"You've involved us knowing that we don't think about the law like you": a qualitative study on Supersavers' perspective of overdose engagement in Skåne county, South Sweden.

Abstract

Background: People with illicit opioid use have a high risk of overdose related morbidity and mortality. A small group of Supersavers (i.e., individuals who have administered naloxone on three or more overdose occasions) carries a substantial burden by managing a high proportion of overdose reversals. Despite their critical role, little is known about how Supersavers' experiences of repeated overdose reversals, their own overdose risks and its mitigation, or the support needed to sustain their engagement. This study examines Supersavers' contextual experiences, their views on risks, responsibility, and overdose engagement, and their need for healthcare support.

Methods: Semi-structured interviews were conducted with thirteen Supersavers recruited from Malmö needle and syringe program. Thematic analysis was conducted whereupon analysis was guided by Bourdieu's theories on habitus, capital and field and Rhode's 'risk environment' framework.

Results: Supersavers were deeply committed to helping others and widely recognized for their skills, often having managed multiple overdoses prior to naloxone availability. This responsibility functioned as an embodied readiness to act, reflecting a habitus shaped through repeated exposure and supported by experiential ("street") capital, including technical skills and peer trust. Access to training and naloxone strengthened this capacity, increasing perceived safety and reducing the physical and emotional burden of overdose reversals. While repeated exposure to overdose contributed to normalization, it also involved cumulative emotional strain, and most participants had not sought professional support despite experiencing multiple traumas.

Conclusion: These findings show how Supersavers' practices emerge through the interplay of habitus, capital, and risk environment, where engagement is sustained by responsibility yet shaped by structural constraints. Strengthening harm reduction responses requires not only continued access to naloxone and training, but also accessible, context-sensitive healthcare support that addresses both Supersavers' own overdose risk and the emotional burden associated with repeated reversals.

Trial registration: NCT03570099, registered on 26 June 2018.