‘Can I keep myself safe?’ in a system lacking support:a qualitative study on overdose risk perceptions by people who co-use benzodiazepine receptor agonists and opioids

Background and aims. Co-use of benzodiazepines and z-drugs (collectively termed benzodiazepine receptor agonists (BZRA)) with opioids is involved in a large proportion of drug-related deaths. Historical and contemporary service provision rarely address the intersection between sociologically inherited disadvantage and current unmet treatment needs in people who use drugs. In this qualitative study, we examined people’s understandings of overdose risk and what strategies, if any, they implemented to keep themselves safe when co-using BZRAs and opioids. Methods. We interviewed 48 people (37 men and 11 women) in community settings who co-use BZRAs and opioids (currently and up to six months before the study) in Bristol, Teesside and Greater Glasgow, United Kingdom. We used a semi-structured topic guide to facilitate in-depth exploration of the ways in which people who co-use managed the risks of an overdose and other drug-related harms. Conceptually, we used the socioecological framework to develop the interview topic guide and frame the analysis and interpretation. All data were transcribed and analysed using reflexive thematic analysis. Results. Intrapersonally, people were aware of the risks associated with co-using (‘consumption roulette’), especially with illicitly obtained drugs. They tended to interrogate their ability to reduce the risk of overdosing within their social, physical and environmental context (‘can I keep myself safe?’). At the intrapersonal level, for those higher in self-efficacy and agency there was a sense of ‘I can keep myself safe’ by implementing tried-and-tested risk minimisation strategies, e.g., consuming drugs in small batches. However, among those lower in self-efficacy and agency, feelings of hope- and helplessness resulted in a belief that ‘there is nothing you can do’. These narratives related back to participants’ perception that system and service-level support was insufficient or lacking altogether (‘they don’t care about us’). Summary. We developed an explanatory self-regulatory model of co-use of benzodiazepine receptor agonists, opioids and risk. Co-use is driven partly by people’s attempts to self-medicate, feel normal and function. Negative experiences (e.g., non-fatal overdose) caused most individuals to reconsider risk taking, with some expressing agency and implementing risk minimisation strategies while others felt disempowered by the wider system and the perceived lack of support and care. This lack of systemic support requires people to balance their needs to function against the risks of co-using by themselves.