"It's just what's around these days": social and contextual pragmatism in substance transitions.

BACKGROUND: The overdose epidemic is presently driven by polydrug use, sparking renewed interest in why people initiate use of certain drugs or drug combinations. Current research privileges the physiological ends of consumption, often ignoring the social and environmental context of use. Framed by social cognitive theory, the purpose of this study was to characterize factors precipitating substance initiation, transition, and combination beyond the immediate effects of the substance(s). METHODS: We conducted 30 semi-structured interviews with people who use drugs across North Carolina, exploring substance use history and risk and protective factors of polydrug use. Participants also completed a visual timeline activity. We used a staged analytic approach, beginning with deductive Structural Coding and ending with inductive Reflexive Thematic Analysis at both the transcript and excerpt levels. RESULTS: We conceptualized substance transitions as pragmatic responses to environments of constraints and opportunities. Socially, transitions facilitated interpersonal closeness, aligned use with network norms, and responded to ubiquitous drug availability. Transitions also reflected navigation of material constraints, including which substances were locally available, logistically accessible, and financially sustainable. CONCLUSIONS: Beyond the desire for new or enhanced physiological effects, substance transitions serve social and practical functions, like facilitating emotional closeness and responding to market conditions. Interventions to reduce the risks of use should expand viable options by addressing structural barriers and promoting safe, affordable, and accessible supply.