"You don't have the right resources to let it hurt": How structural vulnerabilities shape opioid withdrawal experiences among a community sample of people who inject drugs in Los Angeles, California.

Among people who inject drugs and use opioids, the vast majority have reported experiencing opioid withdrawal symptoms during the past six months. People who use opioids experience significant impediments from withdrawal symptoms, including increased risk behaviors associated with overdose, bloodborne infection, and other negative health outcomes. We undertook this analysis to understand how social and structural forces shaped experiences of withdrawal risk, navigation, and management among a community sample of people who use opioids and inject drugs in Los Angeles, California. We conducted 30 semi-structured, in-depth interviews at community sites in Los Angeles. Qualitative data were analyzed using constructivist grounded theory. Our findings indicate that: 1) when people who use opioids experienced overlapping structural conditions (such as unsheltered houselessness and material difficulty) withdrawal becamea vulnerability and was prioritized first 2) severe material hardships necessitated that participants prioritized withdrawal to engage in their daily income generation activities, 3) participants engaged in higher risk behaviors in order to manage intense and urgent withdrawal symptoms, which led to shifts towards stigmatized and criminalized identities and negative self-appraisal. Overlapping structural vulnerabilities such as housing insecurity, material hardship, experiencing theft, and financial precarity compress risks associated with withdrawal while simultaneously constricting ways in which individuals can manage symptoms. Our findings point to ways in which existing withdrawal management options may be made more effective and accessible via structural support such as housing, income, and basic needs support. MOUD expansion may empower people who actively use opioids to navigate complex structural vulnerabilities from a place of assurance rather than urgency and fear; thereby serving as a harm reduction tool that disrupts the cycle of withdrawal management and material precarity.