Abigail Winiker received her PhD from the Johns Hopkins Bloomberg School of Public Health. She currently engages in research and harm reduction practice in Baltimore, MD. She adopts qualitative methodology to amplify the voices of people who use drugs and advocates for stigma reduction and drug decriminalization.

Introduction: To date, most research conducted with people who inject drugs (PWID) remains deficit focused, characterizing vulnerabilities, risk, and negative outcomes associated with substance use. Resilience is defined as the ability to bounce back from stress and adversity and has been associated with improved outcomes among individuals exposed to stressors. However, resilience research among PWID is scarce. This study sought to characterize multilevel resilience mechanisms employed by PWID to better understand the unique ways in which they demonstrate strength when faced with adversity.

Methods: Two rounds of in-depth interviews were conducted with a sample of PWID in Baltimore, MD between April, 2023 and March, 2024. N=22 participants completed a first interview, and N=14 (64%) returned for a follow-up. Inclusion criteria were self-report: 1) past six-month injection drug use; 2) age 18 or older; 3) 1+ lifetime traumatic experience(s); 4) currently residing in the Baltimore area, and 5) willingness to participate in an in-person interview. The initial guide probed participants to describe multilevel responses to stressors. The follow-up guide was adapted to focus upon participants’ abilities to “bounce back”, “move forward”, and “keep going” in the face of adversity.

Results: Participants demonstrated a unique capacity to keep going despite reporting significant histories of trauma. Many unique resilience mechanisms were identified which operate at the individual-level through cognitive, emotional, and behavioral mechanisms; interpersonal-level through social mechanisms; and external-level via community, structural, and place-based mechanisms. The specific factors comprising each mechanism are enumerated in depth.

Conclusions: PWID are highly resilient and demonstrate a unique capacity to adapt to adversity. These findings can inform subsequent programmatic and intervention-work to better support PWID to build and enhance strengths-based responses to stressors. We call for a paradigm shift in substance use research to highlight and enumerate the many strengths and capacities for adaptation demonstrated by PWID.