The habitus of care: Overdose normalization, reversal expertise, and the invisible moral labor of people who use drugs.
Social science & medicine (1982) · 2026-07-06 · Qualitative study
Abstract
BACKGROUND: People who use drugs represent a significant yet underrecognized frontline against overdose fatality. While overdose education and naloxone distribution programs provide basic training, little is known about how expertise develops through repeated real-world encounters with overdose. METHODS: We conducted semi-structured interviews with 74 people who had administered naloxone within the past year, recruited through harm reduction programs in Pennsylvania, Michigan, and California between October 2024 and March 2025. We conducted reflexive thematic analysis, with the Critical Decision Method guiding our elicitation and coding of decision points and contextual cues during overdose response. Bourdieu's theory of practice provided the interpretive framework for understanding how response skills develop and are enacted as embodied expertise in community settings. RESULTS: Most participants had reversed multiple overdoses, with 34 reporting more than ten reversals and four reporting hundreds. Three themes emerged: (1) overdose response became normalized as an expected, obligatory feature of everyday life rather than exceptional heroism; (2) repeated exposure cultivated tacit expertise characterized by calm and confidence, automatic recognition, and intuitive decision-making; and (3) during overdoses, experienced responders described entering focused flow states, taking charge, and improvising effectively under pressure. Despite demonstrating practical mastery comparable to professional emergency response, participants deflected recognition and minimized their contributions. CONCLUSIONS: People who use drugs develop sophisticated, embodied expertise through repeated overdose encounters, yet this labor remains invisible, unsupported, and uncompensated. Public health systems rely on peer response without providing parallel structures of protection, trauma support, or legitimization afforded to professional first responders. Promoting sustainability and equity in community overdose response requires acknowledging and supporting this essential workforce.
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Tags
Antidotes · Bystanders · Clinician perspective · Equity & disparities · Naloxone
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