Table 2.

Factors identified by participants as shaping overdose risk and substance use-related harms in the context of the COVID-19 pandemic, organized by adapting and applying the ‘risk environment’ framework [20, 21]

Risk Environment Domain: Physical
Factors Increasing Risk	Protective Factors
- Physical distancing restrictions and isolation leading to mental health challenges and increased drug use - More use of substances alone without bystanders able to respond in the event of an emergency - Rural challenges (e.g. limited access to affordable and safe substances, fewer services for people who use substances) - Service restrictions and closures	- Increased outreach and temporary supply distribution sites led by people with lived and living experience of substance use
Risk Environment Domain: Economic
Factors Increasing Risk	Protective Factors
- Spike in drug prices early in the pandemic - Loss of readily available economic opportunities - Inconsistencies in the drug supply	- Economic means to respond to rising drug prices
Risk Environment Domain: Social
Factors Increasing Risk	Protective Factors
- Stigma towards people who use substances alongside perceptions of people who use substances as “infectious” - Isolation and increased use of substances alone, without bystanders able to respond in the event of an overdose - Burden of overdose response on peer workers	- Expanded outreach led by people with lived and living experience of substance use and local harm reduction organizations - Social drug use norms and social capital (e.g. trusted relationship with dealer, sharing supplies and substances, buddying up)
Risk Environment Domain: Policy
Factors Increasing Risk	Protective Factors
- Public health orders, including physical distancing, that led to service restrictions (e.g. reduced hours of operation, visitor restrictions, and service closures) - Shifting COVID-19 protocols and increased burden of overdose response of peer workers - Delays in emergency responders stepping in when arriving at the scene of an overdose and personal protective equipment requirements - Border closures and supply chain disruptions	- New programs and policies emerging in the dual public health emergency (e.g. increased availability of pipe supplies, risk mitigation guidance)