There has been an unprecedented shift from injecting to smoking unregulated drugs.

There is a perception that smoking has less overdose risk relative to injecting.

Drug smoking-related overdose is common.

Overdose is complicated by the toxic drug supply, including cross contamination of stimulants with fentanyl.

Smoking unregulated drugs has increased substantially in British Columbia. Intersecting with the ongoing overdose crisis, drug smoking-related overdose fatalities have correspondingly surged. However, little is known about the experiences of overdose among people who smoke drugs accessing the toxic drug supply. This study explores perceptions and experiences of overdose among people who smoke drugs.

We conducted interviews with 31 people who smoke drugs. Interviews covered a range of topics including overdose experience. Thematic analysis was used to identify themes related to participant perceptions and experiences of smoking-related overdose.

Some participants perceived smoking drugs to pose lower overdose risk relative to injecting drugs. Participants reported smoking-related overdose experiences, including from underestimating the potency of drugs, the cross-contamination of stimulants with opioids, and responding to smoking-related overdose events.

Findings highlight the impact the unpredictable, unregulated, and toxic drug supply is having on people who smoke drugs, both among people who use opioids, and among those who primarily use stimulants. Efforts to address smoking-related overdose could benefit from expanding supervised smoking sites, working with people who use drugs to disseminate accurate knowledge around smoking-related overdose risk, and offering a smokable alternative to the unpredictable drug supply.

© 2024 The Authors. Published by Elsevier B.V.