Reviewed work: Kenneth B. Morales et al., “Preference for drugs containing fentanyl from a cross-sectional survey of people who use illicit opioids in three United States cities,” Drug and Alcohol Dependence 204:1 (November 2019).

By: Stacey McKenna

On average, 192 people die every day in the United States due to drug-related overdose. And the crisis shows no signs of slowing: According to the Centers for Disease Control and Prevention, between 2016 and 2017, age-adjusted rates of overdose deaths rose by 9.6 percent. Opioids play a key role in roughly two-thirds of these deaths, and that risk is increasingly exacerbated by the use of extremely potent, low- cost synthetic opioids, such as fentanyl and its analogues, to adulterate heroin or produce counterfeit pharmaceuticals.

Because fentanyl is so common, some communities have begun providing drug-checking kits to people who use drugs. As a harm reduction measure, these represent a promising tool for individuals who want to know whether or not fentanyl or its analogues are in their drugs. However, little is known about peoples’ actual preferences and behaviors when it comes to fentanyl. Accordingly, a recent study published in Drug and Alcohol Dependence by Kenneth Morales and colleagues sought to elucidate “the nature of fentanyl preferences” among people who use drugs by asking them whether they actually prefer fentanyl over, or in combination with, other opioids and why.

To be eligible for the study, participants had to be at least 18 years of age, speak English and report past- month use of fentanyl, cocaine or methamphetamines, or past-month misuse of prescription opioids. Qualified participants then took an anonymous, computer-assisted survey that collected a range of demographic information, details about drug use and overdose, and knowledge about and experiences with fentanyl. In addition, the questionnaire assessed individual preference for fentanyl via a four-point Likert scale. The analysis discussed was limited to the 308 participants “who reported any illicit opioid use in the past six months.”

With respect to findings, a little more than a quarter (27 percent) of the study participants claimed to prefer, or actively seek out, fentanyl. This finding is consistent with prior research, which suggests that, although most opioid users are regularly exposed to fentanyl, few actively look for it. However, this study suggests that those individuals who do prefer fentanyl differ drastically on multiple measures from their counterparts who do not. Specifically, fentanyl-preferers were more likely to be non-Hispanic white, participate in the underground economy and have been arrested within the past year.

Furthermore, when it came to drug use, fentanyl preferers were more likely than non-preferers to initiate opioid use via off-label use of prescription opioids; use drugs daily; inject drugs (including heroin); and report having overdosed in their lifetime. In addition, fentanyl-preferers reported slightly higher rates of recent exposure to the synthetic opioid than their counterparts. However, more than 75 percent of the entire sample suspected having encountered the drug within the last six months. Morales and colleagues point out that this is consistent with reports that fentanyl has become such a common “cut” that it is difficult to avoid—even for those who want to.

In addition to these largely descriptive measures, Morales et al. dove into questions that explore how these preferences might shape behavior. They found that participants reported engaging in similar harm reduction behaviors—such as starting with a “test shot”—regardless of whether or not they preferred fentanyl. The authors suggest that the almost-certain exposure to fentanyl, coupled with the frequency and consequence of overdose (risks that are elevated by the presence of fentanyl) might serve as a protective factor in this regard: People stay cautious.

In addition, the researchers asked participants about their level of interest in the drug-checking approach that is gaining popularity. The vast majority—85 percent—of those surveyed said they would be interested in testing their drugs for fentanyl. However, most fentanyl-preferers (71 percent) said they would not change their drug-use behaviors if their supply contained fentanyl. This is a stark contrast to non-preferers, only 16 percent of whom said they would not change their drug-use behavior if their supply contained fentanyl.

It’s this last finding that has the most potential to inform harm reduction efforts. Not only was drug- checking well received, many participants suggested that results could prevent or reduce overdose risk behaviors, including helping non-preferers avoid fentanyl altogether. It also opens the door for future research into whether and how harm reduction organizations might better serve those individuals who actively seek out fentanyl.

This study fills important gaps in understanding about behavior and preferences related to fentanyl use. However, it is just a start, and Morales and colleagues acknowledge some noteworthy weaknesses. In particular, they write: “Due to fentanyl’s association with high mortality, survivor bias likely influenced our results.” Unfortunately, this is exacerbated by the fact that, given its cross-sectional design, the study gathers information as a snapshot in time. Furthermore, given the survey methods used, there are valid concerns about desirability bias as it pertains to both behaviors and preferences. Future researchers can thus build on these findings and help ameliorate weaknesses via qualitative and ethnographic research. Such approaches would allow researchers to ask more complex questions and observe actual behaviors in context.