Survival Strategies While Using Drugs Alone
This guide reflects knowledge and experience directly from people who use drugs about why solo drug use usually occurs, and on safety strategies employed by people who use drugs to survive amid the fatal overdose crisis.
Survival Strategies While Using Drugs
Alone from People Who Use Drugs
Overview
Using drugs while alone is a leading risk for overdose death. Despite messaging from harm reduction and public health sectors encouraging people who use drugs never to use drugs alone, many who have succumbed to overdoses are found alone. This guide reflects knowledge and experience directly from people who use drugs about why solo drug use usually occurs, and on safety strategies employed by people who use drugs to survive amid the fatal overdose crisis. This is even more critical as fentanyl and other contaminants in the drug supply are implicated in many overdose deaths.
To inform this guide, Project SAFE held harm reduction skillshares and story-shares with a Philadelphia-based collective of women, queer, and transgender people who use drugs and do sex work. (Skillshares, or story-shares, are collaborative workshops held to facilitate sharing of skills, stories and experiences related to a particular topic.) People who use drugs are among the most stigmatized and marginalized populations in our society, and this status is further compounded by gender and sexual identity. Centering these communities in the development of guidelines and services helps to ensure no group is left out, and that unique vulnerabilities and exposures to interpersonal and structural violence are adequately addressed.
In order to remain safe from and prevent the spread of COVID-19, many people who use drugs are following public health guidelines and remaining isolated from others. While critical to controlling the pandemic, these safety measures have led more people to use drugs alone and further complicated messaging. In addition, many people who use drugs have switched from heroin to fentanyl. This guide reflects both of these realities and aims to support service providers in updating messaging to account for current contexts and preferences. Adapting messaging to account for changing community contexts and preferences is vital to survival.
This guide aims to uplift the voices of people who use drugs and educate others about the contexts of their lives, strategies employed for survival in the midst of a fatal overdose crisis, and suggestions for improvements to harm reduction and public health messaging with regards to never use drugs alone.
Table of Contents
In this guide, people who use drugs discuss how they mitigate overdose risk, and their safety-based reasons for using drugs alone. Contents of this guide include:
3 The spaces and situations where drugs are used alone
3 Some reasons for using drugs alone
4 Skills and strategies people have developed for preventing an overdose when using drugs alone
7 Problems with standard messages about safer use
7 Overdose prevention and sex work
8 Suggested messages for safer use from people who use drugs
9 Guidance for hosting a harm reduction skillshare
The spaces and situations where drugs are used alone
People who use drugs alone shared that there are many spaces and situations where it may actually feel safer to use drugs alone.
People use drugs while alone when there is not a safe person around. Spaces where drugs are used alone are not only physical. Using alone also means there isn’t a safe or trusted person around, irrespective of the physical space.
Some spaces for using drugs alone are about convenience, such as a public bathroom, an alley, an abandoned home, a tent, on public transportation, a “quick shot while walking,” or one’s home or room. Fentanyl use has also increased the number of times per day people need to use, making convenient space all the more important.
A person might choose to consume drugs in open view if a safe or trusted person isn’t around, and/or for convenience. However, using drugs in open view may involve similar risks to using drugs alone in an isolated, physical space, if no one is likely to respond to an overdose.
Use in the presence of other people does not ensure safety or overdose response. Just because people are around does not mean anyone will respond to an overdose. For example, if a person is panhandling and overdoses, or is homeless in the street, it is likely others would just continue walking by, assuming the person is sleeping or not caring.
Some reasons for using drugs alone
To address the vulnerabilities of using drugs alone, it is important to understand and contextualize the experiences of solo drug use. People often use drugs alone, and may prefer consuming drugs alone for reasons of safety. Such reasons include:
Being high puts people in a position where they are more likely to be harmed by others. You have to be around someone safe when you are vulnerable. A safe person means someone who:
+ Won’t rob you if you’re really high
+ Won’t assault you
+ Will attend to you if you overdose
Finding someone around like this every time a person wants or needs to use is unlikely. Using drugs alone is sometimes the safest option, despite the accompanying risk of overdose death.
Drugs can be consumed, felt, and embodied to their fullest effect when alone. There are no distractions and no need to worry about guarding from harm caused by another individual. Using drugs alone allows one to feel pleasure, relief from pain, or other desirable effects— and not to be bothered by others.
+ “Peace and quiet. I don’t think of nothing. Being alone is my bag.”
+ “Going to another level, escaping.”
+ “At home. I feel relaxed there.”
+ “Using alone means tranquility.”
Sometimes using with others is accompanied by an expectation of sharing drugs, and when a person hustles hard for their money, it doesn’t feel fair to have to share.
+ “I don’t like using with other people because then I have to cater to them.” + “If it’s on my dollar, it’s going to be alone.”
People who assist with injection and who also use drugs themselves, sometimes called “hit doctors,” don’t always feel like working. For people who work as “hit doctors,” consuming drugs in the presence of others is usually accompanied by an expectation of doctoring others. Consequently, they may prefer to use drugs alone when they don’t want to work.
+ “I love using by myself in the bathroom. That’s the only way to avoid the people who want me to hit them up all the time. I had a line of people this morning.”
Skills and strategies people have developed to prevent an over dose when using drugs alone
People shared many creative and effective strategies that they have developed to help avoid overdose while using drugs alone. Service providers can encourage these strategies as part of a harm reduction approach.
LEARN ABOUT THE DAY’S DRUG SUPPLY
Request feedback from people who use drugs about the day’s drug supply. In many places, it is possible to track different batches of dope (heroin/fentanyl) by the stamp they are given.
+ “I don’t depend on people to reverse an overdose but I do rely on them to tell me about the state of drugs that day.”
+ “I talk to everyone— people call me Sherlock Holmes, I’ve never overdosed. I ask a lot of questions about the dope.”
- Local harm reduction service providers should maintain a public tracking system about the day’s supply, and make sure it’s visible and accessible to people who use drugs.
- Query a local network of peers. Some questions to ask about the day’s supply include:
+ What was the high like?
+ Is it a creeper [i.e. did it take a while to feel it or was there an immediate rush?]?
- If there is no immediate rush, it might be perceived as weak and overused when really, it’s just a creeper.
+ Does it have legs [i.e. how long did it last?]?
+ Does it knock you out/put you to sleep?
+ Does it have K2?
+ Does it make your heart race?
+ When’s the last time you did it?
- Keep asking until there is enough information. Information from peers, specifically trusted peers, whose drug use looks similar to their own is considered trustworthy. This information can help people to decide how to prepare a test shot, maybe starting with one-quarter or one-half a bag, instead of a whole bag.
- The time of day can indicate how strong the dope is at any particular time during the day so learning the patterns of local sales can help understand the fluctuations of the dope throughout the day.
+ “Try not to cop at night. You might get empty bags, get trash. People hang out on blocks that are not theirs and try to sell you inferior stuff.”
USE SENSORY APPROACHES TO GET INFORMATION ON QUALITY AND POTENCY. + Taste - A quick finger dab on the powder and to the tongue to see if it tastes different or off.
+ Touch - Is the dope a different texture or consistency than usual - hard, sticky, crumbly, powdery?
+ Sound - Listen to what people are saying about the bag, or if people’s voices sound odd or they are making gurgling sounds after using.
+ Sight - Is the dope a different color than usual?
+ Observe - Scan how people are reacting to the day’s drugs. If other people seem particularly sleepy or spaced out, it usually means the day’s supply might be contaminated with something strong.
+ Feel - What do others say it felt like or what does using a little bit of the drug feel like? Remember to ask questions.
PLAN BEFORE USING
- Ask someone to check in with you periodically. Some people who use drugs, especially those who are considered elders in the community are paid to sit with other people who are using, to watch and respond in the event of an overdose, acting as “sitters.”
+ “I usually have a neighbor check on me. She does crack so she knows about drugs.”
- Call someone on the phone to talk you through a test shot, and have a plan in case of overdose. Have a safety plan with the person on the phone for what they will do in the event you stop talking.
- Keep a cold drink, ice, or apple cider vinegar on hand, to “perk” up if the effect is too heavy. People sometimes use stimulants like meth and coke to balance a heavy high, but this can be dangerous, and may not be effective.
- Consider how high you want to get. If you want to get REALLY high when you are alone, use a bit around other people first, to test the potency of the batch.
- Use alone, but have a plan to go to a place afterward where naloxone is available, in the event it is needed.
- Some people find it helpful to administer small amounts of naloxone to themselves if they feel the dose is immediately too powerful.
- Some people choose not to use free “samples” that are distributed, because they feel they are too strong.
Service providers can use this knowledge to inform a harm reduction approach. For example, to help people learn about the day’s drug supply, harm reduction service providers could maintain a public tracking system describing the daily supply, and make sure it is visible and accessible to people. Service providers might also routinely ask people about their plan for using drugs during their interactions.
Problems with standard messages about safer use
- “Never use alone.”
- Feels infantilizing, because it’s a no-brainer that using drugs alone is risky. Other safety concerns often outweigh the risks of using drugs alone.
+ “It’s like telling someone to put themselves at-risk of being raped.”
+ “It sounds like someone looked at medical examiner data and decided to tell us what to do.”
+ “They need to ask WHY people use alone rather than tell them not to use alone.”
+ “This sounds shaming because it means if you die it’s like you deserve it for using alone. But these organizations aren’t considering all the other stuff we have to think about when using around other people.”
- Not everyone has friends or trusted peers to use with, or to be around when they use.
Overdose prevention and sex work
It is not uncommon for an infrequent opioid user to negotiate a date that includes opioid use as part of the experience. This often places the person who is selling/trading sex in a position to purchase the drug and respond to an overdose if the client happens to overdose. Lessons from the sex work community offer helpful strategies for managing these situations.
Have a frank discussion with the client about how frequently they use opioids, when was the last time they used opioids, and if they have ever overdosed.
+ Previous overdose increases the probability of future overdose
- Have naloxone on hand— this will increase the safety of both the worker and the client.
+ If the client has no opioid tolerance or isn’t a regular opioid user, they will not wake up in withdrawal from a naloxone dose.
+ If naloxone isn’t on hand, have a plan with your client about what to do or who to call in the event of an overdose. You could plan to use an overdose response app, or a person who is available nearby.
- If possible, spend some time early in the date teaching safer drug use skills and how to respond to an overdose, so that overdose precautions become part of the date.
- “Try before you fly.”
- Sounds ominous, like there is something wrong.
+ “Do they know something about the drug supply I don’t know?”
- This suggestion doesn’t account for how long it can take to find a vein.
- Some noted that they have damaged veins and consume drugs alone because they need the time to patiently locate a viable vein.
+ This results in difficulty doing a test shot because of the amount of time it takes to “see a flash” (find a vein), and so it’s considered most efficient to do the entire shot.
+ Suggestions to inject a small amount while keeping the syringe in the vein is especially complicated if the drug is “a creeper.” One won’t know the strength until it hits (which could take minutes with a creeper).
- People with a high tolerance won’t feel this message applies to them.
+ “It doesn’t translate for me. It doesn’t apply because I don’t ever actually get high. The drugs just go through me. It applies more for new people.”
+ “It doesn’t apply. I just bang it out. You have to understand, I’m a beast. I used to be on 735mg of methadone and I was fine.”
- “Flood the Streets With Naloxone.”
Consider how messaging such as this could have the opposite of the intended effect. + “That scares people and drives them into hiding. No one wants to be “narcanned”. They want to get high.”
Show that naloxone is being distributed responsibly, and people know how and when to use it. Some people who use drugs feel they have been administered naloxone prematurely, and hide from people to prevent that from happening, compounding the already-existing problems of criminalization and stigma.
Suggested messages for safer use from people who use drugs
More effective, nuanced messaging can be developed based on the experiences and perceptions of people who use drugs.
- Tailor messaging to “Never Use Alone.”
Consider that successfully consuming drugs with others is predicated on identifying someone who 1) is trusted, 2) has their own drugs, and 3) knows how to respond to an overdose.
- “Stick with who you trust.”
+ Consider what features make a person trusted or safe
+ Consider hosting a skillshare on trust for overdose prevention
+ “Never use with someone you don’t know. Find your trusted crew and stick with them.”
- “Have a plan. Make a plan. Keep the plan.”
+ Have a road map for holding you over if you are alone, and for getting really high if you are with a trusted person.
- Tailor messaging to “Try Before You Fly.”
Consider how messaging can be geared towards pleasure rather than health outcomes. people who use drugs are seeking substances and experiences that foster pleasure. When pleasure is prioritized, safety will be a byproduct. For example, if “Try Before You Fly” was coupled with “Try It to See if You Like It,” it might land better.
- “You can always do more, you can never do less.”
- “Start out small. You can always add, you can’t take it away.”
- “Listen to your body, everybody wants to get high, wants to get high, wants to get high - but go slow.”
- Consider messages about plans for using drugs, and managing a body response. + “Don’t use anything new alone.”
+ “Don’t change your dose alone.”
+ “Ask others how the daily batch is.”
+ “Drugs fluctuate daily. See what’s going on first.”
+ “Fight the urge to use too much alone”
+ “Wait to get really high until someone safe is around.”
+ “Ask yourself where are you at emotionally? Are you feeling stressed? Take deep breaths. Don’t rush.”
+ “Walk around for a bit after using a new batch until you know how it hits”
Guidance for hosting a harm reduction skillshare
This guide was informed by a collective of women, queer, and transgender people who use drugs. During and after the skillshares that informed this guide, we witnessed a collective-protective effect from reframing people who use drugs as survivors amid a time when the drug supply is fluctuating and isolation and overdose rates are soaring.
Hosting a harm reduction skillshare
A skillshare can be hosted in any community of people who use drugs, so that people who use drugs in different contexts can share expertise to mitigate the risks that impact their daily lives. Below is a step-by-step instruction on hosting a harm reduction skillshare on a selected pre-determined topic.
The goal of a skillshare is to cultivate leadership skills and acknowledge expertise within the community you are seeking to work with and learn from.
When conducting a skillshare:
- Select the topic in advance, and notify participants of the topic you will be discussing.
- Allow the group of participants to establish the time frame.
- Keep the length to 30 minutes to 45 minutes.
- Establish norms and expectations of behaviors, engagement, feedback, and disagreements (i.e. “what’s shared here stays here, what’s learned here leaves here.”)
- Create space for clarification and dialogue during the skillshare.
- Ask the group for a volunteer to facilitate, to open the meeting by discussing the selected topic for 5 to 10 minutes.
- Pay the facilitator and group members for participating, and offer food.
- Skillshares take away from other time needed to raise the funds to purchase drugs and other needs so it is important to compensate people for their time and hard-earned knowledge.
- After the facilitator opens the meeting with their discussion, the skillshare is open for others to discuss and build upon what was said.
- Allow the end of the skillshare to become an opportunity for creating a topic for the next skillshare, and identify a facilitator.
Other ideas for skillshares
- Preventing overdose
- Strategies for using drugs safely in a group
- Sexually Transmitted Infection prevention
- Mixing drugs
- Safety strategies for different styles of consumption
- Dealing with the medical system
- Experiences with medication-assisted treatment
About Project SAFE
Project SAFE is a harm reduction organization whose mission is to provide mutual aid-based harm reduction for women, queer, and trans people involved in the street economies of Philadelphia, PA. Project SAFE is based in the Kensington section of Philadelphia, a neighborhood saturated by drug use and sex work. Philadelphia is consistently among large cities with the highest rates of opioid overdose fatalities. The present guidance document is for people who use drugs and harm reduction organizations, with content developed by people who use drugs through discussions with the Project SAFE community about strategies for survivorship amid the opioid overdose fatality crisis. This document is rooted in principled harm reduction as it: 1) “ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them” and 2) “seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.” This guide affirms those principles by asking people who use drugs for their reasons for using drugs alone, the strategies they use to prevent an overdose when using alone, how current harm reduction messaging lands, and tips for better harm reduction messaging.
www.projectsafephilly.org
safephila@gmail.com
https://www.facebook.com/safephila/
twitter: @ safephila
instagram: safephila
Resources: Never Use Alone Hotline: (800) 484-3731
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