Survival economics and criminalization among women who use drugs during COVID-19 and de facto drug decriminalization in Baltimore, Maryland

Background Women who use drugs (WWUD) often experience social and economic marginalization. Many rely on survival economies that span formal, informal, and illicit income-generating activities, which may increase exposure to the criminal legal system. This study identified exploratory patterns of survival economic strategies among WWUD, then examined associations between income activities and criminal legal exposures during Baltimore, Maryland’s COVID-19 emergency period and de facto drug decriminalization. Methods Data come from the baseline assessment a WWUD cohort ( n =227) in Baltimore, recruited from August 2021 to December 2022. Guided by a sociological framework of income sources among low-income women, latent class analysis was used to identify survival economics across state support, instrumental support (money from family, friends, partners), informal labor, and illicit work (selling drugs, sex work). We then assessed associations between two common income sources (illicit and state support) and criminal legal exposures using Poisson regression with robust variance. Results Three distinct survival economic strategies emerged: mixed and diverse income (57% of sample), primarily state supported (27%), and primarily illicit (15%). Arrest prevalence did not differ across income activities. However, WWUD reporting illicit income compared to not were significantly more likely to report police encounters (adjusted prevalence ratios (aPR) 1.61 95% CI 1.39, 2.01), including abusive ones, although borderline significant (aPR 1.33 95% CI 1.02,1.74). Conclusions WWUD engaged in diverse survival economic strategies and illicit income generation was associated with police contact. Although these findings are exploratory, they highlight the importance of clarifying how criminalized survival economies are policed.