Substance Use
Violence, criminal legal system contact, and incidence of nonfatal overdose among sex workers who use criminalized drugs: Findings of a recurrent event analysis (2010-2024) Shira Goldenberg* Shira Goldenberg Andrea Krüsi Wiebke Bartels Charlie Zhou Sarah Moreheart Kate Shannon
Background: While prior research has highlighted impacts of a toxic drug supply on overdose risk, limited work has examined the gendered impacts of violence and criminal legal system contact among women, which are determinants of health for people who use drugs. We prospectively evaluated the impacts of violence and criminal legal system contact on nonfatal overdose events in a marginalized occupational cohort of women who use drugs.
Methods: Baseline and semi-annual data were drawn from a community-based cohort of women sex workers in Vancouver (2010-2024). Analyses were restricted to participants who used criminalized drugs with valid outcome data; analyses of violence and criminal legal system contact while working were further restricted to visits during which participants did sex work. We used the Andersen-Gill method to develop recurrent time-to-event models of the association between recent gender-based, workplace, and neighborhood violence, criminal legal system contact and nonfatal overdose over 15-years.
Results: Among 600 participants (4647 observations), 39.3% (n=236) experienced at least one nonfatal overdose over 15-years, contributing 511 events and an event rate of 18.95/100PY. The proportion who experienced one, two, or ≥three overdoses over follow-up was 20.8%, 8.5%, and 10%, respectively. In separate models, experiencing recent gender-based (Adjusted Hazard Ratio (AHR): 1.95, 95% CI: 1.63,2.33), workplace (AHR: 1.96, 95%CI: 1.54,2.50), and neighborhood (AHR: 1.38, 95%CI: 1.06,1.79) violence, and police harassment without arrest (AHR: 1.74, 95%CI: 1.18,2.56) were associated with elevated hazard of nonfatal overdose.
Discussion: Sex workers face high incidence of nonfatal overdose, with almost one in five experiencing multiple overdoses over this 15-year study. Structural interventions to reduce criminal legal system contact and violence exposure are recommended, alongside scale-up of women-specific and sex worker-tailored overdose prevention services.