Introduction

The third and fourth waves of the opioid crisis have been marked by widespread fentanyl disruption of the drug market [1]. Fentanyl is 30–40 times more potent than heroin, contributing to the highest overdose prevalence of all opioids [1], and is faster-acting and shorter-lasting [2], reportedly resulting in more severe withdrawal symptoms [3,4]. In this unpredictable fentanyl-dominated drug market, people who use opioids (PWUO) face several disruptions to their social network and barriers to maintaining safety and well-being including 1) increased pressure to intervene in overdose events for self and peers, 2) testing supply to prevent overdose, 3) sourcing contamination and disruption, and 4) supply shocks and heroin scarcity [1].

PWUO often report concern for accidental fentanyl ingestion [5] and personal and peer group fentanyl-related overdose [5,6]. PWUO may be reluctant to rely on emergency first responders as personnel may not be available to respond to overdose and/ or their involvement invites potential stigma and violence [7]. Reliance on social support provides a potentially beneficial mitigation of risk and concerns related to fentanyl.

Opioid overdose fatality prevention programming in the 1990s and 2000s focused on the advent of interpersonal rescue strategies such as naloxone administration [8,9]. Increasing PWUO’s role as peer naloxone administrators has facilitated better first response interventions and reduced feelings of powerlessness in communities where overdose risk is high [10]. Harm reduction strategies such as fentanyl test strip (FTS) or drug sampling strategies may be individual, but others such as naloxone administration are inherently peer intervention strategies as it is administered for other people rather than oneself.

Heroin was the most observed opioid in early overdose prevention programming in the 1990s and 2000s [8]. While the roles of PWUO in intervening to reverse opioid overdoses have been studied, fentanyl has reshaped these roles by increasing the risks of the opioid landscape and thus the burden on individual PWUOs to prevent and intervene in their peers’ overdose events. This paper uses the frame of moral economy [11,12] to examine how interactions among PWUO have been reshaped and intensified by the rapid takeover of fentanyl within illicit drug markets in Los Angeles. Originally formulated by historian E.P. Thompson [13] to analyze 18^th century English bread riots, moral economy denotes how feelings, sociality, moral norms, and other putatively “non-rational” forces can intervene in and regulate economic markets and attendant risks. While earlier formulations of moral economy emphasized the rejection of asocial market norms, namely through riot and resistance, subsequent developments have emphasized the role moral feeling and mutuality play in protecting individuals and communities from economic risks and vulnerability [13–17]. The frame has proved particularly useful for substance use researchers, who often point to the role of moral economy, and related concepts, in both lessening and heightening risks associated with illicit drug markets and substance use disorders. Within moral economies of unhoused PWUO, shared vulnerabilities emerging from shifting drug markets and mutual interdependencies of communities shape relationships and facilitate safer substance use [18]. Substance using behavior is shaped by social forces and as such, the role of social capital in peer groups is important to explore as it is a determining factor of safety among PWUO [11]. Overdose occurrences and risk are also shaped by mental health [19], which is influenced by social support systems. By focusing on PWUO’s perspectives on peer support, we expand the literature by highlighting how mutualistic strategies employed by PWUO to mitigate fentanyl-related health risks are reshaped amidst an increasingly unpredictable drug market.

Methods

This research was conducted with 30 PWUO (n = 30) in Los Angeles, CA from July 29, 2021 to April 6, 2022. All study participants provided written informed consent for participation and publication. To be eligible for this study, participants had to report being 18 years of age or older and any self-reported opioid, cannabis, and injection drug use within the past 30 days (Table 1) [20]. We used these criteria to generate a convenience sample of participants. The University of Southern California Human Research Protection Program (IRB) reviewed and approved all study procedures (Study ID #: HS-18-00624). Additionally, a federal Certificate of Confidentiality protects this data due to the potentially identifiable nature of this dataset. We have changed participant names in the results to ensure anonymity.

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Table 1. Participant sociodemographic characteristics.

https://doi.org/10.1371/journal.pone.0320423.t001

We conducted 60-minute interviews with participants (S1 Interview Guide). Data was analyzed in a series of iterative steps via constructivist grounded theory [21–23] that are described in more depth elsewhere [20]. Analysis consisted of reading transcripts generated from 60-minute interviews, documenting initial analytic findings, and developing a codebook which consisted of 26 thematic codes (S2 Codebook). The codes were conceptually grouped, and results were generated via blocks of coded text from all the interview transcripts using ATLAS.ti [24]. We analyzed and compared across the data to develop a conceptual theory to explain participants’ experiences. In this analysis, we focused on findings pertaining to social relationships and drug market unpredictability which yielded three results.

Results

Discussion

Our findings show that in an unpredictable drug landscape marked by a fentanyl takeover of the illicit opioid supply, people are actively building new and leveraging existing social networks which can counter this unpredictability. Social support systems involved direct action to keep each other safe, which included 1) sharing finances to head off withdrawal effects and mitigate financial changes which hindered opioid access, 2) sourcing from known and trusted people to avoid disruptions to and contamination of supply with fentanyl, and 3) preventing overdose by using with peers, monitoring, and administering overdose reversal agents.

The frame of moral economy is useful for understanding these collective risk mitigation practices. Moral economy situates interpersonal transactions within a moral framework as well as an economic one [13]. This framework explains how moral and collective feelings about the ways in which markets should operate, often contravening values such as self-interest and profit, structure how actual commodities markets do operate. For example, Liang and Richardson [11] analyze the practice of “fronting” that is, provision of drugs on credit or for collateral, as essentially a moral economic practice that leverages participants’ social capital for material resources that may be protective in the short term, but can also expose recipients to potential harm in the form of unregulated and informal debt, violence, and damaged reputation.

We observed that within moral economies of PWUO, systems of exchange of goods (i.e., money, FTS, naloxone) and services (overdose intervention support) were in place to alleviate the strain of an unstable drug market. Sharing finances, substances, and injecting materials are common practices among PWUO [18]. Our data supports prior research indicating that social capital and proximity within peer groups are influential in determining support between dealers and buyers [11]. However, our findings indicate that these strategies take on increased significance in an unpredictable drug market. Existing data demonstrates that there are faster and more severe withdrawals due to fentanyl [3,4,25]. Participants in our sample feared FASH as well as intentional fentanyl use due to the risk these substances posed for dependency, withdrawal, and overdose. Because of this, we observed an increased need to mitigate effects by relying on peer networks and pooling resources. Withdrawal is a debilitating, sometimes fatal, experience comprising a multitude of physical and psychological symptoms not limited to nausea and vomiting, muscle aches and pains, anxiety, and insomnia [3,4,25]. PWUO report in prior data that its painful experience and influence on behavior to avoid it is often minimized or misdirected at individual characteristics [25]. Within a fentanyl-contaminated drug market, PWUO may have more difficulty avoiding withdrawal and overdose due to the need to use more frequent and higher quantities of fentanyl as compared to heroin [25]. Reliance on moral economies of PWUO is one safety strategy to minimize these risks. Despite market shifts, individuals with sufficient social support could lessen the impacts of precarity.

In result 1, participants in our study reported that the ability to manage withdrawal hinges on having the financial means to procure opioids. When this was not feasible, they relied on peers to support them financially so that they could use enough opioids to mitigate withdrawal symptoms. Prior research [25] supports our findings that PWUO rely on peer networks to share opioids or find connections to drug sellers if prior ones were unavailable to avoid withdrawal. Frank and colleagues [25] found that this reliance on peer groups reduced risk behaviors such as illegal money-making strategies or using drugs from unknown sources, which may be contaminated with fentanyl.

Among people who use heroin, participants in result 2 reported on the significance of sourcing uncontaminated opioids from known social ties in a fentanyl-flooded market. Accidental fentanyl exposure is common among PWUO. In one study, despite many opioid-using participants reporting that they did not use fentanyl, nearly 90% tested positive for fentanyl [26]. These results echo findings in the existing literature [5]. Lorvick and colleagues found that participants feared the risk of accidental overdose and wanted to change suppliers upon learning that they had used FASH [5].

Using within peer groups (i.e., “never fix alone”) as an established safety strategy to avoid overdose [18]. Our findings from result 3 demonstrate that this safety strategy has increased urgency with the higher likelihood of overdose and fatality associated with fentanyl. By keeping overdose reversal agents on hand and ensuring that social groups have the skills to administer them, PWUO avoid fatality in situations where they encounter FASH.

In the current landscape, moral economies of PWUO are taking on the burden of risk reduction in lieu of other individuals or systems intervening [27,28]. They are acting as first responders when the alternative involves law enforcement, prohibition enforcement, and the potential for state sponsored violence [28,29]. In many settings, PWUO are unaware of good Samaritan laws which aim to protect them from retribution should they alert emergency services of overdose events [30]. PWUO report fear that involving law enforcement in overdose events, even in a landscape with good Samaritan laws, will result in arrest due to prior legal involvement (i.e., outstanding warrants, drugs and/ or drug paraphernalia possession) and displacement if they are unhoused [31–34]. Fears from PWUO stem from prior mistreatment by police due to unhoused and/ or substance use status [32]. In one Los Angeles study, law enforcement individuals reported that they responded to approximately two thirds of overdose events and made an arrest in 14% of them [35]. This data on criminal justice involvement demonstrates the critical need for interventions which PWUO can rely on to mitigate peer intervention burden without the risk of being criminalized.

Harm reduction-based peer support efforts are examples of prevention situated within the context of social support [36]. Participants in our study reported experiencing the need to prevent, intervene, and act as first responders in opioid overdose events. While peer support plays a critical role in safety and is often reported among PWUO, it results in moral debt that anticipates further reciprocity [11,36]. PWUO who receive support from their social networks are more likely to provide that support in turn [36]. However, these actions hinge on having the means to support those around you, which participants in our study at times did not have access to. Further, burnout among peer workers (PWUO with additional overdose prevention training) is a prevalent issue [37]. Within overdose prevention sites, peer workers are a critical component of the intervention [36,37]. They promote service engagement among PWUO due to improved interpersonal communication and increased feelings of safety [37]. However, burnout among peer workers results due to inadequate compensation, lacking support systems, grief and trauma related to witnessing overdose events and fatalities amidst and overdose epidemic, and personal experiences of financial and housing precarity [37]. Successful relationships between PWUO and peer recovery specialists also hinge on alignment between life stages and experiences [38]. Thus, increased provision of resources and funding support are warranted to address interpersonal and institutional barriers to providing adequate recovery and safety support to PWUO [37,38].

Direct services such as FTS and overdose reversal agent distribution alleviate the degree of harm participants experience by enabling PWUO to intervene when needed [39]. Having accessible supplies allows PWUO to prevent and/ or treat overdose from fentanyl-contaminated opioids within their social networks, which participants in this study described as efforts they are already engaged in. Employing peer-based naloxone distribution may be a way to strengthen moral economies, but myriad barriers to intervention exist. Lack of resource access [8] due to provider stigma, lack of training, unawareness of prescribing legislation [39], and interstate disparities [40] prevent PWUO from obtaining FTS and opioid reversal agents. Additionally, knowledge of use [8] is minimized by changing naloxone doses, shelf life, [41] and training requirements to effectively use it. Finally, time-based pressures to mitigate or avoid opioid withdrawal [18] are in opposition to attempts for safe consumption [42]. These factors complicate the capacity for peer intervention by needing to obtain materials and education. Ongoing efforts are needed to increase access to intervention strategies such as FTS and overdose reversal agents and destigmatize their procurement to mitigate overdose risk among PWUO.

Institutional-level interventions include medication for opioid use disorder (MOUD) in the age of fentanyl [39,43]. While participants in this study did not directly report MOUD use, these further reduce the burden on PWUO by lowering the chances of uncontrolled withdrawal as well as overdose and thus the need for direct intervention within social networks. However, medication-based treatments have limitations such as not being desired by or appropriate for all PWUO (i.e., due to lack of healthcare accessibility or use pattern incompatibility) resulting in underutilization [39]. Due to increased suitability, potency, and availability individuals may instead turn to illicit options [39] which pose risk to peer groups due to likelihood of FASH use and ensuing withdrawal and overdose risks.

Because of these limitations, policy-level changes are warranted and findings from this study have important public health and policy implications. Data from result 1 (Preventing opioid withdrawal symptoms by sharing finances within social networks) shows how withdrawal has important financial implications, especially given the higher cost and shorter half-life of fentanyl [1,2], and how participants relied on moral economies (i.e., networks of friends and peers) to share money and reduce withdrawal occurrence. Data from result 2 (Cultivating and securing known and predictable social ties to prioritize steady supply of opioids) shows how participants build and access social networks within moral economies to source a steady and potentially more reliable dose and composition of opioids amidst a fentanyl-flooded market. Data in result 3 (Mitigating risk of overdose fatality by using opioids with peer groups) shows how participants relied on moral economies for safety assurance when potentially using FASH. Despite the variance in strong or weak social ties within moral economies, they acknowledged that the unregulated drug supply posed a larger threat and there were still high rates of overdose and associated risks.

Policy support for less restrictive prescribing laws, overdose prevention programs (OPPs), and safe/ safer supply are imperative to adequately mitigate overdose occurrence and fatality [39] as well as the social strain from the need for peer intervention (as indicated by result 3). Safe/safer supply and OPPs are two policy interventions to mitigate major risks associated with the unregulated drug supply [39]. Safe/safer supply refers to prescribing pharmaceuticals as an alternative to unreliable substances within the illicit market [39]. This is done to reduce the risk of overdose and other complications from using contaminated, unregulated, and unwanted substances.

OPPs are highly effective at preventing overdose. Participants needed strong social networks to reduce overdose risk and maintain social constancy. OPPs can support this by reducing the moral burden placed upon those intervening in the current opioid crisis [37]. Increasing access to safe consumption sites may reduce consequences of substance use such as overdose and infection while also connecting PWUO to healthcare, social services, and substance use treatment [44]. Implementing radical hospitality (i.e., developing positive relationships with guests via compassionate interactions) within safe consumption sites has been found in prior research to promote positive sociality and protect safety via reducing overdose fatality within groups of PWUO [44]. However, with a fentanyl-contaminated drug supply increasing risk for PWUO, other harm reduction measures are often insufficient to effectively address the burden associated with withdrawal, overdose, and fatality vigilance within social networks. As such, safer opioid distribution of pharmaceutical-grade products is needed [39]. This is further called for to alleviate the strain on finances and difficulty sourcing that our data presents in results 1 and 2 respectively.

We found that participants shared finances to reduce risk of withdrawal and overdose [25]. All of these programs will make accessing drug supplies, withdrawal management, and overdose prevention medication more affordable and accessible via policy interventions.

Low-barrier distribution sites are already in practice, such as at safe consumption sites [45] and opioid vending machines [42] in Vancouver, Canada. That these efforts are already successfully in place indicates the importance not of implementation resources but of community, medical, and governmental support [39,45,46]. We observe a successful history of safe/ safer supply in other countries as well. In Liverpool, England, individuals with decades long heroin prescriptions were medically and socially stable [47,48]. When the clinic was defunded, patients returned to accessing heroin via the illicit market and experienced houselessness, overdose, and other negative ramifications. When Switzerland implemented heroin-assisted treatment (HAT), drug-related deaths decreased significantly from 5.3 to 1.6 per 100,000 residents [49]. Germany also saw improved physical and mental well-being among those engaged in HAT [50].

The combined availability of safe/safer supply with OPPs could reduce risks associated with not knowing the dose and combination of the opioid and the ability to intervene meaningfully in case of overdose. Implementation of safe/ safer supply and OPPs meets the safety needs of PWUO while also serving to decrease drug market-related violence, increase well-being [39], and alleviate some of the demands faced in social networks [51]. While there is still work to be done to improve safe/ safer supply and other OPPs, these efforts are important harm reduction practices which improve social interconnectedness, community, and optimism [51] to improve health outcomes alongside social relationships.

Conclusion

Our findings emphasize that while peer support plays a critical role in safety within moral economies of PWUO, structural changes are needed to address the additional harms from an unregulated drug supply. Harm reduction interventions such as fentanyl test strip and naloxone distribution, as well as MOUD may improve safety. However, with a fentanyl-contaminated drug supply increasing risk for PWUO, safer opioid distribution of pharmaceutical-grade products and OPPs are needed to effectively address the burden of withdrawal, overdose, and fatality prevention within peer groups.

Supporting information

Acknowledgments

We would like to thank our study participants for their contribution to this research. Thank you to our current and past research assistants from the Bluthenthal Lab and Maternal Cannabis Lab who contributed meaningfully to this study.