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Int J Drug Policy. 2019 Jun;68:86-92. doi: 10.1016/j.drugpo.2019.03.012. Epub 2019 Apr 23.

Stigma and drug use settings as correlates of self-reported, non-fatal overdose among people who use drugs in Baltimore, Maryland.

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Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, United States. Electronic address:
Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, United States.
Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, United States.
Johns Hopkins School of Medicine, Division of Infectious Diseases, United States.
Johns Hopkins Bloomberg School of Public Health, Department of International Health, United States.
Johns Hopkins Bayview Medical Center, Department of Medicine, Chemical Dependence, United States.



Fatalities from opioid overdose quadrupled during the last 15 years as illicit opioid use increased. This study assesses how stigma and drug use settings are associated with non-fatal overdose to identify targets for overdose risk reduction interventions and inform overdose education and naloxone distribution programs.


We surveyed 444 people who used drugs in Baltimore, Maryland, USA, from 2009 to 2013 as part of a randomized clinical trial of a harm reduction intervention. Participants reported demographic characteristics, drug use, overdose history, use of a local syringe services program, involvement in the local drug economy, and whether they experienced discrimination from others (i.e., enacted stigma) or stigmatized themselves (i.e., internalized stigma) related to their drug use. We used multinomial logistic regression models to identify correlates of experiencing a non-fatal overdose within the past year or >1 year ago relative to participants who never experienced an overdose.


Stigma was positively associated with experiencing a non-fatal overdose in the past year (adjusted Odds Ratio [aOR]: 1.7, 95% Confidence Interval [CI]: 1.1-2.7) and >1 year ago (aOR [95% CI]: 1.5 [1.1-2.0]) after adjustment for demographic and substance use characteristics. The association of stigma with overdose was stronger for enacted versus internalized stigma. The number of public settings (shooting gallery, crack house, abandoned building, public bathroom, outside) where participants used drugs was also positively associated with experiencing an overdose.


Stigma related to drug use and using drugs in more settings may increase overdose risk. The effectiveness of overdose prevention and naloxone training may be improved by reducing discrimination against people who use drugs in community and medical settings and diversifying the settings in which overdose prevention trainings are delivered. These efforts may be enhanced by use of peer outreach approaches in which people who use drugs diffuse prevention messages through their social networks and within settings of drug consumption outside the medical setting.


Drug use settings; Overdose; Stigma

[Available on 2020-06-01]

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