Understanding Overdose Risk Perception in People who use Drugs - A Systematic Review

Background:  In the context of changing drug markets and the international overdose death crisis, responses require an understanding of the risk perception of people at risk of overdose as understood directly by those with living experience. This study aimed to summarise findings in the qualitative and quantitative literature on individuals overdose risk perception, theories of overdose risk perception, and potential strategies people who use drugs use to reduce their own personal risks.
Method: A systematic review and narrative synthesis of articles from 7 databases was performed (from 1806- March 31st, 2023). The review was completed using the PRISMA guidelines for systematic reviews and preregistered on PROSPERO (CRD 42023403755). Quality appraisal was carried out using the Mixed Methods Appraisal Tool. Papers were included in the study if they contained a description of perception of overdose risk from the view of people who use drugs (one or more opioids, heroin, morphine, benzodiazepines, pregabalin, psychoactive substances, flubromazolam, flualzaprolam, etizolam), and had qualitative or quantitative descriptors of individual level perceptions of risk and/or of behaviours arising from that risk. Papers using mixed methods approaches, cross-sectional, case-control, interviews/focus groups, and cohort studies were included. Only English language papers were included.
Results: From the search 374 papers were found, 229 of these were duplicates, 145 were screened for abstract and title review. 35 papers were included. Narrative analysis of the data extraction are ongoing. Preliminary results would suggest an overall low perception of risk of overdose from people who use illicit drugs more frequently or engage in longer term use. People who have had an overdose more recently have a higher overdose risk perception than those who have not had one recently. People who use drugs had a higher perception of risk for their peers than for themselves, explained through a potential optimism bias. Factors which influence overdose risk perception may be trust of the dealer, having experienced a peer or themselves overdose, self-efficacy of using drugs, knowledge of how to respond in an overdose situation, the type and way of using drug (snorting, injecting, smoking, oral ingestion) and using alone.
Conclusions: Effective solutions to reduce the risk of overdose and fatalities from overdose must take into consideration the voices of those at risk of overdose. It is hoped that this will help support future efforts to improve our overdose prevention and response.