Personal and Vicarious Overdose Experiences Among People Who Co-Use Stimulants and Opioids

BACKGROUND: Overdose is a leading cause of death in the United States, with nearly half of recent fatalities involving both opioids and stimulants. People who use drugs (PWUD) frequently experience and witness overdose, yet relatively little is known about how overdose is experienced and processed by those who survive it, or the factors shaping subsequent changes in drug use behavior, risk practices, or care-seeking. METHODS: This study is a secondary analysis of 30 qualitative interviews conducted with a demographically and geographically diverse sample of people who co-use opioids and stimulants in Maryland. Using a lifecourse thematic approach, we analyzed participants' descriptions of overdose experiences in the context of their broader opioid and stimulant use trajectories to explore how these experiences influenced drug use behavior. RESULTS: Participants described three types of overdose experiences: personal, vicarious, and anticipated. Two primary sets of factors shaped whether behavior change followed personal or vicarious overdose. The first - perceived severity, emotional closeness, and prior exposure - influenced emotional impact. The second - perceived control, mental health needs, and availability of support - shaped whether emotional impact led to behavior change. Anticipated overdose often prompted behavior change not in response to a discrete event but to participants' anticipation of future overdose - driven by fear, declining health, or the unpredictability of fentanyl. CONCLUSION: Findings highlight the post-overdose period as a critical window for timely intervention and underscores the need for proactive engagement well before an overdose occurs. Interventions that address emotional and structural dimensions of overdose risk, including mental health care, housing stability, and compassionate, low barrier support are needed.