Social and structural contexts of the overdose crisis: An ethnography of overdose risk among structurally vulnerable women who use drugs in Vancouver, Canada

Background: North America's overdose crisis is driven by illicitly-manufactured fentanyl and fentanyl-adulterated drugs. Vancouver's Downtown Eastside neighborhood in Canada is one of North America's overdose epicenters. Notably, the majority of overdose deaths in Vancouver are occurring in indoor environments, including single room accommodations (SRA) housing. While there is an awareness of the role social, structural, and environmental factors in producing harm among people who use drugs (PWUD), we do not fully understand how social-structural forces (e.g. housing models, social norms) shape overdose risk for women who use drugs (WWUD). This dissertation seeks to address this gap by examining how contextual factors operating in a street-based drug scene create variegated overdose risk for WWUD. Methods: This dissertation draws on ethnographic research conducted with WWUD living in SRAs in Vancouver's Downtown Eastside from May 2017 to December 2018. Data include in-depth baseline and follow-up interviews, and approximately 100 hours of observational fieldwork in SRAs and neighborhood areas. Analysis drew on an intersectional risk environment approach that was developed and then applied to the data to characterize social-structural dynamics shaping overdose risk for WWUD. Results: Findings underscored how normalized violence against WWUD in the drug scene shaped the social and spatial relations of women, and acted as a driver of overdose risk. First, women challenged gendered power dynamics through embodied drug use practices and using drugs alone. Second, WWUD experienced operational and social environmental barriers that minimized their utilization of low-threshold overdose-related interventions in SRAs, thereby increasing risk of fatal overdose. Finally, WWUD experienced burnout related to care-taking and paid labor responsibilities (e.g. peer overdose response), which led them to use drugs alone to cope. Conclusion: These findings demonstrate how gendered power dynamics operating within a drug scene setting overlapped with social (e.g. stigmatization, gender inequities), structural (e.g. prohibition of smoking in overdose-related interventions), and environmental factors to shape fatal overdose risk for WWUD. These findings underscore the need for wider structural transformations to mitigate morbidity and mortality for WWUD. Modifying and scaling up overdose prevention interventions in the community and within SRAs to make them more accessible to women is also imperative.