How survivors of exploitation who use drugs navigate systems of care: an analysis of survivor insights using the intersectional risk environment

Drug-related risks such as adverse health outcomes, overdose, and violent victimization vary across populations due to the marginalization of identities, structural inequities, and differing environments. Discrimination and criminalization exacerbate drug-related risks specifically for survivors of sexual exploitation who use drugs. This study aims to understand how survivors who are not currently utilizing intensive treatment services perceive their risk environment, including available resources, and identify possible mechanisms to address health equity. Emphasizing the role of harm reduction and the expertise of lived experience, this paper encourages innovative approaches to supporting survivors. A research team conducted seventeen semi-structured interviews with survivors of exploitation who currently or formerly used drugs in a midwestern US state. This project emerged from a larger study exploring how survivors of exploitation navigated substance use treatment services. The team used Deterding and Waters’ twenty-first century flexible coding approach to generate both inductive and deductive codes for data analysis and met weekly to discuss codebook development and code application. The intersectional risk environment framework was used to interpret the findings. Survivors identified characteristics of the physical, social, policy, and economic risk environments that contributed to increased barriers to obtaining long term health and safety. While most participants had previously accessed intensive services for substance use disorder (SUD), restrictions on geographic mobility, poor medical care, and disproportionate criminal-legal involvement were noted as persistent issues faced by survivors upon leaving SUD services, that contributed to ongoing substance use and health inequities. Barriers across risk environments were compounded by the dual stigmatization of drug use and exploitation and further escalated for those with multiple marginalized identities. Increasing access to harm reduction for survivors who use drugs requires a multipronged approach that tackles structural drivers of inequities as well as community and individual level stigma and discrimination. Critical, actionable research that accounts for this complexity is needed to advance health equity for this group.