Through systematic review and thematic synthesis of 27 qualitative studies, the synthesis identifies four key pathways:

1. Resource insufficiency and labor market exclusion
2. Homelessness and housing instability
3. Interactions with policing and emergency services
4. Gendered and racialized dimensions of inequality

These pathways illustrate how SEM exacerbates drug poisoning risk through material, behavioral, psychological, social, and environmental mechanisms. The findings underscore the complex interplay between SEM and overdose, suggesting a need for targeted interventions addressing structural inequalities to mitigate overdose risk effectively.

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