“Another one bite the dust—It happens so much in Black neighborhoods”: Structural barriers and grassroots resources among Black men who use drugs facing fentanyl-era overdose and treatment disparities

Introduction: Black men in the United States have been disproportionately impacted by fatal drug overdose since the proliferation of synthetic opioids like fentanyl. This community based participatory research study examined determinants of overdose risk and substance use treatment disparities among Black men based on their lived experience. Methods: Between February and December 2023, we enrolled 35 Black men reporting past-30-day opioid use to complete semi-structured qualitative interviews. Interviews were analyzed by a team of academic and community-based coders with lived experience using an inductive—deductive approach to thematic analysis. Results: Six key themes were identified. Four themes described racism-related inequities posing overdose and comorbid risks to health and social wellness: (1) social stigma and isolation, (2) pervasive exposure to deadly drugs and overdose, (3) disproportionate exposure to trauma and societal consequences, and (4) gaps in health-related services and resources. Two themes addressed grassroots strategies Black men who use drugs employ to reduce harm and maintain wellness: (5) safe practices in drug purchasing, drug use, and overdose response, and (6) positive community and social supports. Conclusions: Findings demonstrate how structural inequities like neighborhood segregation and economic deprivation interact with racial and substance use stigma, leading to daily experiences of social isolation, trauma, and fentanyl exposure for Black men. Findings extend previous research by illustrating how Black men work in and outside of systems to maintain wellness despite these vulnerabilities. Reducing the burden of overdose among Black men requires policy efforts that redress resource deprivation in Black neighborhoods and builds upon existing grassroots efforts and lived experience.