‘It just doesn't stop’: Perspectives of women who use drugs on increased overdoses during the COVID‐19 pandemic

Abstract

Introduction

In Canada, the COVID‐19 pandemic collided with an ongoing overdose crisis driven by a toxic unregulated drug supply. Public health guidance intended to limit transmission of COVID‐19 (e.g., social distancing) directly contradicted guidance responding to the ongoing overdose crisis (e.g., never use drugs alone), exacerbating harms among people reliant on the toxic unregulated drug supply. While existing literature characterises many harms associated with consuming unregulated drugs during COVID‐19, less is known about the specific impacts on women. We explored the perspectives of women who use unregulated drugs and experienced socio‐economic marginalisation on how the COVID‐19 environment shaped their overdose risk in British Columbia, Canada.

Methods

We conducted semi‐structured interviews remotely with 45 participants between May 2020 and September 2021, and analysed the data thematically using a social violence framework.

Results

Participants identified contamination of the unregulated drug supply, particularly with benzodiazepines, as a significant driver of overdose and gendered violence among women who use drugs. ‘Social distancing’ guidelines (e.g., guest restrictions in supportive housing, reduced capacity in harm reduction services) compounded these risks and resulted in more women using drugs alone, reducing opportunities for timely overdose intervention. In response, participants practiced individualised acts of caregiving (e.g., establishing informal networks that regularly check on each other) to mitigate the risks of overdose and gendered violence for themselves and their community.

Discussion and Conclusions

These intersecting health crises perpetuated individualised approaches to addressing the risks of overdose and gendered violence, rather than addressing underlying social and structural drivers of these risks.

Key points.

• The collision of the COVID‐19 pandemic and the drug toxicity and overdose crisis positioned people who use drugs at the nexus of conflicting public health guidelines.

• Escalating contamination of the unregulated drug supply and social distancing guidelines leading to solitary drug use increased risks of overdose and gendered violence during COVID‐19.

• The elevated risk of gendered violence (particularly sexual assault) and disruption of informal safety networks amplified risks among women who use drugs.

• Rather than addressing the underlying social and structural drivers of overdose and gendered violence, these intersecting health crises perpetuated individualised approaches to risk reduction.

1. INTRODUCTION

In 2020 and 2021, people who use unregulated drugs (PWUD) in Canada were simultaneously exposed to risks associated with two public health emergencies: COVID‐19 and overdoses as a result of an increasingly toxic unregulated drug supply—where ‘unregulated drugs’ refer to drugs of unknown potency and composition, which are increasingly contaminated by fentanyl and its analogues, benzodiazepines or other substances that can harm the consumer [1, 2]. The collision of these two crises positioned PWUD at the nexus of conflicting public health guidelines; COVID‐19 infection prevention and control guidelines prioritised ‘social distancing’, while the drug toxicity and overdose crisis (hereafter referred to as the ‘overdose crisis’) prioritised prompt overdose reversal by ‘never using drugs alone’. The prioritisation of COVID‐19 responses, and simultaneous consideration of overdose risk as a lower priority, largely resulted in neglect of the combined impacts of the dual public health crises at the policy level and perpetuated health inequities among marginalised populations [3]. For PWUD, this operationalised as a lack of guidance on balancing the competing risks associated with these crises, during a period of intensifying social and structural harm (e.g., poverty, food insecurity). Decreased access to essential health and social services (including harm reduction services; e.g., supervised consumption services/overdose prevention sites), increased frequency of people using drugs alone, and amplification of the toxicity and unpredictability of the unregulated drug supply have been consistently identified as increasing overdose risk during the COVID‐19 pandemic [4, 5, 6]. Indeed, the number of opioid toxicity deaths in Canada increased from 3721 in 2019 to 6398 in 2020, and has continued to increase almost every year since [7].

These harms were further exacerbated for the diverse population of women who use drugs (WWUD; including transgender women and gender‐diverse individuals), as public health guidelines were often implemented without consideration of their unique needs (e.g., childcare, violence and culturally informed care) [8]. A social violence framework is useful for situating the experiences of WWUD within the socio‐structural contexts that shape their day‐to‐day lives. Social violence integrates structural violence (e.g., drug criminalisation, patriarchy, colonialism, racism, classism and their intersections) [9], symbolic violence (e.g., internalisation of socio‐structural marginalisation as an individual failure) [10] and everyday violence (e.g., interpersonal harm/violence experienced as a normal and expected aspect of life) [11]. For example, WWUD have previously reported that harm reduction services designed to be ‘gender‐neutral’ (i.e., without attention to the unique needs of WWUD) [8] increase their risk of racialised and gender‐based violence [12, 13, 14, 15], which in turn acts as a barrier to these services [16]. Here, structural violence stemming from drug criminalisation (i.e., increased overdose risk associated with consuming drugs from the toxic unregulated drug supply; hidden drug consumption to avoid criminal sanctions) and patriarchy (i.e., positioning women and gender‐diverse individuals in subordinate roles relative to men) act to encourage access to harm reduction services as a strategy to reduce the risk of fatal overdose, while simultaneously subjecting WWUD to situations of physical and sexual vulnerability (due to co‐location with men while using these services). Social violence therefore provides a particularly useful framework to assess responses to these dual public health crises and their impacts among WWUD, by focusing attention on the socio‐structural factors shaping their experiences.

Specifically, this study sought to explore the perspectives of diverse WWUD on the policies and practices that shaped their overdose risk during the COVID‐19 pandemic through a social violence lens. While men who use drugs have experienced devastating levels of overdose deaths, overdose deaths among women in British Columbia (BC) have continued to rise year after year [17]. Therefore, this study aims to draw attention to the importance of incorporating critical gender‐based analyses when designing, implementing and assessing strategies shaping overdose risk.

2. METHODS

This study was conducted in BC, the Canadian province with the highest rate of unregulated drug toxicity deaths during the study period [7]. Recruitment materials were posted in community‐based harm reduction and health services across BC, resulting in 45 semi‐structured interviews conducted by the senior author and a graduate research assistant over the phone between May 2020 and September 2021. Study eligibility was limited to individuals who: (i) identified as a woman (including cisgender and transgender women) or gender‐diverse individual; (ii) were at least 18 years old; and (iii) used criminalised drugs in BC. While not an inclusion criterion, all participants reported experiencing socio‐economic marginalisation (e.g., poverty, incarceration, housing precarity).

The senior author developed a draft interview guide, informed by her ongoing community‐engaged research program (focusing on WWUD's experiences of overdose and engagement in harm reduction) [16, 18] and the research priorities of several community groups of WWUD. The draft guide was reviewed by each community group, as well as members of our research team with lived/living expertise of drug use. The final interview guide was used to facilitate discussion and explore participant perspectives on: (i) diverse experiences of substance use and overdose risk; (ii) gendered access and barriers to existing and emerging harm reduction interventions; and (iii) perceptions of the intersections of the overdose crisis and COVID‐19. Each participant provided verbal informed consent prior to the interview, and received a $40 honorarium by e‐transfer, bank transfer or cash (picked up at our research office or partnering community organisation). Interviews averaged 45 min in length and were audio‐recorded and transcribed prior to analysis. This study was approved by the University of British Columbia/Providence Health Care Research Ethics Board.

Transcripts were de‐identified and participants were assigned pseudonyms to protect their confidentiality. The data were imported into NVivo (a qualitative data management program) and analysed thematically by using both deductive (pre‐identified themes; e.g., restrictions to service access during the COVID‐19 pandemic) and inductive (emergent themes; e.g., increased overdose risk and reliance on informal networks of care) approaches [19]. This analysis applies a social violence framework to facilitate concerted attention to the roles of structural, symbolic and everyday violence when exploring the impacts of the dual public health crises on overdose risk among WWUD [9, 10, 11]. As critical and feminist drug researchers have called for drug policy discourse that incorporates critical gender‐based analyses that identify and address the socio‐structural factors shaping harm for this population while simultaneously recognising their agency [20, 21], this study also sought to emphasise the strength and resilience of WWUD in response to the dual public health crises.

3. RESULTS

Most participants (n = 44) identified as women and the average age of participants was 48 years old. The majority of participants had not experienced homelessness in the previous year (n = 38); however, many lived in precarious or substandard housing such as single‐room occupancy hotels (SRO). Approximately half of the participants reported previous incarceration (n = 26), half identified as White (n = 26) and half identified as Indigenous (First Nations, Inuit and Métis; n = 21). Participants most commonly reported crystal methamphetamine (n = 19), heroin (n = 16), fentanyl (n = 15) and crack cocaine (n = 15) as their drugs of choice in the month preceding the interview. Approximately half reported experiencing at least one overdose in the past year (n = 24). Table 1 summarises the key demographic and drug use characteristics of study participants.

TABLE 1.

Demographic and drug use characteristics of participants (n = 45).

Characteristics a , b	n (%) or mean (range)
Age, years	48 (28–70)
Gender
Woman	42 (93.3)
Transgender	2 (4.4)
Non‐binary	1 (2.2)
Race/ethnicity
White	26 (57.8)
Indigenous	21 (46.7)
Black/African Canadian	1 (2.2)
Middle Eastern	1 (2.2)
Latin American	1 (2.2)
Previously incarcerated (in jail or holding facility)
Ever	26 (57.8)
No	12 (26.7)
Missing	2 (4.4)
Experienced homelessness in year before interview
Yes	7 (15.6)
No	38 (84.4)
Drug of choice in 30 days before interview
Cocaine (powder)	13 (28.9)
Crack cocaine (rock)	15 (33.3)
Heroin (down)	16 (35.6)
Fentanyl	15 (33.3)
Dilaudid (hydromorphone)	8 (17.8)
Other opiates (extra‐medical)	3 (6.7)
Crystal methamphetamine (jib)	19 (42.2)
Speedball	3 (6.7)
Alcohol	9 (20.0)
Other	6 (13.3)
Method of consumption in 30 days before interview
Inject	22 (48.9)
Smoke/inhale	31 (68.9)
Snort	4 (8.9)
Ingest/swallow	7 (15.6)
Missing/not applicable	6 (13.3)
Number of overdoses experienced in year before interview
1	12 (26.7)
2	7 (15.6)
3 or more	5 (11.1)
None	21 (46.7)
Location of overdose
Home (in suite)	9 (20.0)
Friend's place	1 (2.2)
Overdose prevention site	4 (8.9)
Unsanctioned supervised injection site	1 (2.2)
Outside/public	5 (11.1)
Other	5 (11.1)
Not applicable	20 (44.4)

^a Responses may be higher than 100% as some participants identified with more than one category for some characteristics.

^b All characteristics are based on self‐reported data from participants.

During the COVID‐19 pandemic, the structural violence imposed through drug criminalisation (i.e., escalating toxicity of the unregulated drug supply) led to increased experiences of everyday violence among participants, including overdoses and gendered violence. Indeed, participants discussed frequently learning that another loved one, friend or community member had died as a consequence of this structural violence:

‘A lot of my friends, or a lot of people I know are dying […]. And they're young … some are young. And, like, almost every day I hear about someone dying and it's sad. At least once a week anyway.’ (‘Brooke’)

Similarly, ‘Rebekah’ referenced the unrelenting nature of this experience, stating, ‘it just doesn't stop.’ According to participants, the two primary factors driving increased overdose risk during COVID‐19 were: (i) changes in the unregulated drug supply; and (ii) increased frequency of women using drugs alone. In response, participants identified the individualised responses they practiced to mitigate harm for themselves and their communities in the absence of broader policy support.

3.1. ‘I think the drug supply has gotten worse’: Increased contamination of the unregulated drug supply and gendered violence

While some participants reported no changes in the unregulated drug supply throughout the COVID‐19 pandemic, others reported intensifying contamination that paradoxically increased and decreased the potency of available drugs. For example, when asked whether she noticed a change in the drugs available in the street‐based drug scene since the onset of COVID‐19, ‘Roxanne’ described the escalation of overdoses as resulting from the increased potency of available drugs:

‘Yeah, there has definitely been, there have been more illicit drugs that have been circulating and there has been so many overdoses, it's crazy. I think people are using more too, like I don't really know. It has been a really hard year for people and I think the drug supply has gotten worse. [….] I think there is stronger fentanyl been coming out, oh for sure. [….] There has been a lot of overdoses.’

‘Anjali’ specifically identified the widespread contamination of ‘down’ (commonly used to refer to heroin, fentanyl, or unspecified opioids) with benzodiazepines (‘benzos’) as increasing the potency of available drugs:

‘Yes, actually, there is not as safe drugs available and a lot of the drugs are turning into like benzos and stuff, I don't know. A lot of drugs are laced with whatever people can put into them now and they're not real.’

Indeed, benzodiazepine contamination and its inadvertent consumption were substantial concerns among participants. As central nervous system depressants, concurrent benzodiazepine and opioid (colloquially referred to as ‘benzo‐dope’) consumption often results in complex overdose presentations, reduced effectiveness of naloxone (an opioid antagonist used to reverse opioid‐related overdoses) and extended periods of sedation. ‘Tatiana’ identified the increase in benzodiazepine contamination as ‘scary,’ and described the fear she felt about experiencing a fatal overdose or ‘blackout’ period due to ‘benzo‐dope’ consumption:

‘And that's new and that's COVID, mostly it's the drug supply out there that's caused this because I'm scared now. I've never, never had a reaction before and now every time there's something a bit strange when I use and it scares me because I don't want to drop dead as a result of the drugs. […] I don't know what it is that made it, I just cannot take those drugs anymore. I don't know what this 6, 7 hour later thing is so I'm afraid of the drugs now. You know, I'm afraid to. So I just, yeah, because you know it's almost like going into a blackout alcoholic state. One minute you are completely aware and then all of a sudden you're somewhere else and you have no idea what happened or why you're there. You know all of a sudden you kind of float back to earth and it's like you're on the ground or somebody's putting a cold compress on the lump on the back of your head. That's kind of scary.’

As ‘Tatiana’ illustrates, the contamination of the unregulated drug supply with benzodiazepines—sedatives that are commonly associated with date rape (i.e., drug‐facilitated sexual assault) [22]—has additional implications for WWUD beyond the increased risks of fatal overdose. Indeed, the blackout periods ‘Tatiana’ described were identified as periods of exacerbated violence, as women are at elevated risk of assault—particularly sexual assault—while experiencing unexpected heightened intoxication or during an overdose. For example, ‘Roxanne’ recounted her experiences of assault while experiencing extreme intoxication, which she associated with her identity as a woman:

‘I've had experiences with assault when I was too high. I had experiences with sexual assaults. I've had experiences with emotional stuff, manipulation, like predatory, like things like that. For example, as a woman, I can give you an example, like there was this one day I was accessing an injection site and I met this guy, I was just too high, and yeah he ended up assaulting me. It was really bad. It was not a good situation. For no reason. It was crazy. Women can get pregnant too, that's another thing.’

For participants, given the increased risk of sexual assault associated with ‘benzo‐dope’ consumption, the contamination of the unregulated drug supply during the COVID‐19 pandemic contributed additional considerations when balancing the relative risks associated with each public health crisis.

Another form of contamination emphasised by some participants was the addition of hazardous contaminants that decreased the purity of drugs: ‘[…] like I found someone selling gabapentin when I was doing drug checking and I found somebody selling like drywall dust, just like people selling whatever they could just to get, and somebody sold me powdered milk and kitchen spices […]’ (‘Scarlett’). While not directly influencing overdose risk, the adulteration of the unregulated drug supply with contaminants that are nonetheless hazardous to human health (e.g., drywall dust) contributed to a drug supply that was described by ‘Halima’ as ‘just like garbage, it's not even dope.’ Indeed, ‘Tatiana’ described the increased presence of severe skin wounds as likely resulting from contaminants (e.g., xylazine, a veterinary tranquiliser increasingly identified in the unregulated drug supply [23]):

‘Oh God it's just so horrible down there now. I have gone down Hastings [main street in Vancouver's local drug scene] my whole life. […] It's a hell zone down here now. And it is, you know, when I look at the people my heart is just, I get sad, it's very sad cause I'm looking at all these people that are significantly younger than me, you know, covered in oozing sores. It's just to me is like so horrible. It's such a, you look at people and the rate that we're dying it's just, it almost feels like genocide to me. And some people think you're being paranoid or whatever but there's a whole bunch of us feel like this is almost deliberate this drug supply the way it is. Poison, you're giving us poison, right?’

‘Tatiana's’ portrayal of the contaminated drug supply as akin to ‘genocide’ highlights her perception of government inaction to address the increasing contamination of the unregulated drug supply as a deliberate act to harm those stigmatised as socially ‘undesirable’ (e.g., ‘drug users,’ those experiencing housing/income insecurity), which is normalised as a form of symbolic violence.

3.2. ‘This isolation thing has been really bad’: increased frequency of women using drugs alone

Participants discussed how ‘social distancing’ guidelines resulted in more women using drugs alone with less chance of timely overdose intervention. For example, participants reported constrained access to harm reduction services (e.g., supervised consumption services) due to service closures, reductions in capacity, shifts away from in‐person engagement and inconsistent service hours as a result of these guidelines. ‘Aaliyah’ described how the abrupt removal of outreach services at her community‐run organisation resulted in numerous fatal overdoses among service members:

Aaliyah: ‘Oh actually we had to stop doing outreach for a while. We weren't allowed so it was really worrisome to know what was happening with our members. Where they were getting their stuff and all of that so, people were really worried people were using alone. Yeah, so we lost a lot of members so we were trying to prevent that as much as we could.’

Interviewer: ‘And when you say you lost a lot of members, was it mostly due to overdose?’

Aaliyah: ‘Oh yes. Mostly, yeah. I'd say 99 percent.’

Indeed, ‘Anjali’ reported that the number of fatal overdoses within her community was so significant after the reduction in monitored spaces to consume unregulated drugs that the social distancing guidelines of her service were relaxed to re‐prioritise overdose responses:

‘At first, we weren't allowed to open our facilities and we were just handing out supplies through the doorway and then all the people overdosing and then we kind of got to keep our place open.’

Changes in overdose response procedures to comply with public health orders exacerbated capacity restrictions by further reducing the availability of monitored consumption spaces:

‘[T]he interventions that we were used to using like hands‐on interventions and oxygen and things like that. We had to completely change all of the ways of running [overdose prevention sites] […]. There were a lot of times where we didn't know what to do and there were times when COVID first started, if somebody had an overdose and we had to use oxygen on them, we had to shut the whole site down for half an hour because of aerosolised particles and all this stuff.’ (‘Scarlett’)

As described by ‘Aaliyah’, the reduced capacity at supervised consumption services/overdose prevention sites forced many people to use their drugs elsewhere, including in public or at home. However, for women living in SROs and supportive housing environments, participants reported that pandemic policies limiting guest access to tenant units substantially restricted the opportunity for timely overdose response when using at home:

‘I would say the guest rules, […] that would be [the] kind of rule that they [housing administration] would need to change […] Because most of the people I've known died by themselves and they could have been saved if they had somebody with them. That's just a really sad factor.’ (‘Anjali’)

In balancing the competing priorities of timely overdose response with avoiding experiences of violence, WWUD commonly prioritised protecting themselves from gender‐based violence [16]. Indeed, respondents in our study noted that they commonly relied on trusted peer‐based networks to keep each other safe prior to the COVID‐19 pandemic (rather than formal harm reduction services). For example, ‘Brianna’ explained that women were often encouraged to use their drugs with ‘a buddy’ or ‘a friend’ to reduce their risk of violence:

‘We are treated way differently [than men] after we use. When we can't function, I've been beaten and raped. [….] I didn't wait long enough before I went outside. I am supposed to wait at least 10 or 15 minutes after I do my toke before I go out, and if you're still high you can't function very well and you don't know your surroundings; that's how I've got raped three times. I train more women now and make sure that you use with a buddy or use with a friend.’

However, the implementation of social distancing guidelines in SROs and supportive housing environments disrupted these safety systems—which were developed in response to the normalised gendered violence and death experienced in the day‐to‐day lives of WWUD (everyday violence)—and led to more women using their drugs alone:

‘[B]ecause of the way that the no guest policies and no, like you can't go into each other's rooms, people have been dying alone in their rooms because they don't want to wait, they don't have a phone to use the Lifeguard app, they maybe don't want the staff to know that they're using or they just don't seem to call down, or they don't want to be intruded upon or whatever if they just forget to call back down in five minutes or whatever. So the peer based systems that have been set up informally among people that are tenants in the SROs, have been broken by the COVID rules, so people are using alone and they're fucking dying in greater numbers than we've ever seen before.’ (‘Scarlett’)

3.3. ‘There's always women that go out and take care of people’: Mitigating harms from colliding crises

Community‐level strategies to support and care for each other were common among WWUD. For example, ‘Sophia’ discussed how she navigated conflicting public health guidelines to ensure her relative safety while continuing to care for her community:

‘I wear two masks when I go to places where I shoot up. And I do that at work and when I'm interacting with anybody at the window or out on the street, or doing outreach work, I wear two masks for my own wellbeing.’

Here, ‘Sophia’ demonstrated her commitment to caring for her community by integrating safety measures for both crises (i.e., wearing masks to reduce the risk of COVID‐19 transmission while conducting outreach activities and providing harm reduction supplies to prevent harms associated with the overdose crisis). Similarly, ‘Autumn’ assessed the relative risk posed by each of these two public health crises and, in this case, prioritised overdose prevention over guest restrictions:

‘[…] so I've been here for almost five years and my landlord gave me crap because I had too many people over she said during COVID. There was like four of us here but we didn't want to, if somebody's gonna use I don't want them to use alone, right, and we don't have a safe consumption [site]. So if somebody wants to come here and like just be safe then come over, I don't care. I'll watch them, right, like it's fine, you know. I'm like we wash our hands, we follow all the protocol. It's not like we're complete morons, you know. But I'm not gonna isolate and die alone. Sorry, I'm not doing it.’

‘Autumn’ indicated that she did not completely disregard COVID‐19 safety protocols, but balanced the relative risks of each crisis by integrating safety strategies for both crises together, with a view towards the overall health of herself and her friends.

Some participants discussed care practices that aim to support health more holistically. For example, ‘Aaliyah’ described a safety strategy commonly established among WWUD:

‘Even if I'm not working I like to go out just so I can see the members. And see if people are okay because when you have somebody missing we all ask for them, ‘have you seen so and so’ and we all look out for each other.’

By watching out for each other, participants explained that women in these informal networks established support systems and tended to develop strong emotional connections with each other:

‘Yeah, like I walk to work so it's about six blocks so I usually see the same members and that's how we kind of keep an eye on each other, and if we don't see somebody for like two days, you know, we start asking around, so it's like a family circle. It's our way of taking care of one another. But we've also lost a lot of members since COVID, like even before COVID too, but since COVID started it was like every other day at least one to three members we were losing, that have died either as a result of COVID or another health condition, but it meant a lot and it's really hard because they're friends of mine and I consider them family, so it's tough.’ (‘Leyla’)

As evidenced by the range of care activities discussed among participants, WWUD commonly do what they can to support their fellow community members in light of failed policies that leave gaps in the provision of socio‐structural supports. Despite the risks associated with actively providing care to community members in the midst of intersecting crises, participants framed these practices as strategies they employed to protect their community from harm:

‘I mean it could be the middle of a war, and, yes, it's safer to stay home, but there's always women that go out and take care of people.’ (‘Phoebe’)

4. DISCUSSION

In this study, participants identified escalating contamination of the unregulated drug supply and social distancing guidelines leading to solitary drug use—components of structural violence—as increasing their risk of overdose and gendered violence during the COVID‐19 pandemic. These findings align with existing literature characterising the impacts of the COVID‐19 pandemic on overdose risk, suggesting common factors shaping overdose risk for PWUD, regardless of gender. Despite these common experiences, findings from this study suggest that these risks are amplified for WWUD. Here, participants emphasised the escalated risk of gendered violence (particularly sexual assault) and the disruption of informal safety networks as disproportionately increasing the risk of harm for WWUD.

Strategies for balancing the relative risks of overdose and violence have consistently been offloaded to WWUD themselves [12, 16], illustrating issues of both structural violence (failed policies leaving gaps in socio‐structural supports) and symbolic violence (normalisation of individualised health and safety mitigation strategies). Findings from this study highlight the need for improved efforts in assisting WWUD in balancing the additional risks resulting from the collision of the COVID‐19 pandemic with drug criminalisation (e.g., COVID‐19 transmission, intensifying violence, escalating contamination of the drug supply) [3]. Indeed, Indigenous women in our setting are subjected to elevated rates of overdose—they experienced fatal overdoses at 9.8 times the rate of non‐Indigenous women in BC in 2021 [24]—and racialised and gendered violence as a result of the ongoing legacy of racist and colonial policies [25], further demonstrating the limitations associated with relying on individualised responses to structural violence. While strategies to mitigate overdose risks associated with solitary drug use have been piloted in several jurisdictions (e.g., fixed‐location technology, dedicated phone lines, smartphone applications) [26], their uptake and utility have been limited. For example, WWUD previously reported using fixed‐location devices to request support for other emergencies (e.g., gender‐based violence), yet rarely applied this technology for overdose prevention [27]. Indeed, participants in our study outlined some reasons women consume drugs alone (e.g., to avoid violence or being penalised by housing providers) despite the availability of mitigation strategies (e.g., fixed‐location technology). However, these strategies perpetuate the individualised approach to addressing the risks of overdose and gendered violence, rather than addressing the underlying social and structural drivers of these risks [28]. In order to meaningfully support WWUD in mitigating these risks, purposeful attention is needed at the policy level. For example, removing criminal sanctions associated with drug possession/consumption—either without ending its prohibition (i.e., decriminalisation [29]) or by implementing a legal framework (i.e., legalisation [30])—of currently criminalised drugs has the potential to reduce experiences of everyday violence among WWUD (e.g., reduced need to hide their drug use). Similarly, the provision of a regulated drug supply (known content and potency) has the potential to reduce many of the risks associated with the toxic drug supply identified by participants in this study (e.g., ‘benzo‐dope’‐related sexual assault). Indeed, research in our setting indicates that variability of fentanyl concentrations [1] and benzodiazepine adulteration [2] in opioids rose during the study period. While efforts to reduce reliance on the unregulated drug supply have been implemented in BC (e.g., ‘Risk Mitigation Guidelines’ [31]; unsanctioned compassion club [32]), program restrictions have limited uptake and retention among PWUD in the province [33]. The escalating overdose risks during the COVID‐19 pandemic outlined in this study add to broader critiques of the socio‐structural systems that disproportionately harm the diverse population of WWUD, who will likely continue experiencing elevated overdose risks in the absence of concerted efforts to address the structural factors driving these risks.

Participants in this study also discussed how WWUD established informal community‐based networks to look out for one another in the absence of adequate structural‐ and policy‐level efforts, further highlighting the prominent ramifications of social violence in their lives (i.e., normalisation of everyday violence that occurs as a result of structural violence). Relying on PWUD to care for their fellow community members is a common response to the widespread structural and policy failures related to unregulated drug use [34, 35, 36, 37], and was documented in this study as participants navigated intersecting health crises. However, these failures are particularly salient for WWUD (particularly racialised and poor women) who are additionally failed by drug policy discourse that disregards their unique circumstances [20, 38]. Indeed, women have reported the gendered caretaking expectations imposed upon them, in both formal (e.g., overdose prevention services) and informal (e.g., with their intimate partners) drug use settings [16, 18]. For those working in harm reduction, precarious employment and inequitable access to employment benefit programs (including paid sick leave) render PWUD particularly susceptible to burnout and other harms associated with providing care during ongoing public health crises [18, 35, 36]. These harms are exacerbated for those experiencing economic insecurity, as their financial need limits their ability to take unpaid time off to prevent or address the harms stemming from the emotional toll of this work [35]. The historical (and ongoing) effects of racism and colonialism impede the economic advancement of racialised populations and contribute to their continued economic insecurity [39], further exacerbating these harms among Black, Indigenous and other women of colour who use drugs. While care provision can be a positive experience for women (i.e., providing opportunities for autonomy and outlets for demonstrating care for their peers) [16], the constraints associated with providing care under drug criminalisation often lead to negative consequences for caretakers [16, 18, 36].

This study provides an important contribution to the existing literature due to its attention to the gendered experiences of WWUD; however, several limitations may influence the interpretation and implications of its results. First, conducting interviews remotely may have excluded WWUD experiencing higher levels of instability (e.g., without access to a phone). Second, this study is unable to speak to the unique overdose risks experienced by youth or young adults during the dual public health crises, which may be partially attributable to their underrepresentation in harm reduction services located in stigmatised areas, where our recruitment efforts were concentrated [40]. Finally, the small sample size of participants identifying as gender‐diverse similarly prevented exploration of their unique overdose experiences compared to those identifying as women.

5. CONCLUSIONS

This study draws on a framework of social violence to highlight factors contributing to increased overdose risk among WWUD during the COVID‐19 pandemic, and the individualised mitigation strategies they employed to protect themselves and their communities from harm. Specifically, participants reported intensifying contamination of the unregulated drug supply (particularly ‘benzo‐dope’) and disruption of many harm reduction strategies commonly employed by WWUD as amplifying the risk of gendered violence and overdose. In the context of socio‐structural conditions that disproportionately harm WWUD, participants discussed measures they undertook to protect their peers from overdose‐related harms while simultaneously minimising COVID‐19‐related risks. Together, the intersecting crises perpetuated individualised approaches to addressing the risks of overdose and gendered violence, rather than addressing the underlying social and structural drivers of these risks. The findings presented herein should inform future efforts to meaningfully address overdose risks among WWUD.

AUTHOR CONTRIBUTIONS

Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.

FUNDING INFORMATION

This study was supported by the Canadian Institutes of Health Research (ECP 184180; PJT ‐183952) and the US National Institutes of Health (R01DA044181). KAS is supported by a CIHR Doctoral Research Award: Canada Graduate Scholarship. This study was conducted independently and without the input of the funders.

CONFLICT OF INTEREST STATEMENT

The authors have no interests to declare.

Speed KA, McNeil R, Hayashi K, Maher L, Boyd J. ‘It just doesn't stop’: Perspectives of women who use drugs on increased overdoses during the COVID‐19 pandemic. Drug Alcohol Rev. 2025;44(2):602–612. 10.1111/dar.13996

DATA AVAILABILITY STATEMENT

Research data are not shared.