‘ They just kind of disappeared’: characterizing social network changes and their influence on substance use among people who inject drugs during a pandemic

Background Social networks shape substance use behaviors and health outcomes among people who inject drugs (PWID), yet the ways in which large-scale crises influence network dynamics, particularly through positive changes, remains underexplored. We examine the COVID-19 pandemic’s impact on social networks of PWID and subsequent changes to substance use behaviors.Methods Twenty-eight in-depth interviews were conducted between July 2021 and February 2022. Participants were recruited from the community-based cohort of PWID in Baltimore, Maryland. An iterative, inductive process was adopted to code the transcripts. Subsequent thematic analysis explored COVID-19-related changes in social networks and their impact on substance use behaviors.Results We report substantial shifts in social network size and relationship quality among PWID during the pandemic, with many facing increased social isolation, loneliness, and psycho­logical distress in response to shrinking networks. However, some PWID experienced positive network-related outcomes, including strengthened relationships and increased closeness. We report the mechanisms through which these changes influenced substance use behaviors, resulting in both increases and decreases in substance use.Conclusion We illustrate the influential role of social network changes and environmental context in shaping substance use outcomes during times of social disruption, underscoring the need for interventions that enhance social connectivity and adaptive coping strategies among PWID.