Opioid withdrawal as a barrier to harm reduction: Examining how overdose prevention behaviors are affected by withdrawal

Background and objectives

In the past decade, the increasing availability and prevalence of fentanyl in the drug supply have heightened the risk of fatal overdose and increased the frequency and severity of opioid withdrawal symptoms. We aimed to examine how opioid withdrawal impacts engagement in harm reduction behaviors among people who use drugs.

Methods

Data came from a community-based research study in Baltimore, Maryland, conducted from 2022 to 2024. Participants were adults who used heroin, fentanyl, or prescription opiates to get high in the past month (N = 676). Structured surveys assessed withdrawal as a barrier to testing drugs for potency and overdose prevention. Logistic regression models were used to identify correlates of engagement in harm reduction during periods of withdrawal.

Results

Half the sample (46.6 %) reported that withdrawal “always” or “often” prevented them from testing drugs, and 66.6 % agreed that withdrawal was a barrier to overdose prevention. Depression symptoms (adjusted odds ratio (aOR): 1.56, 95 % CI 1.09–2.25), increased opioid use per week (aOR: 1.12, 95 % CI 1.03–1.22), and White race (aOR: 1.75, 95 % CI 1.16–2.62) were independently associated with lower engagement in drug testing and overdose prevention during withdrawal.

Conclusions

Withdrawal significantly impacts engagement in harm reduction behaviors, even among those with high awareness and receptivity to drug testing and overdose prevention strategies. Withdrawal management and mental health support are emergent and critical components for harm reduction interventions to prevent overdose morbidity and mortality among people who use drugs.