Overdose risk environment for people who use drugs in New Jersey: Imagining possible points of intervention for harm reduction practitioners.

Background: The Risk Environment Framework is widely utilized theoretical framework for understanding the landscape of harm for people who use drugs (PWUD). This study sought to understand factors contributing to risk of overdose for PWUD in New Jersey. Understanding these factors can lead to improved policy interventions, programmatic targets, and a shared understanding that overdose risk is impacted by larger societal forces influencing PWUD. Methods: Using a community based participatory design model, this study conducted 30 semi-structured, in-depth interviews with PWUD and naloxone distributors in New Brunswick and Newark, New Jersey from February to November of 2022. Thematic analysis was performed using a collaborative analytical approach. Results: Risk factors for overdose fell into all four categories of Rhodes's Risk Environment Framework - physical, social, economic, and policy. Many factors overlapped in multiple categories, and most factors had elements existing at both the macro and micro levels. Conclusions: Interventions supporting PWUD should see overdose risk as an environmental, structural consideration, and be constructed to address comprehensive risks, rather than directing themselves exclusively at the individual level. Factors contributing to risk at the macro level included systemic and institutional concerns and stigma toward PWUD. At the micro level, mental health, substance use behaviors, treatment and recovery, and trauma were cited as potential risk factors.