Adapting to changing risk environments: examining overdose risk and socio-spatial patterns of unstably housed people who use drugs during converging public health crises

Abstract

Background The COVID-19 pandemic exacerbated the US overdose crisis and disproportionately impacted unstably housed people who use drugs. Measures to address the pandemic within the context of crisis produced differential effects, particularly among people who use drugs. Examining how unstably housed people who use drugs adapted to shifting risk environments is imperative to responding to future crises. Methods Rapid ethnographic data was collected from June 2020 to April 2021 in Rhode Island. Data include in-depth interviews with 39 unstably housed people who use drugs and approximately 50 hours of fieldwork. Findings COVID-related service disruptions and policing of public space (e.g. city curfews) reinforced participants’ marginality and increased surveillance. This heightened visibility disrupted participants’ socio-spatial patterns as they were regularly relocated and faced increased risk of arrest due to public drug use and housing instability. Participants regularly weighed overdose risk reduction against COVID-19 exposure and risk of arrest, which increased harm. Conclusion Findings demonstrate how COVID-related public health measures intersected with participants’ socio-spatial and drug use patterns in ways that increased overdose risk. Drawing on health equity approaches when responding to crisis situations is critical to address intersecting inequities faced by unstably housed people who use drugs.