experiencing homelessness, issues such as harassment, criminalization, stigma, and discrimination may be mitigated by using in secluded or hidden spaces (Bardwell et al., 2018; Cooper et al., 2005; Papamihali et al., 2020; Rhodes, 2002; Rhodes et al., 2006; Winiker et al., 2020). Notably, most participants of this study did not mention police presence as a reason to use alone in the Fraser East region.

Our findings also revealed a highly complex interplay between feelings of shame, social or family systems, mental health issues, social isolation, personal drug use trajectory, and using alone. In particular, depression led to increased drug use which led to further isolation and using alone. This presents additional challenges in the context of the COVID-19 pandemic. COVID-19 has resulted in globally widespread loss of life, unemployment, and social isolation that ultimately negatively impact mental health (Kawohl & Nordt, 2020). The results of this study should be considered within the context of the overdose crisis prior to the COVID-19 pandemic; however, learnings are particularly relevant during the pandemic due to associated stressors such as social isolation, depression and loss of employment.

Future research

Due to the heightened awareness of fentanyl contamination of the drug supply among PWUD clearly demonstrated in this study and others (Karamouzian et al., 2020), educational campaigns might have limited value outside of reaching those whose solo drug use reflects the variable nature of drug use opportunities and relationships with others. Currently, public health messaging emphasizes the importance of using with others to ensure safe drug consumption (Winiker et al., 2020); however, for many, particularly marginalized groups and those who mistrust peers, such messaging is ineffective due to risks associated with public and/or social drug consumption unrelated to the risk of OD while using alone. For example, risk environments where predatory violence is more likely to occur when using drugs in public spaces are especially prominent among Indigenous women (Boyd et al., 2018).

While some participants in this study identified various barriers to accessing harm reduction services, notably, no participants identified these or other barriers to accessing harm reduction services as a reason for their solo use. The study by Papamihali et al. (2020) further demonstrates that PWUD are choosing to use alone despite also using harm reduction services. With the presence of effective and expanding strategies such as naloxone kit distribution (Irvine et al., 2019; Keane et al., 2018; Thomson et al., 2017), overdose prevention sites (Irvine et al., 2019; Thomson et al., 2017), and supervised consumption sites (Caulkins et al., 2019), differing or conflicting motivations and risk navigation of PWUD clearly presents a need for additional insight. Despite accessing such harm reduction services, there is a phenomenon of PWUD choosing to use alone; this ought to be further explored in order to effectively address the issue of PWUD using and dying alone.

The link between illicit substance use and the various conflicting motivations present in social bonds, including their potential to engender or interrupt isolation, is underrepresented in the literature. Given the prominence of the interrelated themes of shame and social contexts, future research should examine interventions and approaches that address or include support for families to reduce stigma and isolation of PWUD, or community-based interventions that encourage disclosure and promote acceptance of people who use drugs. This may be even more significant within some cultural (Fraser Health Authority: Chief Medical Health Officer’s Report, 2019) or rural contexts (Thomas et al., 2019). Additionally, the presence of religious communities in the Fraser East may offer opportunity for non-judgmental, faith-based interventions and support, particularly for substance affected individuals experiencing mental health challenges (Costello et al., 2021).

Conclusion

Overdose prevention and response strategies implemented in the Fraser East region of B.C. should be multi-dimensional while responding to unique challenges faced by PWUD using alone in private residences. Specifically, public health interventions in the Fraser East region should consider the complexity of family systems, and other social bonds that influence drug use decision-making among PWUD.

Acknowledgements

We are thankful for the assistance, support, and tremendous insight of our study collaborators and research team. We would especially like to thank Connie Long, Dr. Andrew Larder, Dr. Amanda Slaunwhite, Dr. Alexandra Choi, and Dr. Allyshia Van Tol for their important contributions to this study at various stages.

Data availability

Data was collected and managed in concordance with the UBC Research and Providence Health Care Ethics Boards, which do not permit access to this data. Requests to access data for secondary analysis may be submitted to the corresponding author upon reasonable request.

Disclosure statement

There is no conflict of interest to disclose.

Additional information

Funding

This work was supported by the Vancouver Foundation and the Canadian Institutes of Health Research.