Background: Fatal and nonfatal opioid overdoses remain a pressing public health challenge. However, engagement in drug overdose prevention and response behaviors may vary across demographic and social contexts.

Objectives: This study examines individual and social determinants of these behaviors among people who use opioids (PWUO), leveraging data from the OASIS study in Baltimore, Maryland (N = 783). Ordered logistic regression models assessed factors associated with three key behaviors: testing-dosing to assess drug potency, naloxone availability while using with others, and solitary drug use.

Results: The three key overdose prevention behaviors were not strongly correlated with one another. Racial disparities emerged, with Black participants more likely to engage in test-dosing compared to White participants. Gender differences were also notable, with women less likely to use with others who have naloxone available when using drugs. Social network factors played a key role; having a “running buddy” was strongly protective against solitary drug use.

Conclusions: These findings underscore the importance of tailored harm reduction interventions that address racial and gender disparities, enhance social networks, manage withdrawal, and enhance naloxone availability. Integrating harm reduction skill training into peer-driven naloxone distribution and overdose prevention programs, training non-drug-using network members, and addressing structural barriers may enhance overdose prevention strategies.