"The community’s memory is timeless", Exploring Cultural and Community Context to Inform the Public Health Response to the Overdose Crisis in Black Communities

Background: Substance use treatment and harm reduction strategies are vital tools in addressing the overdose crisis, however, effectiveness depends on access and uptake. Little is known about perceptions of harm reduction and substance use treatment efforts among people who use drugs (PWUD) in minoritized communities and how to enhance acceptability and uptake of evidence-based care. Our aim was to explore perceptions of drug use, PWUD and approaches to harm reduction and treatment in an urban, predominantly Black neighborhood heavily impacted by overdose. Methods: We conducted one-on-one, semi-structured interviews with a purposive sample of participants living or working in West and Southwest Philadelphia, focusing on factors influencing uptake of substance use services. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Results: We completed 19 interviews. Mean participant age was 46, 78% were women; 83% were Black/AA. Half of participants worked with PWUD in health or social service roles (50%), and the majority had lived experience of substance use personally or with a close friend or family member (83%). Participants reported several factors of attitudes toward substance use, PWUD, and addiction care in the community. First, participants frequently referenced the legacy of the punitive drug policies regarding current community apprehension about substance use services. Participants reported a high degree of community stigma towards PWUD, as well as a view of harm reduction as an endorsement of drug use rather than a public health effort. Stigma also shaped cultural norms, limiting acceptability of care-seeking among PWUD. In addition, participants highlighted the toll of systemic racism, noting that it contributed to generational trauma, substance use, and overall vulnerability to addiction and overdose. Finally, participants emphasized the importance of community-driven initiatives, culturally appropriate services, and expanded outreach to actively address and dismantle the structural inequities. Conclusion: Overall, participants from West and Southwest Philadelphia described how the combined impact of the war on drugs, systemic racism, and medical system mistrust has shaped the experiences of Black PWUD and their communities. Participants highlighted the need for equitable, culturally responsive public health policies that safeguard the provision of harm reduction services for Black PWUD.