Introduction: Considering the escalating global rates of drug-induced fatalities, our aim was to explore the structural vulnerabilities encountered by individuals with a lived-living experience of overdose among people who use drugs (PWUD). Through the framework of enabling environments, we aimed to analyse these viewpoints, with the objective of informing the development of more inclusive harm reduction strategies tailored to address overdose.

Approach: We utilised an exploratory and co-design approach, engaging individuals with lived-living experience of substance use and overdose as peer researchers. Semi-structured interviews were conducted with 30 PWUDs in Queensland, Australia, who had experienced and witnessed drug overdose incidents. Employing an iterative coding process, we integrated both deductive and inductive coding techniques to analyse the data.

Key Findings: The systemic challenges faced by PWUD contribute to a risk-laden environment that heightens the potential for overdose. Structural barriers such as healthcare and legal stigma surfaced as significant hurdles to reducing harm, shaping individuals' reactions to overdose incidents. Participants stressed the need for a comprehensive harm reduction environment, advocating for the integration of various services including increased peer engagement and workforce, naloxone distribution, drug checking facilities and supervised consumption sites.

Discussions and Conclusions: The results underscore the necessity of a multi-layered harm reduction strategy—including peer engagement and leadership, naloxone, drug checking and supervised consumption. Such an approach would signify a proactive stance in tackling drug-related harm and death, thereby fostering improved health outcomes.

Implications for Practice or Policy: We emphasise the need to destigmatise drug use and prioritise comprehensive enabling environments for PWUDs—free from stigma. Policymakers should heed the call for increased provision of supervised consumption rooms, aligning legislation with harm reduction needs. In practice, we draw attention to the critical importance of expanding peer engagement and workforce within harm reduction initiatives.

Disclosure of Interest Statement: We thank Queensland Mental Health Commission for funding this important work.