“And we just have to keep going”: Task shifting and the production of burnout among overdose response workers with lived experience

Abstract

Overdose response programs in North America increasingly employ task shifting—shifting overdose response tasks to less specialized workers—to increase effectiveness and promote involvement of people with lived/living experience of drug use (PWLE). In Canada, task shifting has occurred through community-driven implementation of overdose response programs staffed primarily by PWLE. The implications of this task shifting on workers’ well-being and service delivery has received little scholarly consideration, despite reports of widespread burnout among frontline responders. This study examines experiences and drivers of burnout among PWLE working at low-barrier supervised consumption sites (“Overdose Prevention Sites” or OPSs) in Vancouver, Canada. Between December 2016 and March 2020, we conducted ethnographic fieldwork at four OPSs, including in-depth interviews with 23 overdose response workers, three site-based focus groups with 20 additional workers, and 150 hours of naturalistic observation. Data were analyzed to explore how working conditions, labour arrangements, economic insecurity and social disadvantage shaped burnout. We found that overdose response workers commonly reported burnout, which they attributed to the precarious and demanding nature of their work. While casual positions offered low-barrier employment, PWLE often lacked the wages and benefits enjoyed by other frontline workers, with limited supports and opportunities for advancement. Due to their social position within drug-using networks, PWLE’s work encompassed hidden care work that participants felt was constant and undervalued. The scarcity of permanent full-time positions, alongside barriers to transitioning into formal employment, prevented many PWLE from earning livable wages or taking time off to ‘recharge.’ This study highlights how the devaluing and casualization of overdose response labour, compounded by other dimensions of structural vulnerability, are central to burnout among overdose response workers with lived experience. Interventions to address burnout within this setting must extend beyond individual-level interventions (e.g. counselling, self-care) to also strengthen working conditions and economic security of PWLE.

1. Introduction

Overdose epidemics continue to impact communities throughout North America, with unintentional drug poisoning now the leading cause of accidental death in the United States and Canada (Centres for Disease Control and Prevention, 2018; Statistics Canada, 2018). The crisis stems from multiple factors. Opioid use increased from the 1990s onward, alongside increased heroin availability in drug markets and growth in pharmaceutical opioid prescribing (Ciccarone, 2017; Dasgupta, Beletsky, & Ciccarone, 2018). Opioid-using populations were exposed to increasingly potent opioids in the 2010s as interdiction efforts incentivized adulteration of drugs with fentanyl, a synthetic, cheaply-made opioid that is easier to transport across borders without detection (Beletsky & Davis, 2017; Dasgupta et al., 2018). Widening wealth gaps and the erosion of social welfare have also been linked to the crisis (Dasgupta et al., 2018).

While responses to the overdose crisis have been diverse, some jurisdictions have scaled up overdose response programs (e.g. supervised consumption sites, naloxone distribution) to identify and reverse opioid-related overdoses (Lambdin, Davis, Wheeler, Yueller, & Kral, 2018; Wallace, Pagan, & Pauly, 2019). One strategy that has emerged to expand these programs is task shifting overdose response from credentialed healthcare professionals to less specialized workers with shorter training and lower pay scales (Buchman, Orkin, Strike, & Upshur, 2018). This study considers the implications of task shifting on people who draw from lived and living expertise of drug use (PWLE) to inform their overdose response work (sometimes termed ‘peers’). Drawing from an ethnographic study of low-barrier supervised consumption sites (‘Overdose Prevention Sites’) in Vancouver, Canada, this article examines how task shifting has entailed a devaluation and casualization of overdose response labour that—given the marginal position of people who use drugs within society and labour markets—renders them more vulnerable to negative health and social outcomes associated with burnout.

1.1. Task shifting and ‘peer’ labour in overdose response

Initially devised as an approach to delivering HIV care in lower-resourced settings, task shifting has since been promoted globally as a pragmatic strategy for reducing staffing shortages and care inequities in various domains (e.g. mental health, substance use, maternal and child health) by shifting healthcare tasks to less specialized health workers with shorter training periods and lower pay scales (European Commission, 2019; World Health Organization, 2008). While typically conceptualized as top-down restructuring in which governments delegate tasks to new groups of workers, task shifting can also occur from below when civic and other voluntary organizations mobilize to fill gaps within healthcare systems (Buchman et al., 2018). This has been the case with overdose response programs in North America, where activists have engaged in grassroots organizing and civil disobedience to establish programs that train PWLE to identify and manage overdoses (Buchman et al., 2018; Davidson, Lopez, & Kral, 2018; McNeil, Small, Lampkin, Shannon, & Kerr, 2014; Sherman et al., 2008). These programs leverage experiential knowledge and networks of PWLE to bring life-saving care to drug-using populations that are stigmatized within healthcare systems, reaching people who might not otherwise receive medical attention during an overdose due to fears of criminalization or other punishments (e.g. losing custody of children or eligibility for public programs) (Buchman et al., 2018; Faulkner-Gurstein, 2017; Kennedy et al., 2019).

In Canada, peer overdose response roles grew significantly through the grassroots implementation of Overdose Prevention Sites (OPSs) staffed primarily by PWLE. Given government inaction and delays responding to escalating overdose deaths, drug-user groups and their allies began establishing OPSs in 2016 as spaces where people may consume illicit drugs under the supervision of non-clinical staff (Wallace et al., 2019). OPSs are lower barrier in that they accommodate modes of drug consumption prohibited in most Federally-sanctioned supervised consumption sites, such as inhalation and assisted injection (Kennedy et al., 2019). Lacking public funding, these programs initially relied on crowdfunding, volunteer staffing, and were often based out of tents, trailers, vans and shipping containers (Wallace et al., 2019). Temporary sanctions and provincial funding for OPSs subsequently facilitated their scale-up, creating waged work as PWLE supervised injections, provided harm reduction education, and reversed overdoses using stimulation (e.g. conversation, physical touch), oxygen and naloxone (Buchman et al., 2018; Kennedy et al., 2019; Wallace et al., 2019).

Previous research documents numerous benefits of this task shifting, locating it within a social movement to involve PWLE meaningfully in the planning and delivery of programs that affect their lives (Kennedy et al., 2019; McNeil et al., 2014; Sherman et al., 2008; Ti & Kerr, 2013). Beyond saving lives, overdose response positions offer low-barrier employment opportunities for people excluded from formal labour markets due to drug use and other structural barriers (Bardwell et al., 2018; Greer et al., 2018). However, the way in which this task shifting has been implemented raises ethical and pragmatic concerns that have received little scholarly attention (Buchman et al., 2018; Dechman, 2015; Kolla & Strike, 2019). It is important to contextualize that this task shifting has occurred on the heels of decades-long austerity budgeting and neoliberal restructuring of public programs that have weakened labour power, lowered wages and increased precarious forms of labour (Peters, 2012; Wacquant, 2009). In Canada and other wealthy democracies, governments increasingly contract out public services to non-profits through competitive bidding processes that mimic market competition and institutionalize imperatives to keep labour costs low (Evans, Richmond, & Shield, 2005). This contracting environment creates downward pressure on labour costs, which are typically more flexible than other service delivery costs (Peters, 2012). The short-term nature of funding contracts further favours casual and temporary roles, as operating organizations often only have funding certainty for six-to-twelve month terms (Evans et al., 2005).

Under these conditions, overdose response positions available to PWLE are frequently low-wage and casual (i.e. non-contract, temporary), lacking the benefits and responsibilities of protected full-time employment (Greer, Bungay, Pauly, & Buxton, 2020; Greer et al., 2018). Although casual positions are important low-barrier work opportunities for some PWLE, the devaluation and casualization of overdose labour risks financial exploitation of PWLE in these roles who are likely to experience heightened economic insecurity and limited formal labour opportunities (Bardwell et al., 2018; Greer et al., 2020; Greer et al., 2018; Richardson et al., 2015). The implications of these processes on working conditions and the delivery of overdose response programs are critical questions that have, with few exceptions, been overlooked in existing research (Buchman et al., 2018; Kennedy et al., 2019; Greer et al., 2020).

1.2. Theoretical approaches to burnout

One concern related to task shifting is burnout among healthcare workers, such as overdose responders, who encounter considerable work stress and hazards (Kennedy et al., 2019). In occupational health and psychology, ‘burnout’ refers to negative psychological symptoms stemming from chronic workplace stressors, including overwhelming exhaustion, feelings of cynicism and depersonalization, and a sense of ineffectiveness or lack of accomplishment (Maslach & Leiter, 2016). Burnout is recognized as a common occupational hazard for workers in people-oriented ‘caring’ professions (e.g., social work, nursing), particularly those whose work entails exposure to traumatic situations (Ben-Porat & Itzhaky, 2015; Jennings, 2003). Previous research finds burnout can impair workers’ mental health and job performance, resulting in lower quality of care and staffing shortages as workers resign or take leave due to work-related stress (Poghosyan, Clarke, Finlayson, & Aiken, 2011; Willard-Grace et al., 2019).

Dominant theories of burnout emphasize individual-level and—to a lesser extent—organizational determinants of burnout, often stopping short of implicating broader labour relations and social conditions (Leiter & Maslach, 2004; Maslach & Leiter, 2016). These models (e.g. the Jobs Demands Resources, Areas of Worklife, and Conservation of Resources models) build from a body of research focused predominantly on full-time and middle-class professionals in stable employment, with comparatively little attention to experiences of precariously employed and low-wage workers (Schaufeli, 2017). As public services are increasingly delivered on a contract basis that favours part-time, low wage and temporary employment (Peters, 2012), there is a need to analyze how these labour relations structure burnout processes and, in turn, the delivery of public programs. Further, burnout research can benefit from considering how other structural changes characteristic of neoliberal governance (e.g. disinvestment from welfare programs) interact with individual and organizational level dynamics to produce burnout.

PWLE’s burnout experiences likely differ from other frontline providers due to their social embeddedness within the communities they work and structurally-imposed vulnerabilities (Kolla & Strike, 2019). The concept ‘structural vulnerability’ captures how the marginal position of groups within social hierarchies renders them more vulnerable to negative health and social outcomes (Quesada, Hart, & Bourgois, 2012). Previous research documents how PWLE face intersecting forms of social and economic marginalization under drug prohibition that heighten their risk of unemployment and financial instability (Bourgois, 2002; Richardson, Wood, & Kerr, 2013). In Vancouver, as elsewhere, soaring housing costs and insufficient social assistance rates have exacerbated these vulnerabilities. In 2018, the welfare income of a single person receiving disability assistance ($14,802 CAD) equalled less than one third of Vancouver’s poverty threshold using the Federally-adopted Market Basket Measure ($48,677) (Djidel et al., 2020). For PWLE with social assistance as their primary source of income, strict earning restrictions (approximately $12,000 annually) constrain labour opportunities to more precarious and informal work (Boyd et al., 2018). These structural arrangements may increase PWLE’s vulnerability to burnout in overdose response jobs, while also depriving them of critical material, social and symbolic resources to mitigate negative consequences (Quesada et al., 2012). Structural vulnerabilities can in turn contribute to stressful workplaces as workers in positions of relative powerlessness direct frustrations at themselves and those with less power — a process referred to as lateral violence (Thobaben, 2007).

This study examines experiences and drivers of burnout among PWLE working in OPSs in Vancouver, BC: an epicentre of Canada’s overdose crisis and home to a range of publicly-funded overdose response programs. Our analysis investigates how burnout is produced among overdose response workers with lived experience, including the role of inequitable working conditions, economic insecurity, and other forms of social disadvantage. We further explore the implications of burnout on the delivery of overdose response programs.

2. Methods

We draw from ethnographic fieldwork conducted in Vancouver between December 2016 and March 2020 to examine OPS implementation. Ethnographic approaches have a longstanding history in health research, leveraging researcher immersion and familiarity with a setting to gather rich data about pressing public health issues (Johnson & Vindrola-Padros, 2017). This study developed as part of a community-based research project and through collaboration with OPS operators, who identified burnout as an urgent research priority. With permission from OPS managers, the authors and two research assistants (community members with lived experience of drug use) conducted 150 hours of ethnographic fieldwork at four OPSs in Vancouver with diverse capacity, staffing and integration with other services. Field sites included an OPS run by a drug user organization; a non-profit-run OPS co-located with an injectable opioid agonist treatment program; a stand-alone OPS with a smoking space; and an OPS trailer located on hospital grounds. Three of the four sites are located in the Downtown Eastside neighbourhood, a central hub of Vancouver’s illicit drug market.

Research team members observed activities within OPSs, engaging in unstructured conversations with staff and service users who were informed of the research. Fieldnotes were written immediately after observation sessions and described formal and informal practices at OPSs, including interactions between service users and staff, overdose response procedures, enforcement of site policies, conflict resolution practices, and division of labour. Simultaneously, the lead author conducted in-depth qualitative interviews with 23 workers recruited from the sites. Interviews were conducted using a semi-structured interview guide that asked about participants’ roles and practices at the sites, situating them within other aspects of their life such as living arrangements, income-generating practices, drug use, and personal overdose experiences. The lead author subsequently conducted site-specific focus groups with 20 additional workers with lived experience, who were recruited from three of the sites. A focus group was not conducted at site #4 as there were few staff at this site. Focus groups explored interpersonal dynamics within worksites, as well as consensus and divergence around issues raised in the individual interviews (e.g. perspectives on wages).

Participants were purposively sampled to reflect a range of positions (e.g., casual and full-time, managerial and non-managerial) and socio-demographic characteristics (e.g., age, gender and ethnicity). Ethnographers recruited participants during fieldwork, sometimes through the referral of a fellow worker. Individuals were eligible to participate if they had worked an OPS shift in the last six months. All interviews and focus groups took place onsite at OPSs, were audio-recorded, and transcribed verbatim. Names and other potentially identifying information were removed from data. Interviews typically lasted 45 minutes, whereas focus groups ranged 40 to 90 minutes in length. All participants provided written informed consent prior to their interview and received $30 CAD cash. The Providence Health Care - University of British Columbia Research Ethics Board approved study activities.

Fieldnotes and transcripts were imported into NVivo, a qualitative software management program, to facilitate analysis. The lead author analyzed data with the aim of critiquing, reconstructing and advancing theoretical understandings of burnout, guided by a coding framework composed of a priori categories derived from existing literature and emergent categories identified through data familiarization (Deterding & Waters, 2018). To enhance validity of findings, we sought feedback from PWLE and other OPS workers through informal conversations, dissemination of research summaries and structured reviews of the manuscript. This feedback helped clarify complex data and make sense of contradictory evidence. Overall, reviewers felt findings accurately captured dynamics in OPSs and resonated with their own experiences. To protect confidentiality of participants, we omit socio-demographic information that could identify participants.

3. Results

3.1. Characteristics and job roles of study participants

Table 1 presents socio-demographic characteristics of study participants. The majority (95%) of workers in this study self-identified as ‘peers’, meaning they had lived or living experience of illicit drug use. Of the 43 participants, 21 were men and 22 were women, including one woman who was transgender. Participants identified predominantly as white (63%) and Indigenous (37%). Participants commonly described receiving social assistance and living in precarious housing circumstances, including some who were unhoused.

Table 1:

Characteristics of participants in ethnographic study of Overdose Prevention Site workers in Vancouver, Canada (n=43)

	Site #1	Site #2	Site #3	Site#4	TOTAL
Participant characteristics	n(%)	n(%)	n(%)	n(%)
(Age Years)
Median (Interquartile range)	54 (44.5–60.5)	46.5 (43–54)	40 (32–51)	34 (32–46.5)	46 (37–54)
Gendera
Men	10 (67%)	4 (40%)	5 (36%)	2 (50%)	21(49%)
Women	5 (33%)	6 (60%)	9 (64%)	2 (50%)	22 (51%)
Race/ethnicityb
White	7 (47%)	9 (90%)	8 (57%)	3 (75%)	27 (63%)
Indigenous	7 (47%)	s1 (10%)	7 (50%)	1 (25%)	16 (37%)
Black/African	1 (6%)	0 (0%)	0 (0%)	0 (0%)	1 (2%)
Identified as a peer
Yes	15(100%)	10 (100%)	13 (93%)	3 (75%)	41 (95%)
No	0 (0%)	0 (100%)	1 (7%)	1 (25%)	2 (5%)

^a.Inclusive of transgender participants

^b.Participants could select more than one response option

Most participants worked part-time and on-call—sometimes picking up shifts at multiple OPSs—and were generally paid in cash at the end of each shift (typically four hours long). Workers were often themselves OPS service users who were recruited into casual work through informal processes. Formal applications and interviews were required for some roles, particularly managerial and supervisory employment. PWLE performed critical jobs at OPSs, including as front-desk attendants, shift supervisors, injection room attendants, and (less frequently) site managers. Training for these positions varied considerably across sites and roles, but occurred primarily through unstructured “on the job” learning. Notably, one site ran a training program that offered regular workshops to PWLE and other OPS workers on overdose management and related skills (e.g. managing extreme situations, safer injection practices, anti-stigma and cultural safety).

Table 2 provides characteristics of the study sites, including site capacity, services, and staffing. In two of the four sites, PWLE in casual peer roles worked alongside unionized support workers employed by the non-profit organization operating the site. Despite performing similar work, wages for casual workers (predominantly PWLE) were sometimes half that of unionized employees. During the study period, wages for non-union workers ranged from a low of $8.50 CAD/hour (reception position) to a high of $18.50 (shift supervisors). Most participants earned between $10 to $12/hr, which is less than the 2018 provincial minimum wage ($12.65/hr) and significantly less than the estimated ‘livable wage’ required to meet basic needs in Vancouver ($20.91/hr) (Ivanavoa & Saugstad, 2019).

Table 2:

Characteristics of Overdose Prevention Sites included in the study

	Site #1	Site #2	Site #3	Site #4
Location	Within a drug user organization in the DTES	At the base of a non-profit housing building in the DTES	Within an alley in the DTES	Trailer located on the grounds of an urban hospital outside of the DTES
Max Capacity	6	16	24	8
Operating Organization	Drug user organization	Non-profit	Non-profit	Non-profit
Staffing	All PWLE staff, paid by cash honorarium	PWLE staff paid by cash honorarium or payroll Unionized support workers Nurse at hydromorphone station	PWLE and nonPWLE staff paid by cash honorarium	Each shift has at least one casual PWLE worker (paid by cash honorarium) and one unionized support worker
Services	-Naloxone and oxygen administration -Harm reduction supplies and education -Support and advocacy programs -Client-to-client injection assistance permitted	-Naloxone and oxygen administration -Harm reduction supplies and education -Overdose response training -Client-to-client injection assistance permitted -Spectrometer drug checking twice weekly -Hydromorphone program (for enrolled patients) -Co-located with an injectable opioid agonist treatment program (for enrolled patients) -Primary care access -Physician on site once weekly	-Naloxone and oxygen administration -Harm reduction supplies and education -Supervised smoking tent -Client-to-client injection assistance permitted -Spectrometer drug checking twice weekly	-Naloxone and oxygen administration -Harm reduction supplies and education -Client-to-client injection assistance permitted -Spectrometer drug checking once weekly
Hours	10am-10pm Everyday, except Thursday	1pm-11pm Everyday	8am-10:30pm Everyday	11am-11pm Everyday

^a.DTES: Downtown Eastside neighborhood

^b.PWLE: People with lived/living experience

The findings presented herein draw from ethnographic fieldnotes and excerpts from individual interviews and focus groups. When focus group excerpts include the voices of multiple participants, dialogue is presented in order, as it occurred organically during conversation.

3.2. Characterizing burnout in overdose prevention sites

Workers reported substantial psychological challenges related to their work, which they commonly labelled as “burnout.” Across all sites, participants described feeling exhausted from their work due to challenging working conditions and the demanding nature of overdose response: “it’s just a weariness that you can’t even explain to anyone who doesn’t do this job.” Witnessing and responding to overdoses was stressful and traumatic, and most participants had lost close friends or family members to overdose. Workers described feeling “numb” to death and avoiding “dealing with” grief in order to continue doing their job. As expressed by focus group participants:

R1: Like there’s a lot of “I’ll deal with this later. I will deal with this later” […] And later hasn’t come in three years.

R2: The countless times that you hear the name of somebody you’ve really come to care about and they’re gone. [...]

R3: Like, you’ve normalized it in a sense that you can still function with it.

R2: We normalize it all just to be able to come to work every day.

Job-related stress also manifested as physical ailments. We observed that workplace tasks were sometimes physical, such as when workers moved boxes to restock supplies or repositioned someone to facilitate overdose response. Physical work tasks could exacerbate pre-existing injuries and chronic pain, which were common among participants. Participants also described hypervigilance that generated tension and pain in their bodies. One woman explained how she became aware of muscle tension after taking a seven month leave from overdose response work and receiving coverage for massage therapy through a different job:

I never realized how tight I actually was ‘till this woman went and like took out the knots. I cried. I screamed. […] And she flat out said. She said “you hold all your stress in your muscles. That’s where your stress is. It’s just three years of stress is everywhere in your muscles.

Many participants coped with grief and stress by increasing drug use. While some found drug use helpful for alleviating suffering, others were distressed by escalating drug use. As one woman described:

In 2016 I ended up relapsing because I wasn’t able to process everything the way I should have, and I’m desensitized to, you know, death, and the overdoses. I’m not surprised when I hear someone overdosed, and I can’t feel sadness for it. So, because of those two things, and just continuing to work, work, work myself to the bone– [relapsing] was the easiest solution for me.

As documented in fieldnotes and interviews, many workers left their role for periods of time or reduced their hours due to stress. Staff turnover was most common among casual staff, but also occurred among supervisors. Many supervisors interviewed or observed at early stages of fieldwork were no longer in this role a year later.

While workers expressed feeling “defeated” and “demoralized” by work, many felt obliged to keep working. As one participant expressed: “We’re broken people and we just keep going.” The obligation to continue working was couched in terms of collective responsibility to prevent overdose deaths. When asked whether they ever needed to step back from their role due to burnout, workers in one focus group explained:

R1: There’s no option to step back because—

R2: Step back, people die.”

3.3. Drivers of burnout among overdose response workers with lived experience

3.3.1. Economic Insecurity & Job Precarity

Participants’ accounts highlighted how economic insecurity and job precarity exacerbated work-related stress and contributed to burnout. Economic insecurity was structurally linked to stagnating social assistance rates, limited employment opportunities, and the cost of living in one of the world’s most unaffordable housing markets (Demographia, 2020). While many casual workers had social assistance as their primary source of income, recipients needed to supplement this income to meet survival needs. Overdose response work was described as one of the few formal labour opportunities available to PWLE, particularly those with little formal training and education. As one man said: “What else could I do at 59 years old after being a drug addict all my life?”

The provincial social assistance system maintained economic insecurity by failing to provide adequate income and clawing back employment income earned beyond ‘exemption limits.’ OPSs partly circumvented this issue by successfully advocating that casual ‘peer’ work be considered an ‘exempted income’ not counting towards annual earning limits for assistance recipients. However, significant barriers remained for people wishing to transition into full-time and managerial positions. As full-time protected work was not considered ‘exempted income,’ workers transitioning into more secure contract positions risked losing eligibility for critical supports, such as disability and income assistance, subsidized housing, and medication coverage. As one participant explained:

I’m in BC housing [subsidized housing] and when I was on straight assistance, I was paying $328 a month. Then I was working. All of a sudden I’m paying $560 a month, which is like $240 increase. That’s quite substantial […] I was better off on welfare.

Stipends from casual work helped alleviate the economic strain of living off monthly social assistance payments, yet wages were often insufficient to achieve economic security. OPS managers interviewed for this study were supportive of increasing wages for casual positions, but were constrained by funding agreements with the local health authority. Some managers described low wages as a strategy to “spread out” work opportunities, given that interest for overdose response work outstripped what could be supported with funding. As casual positions were not considered protected employment, most PWLE working at OPSs lacked benefits such as vacation, extended health coverage, and sick leave. This economic insecurity and lack of benefits prevented workers from taking time off or engaging in practices that might prevent burnout (e.g. counselling, vacation). As one participant explained:

I worked three years. I never got a vacation. I couldn’t afford one if I did. I can’t afford stress leave because our pay cheques aren’t enough that the 60% that [Employment Insurance] would give us is not enough to live on. And we just have to keep going and going.

As casual positions were not covered by provincial labour laws, most PWLE working at OPSs also had no protections if they were injured at work or needed to take leave for health reasons. Some of the more experienced workers in casual roles felt they had to “pick up the slack” when unionized employees went on leave, fueling animosity and distrust among workers. Some participants shared stories of feeling punished for taking unpaid time off by being demoted or facing challenges securing shifts upon return.

Low wages were a source of symbolic injury for PWLE, who were aware they were paid less than other frontline providers not defined by their drug use, despite performing similar tasks. Participants felt their labour was devalued because they were labelled as ‘peers’ and that pay inequities reflected ambivalence toward the lives of people who use drugs. As expressed by focus group participants:

R1: Just because we use drugs, I mean, they don’t think that we deserve to be making that [the same pay as other frontline providers].

R2: We don’t deserve it, and they don’t think that people deserve to live that are on drugs. They’re: “Well, let them die then. You know. I mean why should we waste our money on them.”

Other participants believed the devaluation of their labour was integral to government support for OPSs: “Why do you think the government likes it so much? It’s cheap.”

The limited opportunities for advancement also contributed to burnout. Workers with lived experience described reaching a professional ceiling or cap, with few opportunities to move into more desirable and better compensated positions. One participant explained:

I started this crisis back in August 2016 when these sites were opened. […] I’m a supervisor. I actually had to quit for a while because of burnout, because I needed to get away and because there was no advancement opportunity, which was a big deal to me.

As this quote exemplifies, PWLE’s expertise from overdose response work did not always translate into better job prospects in their worksite (e.g. in managerial and training roles) or the broader labour market. The scarcity of advancement opportunities could make the job feel like a dead end, or, as one participant framed it: “there’s nothing at the end of this.” PWLE were keen to progress in their roles by taking on mentorship responsibilities. When asked what could be done to prevent burnout, one worker replied: “give the veteran peers the chance to mentor and don’t hold us back because of our roles.”

Interviews suggested lack of control over working conditions was a core component of burnout: “You don’t know what’s going to happen around the corner […] you never know what’s next.” Feelings of burnout were pronounced at higher-volume sites, where working conditions were described as “unpredictable” and where staff sometimes responded to multiple overdoses simultaneously. Recounting their earliest shifts at a high-volume OPS, one worker noted: “we kept having overdose, overdose, overdose. Like sometimes seven overdoses to ten overdoses in a seven-and-a-half-hour shift. And I was like: I didn’t join up to be a paramedic!” Workers who expressed having greater autonomy in their role and control over the working environment (typically supervisors) conveyed greater job satisfaction and resilience in the face of burnout. One woman preferred supervisory work, explaining: “I have more say in what they [other staff] are going to do and what they’re not going to do.”

Some workers believed unionizing or collectively organizing was required to secure better working conditions, wages, and job security. As one participant asserted: “it’s three years in and we’ve earned a union, a year of representation. We’ve earned benefits. We’ve earned job security, further education. We’ve earned people’s respect.”

3.3.2. Invisible and unpaid labour

Psychological models of burnout posit that burnout can emerge when workers are not rewarded appropriately, materially or symbolically, for dedication to work (Neckel, Schaffner, & Wagner, 2017) - a prominent dynamic in participants’ accounts. PWLE employed at OPSs performed a broader range of caring work than overdose prevention. One participant described her roles as such: “We’re mental health workers, we’re bartenders, we’re babysitters. We’re moms, dads, you know, foster [parents] to all of these people and shit.” As captured in this quote, one aspect of invisible labour was mental health support. Participants noted that many service users lived with mental health challenges that required additional training and sensitivity to accommodate. To do their job well, workers emphasised the importance of being able to distinguish when someone was experiencing a mental health crisis that could otherwise be overlooked as intoxication. As one participant explained:

A lot of people out here have the dual diagnosis, right, of mentally challenged as well as the drug addiction and the two are so close that it’s like ADHD and addiction. A lot of them are parallel, right. They look the same. And a couple of times I’ve found myself talking to somebody who was actually mentally hurt or broken and not in the drug stupor that I thought he was in, right.

Conflict resolution was another stressful form of hidden labour, as fieldnotes documented that workers with lived experience were frequently responsible for diffusing conflict within OPSs. We observed that PWLE often took charge of conflict de-escalation given their prior relationships with service users. Similarly, participants described keeping an eye out to prevent theft or protect service users they considered vulnerable: “I’m supposed to keep it as safe as I can for everybody here, with violence, with theft, whatever I can do [...] [It is] a lot of very hard work and a lot of very unpaid work.”

Relationship-building and social support featured prominently in participants’ work. We observed that workers with lived experience received requests for multiple types of support during their shift (clothing, cigarettes, a place to stay), which some considered a key part of their job. As one man shared:

If they need help we do housing, shelter, food. You know, if someone’s homeless then we try to get them into a shelter if they need help. Clothing, or refer them to anywhere if they need it. Detox, anything. We try to help them with everything.

While workers took pride in providing social support, they could also feel overwhelmed by requests since OPSs do not typically receive additional funds to support this work. Some reported using their own money or resources to help service users. As one woman described:

I mean, I spent three years developing relationships which are deeper than that now. Like, I mean, I’ll sit with them while they’re dopesick and just cuddle for three hours until we come up with ten bucks together to get them well. Or I’ve given them the money to get them well or take them out for something to eat when they’re hungry.

Fieldnotes documented frequent instances of people voluntarily working outside of their formal hours. One worker regularly arrived an hour before the site opened to “check in” with people waiting outside the OPS, and to help people manage appointments and navigate bureaucracies. While outreach was part of his job, this work often went unlogged and therefore unpaid.

3.3.3. Challenges negotiating professional and personal boundaries

The hidden work described by participants was linked to their social positions within drug-using networks and expectations around mutual support. For workers embedded in the communities they served, boundary setting was challenging and even undesirable despite being considered protective of burnout. The logic of task shifting overdose response to PWLE is predicated on the intersection of professional and personal, as workers with lived experience are expected to engage people within their social networks and bring expertise based on shared experience. The binary of ‘professional’ and ‘personal’ life did not exist for many PWLE, for whom overdose response work at OPSs was an extension of the care work they already did within their networks. As one participant explained: “you do this [OD response] when you walk out the door. You do this at your home.”

Overlapping professional and personal lives contributed to burnout as participants felt they were never truly able to leave their role. For women working at OPSs, gendered care expectations contributed to requests that went beyond their job responsibilities and sometimes placed them in unsafe situations. For example, one woman shared:

You know, guys seem to be a little aggressive or whatever […] if they feel that they want something, you know? And women can be a little bit taken advantage of, right? That’s why a lot of these guys [coworkers], they go walking over or walking me to the bus stop so that if people are approaching me for things, right? And they are approaching me for lots, like money and cigarettes, and can they stay the night and stuff like that, and it’s hard to say no, you know?

We observed that workers were often responsible for enforcing OPS rules and regulations among friends and family, which could strain relationships. Tensions often arose when moving people along from tables after they finished injecting:

Like [friends] come in and, you know, they kind of take advantage sometimes, you know, want to stay late […] and when other people are waiting it’s kind of hard to say, “Like I know you’re my buddy and everything, but you’ve got to get off the table.”

Participants voiced safety concerns stemming from rule enforcement that spilled into their life outside of work, as exemplified in this quote:

I’ll be great friends with somebody and then they’ll break a rule and I will have to enforce it and now I’m the enemy and it carries over. Like they don’t drop shit when they leave here like we do. They carry it over. I’ve been threatened to be stabbed by a client who was a really good friend.

Moreover, PWLE often did not have the same protections from threats as other healthcare professionals, such as the means to live anonymously in a ‘safer’ neighbourhood.

3.3.4. Lateral and gendered violence in the workplace

Conflict and harassment were routine aspects of the job that contributed to burnout. Our fieldnotes indicated that a recurrent source of interpersonal conflict was the use of OPSs for non-drug-related activities such as grooming, phone charging, socializing and (where they existed) washroom use. OPSs were refuges from inclement weather and important spaces for meeting other survival needs. However, this ancillary function of OPSs was a source of conflict and even violence when it caused delays accessing injection booths, or when workers denied people access to sites for other purposes. In one focus group, for example, a worker described having a knife pulled on him while enforcing rules around time limits for using the bathroom.

Women working at the sites encountered misogyny and gendered harassment, including sexual remarks and instances of being followed after their shift. As one woman described: “Sometimes guys, especially if they’re doing crystal meth, they get all horny and weird […] there’s unwanted attention that happens.” Some women felt they lacked respect from coworkers and that their concerns were not taken seriously by management:

And I mean it’s peers not respecting us, males in particular. It’s a sausage party here. But it’s also from the management. Men complain, shit gets taken care of. Women complain, we’ve got our period. We’re just having a bad hair day. Something, everything’s always minimized when it comes to women’s concerns.

Threats were sometimes minimized by women themselves, who conveyed that gendered harassment was to be expected, even from coworkers. In a focus group at one OPS, three women described how a male co-worker referred to them using a gendered derogatory term (‘cunt’) and issued what they perceived as empty death threats. The women nonetheless expressed understanding for the man’s behaviour, explaining “this isn’t normal work” and that they “had been called worse, by better.” One woman said she started using the word frequently at work to diminish its power to demean her and other women: “I used that word to such a point because I needed women to not flip out every time they heard it because if someone calls you a cunt, it wrecked your whole week.”

Other forms of lateral violence between coworkers were documented during fieldwork, including animosity towards workers who were considered less ‘worthy’ of their position—for example, due to perceived inappropriate drug use while working—and towards those who had access to benefits or opportunities not available to others. In one focus group, a participant expressed disdain for a co-worker she assumed received social assistance:

R1: You know what though? But some of us aren’t really here for the pay because I know I’m not really here for the pay ‘cause I come in here almost 24/7 just to make sure everything’s okay and…

R2: [Interrupting] It’s nice to not to have to worry about having your rent paid.

R1: Oh trust me, I have to worry about having my rent paid, trust me. I don’t, I’m not on welfare or nothing so that’s why I work at all these places but still…

R2: Yeah, it’s like people … if I don’t work I don’t have anything.

As this excerpt illustrates, workers’ frustration at their economic insecurity was sometimes misdirected toward other PWLE working in the OPS, contributing to interpersonal tensions.

Despite interpersonal tensions, coworkers were viewed as an important resource for mutual support as they understood the unique challenges of the work: “And it does have to be a co-worker too because people in the street don’t understand what we’re doing, right. What our stressors are.” Some participants found that opportunities to socialize outside of work helped reduce stress and improve working conditions by strengthening relationships between staff:

Just getting to know different people on a different level has been really helpful and amazingly it’s like the other peers that—and the clients from time to time—keep me from burning out completely and keep it inspiring enough to stick around.

3.4. Implications of burnout on service delivery

While burnout exacted a physical and mental toll on workers, it also posed operational problems. Staff turnover and missed shifts presented multiple challenges. Fieldnotes documented frequent instances of OPSs being unable to open on time as supervisors “fished” for people to fill shifts. To fill staffing shortages, workers would sometimes work back-to-back shifts that left them feeling exhausted and less able to cope with job demands:

Yeah [I’ve experienced burnout], when you’re doing say back-to-backs or you’ve done a shift and somebody stands you up so now you’re doing another shift and it’s just one of those days that there’s a lot of angry people out there and they just seem to be all coming through the front door.

We observed that staffing shortages occasionally resulted in less experienced people on the floor and communication breakdowns between team members who did not often work together. As one worker remarked: “you can tell when the crew is not tight, you know?”

Drug use to cope with stressors occasionally presented operational concerns. Workers were sometimes able to have what they called “maintenance shots” at work to avoid withdrawal and stay well during their shift. While perspectives on drug use at work were mixed, accommodation of drug use among workers was considered important for ensuring a low-barrier work environment. However, participants noted that stress and trauma could lead some workers to increase drug use in ways that made it difficult for them to perform their job: “I mean there’s people that like show up and they’re like good and then they just disappear halfway through the shift. Like an hour into their shift, they’re sitting on the table getting high.” Given uncertainties regarding the potency of unregulated opioids, opioid-using workers could become overly intoxicated when drugs were more potent than anticipated, inhibiting their ability to perform some tasks.

There was a perception that chronic burnout over the course of the overdose crisis had eroded a culture of mentorship and mutual support that existed among PWLE with long-standing involvement in community organizing and advocacy. One woman described how a ‘team culture’ eroded over time as workers became burnt out:

When I first came into the work, I had a bunch of people willing to teach me, and so I was a sponge of information. And now because of the burnout, because of, you know, the experiences folks have had without maybe necessarily engaging in the supports they should have, or didn’t get the supports that they should have, you know, [they] come from this “out for yourselves” [culture], when it should be team building and more mentorship-based.

4. Discussion

In summary, overdose responders experienced burnout that had adverse implications on their well-being and the delivery of OPSs. In this setting, task shifting formally expanded peer workers’ scope of practice and skills to include activities PWLE are well-positioned to perform, including overdose management, conflict de-escalation, social support, and operations of OPSs. However, PWLE employed in ‘peer’ roles do not always receive the pay and benefits that would support them to thrive in these roles. The economic insecurity experienced by PWLE and precarious nature of their work meant they had little power to refuse stressful work, and lacked resources to alleviate burnout such as paid time off and separation of their work and personal lives. The structural vulnerability of workers and service users could further contribute to burnout, as dissatisfaction regarding economic insecurity and social marginalization were sometimes directed laterally towards other PWLE.

The social position of workers with lived experience shaped burnout experiences as they encountered expectations for care work that extended beyond their formal overdose response roles. Previous ethnographic research documents how marginalized drug-using communities are held together by moral economies of sharing in which webs of mutual obligation and reciprocity are essential to survival (Bourgois, 1998). This analysis suggests a moral economy of sharing shaped burnout in multiple ways. Given their social position, PWLE faced greater expectations for care work than coworkers who were not defined by their drug use, and expressed challenges maintaining professional and personal boundaries. In some cases, workers’ responsibilities (e.g. enforcing site rules) conflicted with social obligations to friends and family members using the site, resulting in interpersonal tensions and safety concerns.

As documented elsewhere, overdose response workers with lived experience provide invaluable care and support to service users, and have saved many lives through their work (Irvine et al., 2019; Kennedy et al., 2019). However, this research raises ethical and pragmatic concerns regarding how task shifting has been implemented, specifically that it may produce and reinforce labour inequities when the labour of PWLE is not compensated and supported equitably. Activists and scholars have argued that, when PWLE are not integrated equitably within healthcare workforces, task shifting may worsen power imbalances and pay disparities between formal ‘non-peer’ workers and casual ‘peer’ workers (Buchman et al., 2018). Our study echoes these concerns and contributes evidence that task shifting of overdose response tasks in this setting produced ‘peer’ jobs that are more precarious and lower paid than the work performed by formal health care workers. While this task shifting has been primarily motivated by the movement to better involve PWLE in service delivery, it has also occurred alongside broader transformations to the labour market and welfare system, including the decline of full-time employment in favour of part-time and temporary work, diminishing power of collective labour organizations such as unions, housing insecurity, and stagnating social assistance rates (Klein, Ivanova, & Leyland, 2017; Peters, 2012). All these factors worsen the economic insecurity and job precarity of PWLE, who face substantial barriers to employment due to criminalization of substance use and the exclusion of drug-using populations from the labour market through techniques such as criminal records checks and drug testing (Bourgois, 2002; Boyd et al., 2018; Greer et al., 2018).

As PWLE assume a greater proportion of overdose-related work, governing bodies have a role to play in funding programs adequately to ensure equitable compensation and supports for these workers. Participants in this study conveyed that pay rates were insufficient for the scope of their work, and should be tied to at least a livable wage (Ivanavoa & Saugstad, 2019). Improving wages requires addressing structural issues with the social assistance system which pose barriers to transitioning into formal, protected labour. This research further suggests that fostering opportunities for PWLE in decision-making roles could alleviate burnout by creating opportunities for advancement and increasing their control over working conditions (Marshall, Dechman, Minichiello, Alcock, & Harris, 2015). Unionization and collective organizing among workers could help advance labour rights and improve working conditions, as has been attempted in other settings (Bedard, 2014).

Our findings urge a rethinking of dominant theories regarding burnout, demonstrating the value of applying a structural vulnerability lens to understand how burnout is produced and experienced by workers who occupy a marginal status within labour markets and society. Conceptual models of burnout processes have been largely based on cases of exhaustion among full-time employees in specialized ‘caring’ professions with stable employment and relatively high socio-economic status (Schaufeli, 2017). Our research indicates these models are nonetheless useful for identifying organizational level contributors to burnout among low-wage and casual workers. As is posited in the Areas of Worklife model, many drivers of burnout identified in overdose responders’ accounts stemmed from stressors related to workload, control over work, perceived unfairness, and insufficient rewards for their work (Leiter & Maslach, 2004). However, this analysis documents how stressors in these domains were reinforced by inequities stemming from PWLE’s marginal status in society and the labour market, which shaped how labour was organized and compensated within OPSs. Further, workers’ social position within drug-using networks—and related expectations around care work—constructed unique social vulnerabilities to burnout not captured in dominant theories of burnout that instead emphasize organizational context and individual personality traits (Maslach & Leiter, 2016). Our findings also draw into question the effects of labelling workers’ psycho-social suffering as ‘burnout’ given the potential of this concept to individualize and medicalize a phenomenon that, in this case, links closely to challenging working conditions, economic insecurity and precarious labour practices.

There are limitations to this study. As participants were recruited directly from OPSs, this study does not capture perspectives of workers who permanently left work due to burnout. Secondly, focus groups were conducted at OPSs and included a mix of supervisors and casual workers, which may have discouraged some workers from criticizing working conditions. For this reason, individual interviews were also conducted in private settings to accommodate critical perspectives. Finally, this study was conducted in a higher-income jurisdiction that invests relatively considerable funding to enable PWLE involvement in overdose response. We anticipate that the structural vulnerability of PWLE in lower-resourced settings is even more pronounced, particularly where no systems exist to compensate those in ‘peer’ roles for their labour (Greer et al., 2018).

5. Conclusion

This study illuminates how the devaluing and casualization of overdose response labour engendered by task shifting, compounded by other dimensions of structural vulnerability, were central to the production and experience of burnout among overdose response workers with lived experience. Our findings highlight concerns regarding how task shifting has been implemented within overdose response programs, including the adverse impacts of low wages and job precarity on workers’ well-being and delivery of programs. While recognizing that stressors associated with overdose response may only be eliminated by addressing root drivers of the overdose crisis, this research indicates burnout may nonetheless be alleviated by strengthening working conditions, compensation and economic security for workers with lived experience.

Highlights

• Rapid ethnography of low-barrier supervised consumption sites in Vancouver, Canada

• Examines burnout among overdose responders with lived experience of drug use

• Describes social and structural contributors to burnout

• Highlights need to strengthen working conditions, job protections and supports