Out of Sight: Sex Differences in Public and Semi-Public Drug Use Settings Among People Who Use Opioids in Baltimore, Maryland

BACKGROUND: Drug use settings are critical determinants of overdose risk and other drug-related harms. Although sex differences in drug use patterns are well documented, less is known about sex differences in the types of locations where people use drugs. This study examined sex differences in drug use settings among people who use opioids. METHODS: Data were from the baseline survey of the OASIS project, a community-based study conducted in Baltimore, Maryland (N = 869), focusing on 9 specific types of locations where participants reported drug use in the past 30 days: their own residence, someone else's residence, street, alley, park, abandoned building, public restroom, car, and other locations. Bivariate and multivariable logistic regression models examined associations between sex and drug use settings, adjusting for age, race, education, homelessness, and frequency of drug use. RESULTS: The sample included 346 women and 523 men. In adjusted models, women had significantly lower odds than men of using drugs on the street (aOR = 0.49, 95% CI 0.35-0.70), in alleys (aOR = 0.50, 95% CI 0.35-0.69), parks (aOR = 0.57, 95% CI 0.42-0.78), abandoned buildings (aOR = 0.53, 95% CI 0.38-0.75), cars (aOR = 0.55, 95% CI 0.41-0.73), and other locations (aOR = 0.59, 95% CI 0.37-0.94). Sex was not significantly associated with drug use at one's own residence or someone else's residence. CONCLUSIONS: Women who use opioids were significantly less likely than men to use drugs in public and semi-public settings, which may reflect gendered patterns of stigma, interpersonal violence, and safety concerns. Harm reduction programs should focus on making current drug use settings safer and developing additional safer settings with an emphasis on addressing barriers for women to access harm reduction services, including women-centered overdose prevention centers and household-based overdose response training.