Carescapes of Drug Use: Reframing Risk and Care Among Women Who Use Drugs for Social Work Practice and Policy

Background:
Research on women who use drugs (WWUD) has largely centered on risk—overdose, infection, and structural vulnerability—while giving less attention to how women actively produce care within these same environments. Within social work, this emphasis on vulnerability aligns with dominant risk-oriented and deficit-based frameworks that often guide assessment, intervention, and policy design. Existing frameworks, including Rhodes’ Risk Environment Framework, have advanced structural understandings of harm but remain less attentive to how WWUD navigate these conditions through relational practices. A feminist ethics of care offers a critical lens to foreground these dynamics and is closely aligned with social work’s person-in-environment orientation.

Objective:
To map the socio-structural factors shaping WWUD’s drug use practices and to theorize how care practices—including drug use assistance and first-time injection assistance—function as harm reduction strategies, with explicit attention to implications for social work practice, policy, and education.

Methods:
I conducted a scoping review of 57 peer-reviewed studies across the United States, Canada, and Mexico, guided by Arksey and O’Malley’s framework and PRISMA-ScR guidelines. Studies were thematically analyzed using Rhodes’ Risk Environment domains (political, physical, social, with economic factors embedded). A feminist ethics of care framework was applied to interpret how relational practices mediate structural conditions and to identify implications for social work intervention and systems design.

Results:
Across studies, WWUD’s drug use practices were shaped by intersecting socio-structural conditions, including criminalization, housing instability, healthcare exclusion, gender-based violence, and child welfare involvement. Within these constraints, WWUD engaged in a range of practices—providing injection assistance, sharing drugs and supplies, creating informal supervised consumption spaces, and facilitating access to services. While commonly framed within social work and public health as risk behaviors, these practices functioned as forms of care and mutual aid. They enabled women to mitigate overdose risk, manage withdrawal, navigate unsafe environments, and sustain one another in contexts where formal systems were absent, inaccessible, or punitive. These findings reveal a critical misalignment between how risk is conceptualized within formal systems and how care is enacted in everyday practice.

Conclusions:
I conceptualize these dynamics as a carescape: a relational field in which care is continuously produced and negotiated within structural constraints. This framework extends risk environment approaches by centering care as a core analytic and practice concern. For social work, this has three key implications: (1) Practice—interventions should recognize and engage existing peer-based care practices rather than disrupt them; (2) Policy—regulatory frameworks, including prohibitions on assisted use, may inadvertently undermine care networks and exacerbate harm; and (3) Education—social work training should move beyond individual risk models to incorporate relational and structural understandings of substance use. A carescape approach supports the development of interventions that align with, rather than replace, existing infrastructures of mutual aid.