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A qualitative study of street fentanyl in Dayton, Ohio: drug markets, trajectories, and overdose risk reduction

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A qualitative study of street fentanyl in Dayton, Ohio: drug markets, trajectories, and overdose risk reduction

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Content i

A QUALITATIVE STUDY OF STREET FENTANYL IN DAYTON, OHIO:

DRUG MARKETS, TRAJECTORIES, AND OVERDOSE RISK REDUCTION

by
Tasha Perdue

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF PHILOSOPHY
SOCIAL WORK

August 2021

Copyright 2021 Tasha Perdue

ii
Dedication
To my parents, James and Janet Perdue. This dissertation is a testament to your
sacrifice. Dad - you taught me the value of hard work and when to take a gamble. Mom -
I wouldn’t be here without your guidance and support throughout these years. It seems
fitting that I finished this dissertation in my childhood bedroom - it really brought
everything full circle for me.

Although they can’t read this - to my steadfast feline companions. To Amelia and
Gideon who started this journey with me in 2005 and are now with me in spirit. To
Farley, who has been with me since 2006, and is the best little spoon. Finally, to the
newest addition, Juniper, who is the sweetest lap cat. I couldn’t ask for better company
and emotional support throughout this process. “What greater gift than the love of a cat.”
- Charles Dickens

Most importantly, to my husband and dearest friend, Ryan Forquer. You’ve been
the absolute best travel companion, board and video game adversary, sous-chef,
backcountry camping partner, editor, critic, audience member, graphic designer, and
source of unconditional love and support on this adventure. I know that you will always
be there when I collapse on the sand in utter defeat with a 50-pound pack on my back,
whether literally or figuratively, to pick me up. Thank you so much for your patience and
enthusiasm throughout this journey. Your love and support made this all possible.

iii
Acknowledgements
Academia was a very unfamiliar concept for this first-generation college student
from a rural working-class background. I would not be completing my PhD without the
support of several influential people who took an interest in my life and pushed me out of
my comfort zone. First, I must acknowledge my early mentors who were instrumental in
providing a foundation for my academic career.
Dr. Jeff Holcomb – thank you for being my first mentor during my bachelor’s
degree. You introduced me to research and grant funding when I completed my
honors thesis. Later, when I was uncertain what path to take, you encouraged me
to pursue my master’s degree. This was one of the best pieces of career advice I
have ever received. Thank you.
Dr. Celia Williamson - you built the foundation for me to pursue my PhD. You
entrusted me with such responsibility and had more confidence in my abilities than
I did at times. I look up to and admire you so much and hope to have half the
impact that you have had on the world. You have been such an inspiration not only
to me but to countless others. Thank you for all the realness and the laughs over
the years. There is no one else like you.
To my dear friend, Dr. Lisa Fedina. Thank you for the countless cat videos, encouraging
texts, and for being such a positive source of support. I am so lucky to have you as a
colleague and a friend. To one of my oldest friends, Koerbie Sweet, who provided critical
copy-editing support. I appreciate your friendship and encouragement throughout the
years.

iv
To the members of my cohort (Carolina Villamil Grest, Taylor Harris, Cary
Klemmer, Carrie Lucas, Hadass Moore, Judith Perrigo, Joshua Rusow, Qianwei Zhao).
It was such an honor to learn and grow with you all throughout the PhD journey. To the
wonderful faculty and staff of the Suzanne Dworak-Peck School of Social Work. A
special thanks to Malinda Sampson for always having an answer and for keeping me on
track in the program. Special thanks to the program director, Dr. Michael Hurlburt, and
to Dr. Suzanne Wenzel, and Dr. Julie Cederbaum who provided training and mentorship.
And to the research support staff, Rosine Sarafian and Muoi Thang, who have been so
helpful in navigating the funding process from pre to post award.
To the Valdez/Cepeda research team. I have enjoyed working with and getting to
know everyone on the team. You have all helped me to grow as an investigator and some
of my fondest memories of these past few years involve the times that we were together.
Dr. Charles Kaplan – I have learned so much from our writing sessions. You have
such an expansive knowledge of the literature and I have developed a deeper
appreciation for theory after working with you.
Dr. Kathryn Nowotny – Thanks for the career guidance and for always having an
answer. Your limitless energy and passion for research is inspiring and I look
forward to working on projects with you in the future.
Jessica Frankeberger – Thanks for showing me the ropes in the office and for
helping to integrate me as part of the team. I look forward to celebrating with you
when you reach this milestone and collaborating with you in the future.

v
Esme Ramirez – I have loved having the opportunity to get to know you and Baldo
while working on projects in San Antonio. Thanks for showing me the best time in
SA and for being such a great and positive person to work with.
Erika Smith – Thanks for keeping everything running! I’ve learned so much about
grant administration from you. I so appreciate your knowledge and patience in
answering multiple emails – sometimes regarding the same question!
I have had the good fortune to work with an accomplished group of researchers
throughout this process. This would not have been possible without the guidance and
support I received from a team of researchers from the University of Southern California
and the Center for Interventions, Treatment, and Addictions Research (CITAR) at Wright
State University.
To the CITAR Team – thank you for welcoming me into the office and for taking an
interest in the success of this project. You all made me feel part of the team!
Angela Zaragoza – even though I spent a brief time in the CITAR office I learned
so much from you and appreciated your time in getting the project going. I
enjoyed our conversations and the opportunity to learn more about your work.
Dr. Sydney Silverstein – I feel like we are kindred spirits in our approach to
research and thinking about the world. I look forward to living closer to you and I
am so excited to collaborate with you on future projects.
Dr. Raminta Daniulaityte – I appreciate and admire your approach to research.
You feedback has helped me to develop as a researcher and I have benefited

vi
greatly from your thoughtful comments and edits. I look forward to opportunities
to collaborate with and learn from you in the future.
Dr. Robert Carlson – thank you for welcoming me into the CITAR team! I feel
fortunate that I have had your guidance throughout this process. I have enjoyed
getting to know you on a personal and professional level. I cannot express my
gratitude enough to you for making this research possible. Thank you for this
invaluable learning opportunity.
To my USC mentors – thank you for the patience and guidance throughout the years. You
have all been so critical in my development as an investigator. I could not ask for a better
group of researchers to guide me during the doctoral program.
Dr. Ricky Bluthenthal – It has been such an honor to have had the opportunity to
work with you. I learn something new every time I talk to you, and I am in
constant appreciation for your ability to direct future research agendas. I look
forward to learning more from you and collaborating in the future.
Dr. Avelardo Valdez – I have enjoyed working with such an established researcher
who is dedicated to improving conditions for the most vulnerable. You are a great
storyteller and I love hearing and reading about your adventures. Some of my most
important research and career lessons have come from our conversations. Thank
you for instilling in me the need to remain curious and the importance of always
having my researcher hat in place.
Dr. Alice Cepeda – To my chair and constant source of support throughout this
process. You have provided such fantastic opportunities for growth on the

vii
personal and professional level. Thank you for always believing in my abilities
and for pushing me to continue to develop by taking on new roles and
responsibilities. Your mentorship has made this all possible and I will forever be
grateful for your dedication to my development into a scholar. I am so honored to
be a part of the family, and I look forward to the future research projects and
conference meetings that can bring us together again.
Finally, to the participants who took time to share their experiences with me during the
pandemic; a time that presented unprecedented challenges and much uncertainty in the world. I
feel fortunate to have connected with everyone in the study and I hold these interviews dear to
my heart. My career is dedicated to improving conditions for people who use drugs through
ending stigma and increasing access to evidence-based treatment and harm reduction services. I
will carry your stories with me as I strive for drug policy reform and an end to the War on Drugs.

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Table of Contents
Dedication ....................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
List of Tables and Figures ............................................................................................................... x
Abstract .......................................................................................................................................... xi
Chapter 1: Overview of the Three Studies ...................................................................................... 1
Introduction ................................................................................................................................. 1
Study Location ............................................................................................................................ 3
Conceptual Model ....................................................................................................................... 4
Methodology ............................................................................................................................... 6
Overview ................................................................................................................................. 6
Participant recruitment ............................................................................................................ 7
Data collection ........................................................................................................................ 7
Study Variables ....................................................................................................................... 8
Data analysis ........................................................................................................................... 8
Three Study Overview ................................................................................................................ 9
Study One................................................................................................................................ 9
Study Two ............................................................................................................................. 10
Study Three ........................................................................................................................... 11
References ................................................................................................................................. 13
Tables and Figures .................................................................................................................... 21
Chapter 2: Study 1 “Do you have fetty?”: A qualitative description of an evolving fentanyl drug
market in Dayton, Ohio Abstract .................................................................................................. 24
Introduction ............................................................................................................................... 26
Methods..................................................................................................................................... 28
Results ....................................................................................................................................... 29
Study sample ......................................................................................................................... 29
Illicit opioid drug market: dominance of fentanyl ................................................................ 30
Demand for fentanyl: preferences for pharmacological effects ............................................ 32
Fentanyl quality: the role of dealers in managing potency ................................................... 34
Fentanyl contamination in drugs other than heroin .............................................................. 36
Pressed fentanyl pills ............................................................................................................ 37
Discussion ................................................................................................................................. 39
Limitations and Strengths ......................................................................................................... 43
Conclusion ................................................................................................................................ 44
References ................................................................................................................................. 45
Tables ........................................................................................................................................ 53
Chapter 3: Study 2 Prescription opioid, heroin, and street fentanyl trajectories: Contextualizing
the three waves of the opioid crisis Abstract ............................................................................... 55
Introduction ............................................................................................................................... 57
Methods..................................................................................................................................... 61
Results ....................................................................................................................................... 63
Drug Use History .................................................................................................................. 63

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First wave: prescription opioids ............................................................................................ 63
Second wave: heroin ............................................................................................................. 66
Third wave: fentanyl ............................................................................................................. 69
Emerging trajectories: a fentanyl future ............................................................................... 75
Discussion ................................................................................................................................. 77
Limitations and Strengths ......................................................................................................... 81
Conclusion ................................................................................................................................ 82
References ................................................................................................................................. 83
Tables and Figures .................................................................................................................... 96
Chapter 4: Study 3 “You can’t do less, you can always do more”: Understanding overdose risk
reduction in a street fentanyl dominated drug market .................................................................. 99
Abstract ..................................................................................................................................... 99
Introduction ............................................................................................................................. 101
Methods................................................................................................................................... 104
Results ..................................................................................................................................... 106
Overdose Risk Prevention ....................................................................................................... 107
Buying from a trusted source .............................................................................................. 107
Drug use modifications ....................................................................................................... 109
Managing withdrawal ......................................................................................................... 110
Drug testing ......................................................................................................................... 113
Overdose Response ................................................................................................................. 114
Using with others ................................................................................................................ 114
Naloxone ............................................................................................................................. 116
Discussion ............................................................................................................................... 117
Limitations and Strengths ....................................................................................................... 122
Conclusion .............................................................................................................................. 123
References ............................................................................................................................... 124
Tables and Figures .................................................................................................................. 133
Chapter Five: Conclusion ........................................................................................................... 135
Summary of the Three Studies ................................................................................................ 135
Study 1 .................................................................................................................................... 135
Study Implications .............................................................................................................. 136
Study 2 .................................................................................................................................... 137
Study Implications .............................................................................................................. 137
Study 3 .................................................................................................................................... 138
Study Implications .............................................................................................................. 139
Recommendations for Policy, Practice, and Future Research ................................................ 139
Limitations .............................................................................................................................. 143
Conclusion .............................................................................................................................. 144
Appendix Materials ..................................................................................................................... 151
Project Screener ...................................................................................................................... 151
Brief Demographic Survey ..................................................................................................... 152
Qualitative Interview Themes ................................................................................................. 160
Analytic Process ...................................................................................................................... 163

x

List of Tables and Figures
Figure 1.1 Conceptual Model ....................................................................................................... 21
Table 1.1 A Priori Study Domains and Constructs ....................................................................... 22
Table 2.1 Sample Demographics (N=60) ..................................................................................... 53
Table 2.2 Fentanyl Use, Preferences, Availability, and Contamination in Other Substances
(N=60) ........................................................................................................................................... 54
Table 3.1 Lifetime Substance Use History and Age of Initiation (N= 60) ................................... 96
Figure 3.1 Three Waves of the Opioid Crisis ............................................................................... 97
Figure 3.2 Emerging Fentanyl Trajectories .................................................................................. 98
Table 4.1 Overdose, Naloxone, Overdose Risk Reduction, Withdrawal Prevention (N= 60) ... 133
Figure 4.1 Overdose Risk Reduction .......................................................................................... 134

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Abstract
The emergence of synthetic opioids, such as illicitly manufactured fentanyl, into the illicit
opioid supply has presented unique challenges in mitigating opioid-related risks. While
epidemiological patterns of risk are known from previous studies of heroin use, what is not clear
is how individual behaviors, strategies, and local social and situational factors in the current
synthetic opioid/illicitly manufactured fentanyl crisis are promoting risk factors and/or self-
protective behaviors in distinct emerging fentanyl “hot spots” such as Ohio. Informed by the
Drug, Set, and Setting Framework with concepts from the Symbiotic Model of Risk Reduction,
this dissertation explores the impact of the emergence of fentanyl on drug markets, illicit opioid
use trajectories, and risk or self-protective behaviors among individuals who use illicit opioids in
Dayton, Ohio.
In recent years the drug supply in Dayton has been increasingly contaminated with
fentanyl making this an excellent location to understand the rapidly evolving heroin/fentanyl
crisis. People who use illicit opioids in environments with a fentanyl contaminated heroin supply
represent a nexus of risk and vulnerability for fatal overdoses and disease transmission and
require an in-depth understanding of the conditions and contexts under which these populations
live. Designed with this scientific premise in mind, this dissertation is guided by the urgent need
for qualitative research in understanding current heroin/fentanyl behaviors and shifts in drug use
practices to inform implementation science for innovative harm reduction interventions. This
dissertation adds to the emerging literature on the patterns and histories of heroin/fentanyl use
and the practices by which fentanyl heightens behavioral risks for people who use illicit opioids
and the susceptibility for detrimental health conditions and mortality, such as fatal overdose. The

xii
three studies, presented across three distinct chapters in this dissertation, have timely and direct
implications for geographically tailored responses to the opioid crisis.

1
Chapter 1: Overview of the Three Studies
Introduction
As prescription opioid related overdose deaths have leveled in recent years (Abuse, 2017)
heroin related fatalities tripled (Rudd, 2016) with a large number of these attributed to synthetic
opioids such as illicitly manufactured fentanyl. The current opioid crisis is characterized by a
heroin supply contaminated with synthetic opioids (e.g., non-pharmaceutical fentanyl and
analogues such as carfentanil, acetylfentanyl, butyrylfentanyl, and other nonfentanyls such as U-
47700) (Armenian et al., 2018; Daniel Ciccarone, 2017b; Prekupec et al., 2017). Recent data
indicates 50% of U.S. opioid-related deaths involve synthetic opioids, the majority of these
fentanyl (Jones et al., 2018; Mattson et al., 2021). Traces of fentanyl can be so small that heroin
may not have any identifiable color or consistency changes (Griswold et al., 2018; Rogers et al.,
2016), making people who use illicit opioids (PWUIO) highly susceptible and unknowingly
exposed to contaminated heroin (Macmadu et al., 2017). This contamination causes fluctuations
in heroin potency, and greatly escalates overdose risk (e.g. immediate respiratory depression)
(Helander et al., 2016; Higashikawa & Suzuki, 2008). Confounding the market risks are the
physiological effects characterized with shorter duration highs leading to patterns of frequent
injection behavior, which further increases risks for overdose and disease transmission (Carroll
et al., 2017; Daniel Ciccarone, 2017b; Lambdin et al., 2019; S. Mars et al., 2018a).
Further research is needed to understand techniques for identifying suspected fentanyl
contamination, user preferences for fentanyl, changes in drug use practices, perceptions about
risks associated with distinct heroin/fentanyl drug combinations, and facilitators and barriers to
risk reduction practices among individuals who use heroin/fentanyl (D Ciccarone et al., 2017; S.
Mars et al., 2018b; Mars et al., 2019). People who use illicit opioids in environments with a

2
fentanyl contaminated heroin supply represent a nexus of risk and vulnerability for fatal
overdoses and disease transmission and require an in-depth understanding of the conditions and
contexts under which these populations live. Designed with this scientific premise in mind, this
dissertation is guided by the urgent need for qualitative research in understanding current
heroin/fentanyl behaviors and shifts in drug use practices to inform implementation science for
innovative harm reduction interventions (D Ciccarone et al., 2017; Marshall et al., 2017; N.
Peiper et al., 2019; N. J. Somerville et al., 2017).
Studies are beginning to document the increased prevalence trends, characteristics of use
(perceptions and motives), and negative consequences (increased injection frequency, tolerance,
overdose) of heroin contaminated with synthetic opioids (Carroll et al., 2017; D Ciccarone et al.,
2017; Cicero et al., 2017; Latkin et al., 2019; Macmadu et al., 2017; S. Mars et al., 2018a;
McLean et al., 2019; N. Somerville et al., 2017). Considering that studies have documented
preferences for fentanyl among people who use heroin (Carroll et al., 2017; D Ciccarone et al.,
2017; Sarah G Mars et al., 2018; McLean et al., 2019) more research is needed to understand the
impact the existing fentanyl drug market has had on heroin drug use patterns and related health
risks. Acquiring firsthand knowledge of current initiation and transition histories, experiences
with fentanyl contaminated heroin, and perceptions/practices of use will help address the opioid
crisis by informing the unique drug risk behaviors and risk reduction strategies associated with
an evolving illicit opioid drug market.
The premise of this dissertation rests on emerging qualitative studies demonstrating a
myriad of experiences with intentional and unintentional fentanyl laced heroin and reported
differences in perceived effects and preferences of distinct types of drug combinations (heroin
alone, heroin-fentanyl combined) (Daniel Ciccarone et al., 2017; S. Mars et al., 2018a; McLean

3
et al., 2019). More recently, research is detailing shifting user practices in response to a
heightened risk for overdose including fentanyl test strips, drug sampling (e.g. “test hit” or
“taster shots”), using with others, and carrying naloxone (Krieger et al., 2018; S. Mars et al.,
2018b; McKnight & Des Jarlais, 2018; N. C. Peiper et al., 2019). Limitations in existing research
are noted as current qualitative studies have primarily focused on the East Coast (Carroll et al.,
2017; D Ciccarone et al., 2017; Latkin et al., 2019; S. Mars et al., 2018a; McKnight & Des
Jarlais, 2018) and we know little of the everyday experiences and challenges that current
PWUIO in other regions of the US face in the midst of this fentanyl market. This dissertation
adds to the emerging literature on the patterns and histories (trajectories) of heroin/fentanyl use
and the practices by which fentanyl heightens behavioral risks for PWUIO and the susceptibility
for detrimental health conditions and mortality (fatal overdoses). The three studies, presented
across three distinct chapters in this dissertation, have timely and direct implications for
geographically tailored responses to the opioid crisis.
Study Location
In recent years Ohio has consistently ranked within the top five states for overdose death
rates. Overdose deaths in Ohio started significantly increasing in 2015 with over 3,000 deaths,
peaked in 2017 at over 4,800, and then declined to under 4,000 in 2018 (Harm Reduction Ohio,
2021a). However, rates started increasing again in 2019 with over 4,000 overdose deaths (Harm
Reduction Ohio, 2021a). Preliminary data indicates that 2020 was the deadliest year to date for
overdoses in Ohio, with over 5,000 drug overdose deaths (Harm Reduction Ohio, 2021a). Data
on drugs involved in overdose deaths are not yet available for 2020. However, in 2019 opioids
accounted for 83.7% of drug overdose deaths in Ohio, with fentanyl responsible for 76.2% of all
drug overdose deaths (Ohio Department of Health, 2020). Drug combinations such as fentanyl

4
and cocaine (23.1%), fentanyl and psychostimulants (14.9%), and fentanyl and heroin (10.6%)
also comprised large percentages of Ohio drug overdose deaths in 2019 (Ohio Department of
Health, 2020).
While Ohio has one of the highest per capita overdose rates in the country, different
regions within the state have worse opioid-related outcomes. Dayton, located in Montgomery
County, Ohio has been identified as an epicenter of the opioid crisis on the state and national
level. This is an important region in understanding the evolving opioid crisis, as Montgomery
County had the second highest 2014-2019 average age-adjusted overdose fatality rate in the state
of 63.5 per 100,000 (Ohio Department of Health, 2020). Previous research on fentanyl in the
Dayton region documented an increase in unintentional overdose deaths attributed to fentanyl
analogues (Daniulaityte et al., 2019b) and high rates of self-reported use of fentanyl
(Daniulaityte et al., 2019a). Further, over 90% of unintentional overdose deaths in Dayton in
early 2017 tested positive for fentanyl and/or fentanyl analogues (Daniulaityte et al., 2019b).
Existing studies have examined risks related to fentanyl in the Dayton area (Daniulaityte
et al., 2019a; Daniulaityte et al., 2019b; Silverstein et al., 2019) but less is known about overdose
risk reduction strategies in this population. Considering the unique environment in Dayton this
dissertation makes a significant contribution by examining strategies and practices that PWUIO
have incorporated in a rapidly changing context. The qualitative findings enhance our
understanding of how context-based practices, strategies, and tactics of PWUIO may reduce or
escalate drug risk behaviors in this community.
Conceptual Model
Drug related variables such as availability and potency do not fully explain why some
regions have more risks and health consequences. Availability must be considered within the

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context of the social and psychological factors creating demand for use (Zinberg, 1986).
Therefore, determinants such as the external physical and social setting (Zinberg, 1986), and the
cultural traditions, perceptions and attitudes in specific regions must also be considered when
examining substance use patterns and risk behaviors (Galea et al., 2003; Keyes et al., 2014).
Figure 1.1 presents the overarching model guiding this dissertation. This model blends
two theoretical frameworks: Drug, Set, and Setting and the Symbiotic Model of Risk Reduction
with current literature on user driven modifications for risk reduction. Drug relates to the
pharmacologic action and properties of the substance itself (Zinberg, 1986). Set includes the
individual attributes such as personality structure, past experiences, mood, motivations, and
perceptions (McElrath & McEvoy, 2002; Zinberg, 1986). Setting is the physical (place, people,
and things present during time of use) and social setting (other people present and their broader
beliefs that establish the cultural and social values) in which drug use occurs (Moore, 1993; Mui
et al., 2014; Zinberg, 1986).
Thus, the interconnectedness of individuals to the surrounding drug supply and the social
and cultural context ultimately shapes safer or riskier drug use. The Symbiotic Model of Risk
Reduction suggests that individuals engaged in substance use have symbiotic goals that are not
focused on disease prevention or risk reduction, but which may help reduce related drug risk
behavior (Friedman et al., 2011). Symbiotic goals may include, for example, strategies to avoid
withdrawal, or securing and retaining certain social connections with people who can provide
drugs, money, or other resources (Connors, 1994; Friedman et al., 2011; Mateu-Gelabert et al.,
2005; Mateu-Gelabert et al., 2010). Therefore, to understand strategies, practices, and tactics for
safer use it is necessary to explore not only behavioral interventions and user strategies
specifically aimed at risk reduction, but also the symbiotic processes developed by people who

6
use drugs that inadvertently result in risk reduction. Policies and interventions that can capitalize
on processes that PWUIO are comfortable and willing to engage with will have the most impact
on addressing harms related to injection heroin/fentanyl use.
Methodology
Overview
Data for this dissertation comes from the R36 dissertation study, An Examination of the
Effects of Synthetic Opioids on Injecting Heroin Trajectories, Practices, and Risk Behaviors
(NIDA Grant No. R36 DA048343-01A1). The overall objective of the R36 dissertation study is
to improve our understanding of heroin/fentanyl use histories and the related perceptions,
practices, and strategies for risk reduction in Dayton, Ohio. Informed by the Drug, Set, and
Setting theoretical framework and Symbiotic Model of Risk Reduction, the specific aims of the
R36 dissertation are:
1. Provide an in-depth qualitative description of how a rapidly changing heroin/fentanyl
market (type/quality, availability) has impacted injecting heroin/fentanyl use trajectories
(initiation, drug switching, concurrent use) and adverse health related drug risk behavior
(overdoses, syringe sharing) in Dayton, Ohio.
2. Examine individual-level perceptions, preferences, and perceived effects regarding
synthetic opioids, related strategies for the identification of heroin adulterated with
synthetic opioids, and current risk reduction practices among individuals who use
heroin/fentanyl in Dayton, Ohio.
3. Characterize qualitatively the influence of cultural and social context on strategies,
practices, and tactics for safer or riskier behaviors among individuals who use
heroin/fentanyl in Dayton, Ohio.

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Participant recruitment
Initial participants were notified about the study by researchers who have established
relationships with the study population. Interested participants contacted the lead author and
were screened for eligibility. See appendix for screener. To be eligible for the study participants
had to be over the age of 18, reside in the Dayton region, self-report use of heroin/street fentanyl
within the past 30 days, and not be in abstinence based treatment such as Alcoholic
Anonymous/Narcotics Anonymous or residential treatment. These forms of treatment were not
eligible because the study aims were to understand current use experiences. Participation in
buprenorphine or methadone treatment was permitted. Additional recruitment methods included
peer referrals and Facebook. Participants received $30 for study participation and $10 per
referral.
Data collection
Data collection began in March 2020 and was completed in November 2020. Data
collection occurred during the COVID-19 pandemic, so the research pivoted from in-person to
virtual methods. A total of 13 in-person interviews were completed before study procedures
shifted to virtual methods. The remaining 47 interviews were conducted and recorded using
Zoom video conferencing software. Informed consent was obtained from all study participants.
For those completing in-person interviews consent was obtained on the day of the interview. For
those completing virtual interviews the first author would review the consent with participants
once they were deemed eligible during the screener process. The first author would then send the
link for the participant to review and digitally sign the consent on REDCap. For the scheduled
interview, the first author would ask the participant if they had any questions over the consent
and review before starting.

8
Interviews included a brief demographic survey and a semi-structured interview. The
brief demographic survey included questions about drug use history, harm reduction utilization,
and risks – which lasted between 15 to 30 minutes. Semi-structured qualitative interviews were
focused on understanding experiences and preferences related to fentanyl, harm reduction
strategies, and perceptions of drug markets and lasted between 30 and 60 minutes. The lead
author wrote field notes following interviews. Analytic memos were recorded during
transcription review and throughout the coding process. The first author shared all field notes
and analytical memos while checking-in with members of the study team throughout data
collection and analysis.
Study Variables
For a brief description of domains and constructs see Table 1.1. The brief demographic
survey consisted of socio-demographics, drug use history, and related risk behaviors. The semi-
structured qualitative interviews focused on key concepts to capture elements of each aim and
the conceptual model (Figure 1.1). Since not all participants had experiences related to each
potential area of inquiry, there was no particular order for questions. Interviews and questions
were organized around major life events, experiences, or conditions each individual reported as
having an impact on their drug use behaviors. Non-leading questions probed additional processes
and mechanisms as relevant. See appendix for complete brief demographic survey and
qualitative interview guides.
Data analysis
Interviews were transcribed, checked for accuracy by the first author and entered into
NVivo (Version 12, QSR International, Melbourne, Australia). Following a lone-wolf coder
approach (Saldaña, 2021) the first author coded an initial set of transcripts based on questions
and categories from the qualitative interview guides. The first author then discussed the coding

9
approach with co-authors, sharing field notes and the analytic and transcription memos along
with the codebooks. Adjustments were made to the coding schema following in-depth
discussions and recommendations from co-authors. The first author then applied the revised
coding schema to the remaining transcripts, revising as new themes emerged. Using the
interview guide and field notes, the first author identified categories and key concepts. Once no
new codes were derived this indicated inductive thematic saturation (Saunders et al., 2018). The
thematic data analysis was an iterative and reflexive process (Braun & Clarke, 2019) and
informed by existing literature related to drug markets, opioid use trajectories, and overdose risk
reduction. Qualitative interview data was triangulated with the demographic survey data to
further understand participants perspectives and experiences. All study procedures were
approved by the University of Southern California Institutional Review Board. Names used in
the studies are pseudonyms. To further protect participants, unique names are used across the
studies. For example, if a participant is quoted in study one and in study two, they are identified
by a unique name in study two.
Three Study Overview
Study One

The purpose of this study is to understand changes in the illicit opioid drug market in
Dayton (Montgomery County), Ohio. This is an important region in understanding the evolving
opioid crisis, as Montgomery County had the second highest age-adjusted overdose fatality rate
in the state with 63.5 deaths per 100,000 from 2014 to 2019 (Ohio Department of Health, 2020).
Reported preferences for fentanyl are mixed as over half of participants preferred heroin in one
study (Daniulaityte et al., 2019a) with a qualitative study indicating that participants preferred
and sought out fentanyl (Silverstein et al., 2019).

10
Studies have documented perceptions and preferences as fentanyl first emerged in the
illicit opioid market (Carroll et al., 2017; Daniel Ciccarone et al., 2017; S. Mars et al., 2018a;
McLean et al., 2019). However, additional qualitative research is needed to understand how the
drug market continues to evolve over time and the resulting impact on preferences and use
patterns. In-depth first-hand knowledge from people who use drugs is especially valuable in
providing detailed descriptions of drug markets including participant behaviors and transactional
details related to price, dealer interactions, and product quality (Ritter, 2006). To better
understand changes in the illicit opioid drug market in Dayton, Ohio, this study aims to
qualitatively characterize current perceptions on availability, preferences, and current potency of
street fentanyl.
Study Two

Extant qualitative literature exists on the transitions from prescription opioids to heroin
(Harocopos et al., 2016; Lankenau et al., 2012; Mars et al., 2014) but there are few studies
comparing motivations for use and differences in transition experiences into synthetic opioids,
such as fentanyl. While studies have explored perceptions and preferences related to fentanyl
(Carroll et al., 2017; D Ciccarone et al., 2017; Daniulaityte et al., 2019a; S. Mars et al., 2018a;
McLean et al., 2019), to the author’s knowledge there are currently no qualitative studies
providing an in-depth understanding of pathways into fentanyl, motivations for use, and how
these experiences relate to trajectories with other opioids. Further, research on how fentanyl has
changed drug use trajectories is lacking. Heroin contaminated fentanyl has now been in the
market for approximately seven to eight years. In this time period we have seen shifts in
availability from heroin contaminated fentanyl to fentanyl only products. As a result, we are
unaware of the nature by which current initiation into fentanyl may be occurring and if it is

11
occurring in a different manner than when it first emerged. Indeed, fentanyl may be changing
opioid use patterns, but it is unclear how motivations and the socio-environmental context is
shaping fentanyl use. Therefore, understanding emerging fentanyl use motivations and
trajectories is essential in creating responsive prevention and intervention strategies.
The purpose of this study is to contextualize the three waves of the opioid crisis to better
understand motivations associated with illicit opioid use and transitions. In addition, this study
explores new fentanyl initiation trajectories through interviews with people who use illicit
opioids in Dayton (Montgomery County), Ohio. In-depth perspectives from people who use
drugs are especially important in understanding drug availability and use patterns and are critical
in developing appropriate public health responses (Daniel Ciccarone, 2017b; Harris et al., 2015;
Mounteney & Leirvåg, 2004). Qualitative research is needed to better understand the nuances of
a fentanyl contaminated drug market and to identify emerging trends.
Study Three

Previous research on fentanyl in the Dayton region documented an increase in
unintentional overdose deaths attributed to fentanyl analogues (Daniulaityte et al., 2019b) and
high rates of self-reported use of fentanyl (Daniulaityte et al., 2019a). PWUIO in the Dayton
region now assume fentanyl contamination in the illicit opioid market, but the various analogues
of unknown potency create unpredictability in the supply, increasing overdose risks (Daniulaityte
et al., 2019b; Silverstein et al., 2019). While existing studies have examined risks related to
fentanyl in the Dayton area (Daniulaityte et al., 2019a; Daniulaityte et al., 2019b; Silverstein et
al., 2019) less is known about overdose risk reduction strategies among this population.
Understanding overdose risk reduction strategies from the perspective of people who use drugs is
critical in tailoring local harm reduction initiatives. Research indicates that PWUIO have

12
responded to the increasingly fentanyl contaminated heroin supply by incorporating a variety of
strategies, tactics, and practices for risk reduction. Some commonly reported overdose risk
reduction strategies related to fentanyl include tester shots, buying from trusted sources, carrying
naloxone/Narcan, using with others, and drug checking via fentanyl test strips (S. Mars et al.,
2018b; McKnight & Des Jarlais, 2018; N. C. Peiper et al., 2019; Zibbell et al., 2021). While
studies have explored risk reduction in other contexts, more distinction is needed between
overdose prevention and overdose response. For the purposes of this study overdose prevention
includes practices that can prevent non-fatal and fatal overdoses, while overdose response
involves those practices that occur after an overdose has occurred. Responses are used to reverse
overdoses and for fatality prevention.
Qualitative interviews with people who use illicit opioids (PWUIO) in Dayton, Ohio are
applied to examine perspectives and strategies for overdose risk reduction. Research that
explores risk reduction from the perspective of people who use drugs is needed to understand
what motivates their use to provide targeted public health interventions (Messac et al., 2013).
This study contributes to the literature by examining strategies for overdose prevention and those
for overdose response. Indirect methods of risk reduction are also included. Programming and
policy recommendations to better support individual overdose risk reduction strategies are
discussed.

13
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21
Tables and Figures

Figure 1.1 Conceptual Model

22
Table 1.1 A Priori Study Domains and Constructs
Domain Constructs Rationale
Brief Demographic and Drug/Risk Behavior Survey
Participants will be asked to complete a brief survey prior to
participating in the qualitative interview portion to gather information
on demographics, drug use, and related risk behaviors.
Rationale by
Question
Demographics Age, Gender, Education, Race/Ethnicity,
Employment Status, Relationship Status, Housing
Socio economic
status
Family make-up
Structural/communit
y factors
Drug Use &
Related Risk
Behaviors
Substances used lifetime; Substances past 30-days;
Frequency of use; Overdose experiences; Reported
naloxone use; Self-reported Hepatitis C/HIV status;
Syringe sharing behaviors; Syringe access
Drug Use Patterns
Drug Risk Behaviors
Harm Reduction Use
Exposure to
HCV/HIV

Qualitative Interview
Participants will be asked to provide open-ended responses that pertain
to the constructs of Drug, Set, Setting and the Symbiotic Model of Risk
Reduction.

Rationale by
Conceptual Model:
(See Figure 1)
Aim 1: Drug
Pharmacologic
al contexts
• Discussion of substance use initiation experiences
with a focus on understanding the transition to &
ongoing use of heroin/NPF.
• Modes of consumption (nasal inhalation, smoking,
injection) & changes over time.
• Sequencing & frequency of substances used & the
development of different drug-using patterns.
• Experiences with exposure to heroin perceived as
contaminated with synthetic opioids.
A: Drug
• Discussion of harm reduction utilization (syringe
exchange, naloxone, fentanyl test strips).
D: Behavioral
Interventions
• Individual practices, strategies, tactics for reducing
heroin-injecting risks in the current contaminated
heroin market.
E: Drug Use
Adaptations
• Assessment of goals that may inadvertently result
in risk reduction practices (saving a shot to avoid
withdrawal).
F: Symbiotic
Processes
• Discussion of experiences with drug risk behaviors
(overdose and syringe sharing).
G: Drug Risk
Behaviors
Aim 2: Set
Individual-
Level
Perceptions
• Perceptions of how synthetic opioids have changed
injecting heroin practices & risk & protective
behaviors.
• Rationale for reported preferences or avoidance of
heroin perceived as contaminated.
B: Set

23

• Perceptions of the changing attitudes of both users
and non-users toward psychoactive drug use.
• Perceptions of availability of harm reduction (i.e.
access to syringe exchange, naloxone) on increased
or decreased risk behaviors.
D: Behavioral
Interventions
• Perceptions and attitudes impacting strategies and
tactics for reducing heroin-injecting risks in the
current contaminated heroin market.
E: Drug Use
Adaptations
• Assessment of goals inadvertently resulting in risk
reduction practices (i.e. avoiding certain heroin due
to dislike of perceived effects).
F: Symbiotic
Processes
• Perceptions of drug risk behaviors associated with
heroin/NPF (overdose & syringe sharing).
G: Drug Risk
Behaviors
Aim 3:
Setting
Social &
cultural
contexts
• Discussion of how social stressors contributes to
substance use over time.
• Discussion of social relationships as protective, or of
the lack of them, as a factor in risky use.
• Discussion of relationships with other people who
inject drugs as impacting substance use patterns.
• Reports of the social context & the process of
socialization for patterns of heroin/NPF use.
• The cultural factors influencing low-risk and high-
risk outcomes.
C: Setting
• Discussion of the social acceptability harm reduction
(access to syringe exchange, naloxone).
D: Behavioral
Interventions
• Social & cultural factors impacting strategies &
tactics for reducing heroin-injecting risks in the
current contaminated heroin market.
E: Drug Use
Adaptations
• Assessment of goals inadvertently resulting in risk
reduction practices (i.e. maintaining protective
social ties for access to certain drugs).
F: Symbiotic
Processes
• Discussion of how social & cultural factors impact
drug risk behaviors (overdose & syringe sharing.
G: Drug Risk
Behaviors

24
Chapter 2:
Study 1
“Do you have fetty?”:
A qualitative description of an evolving fentanyl drug market in Dayton, Ohio
Abstract
Background: While studies have documented fentanyl in the illicit opioid market,
further qualitative research is needed to understand how the market continues to evolve over
time. The goal of this study is to qualitatively characterize changes in the fentanyl drug market in
Dayton, Ohio, to understand current perceptions on availability, preferences, and quality of street
fentanyl.
Method: Sixty people who use illicit opioids were recruited from Dayton, Ohio.
Participants completed a brief demographic survey and a semi-structured qualitative interview.
Interviews were conducted from March to November 2020 with a total of 13 in-person and 47
virtual interviews. Qualitative interviews were transcribed in their entirety and interview data
was analyzed thematically using NVivo 12.
Results: Qualitative results indicate a shifting drug market, with fentanyl dominating the
opioid market and limited to no heroin availability. Fentanyl was reported as a having a distinct
market apart from heroin, and over half of participants (57%) indicated that fentanyl is currently
being sold as fentanyl or “fetty.” This is influencing preferences as the majority of participants
preferred fentanyl alone. Participants perceived dealer adaptations to avoid overdose risks to
clients has resulted in decreased potency, with sleeping pills commonly reported as cutting
agents. The emergence of pressed pills containing fentanyl were attributed to increased overdose

25
risks. In addition, methamphetamine and cocaine were reported as contaminated with street
fentanyl.
Conclusions: Drugs markets continue to evolve, with fentanyl replacing heroin as the
drug of choice, and findings indicate the importance of increased awareness of fentanyl
contamination in substances other than heroin. Comprehensive harm reduction is needed beyond
those who identify illicit opioids as their drug of choice. More research is needed to explore
other innovative harm reduction measures, such as encouraging drug testing among dealers, in
order to increase access to a safe supply.

26
Introduction
The opioid overdose crisis is marked by three waves beginning in the late 1990’s with
prescription opioids, followed by heroin in 2010, and illicit synthetic opioids in 2013 (Daniel
Ciccarone, 2017a, 2017b; Ciccarone, 2019; Control & Prevention, 2011; Gladden et al., 2016;
O’Donnell et al., 2017a; O’Donnell et al., 2017b; Rudd et al., 2014). Non-pharmaceutical or
illicitly manufactured fentanyl, produced in clandestine labs, is one of the most common illicit
synthetic opioids in the drug market (Drug Enforcement Administration, 2020; Mattson et al.,
2021; Reuter et al., 2021; Wilde et al., 2019). Fentanyl can be up to 100 times more potent than
morphine (Higashikawa & Suzuki, 2008; Volpe et al., 2011) and the adulteration of heroin with
fentanyl causes fluctuations in heroin purity, escalating overdose risks (Carroll et al., 2017;
Daniel Ciccarone et al., 2017; Daniulaityte et al., 2019b; Macmadu et al., 2017). Overdose
deaths attributed to synthetic opioids increased 1,040% from 2013 to 2019, and almost half of
the more than 70,000 drug overdose deaths in 2019 involved synthetic opioids (Mattson et al.,
2021).
Fentanyl’s emergence in the drug market has been attributed to positive supply shocks in
response to changes in the heroin drug market rather than demand-led preferences (Daniel
Ciccarone, 2017b; Mars et al., 2019). That is, the drug market changes occurred due to
fluctuations in the supply of heroin and an increased availability of lower cost fentanyl, rather
than a response to user preferences for the pharmacological effects of fentanyl (Daniel
Ciccarone, 2017b; Mars et al., 2019). Qualitative studies have documented that exposure to
fentanyl ranges from unknowing exposure to actively seeking it out, that personal attitudes
toward fentanyl often evolved from fear to interest, and that participants reported significant
differences in heroin and fentanyl preferences (Carroll et al., 2017; Daniel Ciccarone et al., 2017;
S. Mars et al., 2018a; McLean et al., 2019). The market has continued to evolve since these

27
studies, with an increasingly volatile drug supply and a resurgence of methamphetamine use
dubbed the “twin epidemic” (Fischer et al., 2021; Strickland et al., 2019). Understanding current
experiences and perceptions is critical in developing public health responses.
The purpose of this study is to understand changes in the illicit opioid drug market in
Dayton (Montgomery County), Ohio. This is an important region in understanding the evolving
opioid crisis, as Montgomery County had the second highest age-adjusted overdose fatality rate
in the state with 63.5 deaths per 100,000 from 2014 to 2019 (Ohio Department of Health, 2020).
Previous research on fentanyl in the Dayton region documented an increase in unintentional
overdose deaths attributed to fentanyl analogues (Daniulaityte et al., 2019b) and high rates of
self-reported use of fentanyl (Daniulaityte et al., 2019a). Reported preferences for fentanyl are
mixed as over half of participants preferred heroin in one study (Daniulaityte et al., 2019a) with a
qualitative study indicating that participants preferred and sought out fentanyl (Silverstein et al.,
2019).
Studies have documented perceptions and preferences as fentanyl first emerged in the
illicit opioid market (Carroll et al., 2017; Daniel Ciccarone et al., 2017; S. Mars et al., 2018a;
McLean et al., 2019). However, additional qualitative research is needed to understand how the
drug market continues to evolve over time and the resulting impact on preferences and use
patterns. In-depth first-hand knowledge from people who use drugs is especially valuable in
providing detailed descriptions of drug markets including participant behaviors and transactional
details related to price, dealer interactions, and product quality (Ritter, 2006). To better
understand changes in the illicit opioid drug market in Dayton, Ohio, this study aims to
qualitatively characterize current perceptions on availability, preferences, and current potency of
street fentanyl.

28
Methods
Initial participants were made aware of the study by researchers who have established
relationships with the study population. Interested participants contacted the lead author and
were screened for eligibility. To be eligible for the study, participants had to be over the age of
18, reside in the Dayton region, self-report use of heroin/street fentanyl within the past 30 days,
and not currently participating in abstinence-based substance use treatment. Additional
recruitment methods included peer referrals and Facebook-based ads. Participants received $30
for study participation and $10 per referral.
Data collection began in March 2020 and was completed in November 2020. Data
collection occurred during the COVID-19 pandemic, so the research pivoted from in-person to
virtual methods. A total of 13 in-person interviews were completed before study procedures
shifted to virtual methods. The remaining 47 interviews were conducted and recorded using
Zoom video conferencing software. Informed consent was obtained from all study participants.
For those completing in-person interviews, consent was obtained on the day of the interview. For
those completing virtual interviews, the first author would review the consent with participants
once they were deemed eligible during the screening process. The first author would then send
the link for the participant to review and digitally sign the consent on REDCap. During the start
of the scheduled interview, the first author would ask the participant if they had any questions
over the consent and review before beginning the interview.
Interviews included a brief demographic survey and semi-structured questions. The brief
demographic survey took between 15 to 30 minutes to administer and included questions
regarding drug use history, harm reduction utilization, and risks. Semi-structured qualitative
interviews lasted between 30 and 60 minutes, and they were focused on understanding
experiences and preferences related to fentanyl, harm reduction strategies, and perceptions of

29
drug markets. The lead author wrote field notes following interviews. Analytic memos were
recorded during transcription review and throughout the coding process. The lead author shared
all field notes, analytic memos, and checked with members of the study team throughout data
collection and analysis.
Interviews were transcribed, checked for accuracy by the first author and entered into
NVivo (Version 12, QSR International, Melbourne, Australia). Following a lone-wolf coder
approach (Saldaña, 2021) the first author coded an initial set of transcripts based on questions
and categories from the qualitative interview guides. The first author then discussed the coding
approach with co-authors, sharing field notes and the analytic and transcription memos along
with the codebooks. Adjustments were made to the coding schema following in-depth
discussions and recommendations from co-authors. The first author then applied the revised
coding schema to the remaining transcripts, revising as new themes emerged. Using the
interview guide and field notes, the first author identified categories and key concepts. Once no
new codes were derived this indicated inductive thematic saturation (Saunders et al., 2018). The
thematic data analysis was an iterative and reflexive process (Braun & Clarke, 2019) and
informed by existing literature related to heroin and fentanyl drug markets. Qualitative interview
data was triangulated with the demographic survey data to further understand participants
perspectives and experiences. All study procedures were approved by the University of Southern
California Institutional Review Board. Names used in the paper are pseudonyms.
Results
Study sample

The mean age of participants was 37. The majority of participants were non-Hispanic
white, female, heterosexual, and had a high school education or less. Almost half reported a past

30
month income of less than $1,041. Around a quarter were homeless or unstably housed and
among those who were unhoused the average time homeless was 8 months (Table 2.1).
All but one participant reported past 30-day fentanyl use, with a little over three-quarters
reporting past month heroin use. Less than one-quarter of participants reported non-prescribed
prescription opioid use. Other commonly reported past 30-day illicit substance use included
marijuana, methamphetamine, and non-prescribed benzodiazepines. The majority of participants
preferred fentanyl alone. Participants primarily identified fentanyl by color, taste, effects, and
texture. Over 90% of participants reported they suspected that fentanyl has been mixed
(adulterated) into other substances they used in the past 30 days including heroin,
methamphetamine, benzodiazepines, and powdered cocaine. Over 60% of participants preferred
heroin adulterated with fentanyl. Participants indicated a slight preference for fentanyl
contamination in cocaine and methamphetamine. (Table 2.2).
Illicit opioid drug market: dominance of fentanyl
Fentanyl is sold as “fetty,” with one participant reporting his dealer selling it as “nal.”
Participants identified that they have purchased fentanyl primarily through visual appearance,
taste, and subsequently, duration of effects. Fentanyl reportedly has a “sweet” taste and is
described as “fluffy” or a “very fine powder” that is “white.” Other colors for identifying
fentanyl included “blue, pink, and purple.” “Yellow” was reported as indicating the fentanyl
analogue carfentanil. In comparison, participants described heroin as “chunky” and “brown” or
“light tan” in color with a “bitter” taste. Participants explained that fentanyl effects are more
immediate and “intense,” with the length of effects typically lasting between “one” to “three”
hours, compared to heroin effects that are less immediate, with lengths stretching for at least
“six” to “eight” hours.

31
Participants described the current illicit opioid market as dominated with fentanyl, and
only limited availability of unadulterated heroin without any fentanyl contamination. Participants
described their perceptions that fentanyl is mixed with heroin to make it “stronger.” As Tom
(white male, 27) explained: “Within the last, probably I'd say within the last three or four years,
I think fentanyl has totally like dominated over heroin in this area. At least like I said, I've lived
in Dayton my whole life.” George (white male, 36) also suggested, “Yeah, it's all fentanyl now.
You can't, I don't even think you can get heroin anymore, to be honest with you.” Bill (white
male, 39) reflected on hearing about unadulterated heroin but being unable to obtain this:
And now it is all powder. Sometimes it's chunky powder, sometimes not. But it's white. So,
it's like, it's like all fentanyl now. I mean I've heard about actual heroin going around, but
as far as I know, I haven't had any for a while.

Some participants acknowledged that unadulterated heroin is still available in the area,
but it is much harder to find, and it can be more than double the cost of fentanyl, as Bobby (white
male, 36) explained:
I mean, heroin is just, even now, if you're trying to get heroin, it's more expensive than
fentanyl. You're going to pay $125 or more for a gram of legit heroin. And, you know,
you can just go spend fifty bucks and get, you know, a gram of fentanyl.

In contrast, John (white male, 43) claimed that there are fewer fentanyl dealers in the area
and commented, “Oh yeah, it's mostly heroin now on the street.” He was the only person
interviewed to claim this, and it is likely due to his age and his drug network connections, as the
remaining participants perceive limited heroin and an abundance of fentanyl in the drug supply.
Mary (white female, 31) has a large network and has retained access to some unadulterated
heroin, although it is difficult for her to find:
It's a lot harder, but it's still there [heroin]. I know a lot of people, so I could find it. Like,
but I can tell you a while back, I went to the county jail for the night. And, you know, they
drop you when you go in there… But they recently, the way the nurse asked me like,
“Where do you get your drugs at?” I'm like, “Excuse me?” She's like, “I'm just asking

32
because you're the first person in six years that has came in here and has pure heroin in
your system.”

Like Mary, many participants rely on drug test results through jails, probation, or
treatment providers, such as methadone clinics, to determine if they are using heroin or fentanyl.
As Scotty (white male, 39) disclosed:
…that's how I kind of knew when it was completely switched over by the drug test
results. …I have not had one, because the heroin shows up as morphine in the drug test, I
have not had one show up for morphine for a very long time.

Demand for fentanyl: preferences for pharmacological effects
Most participants reported that when fentanyl initially emerged in the drug market, they
would try to seek out unadulterated heroin because they were frightened of the increase in
overdose deaths associated with fentanyl. However, with the market flooded with fentanyl, most
participants now report a preference for fentanyl, or a heroin and fentanyl mixture as Gloria
(Hispanic female, 26) explained:
I think people at first, like I said, were scared of it, and then when they realized that it
was a much more intense high, I think that’s when people started to seek it out… like
once I got introduced to the fentanyl and that’s all I wanted. I would prefer it to be mixed
with the heroin because it would give me, like, those legs, that lasting time. But as far as
like, if I had to have one or the other, I would go with the fentanyl.

When describing effects, participants used terms like Gloria and explained that heroin has
“legs” to indicate that the heroin has a longer length of effects compared to fentanyl, which
provides a shorter intense rush. Stephanie (white female, 33) further explained why someone
might prefer a mixture of heroin and fentanyl, “Because the heroin lasts longer. And then the
fentanyl gives that feeling like upfront. So, you kind of get both, like the best of both worlds.”
Participants also spoke of distinct characteristics that differentiated preferences in the
community. For instance, younger participants perceived that “older” people who had longer
heroin histories preferred unadulterated heroin. Participants also spoke of their observations as to

33
the motivation or reason for use that would determine individuals’ preferences. It was reported
that people who prefer unadulterated heroin would use for “pain management,” for the
“energetic effects,” and to “stay well.” In comparison, those who are seeking a “rush” and
“high” were perceived as more likely to prefer fentanyl alone. Hannah’s (white female, 34) story
revealed that her access to unadulterated heroin increased when dealers are released from prison
and return to selling unadulterated heroin that they stashed prior to their incarceration. Hannah,
who initiated into heroin at age 18, described her preference for heroin:
Well, ok, older people that have been using heroin for a long time, they want the real
heroin. Kids or younger people that just started, they want the fentanyl. Because it's two
totally different effects. You know what I mean? So, like people that just started using,
younger people, they think that they want that instant rush with the fentanyl. Rather than
like, I want that slow, like long lasting, like, I'm staying awake, like I can have energy to
do stuff.

Participants have become accustomed to the intense rush and stronger effects associated
with fentanyl and may find it difficult to return to unadulterated heroin as Jerry (white male, 52)
explained: “Yeah once you have fentanyl you're not going to go back to heroin. I mean, for me
anyways, I think that's for a lot of people too. Because it's just so strong.” The much more potent
fentanyl provides such different effects that as Paul (white male, 41) explained: “People actually
complain that they say that they don't get high off the heroin anymore because of the fentanyl.”
Therefore, even if unadulterated heroin were to become more available in the region, participants
may continue to seek fentanyl, because they will no longer feel the same effects from
unadulterated heroin. Janet (white female, 25) reported using fentanyl for five years. She
clarified the difference in effects between heroin and fentanyl:
Well, okay, the fentanyl is stronger than the heroin if you’ve never done it, but once you
do it and you get a tolerance, it doesn’t get you high like that. With heroin you would be
blowed every time. But now since I’ve done fentanyl, it’s so weird. I couldn’t go back to
heroin because it doesn’t do anything to me. Even though the heroin was a better high,
you see what I’m saying? The fentanyl is so much stronger.

34

Molly (white female, 34) who has used fentanyl since age 28, described a recent
experience with what she perceived to be unadulterated heroin after using fentanyl for a few
years:
We had gotten some, like, what we thought was like heroin. It was like that, like brown
chunky, whatever…. That’s just like fentanyl is like white and straight powder. So, we
saw that we found like somebody had gotten this, like this [heroin], we were like, “Oh,
my God. Look this is going to be great.” And we did it. And we were very disappointed.

Fentanyl quality: the role of dealers in managing potency
Most participants commented that dealers often were unaware of the potency of fentanyl
when it first emerged in the area. A few recounted stories of dealers calling them in tears because
they learned that someone overdosed from their supply. Joe (Hispanic male, 40) commented on
the impact of fentanyl in the region:
I think nobody really knew that it was going to be so damn powerful. Like we all knew
what it was. We knew fentanyl was powerful, but I don't think anybody was really
prepared for, especially the dealers you know. I don't know where they got their stuff
from and I don't know who mixed it, and who mixes it and stuff, but I think a lot of
dealers are even surprised from what I can understand. ‘Cause as a dealer, you need
those people coming back and you've got people dying. It's like shit, something's wrong
with your stuff.

Participants reported that current fentanyl potency varies greatly, and the quality depends
on the experience of the dealer. Many participants perceived that the quality of fentanyl is
generally lower in the region, because dealers are cutting the product to make more profit and to
prevent their clients from overdosing, while also protecting themselves from criminal
prosecution. As Tommy (white male, 36) explained: "And now you have guys that are scared to
even sell, you know, more pure stuff. They're cutting it just because they're afraid of what they
got is too strong." The change in fentanyl potency has caused some participants to seek a return
to unadulterated heroin as Diane (white female, 45) discussed her response to a change in
quality:

35
I'd ask, “Do you have fetty? I want fetty.” But then when the government started busting
people for it and it started getting lower and lower [quality] and the prices got higher,
then I didn't want it no more. I wanted to go back to my heroin that lasted longer.

Most participants perceived limited carfentanil in the region, indicated by a decrease in
overdose deaths in the area and a lack of “yellow” product in the market. Some attributed
changes in the availability to a lack of supply, due to larger busts. Others identified that dealers
did not want to sell carfentanil because of the overdose risks. A few participants observed that
carfentanil might still be in the area, but that dealers are more adept at cutting it now, as noted by
Megan (Black female, 26):
I think it was killing too many people and a lot of like drug dealers are going to jail over
it [carfentanil]. So, I don't know if they stopped using it or if they just like cut, cut it a lot.
I'm not sure. I just know, I haven't really, I haven't heard of anybody doing any.

Dealers are reportedly cutting fentanyl with “creatine, coffee creamer, benzodiazepines,
fiber powder, powdered sugar, mannitol, Similac, pain pills, Seroquel, powdered vitamins” and
“in desperate times, people use anything white.” Sleeping pills, such as “Dormin” were
mentioned as common agents for cutting fentanyl, because these pills mimic some of the effects
of higher quality fentanyl, in that it will make people “nod” and fall asleep. Experiencing
drowsiness after use makes the product seem stronger. Margaret (white female, 51) explained:
A lot of them puts in like sleeping pills in with the powder [fentanyl] and crushes them
up. And that'll be their cut. And people that's new to like the drugs and everything, you
know they're falling out constantly, can't stay awake. They think they got killer dope. And
all they really got was some sleeping pills.

Participants reported using only fentanyl but having other drugs such as “barbiturates,
Benadryl, methamphetamine, cocaine, codeine, other synthetic opioids, benzodiazepines and
Tramadol,” show up in their drug test results. Sally (white female, 27) reflected on a drug testing
experience at a methadone clinic:

36
When they did the test, I would only, I would think I'm just buying fentanyl and I would be
flagged… and then have to talk to a counselor if we dropped dirty. And I told my
counselor, he was like, “Well, you dropped dirty for cocaine, methamphetamine,
barbiturates.” And I'm like, “I only did fentanyl.” He was like, "Listen, this is what I've
been hearing. Most of the clients in here have been flagged for other stuff, too. And they
swear up and down, they haven't done it.” So, he was like, "You need to get it from
somebody new because that person's cutting it and don't give a shit."

Fentanyl contamination in drugs other than heroin
Reports of fentanyl contamination in substances other than heroin were commonly
reported in the region. Participants remarked that fentanyl is mixed into cocaine or
methamphetamine to “stretch” the product or to make people “sick” if they don’t come back to
buy the product. However, contamination was also thought to happen unintentionally.
Historically, illicit opioids were sold by caps in Dayton. This has changed as the majority of
participants reported the practice of selling by weight is now more common. Some participants
felt that this change was motivated by buyer preferences, but others noted that it is easier for
dealers to sell by weight than to prepare caps. Typically, participants buying in increments of
less than $20 will receive caps, but larger amounts will be sold by weight, with a half gram
costing approximately $40, and a gram averaging between $60 and $80. With the transition to
weight, smaller amounts are not as available to consumers, “We buy about twenty dollar
increments now for weight. Before when he capped it, you could buy like a five-dollar cap, ten-
dollar cap, whatever. Now the least you can buy is $20 and up.” Participants suggested that the
increased practice of selling by weight was reason for fentanyl contamination in other drugs. It
was reported that most dealers sell multiple types of drugs, so if the dealer is using the same
weighing methods for multiple drugs and does not clean between transactions, contamination
may occur.
Some participants believed they have consumed drugs other than heroin that have been
contaminated with fentanyl. Roger (white male, 42) reports using fentanyl to help with side

37
effects of his methamphetamine use. He reflected that the quality of methamphetamine has
changed, likely due to contamination with fentanyl, and he did not like the reduced effects: “I
used to feel stuff for days on this stuff [methamphetamine]... Now I don’t.” Like Roger, the
majority of participants who had purchased what they perceived as fentanyl contaminated
products did not prefer the effects, as Susan (white female, 38) explained:
We've gotten meth one time that had fentanyl in that we knew for sure. It didn't even feel like ice
‘cause we were completely out of it. Completely didn't remember the next day what happened the
day before. Yeah, it was awful. And we called the guy and he still denied it.

However, according to Rachel (white female, 33) someone who regularly uses fentanyl
may not notice that it is mixed into their other drugs:
Honestly, I wouldn't be able to tell, but somebody that doesn't do fentanyl and did
cocaine would, because my body, since my body's already taken it in. If I did a big thing,
of coke and it had fentanyl, I probably might notice after shooting it like, oh, there might
have been a little boy in there, you know, a little come down but nothing like that, like
terrifying or anything. Unless there's too much then that can cause an overdose.

Pressed fentanyl pills
Illicit pressed pills, such as fake Xanax or fake Percocet/Roxicet (“Dirty 30’s”), were
reported as becoming readily available in the area, within the past year. These pills are typically
pressed with fentanyl and filler, but some participants reported receiving pills containing all
filler. Over half of participants mentioned personal experiences with pressed pills with most
people snorting or swallowing them. People may unknowingly buy pressed pills and
unintentionally initiate into fentanyl, like Megan’s (Black female, 26) sister, “My sister, the
reason she got on fentanyl, well she wasn't trying to be on fentanyl, but she had gotten pressed
Percocets. And that's how she got the fentanyl in her system.”
The majority of participants prefer pharmaceutical versions of the pills, because the
variation in the potency of the pressed pills increases overdose risks. Participants claimed that

38
pharmaceutical versions of pills are still available, but they are very expensive and typically
range from $1 to $2 a milligram, as Joey (white male, 36) commented:
Fifteen to twenty bucks for them. 10 milligrams of Percocet, and that's ridiculous to me, I
mean. But people pay it, I guess if they want it, whatever, they'd rather do that than spend
less money on heroin or fentanyl ‘cause it's fentanyl, you know.

For those without extensive prescription pill use history, or for those buying from dealers
who are adept at pressing, it can be difficult to distinguish between pharmaceutical and pressed
versions of pills as indicated by Harry (white male, 29):
It just depends on how good they press it. ‘Cause sometimes they look a different color,
too, and sometimes they'll be a little spotty. So, it just depends on how good the person
who pressed them is. Like me, I can tell a difference, but if someone didn't know, they
couldn't tell a difference.

Identification strategies were discussed by participants. Visual identification is often used
with many participants noting that pressed pills typically have a “dent” from the machine. Joyce
(white female, 36) provided techniques to identify pressed pills:
I mean, you can Google it all day, you know. What does it look like? But it's all about like
is it hard, or is it soft? Is it flaky? The color the taste, the size? You know, is it marked
correctly? But a lot of times how you really can tell is it will be soft… you could squeeze
it. If you squeeze it really, really, really, really hard. And it would crush eventually, you
know what I mean. You wouldn't have to use a pill crusher.

Fentanyl pills were reported to have less stigma than fentanyl powder. These perceptions
of lower stigma may motivate people to seek out and use the pressed fentanyl pills. Zach (white
male, 27) was initially unaware that he was using pressed fentanyl pills and commented:
I mean, you, you try to pretend like you don't know. But again, like I said, like not even,
nobody has that many Oxy, like in today's world, like, it's nonexistent. But it makes you
feel good, you know? You're getting a pill, like I'm not on dope, you know what I mean?

Tom (white male, 27) disclosed a history of pressed fentanyl pill use. During the
discussion he shared that he had friend who died from an overdose related to pressed pills. He

39
discussed that his friend knew he was buying pressed pills, but believed them to be pressed
Oxycodone rather than fentanyl:
I mean, my friend that overdosed and passed away…he, to my knowledge…he was aware
that he was doing pressed pills, but he was not aware that they were pressed with
fentanyl. And he thought he was just doing pressed Oxycodone pills. But in my
experience, having had done fentanyl before and trying to tell him, “Hey, man, these pills
that we're doing are definitely fentanyl, they're not Oxycodone.” I mean, he just didn't
want to believe it. Because, I'm assuming, he didn't want to admit to himself that he was
dependent on fentanyl. He would have rather been dependent on OxyContin or
Oxycodone.

Nancy (white female, 35) previously sold pressed pills. She discussed that she would not
return to selling them because of the deception involved in selling these to people unaware they
are buying pills containing fentanyl:
I didn't want to have that over my head. ‘Cause you hear like people tell you like the
Xanax bars that are pressed it's killing people ‘cause my sister overdosed on them three
times and she's like, “Well they're just Xanax that I'm overdosing on.” It's not though, I
know what it is. …I just didn't really want to be a part of it this time. It's shitty to deceive
people.

Nancy continued and explained that dealers are motivated to sell pressed pills because of
the profit in selling these compared to powder fentanyl:
And they're like,” Why would they put that in there?” Because when you take a Xanax,
you're supposed to feel something. But it's more expensive to get that drug than it is to get the
fentanyl. So put the fentanyl in there so you feel something. It's literally $2 worth of fentanyl
and they're charging, you know, eight bucks for a Xanax bar. It's probably not even that, it's
probably twenty-five cents or fifty cents [of fentanyl] if you're doing those. And, you know,
it's just ridiculously cheap for what they're getting and it's literally killing them. …And that's
why, like I was trying to explain to somebody the other day like, “Well I don't understand
why they put anything in it at all.” Well, because people will stop buying it if they don't have
any effect from it at all.
Discussion
The present study provides an in-depth examination of current insights and perceptions of
the evolving illicit opioid drug market in Dayton, Ohio. Findings point to individual experiences
in changes in fentanyl availability, preferences, and quality over time. Results indicate

40
perceptions of a changing drug market characterized with lower quality fentanyl dominating the
opioid market and limited availability of unadulterated heroin. Most participants reported
minimal knowledge on current fentanyl analogues but claimed that carfentanil is not currently in
the drug supply. Participants perceived that dealer adaptations to avoid overdose risks to clients
and personal prosecution has resulted in decreased quality, with sleeping pills commonly
reported as cutting agents. Fentanyl contamination is also reported in drugs other than heroin.
Moreover, the emergence of pressed pills containing fentanyl were attributed to increased
overdose risks. Findings yield three main conclusions.
First, while participants described initial hesitation to use fentanyl due to overdose fears,
the majority of participants now report a preference for fentanyl or heroin/fentanyl mixture.
Supporting previous literature (Mars et al., 2019), users in Dayton have become familiarized
with the effects of fentanyl and find it difficult to return to unadulterated heroin use. Participants
report that unadulterated heroin no longer provides the desired effects or helps them in managing
withdrawal symptoms. This pattern has similarities to the process by which individuals
transitioned from prescription pills to the more potent effects of heroin. The pharmacological
effects of fentanyl appear to be distinct from heroin, that if unadulterated heroin becomes more
available in the area, a separate market and customer base may emerge. Overall, participants
indicate that although attempts were made to avoid fentanyl when it first emerged, there is more
acceptance, and even developing preferences for fentanyl in the area.
Providing additional support for the acceptance of fentanyl in the area, the lack of slang
terms for fentanyl has previously been noted as an indication that fentanyl has not gained
popularity among people who use drugs (Ciccarone, 2021). The reported slang term, “fetty”
when referring to fentanyl, was also reported in a previous study (Silverstein et al., 2019), and

41
indicates an increased acceptability of fentanyl among participants in the region. While the
introduction of fentanyl into the supply was initially supply-led as noted in previous research
(Daniel Ciccarone, 2017b; Mars et al., 2019), the current findings raise the question over how
demand for fentanyl will influence the future market dynamics and risks.
Second, the findings indicating that dealers are cutting the product to minimize overdose
risk provides additional insights to the observed drug market adjustments documented in
previous research (Rosenblum et al., 2020). Our findings point to the potential practice of dealers
actively monitoring their products for potency and overdose prevention that has been previously
described (Bardwell et al., 2019; Betsos et al., 2021; Kolla & Strike, 2020). For instance, one
study found that sellers understood risks in varying potency of their product and engaged in drug
checking to provide a safer supply to clients (Betsos et al., 2021). While research has identified
trusted dealers as a source of risk reduction (Carroll et al., 2020; Carroll et al., 2017; S. Mars et
al., 2018b; McKnight & Des Jarlais, 2018), additional studies are needed to understand dealer
perceptions on implementing more formal processes for user safety and drug checking (Bardwell
et al., 2019).
Third, fentanyl contamination in non-opioid drugs such as crack, powdered cocaine, and
methamphetamine has been documented in other regions of the US (Drug Enforcement
Administration, 2020; Jones et al., 2020; Klar et al., 2016; Tomassoni et al., 2017). Recent data
indicates that Ohio has high rates of fentanyl contamination in drugs overall. In 2014, Ohio
Crime Lab testing identified fentanyl contamination in 3.5% of heroin, 0.7% of cocaine, and
0.2% of methamphetamine tested (Harm Reduction Ohio, 2021b). The 2020 Ohio Crime Lab test
results indicate a notable increase with fentanyl contamination detected in 75% of heroin, 12% of
cocaine, and 4% of the methamphetamine (Harm Reduction Ohio, 2021b). Increased practices of

42
selling by weight that were discussed by participants has important considerations. However, it
should be noted that it is unclear if the contamination is intentional or a result of polydrug
operations, as suggested in other research (Jones et al., 2020).
Polysubstance use, especially of methamphetamine, has been documented among people
who use illicit opioids in other regions (Al-Tayyib et al., 2017; Cicero et al., 2020; Ellis et al.,
2018; Glick et al., 2021; Hayashi et al., 2021). These patterns have also been observed in the
local Dayton area (Daniulaityte et al., 2020). Nevertheless, this research has not been able to
document to what extent purchasing fentanyl contaminated drugs other than heroin is desired.
The present study provides evidence of experiences where individuals described purchasing
fentanyl-contaminated stimulants. Qualitative data indicates that consumers do not prefer
fentanyl in substances other than heroin. However, survey data (Table 2) indicates that
participants who have purchased contaminated stimulants reported a slight preference for
purchasing powdered cocaine adulterated with fentanyl and about one-third of participants
reported a preference for purchasing methamphetamine contaminated with fentanyl. Additional
research is needed with larger samples to understand preferences for fentanyl in non-opioid
drugs. Ultimately, this highlights the timely need for increased access to drug checking (Laing et
al., 2018), so that consumers can be informed of the existing street supply, rather than gauging
contamination in drugs by visual and pharmacological effects.
Access to pressed pills sold as Xanax, OxyContin, Percocet, and Roxicet was described
as increasing in the area and attributed to elevated risks for overdose. While studies have
documented pressed pills and overdose risks associated with unintentional exposures (Armenian
et al., 2017; Green & Gilbert, 2016; Sutter et al., 2017), less is known about motivations for
seeking pressed pills. One participant with an extensive use history of pressed pills noted lower

43
stigma with pressed pills compared to fentanyl powder. This is similar to perceptions of more
social acceptability of prescription opioids compared to heroin, in the early stages of the
epidemic (Daniulaityte et al., 2012; Mars et al., 2014). Despite the availability in the market,
most participants would prefer pharmaceutical versions of the pills because of the risks
associated with unknown potency and the cutting agents in pressed pills. Further research is
needed to understand perceptions related to pressed fentanyl pills and motivations for intentional
use.
Limitations and Strengths
Study limitations are noted. The study procedures transitioned from in-person to virtual
due to COVID. This impacted the initial recruitment plan which included targeted community
outreach. Recruitment then relied more on peer driven referrals, which can limit sample diversity
when participants recruit peers with similar characteristics (Erickson, 1979; Heckathorn, 2002;
Magnani et al., 2005). As a result, the racial and ethnic diversity is limited, so these experiences
primarily reflect those of non-Hispanic white people who use illicit opioids in the region.
However, a strength of the sample is that the majority of participants were females, a population
that remains underrepresented in drug research (Meyer et al., 2019). All data is self-reported and
can be subject to social desirability and recall bias. Finally, the study location is unique, and it is
unclear how experiences in this region reflect other parts of Ohio or the United States. Therefore,
the study may not be able to provide conclusive findings but can generate hypothesis.
Consequently, the specificity is also a strength of this study in that it provides detailed analysis
of drug market changes that can be used to inform other larger scale representative studies
(Ritter, 2006).

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Conclusion
Despite some limitations, this study provides an understanding of the evolving illicit
opioid market in a region identified as an epicenter of the opioid crisis. While the introduction of
fentanyl was initially supply-led, findings indicate that the current market is becoming
influenced by user preferences for fentanyl. As the opioid drug market continues to transform, it
is important to document these changes to understand the impact on substance use patterns and
risk reduction practices among people who use illicit opioids. Much of the current focus on risk
reduction is concentrated on the opioid-using population, but opioid-related risks may extend to
other substances, as fentanyl contamination is suspected in drugs other than heroin.
Comprehensive harm reduction is needed beyond those who identify illicit opioids as their drug
of choice (Jones et al., 2020). Other innovative measures such as implementing and encouraging
drug testing among dealers needs to be explored to increase access to a safe supply (Bardwell et
al., 2019). Finally, research is needed to understand preferences for other drugs contaminated
with fentanyl, as there may be emerging markets for fentanyl contaminated substances other than
heroin.

45
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Tables

Table 2.1 Sample Demographics (N=60)

Demographics N (%)
Gender
Female 34 (56.7)
Male 26 (43.3)
Age
Year (Mean, St. Dev.) 37 (7.3)
Race/Ethnicity
Non-Hispanic White 52 (86.7)
Black, Indigenous, People of Color 8 (13.3)
Sexual Orientation
Straight/Heterosexual 52 (86.7)
Gay/Lesbian/Bisexual 8 (l3.3)
Education
Less than High School 13 (21.7)
High School/GED 21 (35.0)
Some College or More 26 (43.3)
Past Month Income
Less than $1,041 28 (46.7)
Homeless/Unstably Housed
Yes 14 (23.3)
Months Homeless (Mean, St. Dev) 8 (12.8)

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Table 2.2 Fentanyl Use, Preferences, Availability, and Contamination in Other
Substances (N=60)
N (%)
Past 30-Day Illicit Opioid Use
Heroin 47 (78.3)
Street Fentanyl 59 (98.3)
Non-Prescribed Prescription Opioids 13 (21.7)
Past 30-Day Substance Use
Alcohol 26 (43.3)
Marijuana 43 (71.7)
Non-Prescribed Benzodiazepines 27 (45.0)
Crack Cocaine 13 (21.7)
Powdered Cocaine 21 (35.0)
Speedball Cocaine and Heroin/Fentanyl 15 (25.0)
Methamphetamine 34 (56.6)
Speedball Methamphetamine and Heroin/Fentanyl 19 (31.7)
Fentanyl Preference
Heroin Alone 19 (31.7)
Street Fentanyl Alone 22 (36.7)
Heroin mixed with Street Fentanyl 19 (31.7)
Fentanyl Availability
Sold as fentanyl 34 (56.7)
Sold as heroin 15 (25.0)
Sold as mixed 10 (16.7)
Fentanyl Identification Methods
Color 41 (69.5)
Taste 36 (61.0)
Texture 20 (33.9)
Smell 9 (15.3)
Effects 26 (44.1)
Dealer told them 9 (15.3)
Perceived Fentanyl Contamination in Other Substances (Past 30-Day)
Yes 55 (91.7)
Marijuana (n=39) 3 (7.7)
Crack Cocaine (n=13) 1 (7.7)
Powdered Cocaine (n=19) 7 (36.8)
Heroin (n=45) 44 (97.8)
Methamphetamine (n=32) 15 (46.9)
Prescription Opioids (n=13) 3 (23.1)
Benzodiazepines (n=26) 11 (42.3)
Preferred Substance Mixed with Fentanyl
Marijuana (n=3) 1 (33.3)
Crack Cocaine (n=1) 0 (0.0)
Powdered Cocaine (n=7) 3 (42.9)
Heroin (n=44) 28 (63.6)
Methamphetamine (n=15) 5 (33.3)
Non-Prescribed Prescription Opioids (n=3) 2 (66.7)
Non-Prescribed Benzodiazepines (n=11) 1 (9.1)

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Chapter 3:
Study 2
Prescription opioid, heroin, and street fentanyl trajectories:
Contextualizing the three waves of the opioid crisis
Abstract
Introduction: The third wave of the opioid crisis is marked by the rise of synthetic
opioids, such as illicitly manufactured fentanyl. The purpose of this study is to contextualize the
three waves of the opioid crisis to better understand motivations associated with illicit opioid use
and transitions. In addition, this study explores new pathways into fentanyl use. Understanding
the impact of fentanyl on opioid use trajectories is critical in developing appropriate prevention
and intervention strategies.
Methods: Sixty people who use illicit opioids were recruited from Dayton, Ohio.
Participants completed a brief demographic survey and a semi-structured qualitative interview.
Interviews were conducted from March to November 2020 with a total of 13 in-person and 47
virtual interviews. Qualitative interviews were transcribed in their entirety and interview data
was analyzed thematically using NVivo 12.
Results: The average age for initiation into prescription opioid misuse was 20, compared
to 25 for heroin, and 31 for street fentanyl. Supply side changes were noted as influencing
trajectories for all three waves. However, differences were noted in the experience of
prescription opioid and heroin initiation with these trajectories influenced by the
pharmacological effects, pain management, curiosity, intergenerational use, pricing, and peer
influences. In comparison, most participants were unaware that they were initiating into street
fentanyl, and many overdosed during their first use of fentanyl. A new trajectory into fentanyl

56
was identified among a few participants involving an initiation with pharmaceutical pills,
followed by a transition to pressed pills contaminated with street fentanyl, and then to powdered
street fentanyl. Transitions from pressed fentanyl pills to powder fentanyl were financially
motivated.
Discussion: Understanding influences on opioid trajectories is important in addressing
associated harms. Peers, family, and traumatic experiences were noted as critical components of
each wave of the crisis. Interventions are needed to address not only the substance use but to also
consider the socio-environmental influences on trajectories. More research is needed to
understand appropriate prevention and intervention strategies as the fentanyl market continues to
evolve.

57
Introduction
The opioid crisis, officially declared a public health emergency by the Department of
Health and Human Services in 2017 (US Department of Health and Human Services, 2017), has
had a devastating impact on individuals and communities throughout the United States. Since the
late 1990’s there have been significant increases in opioid-related emergency room visits and
hospitalizations related to opioid use (Ronan & Herzig, 2016; Unick et al., 2013; Vivolo-Kantor
et al., 2018), opioid-related overdose deaths (Mattson et al., 2021; National Institute on Drug
Abuse, 2021; Rudd et al., 2014; Rudd et al., 2016), and injection-related blood-borne infections
such as Hepatitis C (Centers for Disease Control and Prevention, 2020a; Liang & Ward, 2018;
Powell et al., 2019) and HIV (Hodder et al., 2021). The current crisis has also had economic
impacts related to the loss of or reduced quality of life, lost job productivity, and the associated
health and criminal justice costs, totaling an estimated $1.02 trillion in 2017 alone (Florence et
al., 2021).
This crisis is defined by three waves, beginning with prescription opioids in the late
1990s, followed by heroin in approximately 2010, and synthetic opioids in 2013 (Ciccarone,
2019, 2021). The first wave is associated with policy changes in the medical field related to pain
management. Specifically, the mandate to treat pain as the 5
th
vital sign, paired with increased
marketing by pharmaceutical companies that minimized the potential risk for dependence on
prescription opioids, resulted in increased prescribing of pain medication in the United States
(Chidgey et al., 2019; US Department of Health and Human Services, 2021). Prior to the
mandate, prescription opioids were used for managing severe pain related to surgeries, cancer, or
hospice care. The changes in pain management standards encouraged doctors to treat broader
pain variations with potent prescription opioids, most notably, OxyContin (extended-release
oxycodone) (Chidgey et al., 2019; Guy Jr et al., 2017). As a direct result of these changes the

58
number of opioid prescriptions in the United States increased 104% from 43.8 million in 2000 to
89.2 million in 2010 (Sites et al., 2014). This significant rise meant that enough pain killers were
prescribed in 2010 to medicate every adult in the US for an entire month (Signs, 2011).
In addition to the increase in the number of individuals receiving opioid prescriptions,
patients were also receiving higher milligrams of prescriptions for longer lengths of time,
increasing risks for dependency (Boudreau et al., 2009; Centers for Disease Control and
Prevention, 2019; Edlund et al., 2014; Guy Jr et al., 2017). Correlating with this period of
seemingly unregulated prescribing, the prescription opioid-related overdose death rate in the
United States increased from around 3,000 deaths in 1999 to over 17,000 in 2017 (National
Institute on Drug Abuse, 2021). Measures such as prescription drug monitoring programs;
improved patient and doctor education; the targeting and closures of pill mills; and the
reformulation of opioids with abuse-deterrent properties were enacted in response to the rising
concerns related to overdose deaths involving prescription opioids (Bao et al., 2016; Butler et al.,
2013; Chakravarthy et al., 2012; Finley et al., 2017; Gourlay et al., 2005; Haffajee et al., 2015;
Hahn, 2011; Kennedy-Hendricks et al., 2016; Kuehn, 2014; Lyapustina et al., 2016; Patrick et
al., 2016; Penm et al., 2017). Implementing these policy changes led to reduced street
availability and increased street pricing for prescription opioids, which had the unintended
consequences of facilitating transitions from nonmedical prescription opioid use to heroin (Al-
Tayyib et al., 2017; Carlson et al., 2016; Gaines et al., 2020; Guarino et al., 2018; Mars et al.,
2014). Compounding this, as prescription pills were becoming more expensive and harder to
find, a less expensive and purer heroin flooded into communities (Ciccarone et al., 2009;
Rosenblum et al., 2014; Unick et al., 2014).

59
The second wave of the crisis is associated with transitions from prescription opioids to
heroin. Over a hundred million prescription opioids are dispensed each year (Centers for Disease
Control and Prevention, 2020b), and an estimated 20 to 30 percent of patients misuse these
prescriptions (Vowles et al., 2015). Small percentages of those misusing prescription opioids
transition into heroin use (Carlson et al., 2016; Compton et al., 2016; Muhuri et al., 2013).
However, this still amounts to thousands of people transitioning from prescription opioids to
heroin each year (Cicero et al., 2014; Muhuri et al., 2013). Reflecting the increase in transitions
from prescription to heroin, the rates of heroin-related overdoses in the United States increased
from under 2,000 in 1999 to almost 16,000 in 2016 (National Institute on Drug Abuse, 2021).
Heroin use increases negative health outcomes, especially among those who transition into
injection as a method of consumption. Injection use increases risks for overdose and exposure to
blood-borne infections and injection-related infections such as abscesses and cellulitis (CDC,
2018; Darke et al., 2006; Mathers et al., 2013).
The third wave of the crisis is marked by supply-led changes in the illicit opioid market.
Synthetic opioids, a large portion of these illicitly manufactured fentanyl (Drug Enforcement
Administration, 2020; Mattson et al., 2021; Reuter et al., 2021), emerged into the drug market
around 2013 (Ciccarone, 2017, 2021). Research indicates that the emergence of fentanyl into the
market is a result of changes in pricing and the availability of heroin, rather than user driven
preferences for fentanyl (Ciccarone, 2019; Mars et al., 2019). This led to fentanyl of varying
potency being mixed into the heroin supply, causing individuals to be unintentionally exposed to
fentanyl, and relying on strategies such color, taste, smell, or the physical effects to identify
contaminated heroin (Carroll et al., 2017; Daniulaityte et al., 2019; Hayashi et al., 2021). Due to
the fluctuating potency, and difficulty in identifying fentanyl contaminated products, the

60
introduction of fentanyl into the illicit opioid supply has had a notable impact on opioid-related
overdoses. The near 40,000 deaths related to synthetic opioids in 2019 accounted for almost 75%
of opioid-related deaths that year (Mattson et al., 2021).
Extant qualitative literature exists on the transitions from prescription opioids to heroin
(Harocopos et al., 2016; Lankenau et al., 2012; Mars et al., 2014; Monico & Mitchell, 2018), but
there are few studies comparing motivations for use and differences in transition experiences into
synthetic opioids, such as fentanyl. While studies have explored perceptions and preferences
related to fentanyl (Carroll et al., 2017; Ciccarone et al., 2017; Daniulaityte et al., 2019; Mars et
al., 2018b; McLean et al., 2019), to the author’s knowledge there are currently no qualitative
studies providing an in-depth understanding of pathways into fentanyl, motivations for use, and
how these experiences relate to trajectories with other opioids. Further, research on how fentanyl
has changed drug use trajectories is lacking. Heroin contaminated fentanyl has now been in the
market for approximately seven to eight years. In this time period we have seen shifts in
availability from heroin contaminated fentanyl to fentanyl only products. As a result, we are
unaware of the nature by which current initiation into fentanyl may be occurring and if it is
occurring in a different manner than when it first emerged. Indeed, fentanyl may be changing
opioid use patterns, but it is unclear how motivations and the socio-environmental context is
shaping fentanyl use. Therefore, understanding emerging fentanyl use motivations and
trajectories is essential in creating responsive prevention and intervention strategies.
The purpose of this study is to contextualize the three waves of the opioid crisis to better
understand motivations associated with illicit opioid use and transitions. In addition, this study
explores new fentanyl initiation trajectories through interviews with people who use illicit
opioids in Dayton (Montgomery County), Ohio. In-depth perspectives from people who use

61
drugs are especially important in understanding drug availability and use patterns and is critical
in developing appropriate public health approaches (Ciccarone et al., 2017; Harris et al., 2015;
Mounteney & Leirvåg, 2004).
Methods
Initial participants were made aware of the study by researchers who have established
relationships with the study population. Interested participants contacted the lead author and
were screened for eligibility. To be eligible for the study, participants had to be over the age of
18, reside in the Dayton region, self-report use of heroin/street fentanyl within the past 30 days,
and not currently participating in abstinence-based substance use treatment. Additional
recruitment methods included peer referrals and Facebook-based ads. Participants received $30
for study participation and $10 per referral.
Data collection began in March 2020 and was completed in November 2020. Data
collection occurred during the COVID-19 pandemic, so the research pivoted from in-person to
virtual methods. A total of 13 in-person interviews were completed before study procedures
shifted to virtual methods. The remaining 47 interviews were conducted and recorded using
Zoom video conferencing software. Informed consent was obtained from all study participants.
For those completing in-person interviews, consent was obtained on the day of the interview. For
those completing virtual interviews, the first author would review the consent with participants
once they were deemed eligible during the screening process. The first author would then send
the link for the participant to review and digitally sign the consent on REDCap. During the start
of the scheduled interview, the first author would ask the participant if they had any questions
over the consent and review before beginning the interview.

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Interviews included a brief demographic survey and semi-structured questions. The brief
demographic survey took between 15 to 30 minutes to administer and included questions
regarding drug use history, harm reduction utilization, and risks. Semi-structured qualitative
interviews lasted between 30 and 60 minutes, and they were focused on understanding
experiences and preferences related to fentanyl, harm reduction strategies, and perceptions of
drug markets. The lead author wrote field notes following interviews. Analytic memos were
recorded during transcription review and throughout the coding process. The lead author shared
all field notes, analytic memos, and checked with members of the study team throughout data
collection and analysis.
Interviews were transcribed, checked for accuracy by the first author and entered into
NVivo (Version 12, QSR International, Melbourne, Australia). Following a lone-wolf coder
approach (Saldaña, 2021) the first author coded an initial set of transcripts based on questions
and categories from the qualitative interview guides. The first author then discussed the coding
approach with co-authors, sharing field notes and the analytic and transcription memos along
with the codebooks. Adjustments were made to the coding schema following in-depth
discussions and recommendations from co-authors. The first author then applied the revised
coding schema to the remaining transcripts, revising as new themes emerged. Using the
interview guide and field notes, the first author identified categories and key concepts. Once no
new codes were derived this indicated inductive thematic saturation (Saunders et al., 2018). The
thematic data analysis was an iterative and reflexive process (Braun & Clarke, 2019) and
informed by existing literature related to opioid use trajectories and the three waves of the opioid
crisis. Qualitative interview data was triangulated with the demographic survey data to further
understand participants perspectives and experiences. All study procedures were approved by the

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University of Southern California Institutional Review Board. Names used in the paper are
pseudonyms.
Results
Drug Use History
Results from the brief demographic survey provide participant drug use history (Table
3.1). High rates of lifetime polysubstance use were reported in the sample. While all participants
reported a history of illicitly manufactured fentanyl use, two participants reported no history of
non-prescribed prescription opioid use, and all but one participant reported a history of heroin
use. The average age of initiation into prescription opioids was around 20, followed by heroin at
25, and street fentanyl at 31.
First wave: prescription opioids
The first wave of the crisis is marked with increased prescription opioid use. Participants
most commonly reported initiating into prescription opioid use through prescriptions for medical
conditions. As described in participant narratives, most were unaware of the risks associated with
the large milligrams of pain medications that they were prescribed each month. A few
participants recalled receiving pamphlets explaining risks or seeing warning stickers related to
drowsiness on the prescription bottle. However, the majority of participants stated that medical
staff did not provide direct warnings over risks associated with prescription opioid use and
potential dependence. Shelly (white female, 45) explained her limited knowledge of risks:
No, he didn't say a word [the doctor]. And I didn't, like I said, I'd never done drugs. I
didn't realize, well, I was a grown woman. I should have realized when someone says,
“Hey, you should take a couple extra of those,” that addiction would come. But I had
never been around addicts in my family. I'm the only one in the family that does drugs.
So, I'd never been around addiction or addicts, so I didn't know. And so, but he never told
me about risks or anything.

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The abrupt discontinuation of participants’ access to prescriptions, largely linked with
changing prescribing policies, preceded transitions to buying opioids from the street market.
Alicia (white female, 31), described how her prescriptions were terminated because of a criminal
investigation against her doctor, causing her to seek other sources for physical pain management:
…. like that whole year between 2017 and 2018, I was on prescription pills because of
sciatic nerve damage. I was prescribed Xanax and Percocet. Well, he [doctor] ended up
with charges filed on him.. I guess he was writing fraudulent scripts…But I wasn't getting
fraudulent scripts from him. But after his office shut down I never got my prescription
pills back. I couldn't really find a doctor to go to. And then when I was trying to find my
file to find a new doctor, they said all the files was with detectives or something under
investigation….and that's when I just started buying pills off the streets.

Related to the changing policy landscape and increased prescribing oversight, positive
drug tests were cited as another reason for removal from the doctor office. Participants described
being terminated as patients from doctor offices after testing positive for illicit substances, as
well as for nonprescribed use of other prescriptions, including prescription stimulants such as
Adderall. As Tammy (white female, 38) explained, testing positive for cocaine was a factor in
her removal from her doctor’s office:
Interviewer: And why did you get kicked out of the doctor?

Tammy: I tested positive for cocaine…. It’s devastating and it leaves us, a lot of us
women, up to extreme circumstances just to stay well and take care of our family. You
know, that can be the difference between being a prostitute and not…. Yeah, that was
basically it. We're not seeing you anymore. And then they said that I had a chance to
potentially come back if I passed the drug test the next month, but that's kind of what
leads you into just becoming an addict, because you find out how easy it is to get on the
streets and you can have and do as many as you want without worrying about that.

Prescribing changes and related initiatives, such as prescription drug monitoring
programs, were implemented after the majority of participants had already initiated into
prescription opioid use. Participants commented on these larger macro-level policy changes
when describing their drug trajectories. Many noted that prescribing practices are much different

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now compared to when they first initiated. However, some participants like Rob (white male,
27), feel that the pendulum may have swung too far, and that this overcorrection is negatively
impacting those who need pain management:
So, they're just not prescribing them, even people who are in pain can't get them, which I
think that's kind of fucked up… there's legitimate, like, use out here. Like people that get
like they got plates in their body and shit and like they're telling them to take a Tylenol.

Physical and emotional trauma compounded prescription opioid trajectories for the
participants. Over half of participants described experiencing traumatic events such as car
accidents, sexual assaults, divorces/break-ups, and physical abuse. Rose (white female, 33)
simultaneously experienced a serious car accident and the death of her brother. She reflected on
how the combined physical and emotional pain impacted her prescription opioid use:
I was emotionally unstable and physically in pain. So, when I ran out of those
prescriptions is when I turned to the dark side, you might say. My brother died in a car
accident…, and I was in the car. I was a passenger. And then, the car he was driving and
the car that was hit, another person died. So, it was a lot of grief for me and shame and
guilt. So emotionally. That's how I was emotionally unstable. And then I was, you know, it
was a pretty bad accident. So, I was in a lot of pain, and I had a lot of injuries. So, the
combination of both.

Curiosity and peer influence were the most common motivators for those initiating into
prescription opioid misuse without a prior history of receiving medical prescriptions. Sally
(white female, 36) initiated into non-prescribed prescriptions at age 14 with her friends and
discussed the ease of access in medicine cabinets:
Yeah, everybody had something, it seemed like everybody's parents or grandparents had
some kind of pills in their medicine cabinets, when we was kids that we experimented
with. And decided that we liked these ones, and these ones, so we'd do them a few times a
week.

For others, like Pam (white female, 30), the use of prescription pills was socially
acceptable and a common occurrence within the family system. She described family members
generously providing pills to assist her in pain management:

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I had family members that was getting them prescribed. So, I was getting them from
pretty much my family members… like I wasn't stealing them, but I mean, like they were,
they had them and would give them to me if I said I like, I don't know, worked all day and
my back hurt, they would give me a couple.

Infrequent experimentation with pills prior to any routine use marked many trajectories.
Like others, Craig (Black male, 35) experimented with prescription opioids at a young age.
However, he did not start more regular use until his access increased through a romantic partner.
When he lost access, he was not prepared for the withdrawal symptoms:
Yeah, I used to sell it [prescription opioids] a lot and I just had friends that spent a lot of
money on it, and I would take them every once in a while, but they would make me sick.
So, I never really got into them. Until I started dating a registered nurse, and she
basically had them all the time…So, I'd take Percocets every day. And after about a year
and a half, we stopped dating and I woke up to get my kids ready for school and I began
to throw up. And I didn't really think anything of it. And that happened like two or three
times in a week. And then one of my friends told me, like, “You probably, you're noticing
you’re sick.” I'm like, “I’m not a drug addict, what do you mean I'm sick?” And he
explained it to me. And that's when I realized I was addicted to painkillers. It was just a
pain pill to me, so little did I know.

Second wave: heroin
The second wave of the opioid crisis was marked by increased transitions from
prescription opioids to heroin. Following this trajectory, the majority of participants initiated into
heroin after their prescription pain medication was no longer accessible. The loss of medical
prescriptions was a precursor to buying pills and other drugs on the street. Some participants,
like Trevor (white male, 35) attempted to purchase prescription pills on the street but soon
transitioned to buying heroin because of the availability and his better network connections to
heroin:
Well, they tell you the prescriptions are going to stop. And then you're like panicking.
And then I'm like looking for it. Trying to buy it off the street and then it's just, heroin was
just there, because I know everybody that gets high. So, I knew people that got heroin and
then I went straight to it.

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Participants noted that medical staff did not offer to provide them referrals to treatment or
other programs for substance dependence when they were terminated as patients for suspected
dependence or substance misuse. Andy (white male, 35) was removed as a patient from his
doctor office once medical staff suspected that he was dependent on opioids. He commented on
the abrupt discontinuation of prescriptions that he had received for over ten years, and his
doctor’s lack of referrals to treatment, such as methadone:
…. that's the time period that I started to get on heroin then, because I was 27. I had a
habit of doing opioids since the age of 14. And at that time period I was being prescribed
two OxyContin 50 milligrams a day and had been that way since the last ten years. And
so that's when I started doing heroin. Then later on I found out that there was like a
methadone clinic. I kind of wish that I would have been more informed by my doctor or
that maybe that you know when my doctor was going to fire me, I wish my doctor, he
would have maybe, or the nurses, or somebody, would have known about a methadone
clinic and would say, “Hey, look, you know, you can at least go get it, go get methadone
and you'd be all right.”

Heroin became a substitute for participants once their prescription pills were no longer
accessible or became too expensive to purchase on the street. As Samantha (white female, 34)
explains: And then, I didn't have money one day and she was like, "Oh, I have heroin." And she
[friend] gave me like a gram of heroin, and I realized that was a lot cheaper. Heroin was
described as a less expensive and longer lasting alternative to prescription opioids. Amelia (white
female, 38) explained how she learned that she could purchase smaller amounts of heroin for
cheaper prices:
….and then that's when I found the heroin and realized, oh, I can do a third of this cap
that's $5 and be okay for way longer than 10 of these pills. And then gradually you need
more of that, need more of that, need more of that. And then you end up like this.

Peers were influential in communicating how to transition from prescription opioids to
heroin. These peers often had extensive heroin use histories and provided participants with
knowledge on how to purchase heroin, or even instructed them in their first use of heroin. Janie

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(white female, 47) described the influence of peers on her trajectory from prescription pills into
heroin:
I can't remember what it was, but she [doctor] put me on another pain pill. And then my
insurance wasn't covering it. It was expensive. And my friend was like, "Why don't you
try this? It's less expensive." And it was heroin.

The acceptance and social acceptability of heroin use was commonly described by
participants. Tony (white male, 43) eventually became interested in trying heroin after watching
his neighbor. He noticed that heroin would alleviate his neighbor’s withdrawal symptoms, so he
decided to try heroin when pills were not accessible:
And then one day, I couldn't get any [pills]. And I used to give her[neighbor] money to
buy heroin, so she wasn't sick. And so, I’m like, “Give me one of them caps. I want to try
it”. And I sniffed it. Like, damn, I'm like for $5. And for $5, that was like taking three or
four of the Percocet. I mean, exact same feeling. Yeah, like I've been paying $20 for them
and could have paid $5 for this. So, I started buying it and just sniffing and I sniffed for
probably a month or two.

Intergenerational use was common among participants and often played a role in the
transition from pills to heroin. Rachel (white female, 33) who initiated into heroin at age 16
remembered her initiation into heroin use: My older cousin shot me up. I was fresh out of surgery
and ran of pain pills, and they told me that it would make it better. While some participants
described family influences on transitions to heroin to assist with pain management, others felt
that that they were intentionally introduced by others to help cover costs associated with heroin
use. Jasmine (white female, 41) described her initiation into heroin and the influence of family
members that she felt were taking advantage of her:
Me and my aunt grew up like twins, and it was my aunt and her husband. And really the
only reason they had me wanted me to try it was because then I was a stripper and I
made good money and they was just trying to make it where I could help them with their
habit too. Ain't that a shitty way to get someone started on heroin, like really? And that's
exactly what I did, I helped them with their habit because they was the ones that knew
where to get it you know what I mean…and then here I am I'm buying it for them. I'm

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paying more for them to do dope because it's two of them. Than it is just for me to do
dope by myself.

Similar to prescription opioids, many participants reported motivations for heroin use
linked with histories of trauma. These critical points were discussed as influential in transitions
into heroin and escalations in substance use. Coraline (white female, 39) experienced a serious
car accident and the death of her mother in close proximity:
I broke my neck. I fractured my neck in 2002. So, I was prescribed Vicodin. And I didn't
like them at first. They made me feel nauseated and I didn't like them. And then my mom
committed suicide in 2002. That set me in overdrive with my addiction. I mean, I went off
the rails. I smoked crack, pills, heroin

Other participants did not report one significant event, but rather a culmination of
traumatic events throughout their life course that impacted their heroin use. Violet (white female,
54) described an extensive history of traumatic experiences and the use of drugs to cope with
emotional pain:
I was molested from the age of eight to nine from an uncle. My father died when I was
five and my mother got in the wrong crowd. She became a heroin addict. My daddy died
at twenty-four. She died at forty-four. And then I just never felt like I fit in anywhere after
that. After that, the streets just became my comfort zone. I didn't feel judged with the
people I hung with because they were like me…, the emotional part. That's what the
drugs did for me all those years. Covered that part up.

Third wave: fentanyl
Synthetic opioids, such as fentanyl, emerged during the third wave of the opioid crisis.
Unlike the reported initiation stories of actively seeking out heroin, the majority of participants
described being unaware that they were using fentanyl for the first time. Several participants
discussed their experience of unknowingly initiating into fentanyl. Mike (Hispanic male, 31)
thought he had purchased heroin the first time he used fentanyl, so he used his regular amount
and overdosed:
And then one random day I had went with a friend of mine to go get something and I
thought it was regular dope and it ended up being fentanyl, and then that, like the first

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time I did it, I overdosed for the first time. Yeah, like, I just went ahead and did the
regular amount of what I was used to from doing the regular dope. ‘Cause I thought it
was regular dope ‘cause it was brown in color.

The local drug supply was rapidly changing and becoming increasingly adulterated with
fentanyl. Participants were purchasing drugs that were, unbeknownst to them, contaminated with
fentanyl. This caused many participants to experience an overdose the first time they tried
fentanyl. For many, like Lynn (white female, 38) who initiated into heroin use at age 30 and into
fentanyl use at age 34, this was their first overdose experience:
Interviewer: And do you remember the first time that you had street fentanyl?

Lynn: I do. I overdosed.

Interviewer: Was that the first time you had overdosed?

Lynn: Yes, it was.

Interviewer: And did you know that it was fentanyl?

Lynn: I had no clue. I had been clean for nine months, and relapsed. And the boy did not
tell me it was fentanyl. I had never done fentanyl before. So, I definitely overdosed, and
my ex-boyfriend found me when he came home from work. Called 911 and I guess five to
ten minutes later, I would have been done. Dead in the water.
Overdose experiences were common with first use of fentanyl, even if participants were
aware that they had purchased fentanyl. Susie (white female, 33) knew that she was using
fentanyl the first time and decided to try it because she assumed it was similar to heroin.
Unfortunately, her experience resulted in an overdose:
Susie: I knew it was fentanyl. My dope boy told me. He was like, “I got some fentanyl,
you want to try it?” I'm like, “Shit, I already do heroin, so what's the difference? Might
as well.”

Interviewer: And what was the first time doing fentanyl like?

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Susie: I ODed. Yeah, it was way too strong.

Certain participants had higher overdose risks. For instance, those returning to use after
periods of non-use were at elevated risks because their tolerance was lower, and they were
unprepared for the potency of fentanyl. Formerly incarcerated individuals returning to the
community were also at risk. Dean (white male, 27) was incarcerated when fentanyl first arrived
into the area. He heard about fentanyl while in prison and explained how he “fell out” the first
time he used fentanyl with a friend:
I was in prison and I heard about it. I had did heroin for eight years and never
overdosed. And so, it was like 2017, I came home and that's when I got introduced to it
[fentanyl]…and I wasn't used to it so I overdosed 10 times that year. My first experience
with it, I come home and I wanted to relapse and I was living with my buddy, and he's
dead now. And he put out this little cap and he was like, “Man, I could share this with
you.” And I was like, “For real? Come on man, I'd probably need six of them.” …and he
said, “This will knock your dick in the dirt.” And I was like, “Man, I don't know.” But
I'm an addict so I just want to get something in me. I did the shot. And then he woke me
up. Smacking me and hitting me with water.

Peers familiar with the potency of fentanyl attempted to alert participants of overdose
risks when they were initiating into fentanyl. Participants discussed being warned to use less than
the normal amount of heroin, and some were advised on exact amounts to use to avoid overdose
risks. For Daryl (white male, 34) even though instructions were given he was still unprepared for
the effects:
Well, I thought I got ripped off, like my buddy, he comes and gave me just a little bit. I
only had a little bit of money at the time and I bought like $30 off of him or something.
And he's like, “Man,” he’s like, “Don't do, don't do that much.” And he's like, “Lay it all
out and cut it. Like in four fours, you know.” And he's like, “And that still might be a
little too much.” I did that, cut it into fours and I did like one quarter of it. And I fucking
passed out in my mom and dad's bathroom. Busted my lip open and shit on the sink and
was just fucked up.

Ashley (white female, 25) reflected on her first experience with fentanyl. She and her
sister would commonly use together, and Ashley would always use first to test the product. She

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remembers receiving a warning about the strength of fentanyl, but she used her typical amount.
After experiencing the effects, she instructed her sister to abide by the recommendations of
others in the house:
I remember the first time I had [fentanyl], I was up at this place, and me and my sister
was running together., I always had to do it first. And everybody was like, “Don't do two
caps, it's way too strong. It's fentanyl.” And I'm like, “Whatever.” And I went in the
bathroom, and I did two of them [fentanyl caps] ...., and I stood up and I was like, “Ooof,
ooof.” And then after I was through, I went to my sister, "Do not do two." So yeah, that
was my first experience. And then I didn't want it because I like to use Xanaxes and when
you mix Xanax with it just, you know, doesn't go well.

Differences in the pharmacological effects between heroin and fentanyl were noted. Betty
(Hispanic female, 26) explained how she knew that the opioid market was changing when she
noticed a difference in the length of time and intensity of effects. Betty referenced a ranking
scale ranging from 1 to 10 in an attempt to describe her differing experiences with fentanyl and
heroin:
Well, what's and this is so weird, with heroin, the initial feeling is like on a scale of one to
10, right, it’s probably like a five. But you keep a feeling of like a three for a decent
amount of time. Whereas with fentanyl, you initially feel like an eight, or maybe even like
a nine or a 10 and you feel that way for a very short amount of time, and then you go
from like a nine or a ten to like a three or a four. And you don't keep that three or four
feeling for very long. Like your total time, from the time you do it to the time you stop
feeling it, or at least you know physically feeling the effects from it is only about maybe
two hours. So, I think I realized when the length of the high changed and when the
intensity changed.

Rick (white male, 35) used heroin for about ten years before first trying fentanyl.
Although he reported noticing a difference related to the intensity of the effects with fentanyl, he
explained that some of his peers did not have the same experience:
I called somebody to pick me something up. I had gotten it [fentanyl]. I shot it. I was
laying down and my texts were blowing up like crazy and I didn't give a fuck, I was like,
whatever, and I laid there. Felt like I was levitating. I didn't feel my spine…, like I was on
my shoulders or my back and I couldn't feel that, so I was like what the shit, this is
different. And I remember looking at my phone and they [friends] were saying, “This is
bunk.” “This is shit.” “You feel anything?” “I didn't get shit from this.” I'm thinking, are

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you serious? I'm fucking floating and I don't even want to answer you back. ...but like I
said, it's not, I don't feel like it's the same beast, it's totally different [heroin and
fentanyl].

A few participants, like Sally (white female, 39) commented on feeling sick when first
using fentanyl. Sally did not know she was using fentanyl for the first time and described
noticing somethings was different when she experienced negative effects:
It actually, it made me sick the first time I got it [fentanyl]. I couldn't do it for the longest
time without it making me puke after right after I did it when the buzz would start kicking
in. That's how I noticed it was different.

The variation in potency and effects caused some participants to attempt to avoid fentanyl
when it was emerging in the market. Elliot (white male, 43) tried to avoid fentanyl when it was
first available in the area. Elliot initially used color as a way to gauge what he was buying:
I didn't like it at first when it first came out. I didn't even buy it because it was spotty.
Sometimes it's good. Sometimes it wasn't. It was like every time I bought it, it wasn't. So, I
always, I’d even ask is it brown or white? If they said white, no. And then it was like at a
certain point might have even still been in 2014 if not 2015, it was like it hit a place
where all the fentanyl was good. It was like everybody had good fentanyl. And then that
lasted for about three years, I’d say somewhere towards the end of 2018.

Karen (white female, 36) explained that fentanyl would help alleviate withdrawal
symptoms but she noted discernable differences between fentanyl and heroin. Although she
prefers unadulterated heroin, she mentioned that she has no options because of the changes in the
drug market. In addition to detecting fentanyl by effects she explains how she identifies fentanyl
by the taste:
I just I remember, I was telling everybody I was like, “We got ripped off they sold us
something else, this ain't right.” Cause you could feel the difference. You wasn't sick but
you knew that it wasn't what you thought you was getting. I was just happy that I wasn't
sick anymore, but I was pissed because it wasn't what I wanted…. you can tell because
it's got a sweet taste to it. Where heroin has that like real bitter like a coffee bean, like
you chew a coffee bean in half, and it tastes kind of like that mixed with medicine. That
type of bitter. I was upset but that's what was out there, you just kind of had to roll with
it.

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Other participants could not recall the first time that they used fentanyl. These
participants noted that it took longer for them to notice different effects from fentanyl because it
was gradually added into the supply. Buzz (39, white male) explained the emergence of
fentanyl:
The first time, I'm not really sure, because it was like a gradual change over like if you're
changing the kind of food you give your cat. You put just like a little bit of the new food in
and then you, like, slowly add more and more and more. They would add just like a little
bit of fentanyl to it. And then just slowly the fentanyl just started replacing the heroin,
and then it started replacing it like completely.

Although white product is now typically assumed to be fentanyl, the use of color is not
always a reliable indicator in distinguishing between heroin or fentanyl. As Zane (white male,
28) explained he could not identify fentanyl by the color. He mentioned that he did not realize
fentanyl was in the Dayton area until it was reported on the news:
Not really, because dope, you know, heroin has been white, it's been gray, it's been
brown, it's been black, all various colors, so I never really noticed it. I just assumed that
it was China White heroin…that's what the dealers would say, “This is some China White
stuff.” You know, I didn't know it was fentanyl until I started hearing it on the news and
shit, and people were overdosing and all that. I didn't know that I was using fentanyl, you
know, so I didn't notice a difference.

While the majority of participants now prefer fentanyl or a fentanyl and heroin mixture,
some maintained preferences for heroin. Shelly (white female, 45) explained that she prefers
heroin because the effects last longer. She explains that some people may seek out fentanyl for
the intense pharmacological effects that assist with self-medicating for mental or emotional
regulation:
. … it's [heroin] the same price [as fentanyl], but the high lasts longer, so it makes you
not have to get it as often. That's the reason I prefer heroin. I don't know why these
people, because it's very, it is very addicting [fentanyl]…. like these are the people that
probably just like to sit around and do nothing, and maybe their lives are so bad they
don't want to do anything, because it [fentanyl] does make you not care. Fentanyl makes
you, your house could be on fire, and you probably wouldn't care…

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Emerging trajectories: a fentanyl future
Heroin use preceded initiation into fentanyl for the majority of participants and
adulterated heroin was the common pathway for first fentanyl use (Figure 3.1). However, the
Dayton drug markets are now saturated with fentanyl, and unadulterated heroin is difficult to
find. New trajectories into fentanyl were noted from younger participants, or those with a recent
initiation into illicit opioids. A few participants reported current fentanyl use with minimal to no
heroin prior to their initiation into fentanyl. Natalie (white female, 22) reported minimal use of
heroin before fentanyl, “And then heroin. I tried it once in May and then I never touched it till I
was 18 when I started getting fentanyl.” Greg (white male, 27) perceives that he has a limited
heroin use history and commented:
I think the first the first couple of times it was actually heroin, and I only think that
because it was like I mean, the last few years that I've been using it's very, very rare that
I come in contact with a product that is not white. And in the beginning, I was getting
products that were brown and gray, and that's more leaning towards the look and the
appearance of heroin, whereas fentanyl is more of a white color.

Tracy (white female, age 35) did not use or seek out heroin before initiating into fentanyl.
Any heroin she has used has been mixed into other drugs. She currently reports smoking fentanyl
because, “It’s the instant high. It still takes a few minutes sometimes kind of when snorting, and
when you smoke it, I guess people say that it’s similar to when you shoot it where it’s almost like
instant.” Tracy reported a history of prescription opioid use to help with migraines as a youth.
However, she did not seek illicit opioids until she was prescribed fentanyl patches later in life at
age 31 for an injury:
They prescribed fentanyl patches and I literally just kind of fell in love, like it was bad….
I started with the patches and then eventually my prescriptions ran out and things, well, I
mean, I literally even had, like, Roxie's still in my cupboard. Like, I went and had like 90
of them because I just had been able to quit. Well, you can sell those for thirty-five
dollars a pill…. So, I sold my whole script and started buying fentanyl….

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Two participants reported a new trajectory of prescription opioids to pressed fentanyl
pills and then to powder fentanyl. Both participants did not have any heroin use history before
initiating into pressed fentanyl pills. Figure 3.2 provides an overview of the new fentanyl
trajectory described by the participants. Snorting was identified as the method of consumption
for both, likely because snorting was how they initiated into prescription opioids. Rob (white
male, 27) believes that he has never used heroin and that the pressed fentanyl pills he has
obtained do not contain heroin. He initiated into prescription pills for dental surgery at age 16,
then he used those until around the age of 20. He started using pain pills again around the age of
25, due to peer influences. He later discovered that he was buying pressed fentanyl pills:
It's insane. And they're making a killing and that's what's really turned, I think that's
turned more people on to fentanyl. I mean, that's what got me ‘cause you know, I know
all my friends were eating these Roxies. The next thing you know those things disappear
every now and again. But, you know, there's that same guy, “I got some fucking
fentanyl.” You know what I mean? And it's like, well, you've already discovered that
you've been doing it [fentanyl] anyway, so why not?’

Rob then discussed the financial motivation for transitioning from the pressed fentanyl
pills into the powder:
Me and my friend, like my best friend, we went, and we knew a guy and we got a number
to somebody, and it was like the same day we knew we're like, goddamn it, if we do this,
like here we go. It's going to open up, you know, because, but we were spending so much
money on the pills. And we could get seven caps of fentanyl for twenty dollars. So, to me,
I'm like, well, I'm making an investment. I'm going to save money like, so yeah, we went
and did that. And at first it was cool because, shit, like I could do a cap and be fucking lit
and that twenty dollars would last me like, you know, three or four days. But then you
know, the story it turns into, you know, you need more and more and more stuff.

Gary (white male, 29) was first prescribed prescription opioids for an injury at the age of
fifteen. He then used the pills non-prescribed until the age of 28 when he was introduced to
pressed fentanyl pills which appealed to him because, “They're cheaper and, you know, you're
going to get higher.” He used pressed pills until: “Yeah, what happened is our connect,

77
something happened to him, and he stopped getting them. And by that time, I was full blown
addicted, so I started buying the powdered fentanyl.” Unlike Rob, Gary believes that heroin may
be mixed into the fentanyl he purchases, but he has never sought out or used unadulterated
heroin.
Discussion
This study characterizes trajectories for each wave of the opioid crisis. Trajectories into
prescription opioids and heroin were included to further understand fentanyl use trajectories and
how these may relate to or differ from the previous waves. Findings add to the literature on
processes by which the opioid market influences drug use trajectories. Supporting previous
research (D Ciccarone, 2017; Ciccarone, 2019, 2021; Mars et al., 2019), supply side factors were
noted for all three waves. Wave one was driven by increased prescribing and access to potent
prescription opioids, wave two by less expensive and highly available heroin, and wave three by
fentanyl adulteration in the heroin supply. Participant accounts of their trajectories into fentanyl
support the argument that the emergence of fentanyl is related more to supply-led changes in the
heroin drug market rather than demand-led preferences (Ciccarone, 2019; S. G. Mars et al.,
2018). However, there was some indication toward increased knowledge and some growing
preferences for fentanyl in the area. As the illicit opioid market continues to evolve, additional
research is needed to understand how demand for fentanyl will impact opioid use trajectories.
While literature has documented the transition from prescription opioids to heroin, with a
focus on individual motivations (Carlson et al., 2016; Guarino et al., 2018; Lankenau et al.,
2012; Mars et al., 2014), this study provides in-depth insight into factors associated with these
transitions from the perspective of PWUIO. Notably, participants describe limited education over
risks associated with opioids, such as dependence or overdose, from medical staff when

78
receiving prescriptions. In the event of suspected dependence or positive drug tests, the doctor
would stop seeing the patient and terminate prescriptions. Referrals to methadone or substance
use treatment programs were not provided. It is unclear if these actions by medical staff were due
to a lack of education on dependence or if they were driven by stigma towards substance use.
Research has found that doctors’ attitudes and the stigma towards patients who use drugs
influences treatment and the type of care received (Van Boekel et al., 2013). Considering that
around 20 million people aged 12 or older in the US have a substance use disorder (Substance
Abuse and Mental Health Services Administration, 2020) it is critical to understand and address
potential stigma in the medical field. Training medical students in substance use is one approach
in addressing stigma and attitudes towards people who use drugs. A recent study of an addiction
medicine training program showed improved attitudes among medical students towards patients
with substance use (Elman & Borsook, 2019). While medical school training can prepare the
new generations of doctors, additional outreach and continuing education is needed for those
currently practicing.
Supporting previous research, the reported trajectories into fentanyl ranged from
inadvertent exposure to intentional use, and the reported preferences for fentanyl varied (Carroll
et al., 2017; Ciccarone et al., 2017; Mars et al., 2014; McLean et al., 2019). While the commonly
identified opioid trajectories of pills to heroin to fentanyl support existing literature, a new
pathway into fentanyl use involving pressed fentanyl pills was identified. Participants with a
history of pressed fentanyl pill usage discussed their transition into powder fentanyl. These
participants did not have prior heroin use histories and were initially hesitant to use powder
fentanyl. A transition occurred once they became aware that they were using fentanyl in pill form
and that powder fentanyl was less expensive. This echoes the trajectories of the early stages of

79
the crisis where people were transitioning from higher priced prescription pills to the lower cost
heroin (Lankenau et al., 2012; Mars et al., 2014). The developing role of pressed fentanyl pills in
opioid trajectories indicates that more awareness, prevention, and harm reduction efforts are
needed for this component of the fentanyl drug market.
Initiation into fentanyl was associated with overdose events. Many participants reported
they never overdosed until they used fentanyl. Overdoses occurred when participants were
unprepared for the potency of fentanyl and used the same amount as they would typically use for
heroin. In other instances, overdoses would occur when someone had a period of non-use and
was unaware that the illicit opioid drug market contained adulterated heroin. In other regions,
participants have implemented strategies including tester shots, using less, and other drug
sampling methods (Mars et al., 2018a; Rouhani et al., 2019). The extent that these types of risk
reduction tactics have been implemented in the Dayton area where the research is focused is
unclear and additional research is needed.
Over half of the participants reported histories of multiple types of traumas such as
divorces/break-ups, physical and sexual abuse, the death of close friends and family, and serious
car accidents. These traumatic experiences influenced opioid use trajectories. Opioids are
effective in alleviating stress and blocking emotions related to traumatic events (Bali et al., 2015;
Schmidt et al., 2014), and participants identified the use of opioids to assist in coping and
managing with the associated emotional pain and stress. Previous research has identified a
relationship between interpersonal trauma, sexual assault, adverse childhood experiences and
prescription opioid and heroin use (Elman & Borsook, 2019; Quinn et al., 2019; Stone &
Rothman, 2019; Williams et al., 2020a; Williams et al., 2020b); however, literature on trauma
and motivations for fentanyl use is lacking. While traumatic experiences were not directly related

80
to initiation into fentanyl use among participants, it is important to acknowledge the role of
trauma in the overall opioid use trajectory. Notably, preliminary findings suggest that individuals
coping with more life stressors may prefer fentanyl because of the intense effects, which can
block emotional stressors. The role of trauma in fentanyl and heroin preferences is an important
area for future research to better understand trajectories and use patterns.
Peer and family networks were influential in opioid use trajectories. Although these
social networks facilitated drug use patterns, many also provided risk reduction strategies to
participants through safe socialization into drug use and an education of risks associated with
different types of opioids. This is especially noted for trajectories into fentanyl. Participants that
were unfamiliar with fentanyl were cautioned regarding potency and provided suggestions on
ways to minimize overdose risks. This suggests that information sharing is occurring, and
PWUIO are attempting to assist others in mitigating overdose risks. Utilizing peers for
educational outreach strategies can be an effective harm reduction strategy to assist in fentanyl
overdose risk reduction (Latkin et al., 2019). Recent studies suggest providing talking points to
well-connected networks members who will take on the role of harm reduction advocates,
working with older people who use drugs to encourage safe practices among younger network
members, and formal training for peer educators (Bouchard et al., 2018; Latkin et al., 2019;
Mateu-Gelabert et al., 2018). Research is needed to better understand the most effective ways to
encourage information sharing for risk reduction among people who use drugs, and specifically
for fentanyl-related risk reduction.
Intergenerational substance use was a recurring theme among participant trajectories.
Family members were influential in initiation into substance use, with older family members
especially influencing patterns. Despite the financial, health, and social costs that substance use

81
has on family systems (Orford et al., 2013; Ray et al., 2009), prevention and treatment
approaches primarily focus on the individual (Ventura & Bagley, 2017). However, research
indicates greater success in broadening the scope from a focus on individual substance use
outcomes to include other socio-environmental factors by involving family in prevention and
treatment (Copello et al., 2006; Ventura & Bagley, 2017). Importantly, approaches must
acknowledge the complex social and environmental context that influences substance use while
avoiding value judgements and placing blame on the family (Ventura & Bagley, 2017).
Limitations and Strengths
Study limitations are noted. The study procedures transitioned from in-person to virtual
due to COVID. This impacted the initial recruitment plan which included targeted community
outreach. Recruitment then relied more on peer driven referrals, which can limit sample diversity
when participants recruit peers with similar characteristics (Erickson, 1979; Heckathorn, 2002;
Magnani et al., 2005). As a result, the racial and ethnic diversity is limited, so these experiences
primarily reflect those of non-Hispanic white people who use illicit opioids in the region.
However, a strength of the sample is that the majority of participants were females, a population
that remains underrepresented in drug research (Meyer et al., 2019). All data is self-reported and
can be subject to social desirability and recall bias. Finally, the study location is unique and it is
unclear how experiences in this region reflect other parts of Ohio or the United States. Therefore,
the study may not be able to provide conclusive findings but can generate hypothesis.
Consequently, the specificity is also a strength of this study in that it provides detailed analysis
of opioid use trajectories that can be used to inform other larger scale representative studies
(Ritter, 2006).

82
Conclusion
Understanding opioid use trajectories in the age of fentanyl is critical in developing
relevant prevention and intervention strategies. Opioid trajectories for the three waves of the
crisis included a progression from prescription pills to heroin and then exposure to fentanyl. This
study identifies a new trajectory of initiation through pharmaceutical pills followed by a
progression to pressed fentanyl pills and then to powder fentanyl. While opioid use trajectories
are changing in the era of fentanyl, the influence of family, peers, and trauma on trajectories is a
constant. Interventions are needed to address not only the substance use but to also consider the
socio-environmental influences on trajectories. Although this study provides some insights that
can be used to inform harm reduction efforts, further research on the dynamic unfolding of the
opioid crisis in the new era of fentanyl is needed.

83
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Tables and Figures

Table 3.1 Lifetime Substance Use History and Age of Initiation (N= 60)

Lifetime Substance Use History

N (%)
Heroin 59 (98.3)
Street Fentanyl 60 (100.0)
Non-Prescribed Prescription Opioids 58 (96.7)
Non-Prescribed Methadone 32 (53.3)
Non-Prescribed Buprenorphine 45 (75.0)
Alcohol 59 (98.3)
Marijuana 58 (96.7)
Non-Prescribed Benzodiazepines 54 (90.0)
Non-Prescribed Stimulants 37 (61.7)
Crack Cocaine 46 (76.7)
Powdered Cocaine 57 (95.0)
Speedball Cocaine and Heroin/Fentanyl 48 (80.0)
Methamphetamine 58 (96.7)
Speedball Methamphetamine and Heroin/Fentanyl 36 (60.0)

Age of Initiation Mean, Std. Dev
Heroin 24.5, 7.2
Street Fentanyl 30.5, 7.3
Non-Prescribed Prescription Opioids 19.9, 6.2
Non-Prescribed Methadone 27.5, 8.2
Non-Prescribed Buprenorphine 30.2, 7.5
Alcohol 13.6, 2.8
Marijuana 13.2, 2.5
Non-Prescribed Benzodiazepines 20.0, 7.1
Non-Prescribed Stimulants 21.5, 7.5
Crack Cocaine 21.7, 6.5
Powdered Cocaine 19.3, 5.8
Speedball Cocaine and Heroin/Fentanyl 27.7, 7.1
Methamphetamine 28.9, 8.5
Speedball Methamphetamine and Heroin/Fentanyl 30.8, 7.7

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Figure 3.1 Three Waves of the Opioid Crisis

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Figure 3.2 Emerging Fentanyl Trajectories

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Chapter 4:
Study 3
“You can’t do less, you can always do more”:
Understanding overdose risk reduction in a street fentanyl dominated drug market
Abstract
Purpose: Fatal overdose is one of the most significant public health risks associated with
illicit opioid use. Dayton, Ohio has been identified as an epicenter of the overdose crisis, yet
little is known about overdose risk reduction among people who use illicit opioids (PWUIO) in
this area. The purpose of this study is to understand overdose risk reduction from the perspective
of PWUIO in Dayton, Ohio.
Method: Sixty people who use illicit opioids were recruited from Dayton, Ohio.
Participants completed a brief demographic survey and a semi-structured qualitative interview.
Interviews were conducted from March to November 2020 with a total of 13 in-person and 47
virtual interviews. Qualitative interviews were transcribed in their entirety and interview data
was analyzed thematically using NVivo 12.
Results: Lifetime nonfatal overdose was reported by 72% of the sample with a mean of
4.5 overdose events. Of those who ever overdosed 81% reported receiving naloxone during their
last overdose, with an average of 4.7 doses administered. The majority (67%) reported regularly
carrying naloxone. Overdose risk reduction included overdose prevention and overdose response.
Themes related to overdose prevention included buying from a trusted source, user driven risk
reduction strategies such as using less, and moderating withdrawal. Drug testing using fentanyl
test strips was limited due to a reported lack of availability in the area and strips were not used to

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test heroin. Themes related to overdose response include using with others around and carrying
naloxone.
Conclusions: Findings indicate that people who use illicit opioids are engaging in
overdose risk reduction in Dayton, Ohio. However, the fluctuating potency of fentanyl in the
illicit opioid market can compromises harm reduction efforts. Combining first line overdose
prevention strategies with secondary overdose response strategies is recommended for more
comprehensive overdose risk reduction. Harm reduction-oriented policy changes are needed to
support these individual tactics and strategies. Given the importance of overdose prevention, the
expansion of harm reduction though supervised consumption sites, safe supply, and drug
checking is recommended. Increasing the number of naloxone doses distributed can assist with
overdose response.

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Introduction
More than 130 people die from opioid-related overdoses in the United States each day
(Overdose, 2018). Drug overdose, largely associated with opioids, is one of the leading factors in
the increase in midlife mortality rates and the decline in life expectancy in the United States
(Woolf & Schoomaker, 2019). Drug overdose death rates started increasing in the early 2000’s
with prescription opioids, followed by heroin around 2010, and then synthetic opioids in 2013
(Daniel Ciccarone, 2017b; Ciccarone, 2021; National Institute on Drug Abuse, 2021). Deaths
due to prescription opioids and heroin have leveled in recent years and much of the current
opioid-related overdoses are driven by synthetic opioids, the majority related to illicitly
manufactured fentanyl (Ciccarone, 2021; Mattson et al., 2021; National Institute on Drug Abuse,
2021).
Illicitly manufactured fentanyl is produced in labs and can be up to 100 more potent than
morphine (Higashikawa & Suzuki, 2008; Volpe et al., 2011) and up to 50 times more potent than
heroin by weight (Daniel Ciccarone et al., 2017). Fentanyl contamination is increasing, with
customers often unaware that they are purchasing fentanyl adulterated drugs (Daniel Ciccarone
et al., 2017; Ciccarone, 2021; McLean et al., 2019). A fentanyl contaminated drug supply is
especially risky as the fluctuating potency increases overdose risks (Carroll et al., 2017; Daniel
Ciccarone et al., 2017; Daniulaityte et al., 2019b; Macmadu et al., 2017). The consequences of
fentanyl in the drug supply is reflected in the increasing opioid-related overdose deaths rates
which comprised 70% of the over 70,000 total overdose deaths in 2019 (National Institute on
Drug Abuse, 2021). Fentanyl was associated with 75% of the nearly 50,000 opioid-related
overdose deaths in 2019 (Mattson et al., 2021).
Although opioid-related overdose rates have increased throughout the United States in
the past decade, the Northeast and Midwest have been particularly impacted (Mattson et al.,

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2021). Part of this is likely due to heroin distribution in the United States. The Mississippi River
has historically divided the heroin market with black tar available to the West of the Mississippi
and powder available to the East (Drug Enforcement Administration, 2020; Mars et al., 2016).
Powder heroin is much easier to adulterate with other substances, such as fentanyl (Ciccarone et
al., 2009; Drug Enforcement Administration, 2016). Consistent with the drug market divide, the
top five states with the highest age-adjusted rates of drug overdose deaths in 2019 were West
Virginia, Delaware, Ohio, Maryland, and Pennsylvania (CDC, 2021). Ohio’s 2019 age-adjusted
overdose death rate was 38.3 per 100,000, which was an increase from the 2018 rate of 35.9
(CDC, 2021).
Overdose deaths in Ohio started significantly increasing in 2015 with over 3,000 deaths,
peaked in 2017 at over 4,800, and then declined to under 4,000 in 2018 (Harm Reduction Ohio,
2021a). However, rates started increasing with over 4,000 overdose deaths recorded in 2019 and
preliminary estimates indicate over 5,000 drug overdose deaths occurred in 2020 (Harm
Reduction Ohio, 2021a). This would make 2020 the deadliest year to date for drug overdose
deaths in Ohio. Data on drugs involved in overdose deaths are not yet available for 2020.
However, in 2019 opioids accounted for 83.7% of drug overdose deaths in Ohio, with fentanyl
responsible for 76.2% of all drug overdose deaths (Ohio Department of Health, 2020). Drug
combinations such as fentanyl and cocaine (23.1%), fentanyl and psychostimulants (14.9%), and
fentanyl and heroin (10.6%) also comprised large percentages of Ohio drug overdose deaths in
2019 (Ohio Department of Health, 2020).
While Ohio has some of the highest overdose rates in the country, different regions
within the state have worse opioid-related outcomes. Dayton, located in Montgomery County,
Ohio has been identified as an epicenter of the opioid crisis on the state and national level.

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Dayton is an important region in understanding the evolving opioid crisis, as Montgomery
County had the second highest 2014-2019 average age-adjusted overdose fatality rate in the state
with 63.5 per 100,000 (Ohio Department of Health, 2020). Previous research on fentanyl in the
Dayton region documented an increase in unintentional overdose deaths attributed to fentanyl
analogues (Daniulaityte et al., 2019b) and high rates of self-reported use of fentanyl
(Daniulaityte et al., 2019a). PWUIO in the Dayton region now assume fentanyl contamination in
the illicit opioid market, but the various analogues of unknown potency creates unpredictability
in the supply, increasing overdose risks (Daniulaityte et al., 2019b; Silverstein et al., 2019).
While existing studies have examined risks related to fentanyl in the Dayton area (Daniulaityte et
al., 2019a; Daniulaityte et al., 2019b; Silverstein et al., 2019) less is known about overdose risk
reduction strategies among this population.
Understanding overdose risk reduction strategies from the perspective of people who use
drugs is critical in tailoring local harm reduction initiatives. Research indicates that PWUIO have
responded to the fentanyl contaminated heroin supply by incorporating a variety of strategies,
tactics, and practices for risk reduction. Some commonly reported overdose risk reduction
strategies related to fentanyl include tester shots, buying from trusted sources, carrying
naloxone/Narcan, using with others, and drug checking via fentanyl test strips (S. Mars et al.,
2018b; McKnight & Des Jarlais, 2018; N. C. Peiper et al., 2019; Zibbell et al., 2021). While
studies have explored risk reduction in other contexts, more distinction is needed between
overdose prevention and overdose response. For the purposes of this study overdose prevention
includes practices that can prevent non-fatal and fatal overdoses, while overdose response are
practices that occur after an overdose has occurred. Responses are used to reverse overdoses and
for fatality prevention.

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Qualitative interviews with people who use illicit opioids (PWUIO) in Dayton, Ohio are
analyzed to examine perspectives and strategies for overdose risk reduction. Research that
explores risk reduction from the perspective of people who use drugs is needed to understand
what motivates their use to provide targeted public health interventions (Messac et al., 2013).
This study contributes to the literature by examining strategies for overdose prevention and those
for overdose response. Indirect methods of risk reduction are also included. Programming and
policy recommendations to better support individual overdose risk reduction strategies are
discussed.
Methods
Initial participants were made aware of the study by researchers who have established
relationships with the study population. Interested participants contacted the lead author and
were screened for eligibility. To be eligible for the study, participants had to be over the age of
18, reside in the Dayton region, self-report use of heroin/street fentanyl within the past 30 days,
and not currently participating in abstinence-based substance use treatment. Additional
recruitment methods included peer referrals and Facebook-based ads. Participants received $30
for study participation and $10 per referral.
Data collection began in March 2020 and was completed in November 2020. Data
collection occurred during the COVID-19 pandemic, so the research pivoted from in-person to
virtual methods. A total of 13 in-person interviews were completed before study procedures
shifted to virtual methods. The remaining 47 interviews were conducted and recorded using
Zoom video conferencing software. Informed consent was obtained from all study participants.
For those completing in-person interviews, consent was obtained on the day of the interview. For
those completing virtual interviews, the first author would review the consent with participants

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once they were deemed eligible during the screening process. The first author would then send
the link for the participant to review and digitally sign the consent on REDCap. During the start
of the scheduled interview, the first author would ask the participant if they had any questions
over the consent and review before beginning the interview.
Interviews included a brief demographic survey and semi-structured questions. The brief
demographic survey took between 15 to 30 minutes to administer and included questions
regarding drug use history, harm reduction utilization, and risks. Semi-structured qualitative
interviews lasted between 30 and 60 minutes, and they were focused on understanding
experiences and preferences related to fentanyl, harm reduction strategies, and perceptions of
drug markets. The lead author wrote field notes following interviews. Analytic memos were
recorded during transcription review and throughout the coding process. The lead author shared
all field notes, analytic memos, and checked with members of the study team throughout data
collection and analysis.
Interviews were transcribed, checked for accuracy by the first author and entered into
NVivo (Version 12, QSR International, Melbourne, Australia). Following a lone-wolf coder
approach (Saldaña, 2021) the first author coded an initial set of transcripts based on questions
and categories from the qualitative interview guides. The first author then discussed the coding
approach with co-authors, sharing field notes and the analytic and transcription memos along
with the codebooks. Adjustments were made to the coding schema following in-depth
discussions and recommendations from co-authors. The first author then applied the revised
coding schema to the remaining transcripts, revising as new themes emerged. Using the
interview guide and field notes, the first author identified categories and key concepts. Once no
new codes were derived this indicated inductive thematic saturation (Saunders et al., 2018). The

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thematic data analysis was an iterative and reflexive process (Braun & Clarke, 2019) and
informed by existing literature related to overdose risk reduction, overdose prevention, and
overdose response. Qualitative interview data was triangulated with the demographic survey data
to further understand participants perspectives and experiences. All study procedures were
approved by the University of Southern California Institutional Review Board. Names used in
the paper are pseudonyms.
Results
Results from the brief demographic survey indicate risk reduction strategies among
participants (Table 4.1). Almost three-quarters of participants ever experienced an overdose with
an average of 4.5 overdoses events reported. Over 80% of participants received naloxone/Narcan
during their last overdose with the average number of doses reported as 4.7. Over half have
witnessed an overdose in the last six months. Participants reported knowing an average of almost
20 people who have died due to heroin or fentanyl overdose. Risk reduction strategies varied.
Almost 70% report regularly carrying naloxone and most accessed naloxone through the syringe
exchange distribution. Only 3 participants reported using a fentanyl test strip in the last 30 days.
Test strips were commonly accessed through friends or Harm Reduction Ohio. The most
common overdose risk reduction strategies were using less, tester shots, using with others
around, buying from a trusted source, and carrying naloxone. Participants completed the
Withdrawal Prevention Tactics Scale (Vazan et al., 2012) which asks about certain strategies that
individuals have incorporated in the last six months to avoid or prevent withdrawal. Over half of
participants frequently reported saving a hit for the next morning and putting aside money for the
next hit. However, participants were less likely to endorse putting aside drugs for an emergency

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or storing methadone or buprenorphine. The majority of participants reported using other
substances to avoid withdrawal between 1 to 10 times in the past six months.
Overdose Risk Prevention
Buying from a trusted source
The majority of participants discussed buying from a trusted source as a way to avoid
overdose risk. Buying from a trusted source provides perceived consistency in the product
potency. Once participants know the dealer, they are more confident they are buying a product
that will not cause an overdose. Malorie (white female, 31) explains:
I been, buying drugs off of three people pretty much my whole time I've been on drugs. I
try to stay with the same people because you never know. I want to know that the amount
I know that I'm used to using is not going to kill me or anything.

Participants described younger dealers as less trustworthy than older dealers. This is
because younger dealers are viewed as being more concerned about profit. Sarah (white female,
51) explains the way that she intentionally seeks out products from certain dealers because of
perceptions of increased safety:
The younger your drug dealer is the more chance you're taking. And switching drug
dealers. I don't do that. I've been with the same person for years, off and on. When I get
clean, I don't mess with him. When I relapse, I call him because he's an older guy. And I
know what his stuff is, I know what it involves. Every time I've ODed and ended up
having to be Narcaned, it's from buying from someone other than him because you just
never know what you're getting when you buy from these young people out of their cars
and shit, you just never know what you're getting.

Some dealers are more proactive in communicating potency with customers. Close
relationships between dealers and customers often facilitates increased communication about the
anticipated potency of the product. Rosie (Black female, 26) has two dealers that she typically
buys from but has a closer relationship with one dealer. This dealer will often provide warnings

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over the product and typically even monitors her the first time she uses product from a new
supply:
And the other person like he'll tell me like, “This is a bit stronger. So, don't go do a big
shot or something. Like just try a little bit right here in front of me. So, I can watch you
real quick,” and stuff like that. So, I can kind of get a feel for how much I need to do.

Marie (white female, 34) describes the complex relationship with her dealer and how this
impacts her risk reduction. She believes that she has a close relationship with her dealer, even
closer than her family, but she also recognizes the risks that she engages in because of the trust
she has developed:
I hate doing that [buying from a different source] ..., you see, the dope boy that you go to
every day, like I see them like I see my family. Like I know their kids, they know me. They
know, when I'm having a bad day, when I'm having a good day. They know when to call
me. When I will be awake. They know everything about me, more than my family does.
So, I trust them a little bit to be like, "Hey, I got some new stuff." But also, they're like,
"Here, try this." I'll be the first person to be like, "Here I'll try it." You know, it's stupid.

According to participants, most dealers do not use opioids themselves. Dealers then
typically rely on customers to test the potency of new products. Several participants reported
testing for their dealer. Frank (white male, 36) has a few dealers that he trusts. When he feels that
one of his dealers is selling bad product, he will avoid them for a few weeks until they call and
ask him to come try their new product. Frank, like other participants, explained that dealers
typically do not use opioids, so they are personally unaware of the potency of their own product.
He reported managing risks when testing new products for dealers:
I've been a guinea pig for a couple of different dealers. They'll give me a little bundle of
that then they'll say, "Hey, try this first and let me know what you think about it." And
whenever they do say some shit like that, I always go home, and I do a very small amount
and I try it just because I don't know what I'm dealing with. It could be super strong. It
could be a bunch of bullshit. I don't know. And I don't want to make the mistake of doing
what I normally do and then it being something that just knocks my socks off and I never
wake up again.

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Drug use modifications
Many participants reported incorporating risk reduction strategies in response to the
fentanyl contaminated drug supply. These ranged from using smaller amount to transitioning to
non-injection methods of use. Jim (white male, 35) reflected that these modifications, such as
using less, were necessary to reduce overdose risks:
Oh, yeah, you had to [make changes] if you didn't, it would kill you. Like literally like
you would just drop dead, like, boom. And then like my buddies, were dropping dead like
boom, boom, and then I'm like, OK, if I don't change something then that's going to
happen to me too. So, like I had to. It wasn't like I had a choice, or I needed to. It just had
to happen, or you were going to die, like, just flat out.

Using in smaller amounts was one of the most reported changes in drug use that the
participants discussed incorporating for overdose risk reduction. Many participants repeated a
motto like the one that George (Hispanic male, 40) described:
We didn’t, you know, trust a lot of stuff. So, we, you know, adopted that motto, you can
always take more, but you can't take less. So, it's kind of became the motto of the people I
was hanging out with.

A few participants transitioned back to snorting from injection use to reduce their
personal risk. Shelly (white female, 36) recently transitioned back to snorting after injecting
because she perceived snorting as safer. Participants engaging in non-injection use methods
expressed sentiments that they may care more and held assumptions that people they know who
still engage in injection use do not care as much because they have not changed their method of
use. Shelly discussed incorporating multiple strategies for risk reduction:
And like I told you I snort drugs, but I will say that I do value my life, I guess. And with
fentanyl it's like immediate, so there's no going back once you do it. You can't do less,
you can always do more, that's my signature saying. So, when you ask me about my
typical day it also entails, when I get a bag of drugs, I always do a little line first. And
then have to wait about 15, 20 minutes in case it takes longer to hit you. And then if I'm
feeling OK, I feel like I can do more, I will.

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A few participants reported smoking as a risk reduction strategy. Typically, these
participants also engage in methamphetamine use and reported smoking fentanyl because they
are accustomed to smoking methamphetamine. A lower risk was perceived with smoking
compared to injecting and even compared to snorting as Jerry (white male, 41) commented:
I think that it's like more than a lower risk, I think it's like a super duper, duper lower risk
[smoking as a method of consumption]. That could just be me telling myself that like
maybe a little bit of both…. With smoking it, it just happens quicker you know, like almost
instantly, so you know what's happening. And snorting it takes a little while, like 20
minutes to come on. So, I'm kind of scared to do that to be honest, you know? Like, what
if you do too much, it's too late you know.

The use of methamphetamine was also reported as an overdose prevention strategy.
Specifically, participants spoke about the practice of using methamphetamine prior to using
fentanyl to counteract the effects of fentanyl. Participants claimed that the use of the stimulant
before the opioid can prevent an overdose from occurring. Steve (Black male, 35) explains:
I've never overdosed by doing both of them [methamphetamine and fentanyl]. Counters
it. That's the only reason why I haven't, that's the only reason why I don't overdose
anymore. Anybody, who I hang out with who didn't do it, they do it now. Not that I'm
proud of it, but yeah, it's just, anybody that I've been around, they didn't do it at first, but
now they do both [methamphetamine and fentanyl].

Although some participants reported that using methamphetamine prior to fentanyl
prevents overdose other participants described this as a “myth”. Judy (white female, 36)
commented: “Meth is not going to help you not overdose off heroin, if you do too much or bad
dope…. yeah, that's definitely a huge myth.”
Managing withdrawal
Managing withdrawal emerged as an indirect risk reduction strategy. Participants
typically are not engaging in withdrawal management for overdose risk reduction purposes.
However, managing withdrawal can lessen risks during the drug buying and drug consumption
process. As one participant commented, “Withdrawal motivates everything.” Individuals

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experiencing withdrawal may be less cautious when seeking out drugs. Managing withdrawal
reduces potential risks such as buying products from new sources without asking questions. Judy
(white female, 36) explained how withdrawal influences her drug buying:
…. when you're sick, you don't care. I don't ask questions, you know what I mean, just I'll
take what you got… like, that's when it's easy for dealers and stuff to really get people is
when they're sick you know what I mean. When they need that get well. They can mix it
with anything

Withdrawal management is also helpful in regulating the amount that people use. When
participants are experiencing withdrawal symptoms, they are like more likely to use larger
amounts to feel better. As Daryl (white male, 44) explains he typically uses more in the morning
upon waking than he does later in the day when he is not experiencing withdrawal effects:
You know and when I really don't need it at the time, when I'm not really sick, I probably
wouldn't use as much as I would if I like when I get up, you know, in the morning because
I probably would use a little more in the morning. Because I don't feel as good, you
know, as I would like in the middle of the evening…. let’s just say I do like three caps
maybe in the morning, but then maybe in the evening I'll only do one, because I don't
need it like that. I am not as sick.

Participants described several strategies for withdrawal management. Saving something
for the next morning is a typical tactic. One participant remarked: “Anybody, with a brain does. I
mean, there's days I mean, I remember before that I didn't, but typically everybody does. I mean,
if you got it you will, you know.” The ability to save product for the next morning varies and is
particularly dependent on the individual’s financial situation, as a participant commented, “I just
don't withdrawal because I don't run low on cash anymore, no matter what.” Gloria (white
female, 47) typically saves a shot for the next morning, but she explains how the rest of her day
is spent managing withdrawal:
…. a normal day for me is basically worrying about you know, not being sick, chasing
drugs all day. It's really a mess. In the morning, I probably, my day would be like waking
up in the morning and probably first thing I would do would be a shot of fentanyl. And
then that would get me started with some energy, get my body to quit hurting and stuff.

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And then I'd be off to figuring out how I was going to hustle up money for the rest of my
use for the rest of the day, including my boyfriend. So that's two of us, so that makes it
twice as hard.

A few participants reported being in methadone maintenance treatment programs that
were described as reduction programs. In these programs individuals are permitted to maintain
drug use but the overall goal is for them to reduce use. Ashely (white female, 27) explained her
program:
It was a reduction clinic, which means we didn't have to quit altogether. But they had a
lab where would they send our urine and stuff out. They sent it to a lab that could detect
the numbers of how much of that drug we had in our system. And by the numbers, they
could tell if we were reducing.

Participation in methadone treatment is an indirect way for participants to manage
overdose risks. Methadone assists participants in managing their withdrawal symptoms while
using less fentanyl throughout the day. Roy (white male, 27) is currently on 100 mg of
methadone which helps to manage his withdrawal. He still actively uses fentanyl, now mostly in
the evenings, but explained that he can go longer periods without fentanyl:
Before the methadone it was like every like two or three hours. I would just start getting
sick. I mean, if I didn't have any in the morning, I'd be sick by lunchtime and I'd be at my
work just like literally dying… But since I started methadone, it's not been nearly as
bad. I'm not sick but I still have like the craving, like I still want to use.

Methamphetamine is also reportedly used by some participants to prevent withdrawal
symptoms. Withdrawal usually occurs upon waking so methamphetamine is used to avert sleep.
In addition, methamphetamine is thought to prevent the onset of withdrawal symptoms among
participants. Julie (Hispanic female, 26) explains how she uses methamphetamine to avoid
withdrawal symptoms:
So, like here's the best way I can explain it. If I was to do a shot of dope right, and then I
go out and I do some meth, for the next couple of days, as long as I continue to do meth
here and there, I'm not really going to get sick or feel sick. I don't know why but it like

113
psyches your brain out. But if I'm sick, dope sick, and I go do some meth it's not going to
make me better.

Drug testing
The majority of participants reported no prior knowledge of the availability or use of
fentanyl test strips. Heroin is assumed to be contaminated with fentanyl in the area, so the few
participants who reported using test strips used them to test drugs other than heroin. Pressed
fentanyl pills are reported as readily available in in the area and strips are used to test pills as
indicated by a participant, “I've only used the fentanyl test strip to test pills.” Participants also
reported testing methamphetamine but often need to buy larger quantities for testing. One
participant had access to fentanyl test strips but explained, “I haven't bought a substantial
enough amount of ice to test it, really.” Reese (white male, 27) recently obtained strips to test his
roommate’s methamphetamine. His roommate is a primary methamphetamine user without a
history of heroin or fentanyl use. Reese noticed that his roommate was exhibiting symptoms
associated with opioid use after using methamphetamine, and he was curious if the
methamphetamine was contaminated with fentanyl. According to Reese all three tests came back
positive for fentanyl:
I obtained those specifically for my roommate because he has never, to his knowledge,
done fentanyl or heroin, and that is not something that he wants to venture to do. And I
had been noticing like he would do a shot of meth and like he would be falling asleep like
30 minutes later. And that's not normal. You know, you do a shot of meth and he'd be up
for three days normally. So, I started noticing like him, I mean, and he would start
exhibiting like withdrawal symptoms that I would exhibit coming off of fentanyl. So, I
obtained those test strips through one of the exchanges because I tried to tell him, like,
“Dude, I think your stuff has fentanyl in it and I think I think it has heroin in it or
something. There's something in it that is not right.” And he didn't really want to believe
me because he didn't want to think that he had now done fentanyl or heroin…. we tested
his stuff that he got just so I could, I mean, not necessarily prove him wrong, but just to
let him know, like, “Hey, man, you really are. You might be doing, some of this might be
meth, but most of it is fentanyl because these test strips are coming back positive for
fentanyl. So that means there's at least trace amounts of fentanyl in your meth.”

114
Participants expressed curiosity about fentanyl test strips. Most indicated that they and
their peers who use drugs would use the test strips if they were available. However, Joe (white
male, 47) a drug counselor who reported current fentanyl and crack cocaine use, was uncertain
about whether his patients would utilize the strips:
They might, if they were given out, they might, you know. No, they’re not going to go and
buy them. They’re not gonna care,” I just want to get my dope.” Because it’s never, it’s
not going to be here or there. “Well, that’s fentanyl. I’m not doing that.” They’re not
gonna do that. They just spent their money on it. And they’re sick. So, they’re gonna do it.
But now if we gave it out, if they gave it out, yeah, they might do it just out of curiosity to
see if it’s fentanyl or if it’s heroin.

Overdose Response
Using with others
Using with others is a common practice to avoid the risk of fatal overdose. Participants
reported that using with others ensures that someone is there to administer naloxone or call for
emergency services. Alex (Hispanic male, 31) has increased his practice of using with others
since fentanyl emerged. As he explained, the unpredictable potency of fentanyl is one reason for
people to use with others:
Just since the fentanyl has been around have I made it a point to have other people
around…I would say it's more common for that now, because with the fentanyl, I mean,
with the dope and everything, you never know what you're getting, but with the fentanyl
more so, because it's so much more potent.

Some participants try to hide their use from others and prefer to use alone. Rob (white
male, 43) uses alone because he wants to keep his use hidden from his friends and co-workers.
However, he sees benefits in using with others and commented on the benefits for fatal overdose
prevention:
Others around is, it's kind of a rarity, really, for me at least because I live alone. And at
work, I to try to hide it from people I work with. So, I'm more by myself, personally…. But
that's a good way to keep from having a death [using with others]. I mean, it ain't gonna
stop you from overdosing, but it will keep you from dying, maybe.

115

While using with others provides perceived safety if an overdose occurs, there are also
potential risks associated with this practice. Ashley (white female, 27) recalled a conversation
that she had with her counselor at her methadone clinic about her drug test results. He
documented days when she had more opioids in her system and reviewed this with her to
determine any patterns. Ashley then realized that her use fluctuates depending on which peer she
is using with:
And he [methadone counselor] actually showed me, he did a calendar to see what days I
did the most and which days I went down less to try to see if there was a pattern. And you
know, I got to thinking about it as he showed me, I was like, dang, because certain days I
see certain people and so that made kind of sense. And who I was hanging around with,
like if I'm around another person that's an active user it takes twice as much…. Because
alone I try to control my use to where I only get enough to where you know, I stay well,
and I'm not so high that I'm nodding out because I don't want people to see that. I try to
hide that and be presentable. And then if I'm at somebody's house that also uses, I don't
care. I'll get shit faced.

Ashley continued and explained that people typically like to use with others around.
However, she cautioned that people need to be careful in who they select to have around and
make sure that the person will respond to the overdose and not just leave:
Yeah, a lot of people they don't like to use by themselves anymore. But then again, you
gotta watch who you overdose around too. Because they'll rob you and then leave you for
dead and not call the squad. I've seen that happen to people.

Additional risks may be present when using with others. Marie (white female, 34) uses
with her boyfriend and believes that they know how best to respond to one another when
overdosing. She remains with her boyfriend despite a history of interpersonal conflict because
the benefits of overdose risk reduction outweigh the negatives in the relationship:
My boyfriend. Like we have a bad relationship, so we know that we shouldn’t be
together, but we’re afraid that if we’d leave each other that one of us is going to die.
Because I know how to bring him out of it. And he knows how to bring me out of it. You
know what I mean, like right away…but we’ve learned that over three years. It’s not like

116
it’s just been, “Oh, I do this, and she wakes up.” So, like I know when to freak out and
when not to freak out, when other people don’t know that.

Naloxone
Naloxone was reported as “abundantly” available in the area by most participants. Many
participants reported not typically carrying naloxone but having it available in places where they
typically use, as Eric (white male, 36) explains, “They have it around they don’t really carry it
on them. Girls do because they got purses and the boxes are big. But it’s usually in every house
I’m at.” Rachel (white female, 37) explained how she makes sure that naloxone is available at
houses where she uses with friends:
Yeah, and if not, then I’ll leave some at their house, I can always get more [naloxone]….
I like to have it at the house I use at, so the cops don’t have to be called. And I don’t want
my friends to die. Of course, it’s there for anybody, who would overdose there. I don’t
want any of my friends to get in trouble or die. I’ve lost so many friends.

Most participants discussed accessibility of naloxone through sources like local syringe
service programs, methadone clinics and other treatment centers, and physicians. A few
participants mentioned obtaining naloxone through a mail-in program that Harm Reduction Ohio
recently implemented for the state. Despite multiple sources for accessing naloxone a few
participants lacked knowledge of naloxone and made comments such as, “I don’t even know
where to get it at [naloxone], to be honest with you.” Other participants, remarked on limitations
in current distribution hours, “I don’t know where to go to get them [naloxone] except for like I
said, except for the exchange. And that’s only on Tuesdays. So, what if I need to use one…I can’t
get another one until a week later.”
While the majority of participants held positive views of naloxone a few participants
were not as supportive. A few perceived that people may be willing to do “bigger shots” if
naloxone was around, but no participant reported doing this personally. Further, some felt that
naloxone distribution is not extensive enough. Participants commonly reported personally

117
needing or administering multiple doses of naloxone for overdose reversal. Dave (white male,
35) discussed his perspective on naloxone and the futility of trying to reverse an overdose with
only a few doses. He had a recent overdose experience in which he claimed he needed twelve
doses of naloxone. After this experience he has become more cynical about naloxone:
Well, the thing is, the fentanyl is so strong that it takes 12 doses of it [naloxone]. Well, if I
go to get personal Narcan, they’re only going to give me a prescription for two of them
and then that’s not going to do anything anyway. So, what’s the point in going and
getting Narcan when they’re not distributing you 12 units? So, it’s really not doing
anything….so then like to me, Narcan is pointless, like I’m looking at it like, “Yeah, right
dude, like what am I going to administer two to you?” It’s not going to do anything. It
might give you an extra minute or two for an ambulance to get there. You might save
them like by the minutes or seconds. But, if they die, you’re fucked.

Discussion
This qualitative study provides an understanding of overdose risk reduction strategies that
people who use illicit opioids (PWUIO) in Dayton, Ohio have incorporated in response to the
permeation of fentanyl in the drug market. The emergence of illicitly manufactured fentanyl and
fentanyl analogues has produced uncertainty by saturating the local opioid supply. A major
finding of this study is that it highlights the need for strategies for both overdose prevention and
overdose response. Overdose prevention reflected strategies that may prevent a non-fatal or fatal
overdose from occurring. Some of these strategies, such as using less, are purposefully used for
risk reduction. Other strategies are indirect, such as withdrawal management, and inadvertently
result in overdose risk reduction. Prevention begins with managing withdrawal, continues
through interactions with dealers, and is present during drug consumption (Figure 4.1). In
contrast, the overdose response strategies described were focused on preventing fatal overdoses.
Paraphrasing one of the participant’s comments when speaking about using with others and
having Narcan, these strategies “Will not stop people from overdosing, but it will keep them from
dying. Importantly, this research suggests that PWUIO need to engage in both overdose

118
prevention and overdose response strategies. Considering the volatile nature of the current illicit
opioid market combining a multitude of strategies to mitigate harms from a supply of unknown
potency is essential. Recommendations to support programming and policy changes for overdose
risk reduction are provided.
Buying from a trusted source is an integral element of risk reduction. Participants report
consistency in potency and lower overdose risks when they can buy from the same dealer.
However, close relationships with dealers can expose PWUIO to overdose risk if they test
products of unknown potency for their dealer. Providing dealers with access to drug testing tools
is one strategy to lessen the reliance on customers to self-determine potency of the product
(Bardwell et al., 2019; Betsos et al., 2021). Dealers are critical in risk reduction and research has
identified dealers as important elements of overdose risk reduction through their relationships
with customers and providing safe supply through drug checking (Bardwell et al., 2019; Carroll
et al., 2020). However, dealers are often targeted in “Tough on Drugs” policies and can receive
homicide charges for overdose deaths. Criminal sanctions in these situations do not serve as
deterrents, and the unintended consequences of these policies harm vulnerable populations
(Beletsky, 2019; Friedman et al., 2006). As suggested in a recent study, arresting dealers impacts
access to a safe and consistent supply, and likely contributes to increases in overdoses among
customers (Carroll et al., 2020). Therefore, states should reconsider drug-induced homicide laws.
Ohio was recently identified as one of the top states for drug-induced homicide charges so policy
changes are particularly needed (Northeasern University School of Law, 2021). Research should
continue to disentangle the multifaceted relationships between dealers and their customers to
better support risk reduction efforts.

119
Method of consumption and changes in method were associated were lower risks.
Snorting or smoking were perceived as less risky than injection. Most participants that identified
currently snorting had transitioned from injecting back to snorting. The three participants that
identified smoking as their most common consumption method have always preferred smoking.
Although injection use increases overdose risks (Darke et al., 2006; Mathers et al., 2013) it is
important that individuals using other methods of consumption do not become complacent in
their approach to risk reduction. Awareness is needed that overdose risks remain even with
snorting or smoking methods. Harm reduction services also need to provide materials for
alternative methods of consumption, while developing targeted outreach to reach non-injectors.
The current study did not explore the availability of safer snorting or safer smoking materials in
the area. An evaluation of harm reduction services and supplies available in the region is
recommended for future research. Comprehensive harm reduction services in the area should
include materials like straws, plastic cutting agents, and spoons for safer snorting (Jaywork,
2016) and glass pipes, plastic mouth pieces, pipe screen, push sticks, foils, and alcohol swabs for
safer smoking (BCCDC Harm Reduction Services, N.D.)
Withdrawal is associated with riskier injection-related practices (Mateu-Gelabert et al.,
2010) and a few studies have identified overdose risks associated with opioid withdrawal
(Bluthenthal et al., 2020; Coffin et al., 2007). Avoiding withdrawal emerged as an indirect risk
reduction method that supplements other strategies for overdose risk reduction. Managing
withdrawal symptoms was reported as increasing safer practices while purchasing drugs and also
assisting in regulating the amount used. Saving something for the next morning was a common
strategy to assist with withdrawal, but financial barriers, may not make this strategy feasible.
Participation in methadone treatment was also an effective approach for some to regulate

120
withdrawal and the amount of fentanyl used during the day. Methadone treatment as withdrawal
management appealed to some participants who desired to continue using fentanyl but wanted to
manage their use. This preference was because of the lack of negative effects that some
participants associated with buprenorphine and fentanyl use, such as precipitated withdrawal,
that has also been noted in previous research in Dayton (Silverstein et al., 2019). Some
participants preferred methadone treatment, because they no longer structured their day around
locating cash and drugs and were able to maintain fentanyl use at a more controlled level.
Knowledge of fentanyl tests strips is low among participants. Most participants had never
used test strips, and many had to ask the author what they were and how they were used. This
lack of knowledge may be due in part to Ohio’s policy approach toward test strips. Under the
Ohio Revised Code (ORC 2925.14) fentanyl test strips are considered drug paraphernalia. Ohio
should join other states (Lieberman, 2020) and legalize drug testing strips to support efforts in
overdose prevention through drug checking. Participants reported that fentanyl has replaced
heroin in the region, so there is limited interest in testing heroin as it is now assumed to either be
fentanyl or contaminated with fentanyl. However, similar to other research (Krieger et al., 2018)
participants expressed interest in testing other drugs, such as pills to detect if they have
purchased pressed fentanyl pills, or methamphetamine for fentanyl contamination. Improved
access to fentanyl test strips for methamphetamine testing is especially important because
increased methamphetamine use among PWUIO was described in participant narratives and has
been documented previously in the area (Daniulaityte et al., 2020). Reportedly,
methamphetamine assists with withdrawal management and in preventing overdoses among
participants. Methamphetamine as a risk reduction strategy is especially concerning because the
co-use of methamphetamine and opioids is associated with higher risks of overdose and other

121
negative health outcomes (Cano & Huang, 2021; Glick et al., 2021; Shearer et al., 2020). The
methamphetamine in Ohio is increasingly contaminated with fentanyl (Harm Reduction Ohio,
2021b) and 72.4% of methamphetamine-related overdose deaths in 2019 also involved fentanyl
(Ohio Department of Health, 2020). Education and awareness campaigns are needed to
communicate these risks and to better explain the associated negative health outcomes for
concomitant methamphetamine and fentanyl use.
The Ohio Department of Health has expanded overdose education and naloxone access
through Project DAWN (Deaths Avoided with Naloxone). Project DAWN has almost 300
naloxone distribution sites located in 65 out of Ohio’s 88 counties (Ohio Department of Health,
2021). The majority of participants reported high naloxone accessibility. Most participants
reported accessing through syringe service programs, but a few have obtained naloxone through
the mail using a service from Harm Reduction Ohio. Harm Reduction Ohio is the largest
distributor of naloxone in Ohio and reported providing 18,000 naloxone kits in 2020, resulting in
over 1,000 overdose reversals (Cauchon, 2021). While naloxone is accessible, many participants
commented on receiving or administering multiple doses for overdose reversals. Research
indicates that overdoses related to higher potency fentanyl require multiple doses of naloxone
(Moss & Carlo, 2019; N. Somerville et al., 2017; Sutter et al., 2017). Additional research is
needed to better understand the effect that fentanyl has had on the effectiveness of naloxone. As
a result of these concerns over fentanyl potency and doses required for reversal, many
participants suggested that naloxone distribution should not be limited to the two doses
commonly provided. One way to increase access could be through harm reduction vending
machines. Cincinnati, a city located south of Dayton on the Ohio and Kentucky border, recently
implemented Ohio’s first and only harm reduction vending machines to increase distribution of

122
naloxone and safe use supplies (DeMio, 2021). Other regions in the state could benefit from
implementing these machines, specifically rural areas that may not have resources for brick-and-
mortar harm reduction services.
Although PWUIO have made adaptations in Dayton, some of the overdose risk reduction
strategies have associated risks. In addition to potentially increasing risks, some strategies are
practiced inconsistently due to a lack of financial or social resources. Additional community
supports through innovative harm reduction services are needed to bolster individual overdose
risk reduction strategies and alleviate some of the b. Safe supply and safe consumption services
can provide critical overdose prevention and response, while reducing some of the persistent
risks associated with variables in risk reduction strategies. One of the most difficult aspects of
risk management is navigating the fluctuating drug supply. Access to a safe supply could reduce
or replace fentanyl use while alleviating much of the overdose risks (Ivsins et al., 2020; Ivsins et
al., 2021). Supervised consumption services (SCS) are another strategy that can provide
comprehensive overdose risk reduction. Research has demonstrated the effectiveness of SCS in
overdose prevention (Kennedy et al., 2017; Magwood et al., 2020). Ideally, combining safe
supply with supervised consumption sites would yield the most effective approach for overdose
prevention. Safe supply would remove the risks associated with a contaminated drug supply
while supervised consumption services would provide a safe and sterile environment for all
methods of consumption with safeguards in place for overdose response.
Limitations and Strengths
Study limitations are noted. The study procedures transitioned from in-person to virtual
due to COVID. This impacted the initial recruitment plan which included targeted community
outreach. Recruitment then relied more on peer driven referrals, which can limit sample diversity

123
when participants recruit peers with similar characteristics (Erickson, 1979; Heckathorn, 2002;
Magnani et al., 2005). As a result, the racial and ethnic diversity is limited, so these experiences
primarily reflect those of non-Hispanic white people who use illicit opioids in the region.
However, a strength of the sample is that the majority of participants were females, a population
that remains underrepresented in drug research (Meyer et al., 2019). All data is self-reported and
can be subject to social desirability and recall bias. Finally, the study location is unique, and it is
unclear how experiences in this region reflect other parts of Ohio or the United States. Therefore,
the study may not be able to provide conclusive findings but can generate hypothesis and
improve public health interventions (Messac et al., 2013). Consequently, the specificity is also a
strength of this study in that it provides detailed analysis of overdose risk reduction strategies
that can be used to inform other larger scale representative studies (Ritter, 2006).
Conclusion
This study distinguishes between overdose prevention and overdose response strategies.
Encouraging PWUIO to use with others and to carry naloxone is an important component of
overdose risk reduction and preventing fatal overdose. However, a focus on promoting overdose
response strategies neglects the multiple overdose prevention strategies that can prevent both
non-fatal and fatal overdoses. Overdose prevention should be a first line strategy that is
supplemented with overdose response strategies such as naloxone and using with others.
Recommendations for programming and policies to support overdose risk reduction include the
expansion of harm reduction such as supervised consumption services, safe supply, and drug
checking such as fentanyl test strips. Increasing the accessibility and the number of naloxone kits
distributed can assist with overdose response. Future research should continue to explore the
impact of the changing fentanyl drug market on drug use and risk reduction practices

124
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Tables and Figures
Table 4.1 Overdose, Naloxone, Overdose Risk Reduction, Withdrawal Prevention (N= 60)
N (%)
Ever Overdosed
Yes 43 (71.7)
No 17 (28.3)
Overdose Experiences (Mean, St. Dev) 4.5 (7.8)
Naloxone Used During Last Overdose
Yes 35 (81.4)
No 8 (18.6)
Naloxone Doses Administered Last Overdose (Mean, St. Dev) 4.7, 3.9
Witnessed Overdose Past Six Months
Yes 34 (56.7)
No 26 (43.3)
Number of Friends/Family Who Died Due to Overdose (Mean, St. Dev) 19.9 (24.9)
Regularly Carry Naloxone/Narcan
Yes 40 (66.7)
No 20 (33.3)
Where Obtained Naloxone/Narcan Most Frequently in Past 6 months
Syringe Exchange 14 (35.0)
Family/friends 7 (17.50)
Other (pharmacies, dealers, treatment centers, apartments) 19 (47.5)
Used Fentanyl Test Strip in Last 30 days
Yes 3 (5.0)
No 57 (95.0)
Overdose Risk Reduction Strategies
Used less 40 (67.8)
Tester shots 25 (42.4)
Use with others around 26 (44.1)
Buying from a trusted source 19 (32.2)
Carried naloxone/Narcan 9 (15.3)
Withdrawal Prevention Tactics Scale (How often in the last 6 months did you…)
Save a Hit for the Next Morning
Never/Rarely/Sometimes 24 (40.0)
Often/Very often 36 (60.0)
Put Aside Additional Drugs for an Emergency
Never/Rarely/Sometimes 42 (70.0)
Often/Very often 18 (30.0)
Stored Methadone or Buprenorphine
Never/Rarely/Sometimes 40 (66.7)
Often/Very often 20 (33.3)
Put Aside Money for Getting the Next Hit
Never/Rarely/Sometimes 28 (46.7)
Often/Very often 32 (53.3)
How Many Times Did You Use Other Substances to Avoid Withdrawal?
Never 12 (20.0)
1 to 10 times 29 (48.3)
11 or more times 19 (31.7)

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Figure 4.1 Overdose Risk Reduction

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Chapter Five: Conclusion
Summary of the Three Studies
This qualitative dissertation characterized drug markets, trajectories, and overdose risk
reduction among people who use illicit opioids in Dayton, Ohio. Dayton is identified as an
epicenter of the opioid crisis and was a strategic location for participant recruitment. Qualitative
methods were appropriate for the purposes of this dissertation study. In-depth perspectives from
people who use drugs are especially important in understanding drug availability and use
patterns and are critical in developing appropriate public health responses (Daniel Ciccarone,
2017; Harris et al., 2015; Mounteney & Leirvåg, 2004).
Study 1 (Chapter 2) contextualized the evolving illicit opioid drug market in Dayton,
Ohio. Findings from this study highlight the importance of increased awareness of fentanyl
contamination in substances other than heroin. Study 2 (Chapter 3) contextualized the three
waves of the opioid crisis and identified new pathways into fentanyl use. Peers, family, and
traumatic experiences were noted as critical components of each wave of the crisis. Study 3
(Chapter 4) explored overdose risk reduction, making the distinction between overdose
prevention and overdose response. Findings indicate that people who use illicit opioids are
engaging in overdose risk reduction strategies in Dayton, Ohio. However, the fluctuating potency
of fentanyl in the illicit opioid market can compromise risk reduction efforts. Findings across all
three studies suggest the importance of innovative harm reduction strategies to mitigate risks
from a fentanyl drug market of varying and unpredictable potency.
Study 1
“Do you have fetty?”: A qualitative description of an evolving fentanyl drug
market in Dayton, Ohio

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The present study provides an in-depth examination of current insights and perceptions of
the evolving illicit opioid drug market in Dayton, Ohio. Findings point to individual experiences
in changes in fentanyl availability, preferences, and quality over time. Results indicate
perceptions of a changing drug market characterized with lower quality fentanyl dominating the
opioid market and limited heroin availability. Most participants reported minimal knowledge on
current fentanyl analogues but described that carfentanil is not currently in the drug supply.
Participants perceived that dealer adaptations to avoid overdose risks to clients and personal
prosecution has resulted in decreased quality, with sleeping pills commonly reported as cutting
agents. Fentanyl contamination is also reported in drugs other than heroin. Moreover, the
emergence of pressed pills containing fentanyl were attributed to increased overdose risks.
Study Implications
Despite some limitations, this study provides an understanding of the evolving illicit
opioid market in a region identified as an epicenter of the opioid crisis. While the introduction of
fentanyl was initially supply-led, findings indicate that the current market is becoming
influenced by user preferences for fentanyl. As the opioid drug market continues to transform, it
is important to document these changes to understand the impact on substance use patterns and
risk reduction practices among people who use illicit opioids. Much of the current focus on risk
reduction is concentrated on the opioid-using population, but opioid-related risks may extend to
other substances, as fentanyl contamination is suspected in drugs other than heroin.
Comprehensive harm reduction is needed beyond those who identify illicit opioids as their drug
of choice (Jones et al., 2020). Other innovative measures such as implementing and encouraging
drug testing among dealers needs to be explored to increase access to a safe supply (Bardwell et
al., 2019). Finally, research is needed to understand preferences for other drugs mixed with

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fentanyl, as there may be emerging markets for fentanyl contaminated substances other than
heroin.
Study 2
Prescription opioid, heroin, and street fentanyl trajectories: Contextualizing the three
waves of the opioid crisis

This study characterizes trajectories for each wave of the opioid crisis. Trajectories into
prescription opioids and heroin were included to further understand fentanyl use trajectories and
how these may relate to or differ from the previous waves. Findings add to the literature on
processes by which the opioid market influences drug use trajectories. Supporting previous
research (D Ciccarone, 2017; Ciccarone, 2019, 2021; Mars et al., 2019), supply side factors were
noted for all three waves. Wave one was driven by increased prescribing and access to potent
prescription opioids, wave two by less expensive and highly available heroin, and wave three by
fentanyl adulteration in the heroin supply. Participant accounts of their trajectories into fentanyl
support the argument that the emergence of fentanyl is related more to supply-led changes in the
heroin drug market rather than demand-led preferences (Ciccarone, 2019; S. G. Mars et al.,
2018). However, there was some indication toward increased knowledge and some growing
preferences for fentanyl in the area. As the illicit opioid market continues to evolve, additional
research is needed to understand how demand for fentanyl impacts opioid use trajectories.
Study Implications
Understanding opioid use trajectories in the age of fentanyl is critical in developing
relevant prevention and intervention strategies. Initial opioid trajectories for the three waves of
the crisis included a progression from prescription pills to heroin and then exposure to fentanyl.
This study identifies a new trajectory of initiation through pharmaceutical pills followed by a
progression to pressed fentanyl pills and then to powder fentanyl. While opioid use trajectories

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are changing in the era of fentanyl, the influence of family, peers, and trauma on trajectories is a
constant. Interventions are needed to address not only the substance use but to also consider the
socio-environmental influences on trajectories. Although this study provides some insights that
can be used to inform harm reduction efforts, further research on the dynamic unfolding of the
opioid crisis in the new era of fentanyl is needed.
Study 3
“You can’t do less, you can always do more”: Understanding overdose risk
reduction in a street fentanyl dominated drug market

This qualitative study provides an understanding of overdose risk reduction strategies that
people who use illicit opioids (PWUIO) in Dayton, Ohio have incorporated in response to the
existence of fentanyl in the drug market. The emergence of fentanyl has created a novel
landscape of uncertainty produced by a saturation of the local opioid supply and fentanyl
analogues. A major finding that adds to the existing literature is the dichotomy between
strategies for overdose prevention and those for overdose response. Overdose prevention
reflected strategies that may prevent a non-fatal or fatal overdose from occurring. Some of these
strategies, such as using less, are purposefully used for risk reduction. Other strategies are
indirect, such as withdrawal management, and inadvertently result in overdose risk reduction.
Prevention begins with managing withdrawal, continues through interactions with dealers, and is
present during drug consumption.. In contrast, the overdose response strategies described were
focused on preventing fatal overdoses. Importantly, this research suggests that PWUIO need to
engage in a variety of overdose prevention and response approaches. Considering the volatile
nature of the current illicit opioid market combining a multitude of strategies to mitigate harms

139
from a supply of unknown potency is essential. Recommendations to support programming and
policy changes for overdose risk reduction are provided.
Study Implications
This study distinguishes between overdose prevention and overdose response strategies.
Encouraging PWUIO to use with others and to carry naloxone is an important component of
overdose risk reduction and preventing fatal overdose. However, a focus on promoting overdose
response strategies neglects the multiple overdose prevention strategies that can prevent both
non-fatal and fatal overdoses. Overdose prevention should be a first line strategy that is
supplemented with overdose response strategies such as naloxone and using with others.
Recommendations for programming and policies to support overdose risk reduction include the
expansion of harm reduction such as supervised consumption services, safe supply, and drug
checking such as fentanyl test strips. Increasing the accessibility and the number of naloxone kits
distributed can assist with overdose response. Future research should continue to explore the
impact of the changing fentanyl drug market on drug use and risk reduction practices.
Recommendations for Policy, Practice, and Future Research
Several key areas for policy, practice, and future research emerge from this dissertation.
Findings in Study 1 point to the potential practice of dealers actively monitoring their products
for potency and overdose prevention that has been documented in other research (Bardwell et al.,
2019; Betsos et al., 2021; Kolla & Strike, 2020). For instance, one study found that sellers
understood risks in varying potency of products and engaged in drug checking to provide a safer
supply to clients (Betsos et al., 2021). While research has identified trusted dealers as a source of
risk reduction (Carroll et al., 2020; Carroll et al., 2017; S. Mars et al., 2018b; McKnight & Des

140
Jarlais, 2018), additional studies are needed to understand dealer perceptions on implementing
more formal processes for user safety and drug checking (Bardwell et al., 2019).
Study 1 also provides evidence of experiences where individuals described purchasing
fentanyl-contaminated stimulants. Additional research is needed with larger samples to
understand preferences for fentanyl in non-opioid drugs. Ultimately, this highlights the timely
need for increased access to drug checking (Laing et al., 2018), so that consumers can be
informed of the existing street supply, rather than gauging contamination in drugs by visual and
pharmacological effects.
Supporting previous research, the reported trajectories into fentanyl identified in Study 2
ranged from inadvertent exposure to intentional use, and the reported preferences for fentanyl
varied (Carroll et al., 2017; Ciccarone et al., 2017; S. Mars et al., 2018a; McLean et al., 2019).
While the commonly identified opioid trajectories of pills to heroin to fentanyl support existing
literature, a new pathway into fentanyl use involving pressed fentanyl pills was identified.
Participants with a history of pressed fentanyl pill usage discussed their transition into powder
fentanyl. These participants did not have prior heroin use histories and were initially hesitant to
use powder fentanyl. A transition occurred once they became aware that they were using
fentanyl in pill form and that powder fentanyl was less expensive. The developing role of pressed
fentanyl pills in opioid trajectories indicates that more awareness, prevention, and harm
reduction efforts are needed for this component of the fentanyl drug market.
Participants that were aware about fentanyl prior to use were warned about potency and
provided suggestions on ways to minimize overdose risks. This suggests that information sharing
is occurring, and PWUIO are attempting to assist others in mitigating overdose risks. Utilizing
peers for educational outreach strategies can be an effective harm reduction strategy to assist in

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fentanyl overdose risk reduction (Latkin et al., 2019). Recent studies suggest providing talking
points to well-connected networks members who will take on the role of harm reduction
advocates, working with older people who use drugs to encourage safe practices among younger
network members, and formal training for peer educators (Bouchard et al., 2018; Latkin et al.,
2019; Mateu-Gelabert et al., 2018). Additional research is needed to better understand the most
effective ways to encourage information sharing for risk reduction among people who use drugs,
and specifically for fentanyl-related risk reduction.
Study 3 findings yielded the most robust policy and programming recommendations.
Supporting results from Study 1, dealers were found to support risk reduction efforts. However,
dealers are often targeted in “Tough on Drugs” policies and can receive homicide charges for
overdose deaths. Criminal sanctions in these situations do not serve as deterrents, and the
unintended consequences of these policies harm vulnerable populations (Beletsky, 2019;
Friedman et al., 2006). As suggested in a recent study, arresting dealers impacts access to a safe
and consistent supply, and likely contributes to increases in overdoses among customers (Carroll
et al., 2020). Therefore, states should reconsider drug-induced homicide laws. Ohio was recently
identified as one of the top states for drug-induced homicide charges so policy changes are
particularly needed (Northeasern University School of Law, 2021). Research should continue to
disentangle the multifaceted relationships between dealers and their customers to better support
risk reduction efforts.
Awareness is needed that overdose risks remain even with snorting or smoking methods.
Harm reduction services also need to provide materials for alternative methods of consumption,
while developing targeted outreach to reach non-injectors. The current study did not explore the
availability of safer snorting or safer smoking materials in the area. An evaluation of harm

142
reduction services and supplies available in the region is recommended for future research.
Comprehensive harm reduction services in the area should include materials like straws, plastic
cutting agents, and spoons for safer snorting (Jaywork, 2016) and glass pipes, plastic mouth
pieces, pipe screen, push sticks, foils, and alcohol swabs for safer smoking (BCCDC Harm
Reduction Services, N.D.)
Knowledge of fentanyl tests strips is low among participants. Most participants had never
used test strips, and many had to ask the author what they were and how they were used. This
lack of knowledge may be due in part to Ohio’s policy approach toward test strips. Under the
Ohio Revised Code (ORC 2925.14) fentanyl test strips are considered drug paraphernalia. Ohio
should join other states (Lieberman, 2020) and legalize drug testing strips to support efforts in
overdose prevention through drug checking.
Participants can access naloxone, but many suggest that distribution should not be limited
to the two doses commonly provided. One way to increase access could be through harm
reduction vending machines. Cincinnati, a city located south of Dayton on the Ohio and
Kentucky border, recently implemented Ohio’s first and only harm reduction vending machines
to increase distribution of naloxone and safe use supplies (DeMio, 2021). Other regions in the
state could benefit from implementing these machines, specifically rural areas that may not have
resources for brick-and-mortar harm reduction services.
Additional community supports through innovative harm reduction services are needed to
bolster individual overdose risk reduction strategies. Safe supply and safe consumption services
can provide critical overdose prevention and response, while reducing some of the persistent
risks associated with some risk reduction strategies. One of the most difficult aspects of risk
management is navigating the fluctuating drug supply. Access to a safe supply could reduce or

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replace fentanyl use while alleviating much of the overdose risks (Ivsins et al., 2020; Ivsins et al.,
2021). Supervised consumption services (SCS) are another strategy that can provide
comprehensive overdose risk reduction. Research has demonstrated the effectiveness of SCS in
overdose prevention (Kennedy et al., 2017; Magwood et al., 2020). Ideally, combining safe
supply with safe consumption sites would yield the most effective approach for overdose
prevention. Safe supply would remove the risks associated with a contaminated drug supply
while supervised consumption services would provide a safe and sterile environment for all
methods of consumption with safeguards in place for overdose response
Limitations
Dissertation findings should be considered in the context of several limitations. Data
collection for this dissertation began in March 2020. In-person data collection was conducted
until the COVID-19 pandemic halted all research operations in mid-March. The study methods
then transitioned from in-person to virtual data collection methods and data collection resumed
in July 2020. The transition to virtual methods presented some barriers and opportunities. The
interviewer was not experienced in virtual methods and took this opportunity to participate in
training and consult with other researchers. The use of virtual methods removed barriers in
scheduling and allowed the researcher to schedule on weekends and evenings depending on the
participant availability. This also alleviated transportation and childcare barriers that would exist
if the study had been conducted during typical research office hours. The initial recruitment plan
included targeted community outreach. This outreach was not possible due to COVID
restrictions. Recruitment then relied more on peer driven referrals, which can limit sample
diversity when participants recruit peers with similar characteristics (Erickson, 1979;
Heckathorn, 2002; Magnani et al., 2005). As a result, the racial and ethnic diversity is limited, so

144
participant experiences primarily reflect those of non-Hispanic white people who use illicit
opioids in the region. While limited in racial/ethnic diversity the majority of the sample are
females who have been underrepresented in drug research (Meyer et al., 2019). Efforts were
made to increase sample diversity through other recruitment methods, such as Facebook, but
these efforts yielded limited success. All data is self-reported and can be subject to social
desirability and recall bias. Finally, the study location is unique, and it is unclear how
experiences in this region reflect other parts of Ohio or the United States. Therefore, the study
may not be able to provide conclusive findings but can generate hypothesis and can improve
public health interventions. Consequently, the specificity is also a strength of this dissertation in
that it provides detailed analysis of markets, trajectories, and risk reduction that can be used to
inform other larger scale representative studies (Ritter, 2006)..
Conclusion
Findings from the three studies will be used as foundations for future research related to
understanding risk reduction strategies among people who use illicit opioids to inform
programming and policies that support harm reduction efforts. Study 1 (Chapter 2) findings
provided insight into the role of dealers in safe supply. While studies have examined drug
checking practices among dealers (Bardwell et al., 2019; Betsos et al., 2021; Kolla & Strike,
2020) additional research is needed to understand the mechanisms facilitating safer dealer
practices. In particular, more research is needed to understand how relationships between dealers
and customers influences safety practices. Study 2 (Chapter 3) identified a new trajectory into
fentanyl involving an initiation with pharmaceutical pills, followed by a transition to pressed
pills contaminated with street fentanyl, and then to powdered street fentanyl. The developing role
of pressed fentanyl pills in opioid trajectories indicates that more research is needed to

145
understand this component of the fentanyl drug market. Study 3 (Chapter 4) suggests policies to
support overdose risk reduction should include the expansion of harm reduction such as
supervised consumption services, safe supply, and drug checking with fentanyl test strips.
However, the willingness of PWUIO to utilize these services in the area is currently unknown
and research is needed to understand interest and perceived acceptability for these forms of
outreach.
In conclusion, the three studies in this dissertation provide an epidemiologic profile of
fentanyl drug markets, opioid use trajectories, and overdose risk reduction in Dayton, Ohio. The
three studies are complementary, while each yielding their own rich contextual details to assist in
understanding the illicit opioid market and associated risks. Findings from this dissertation have
timely implications for practice, policy, and future research.

146
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151
Appendix Materials
Project Screener
University of Southern California
Suzanne Dworak-Peck School of Social Work
DAYTON USC HEALTH STUDY
SCREENER

1. Current Zip code_____________

2. Age: ___________ 3. Year of Birth_______________

4. Gender: [ ] Female [ ] Male [ ] Transgender

5. Race/Ethnicity: [ ] Black [ ] Hispanic [ ] White [ ] Other:
_____________________

6. Have you used drugs in the past 30 days? [ ] No [ ] Yes

If, yes, what substance(s)?
No Yes
a. MARIJUANA [ ] [ ]
b. CRACK [ ] [ ]
c. COCAINE [ ] [ ]
d. HEROIN [ ] [ ]
e. SPEEDBALL [ ] [ ]
f. GOOFBALL [ ] [ ]
g. AMPHETAMINE [ ] [ ]
h. ECSTASY [ ] [ ]
i. PRESCRIPTION PILLS [ ] [ ]
j. FENTANYL [ ] [ ]
k. OTHER __________ [ ] [ ]

7. Have you injected drugs in the past 30 days? [ ] No [ ] Yes

If, yes, what substance(s)? No Yes
a. MARIJUANA [ ] [ ]
b. CRACK [ ] [ ]
c. COCAINE [ ] [ ]
d. HEROIN [ ] [ ]
e. SPEEDBALL [ ] [ ]
f. GOOFBALL [ ] [ ]
g. AMPHETAMINE [ ] [ ]
h. ECSTASY [ ] [ ]
i. PRESCRIPTION PILLS [ ] [ ]
j. FENTANYL [ ] [ ]
k. OTHER __________ [ ] [ ]

8. Are you currently in substance abuse treatment? [ ] No [ ] Yes

152
Brief Demographic Survey

University of Southern California
Suzanne Dworak-Peck School of Social Work
DAYTON USC HEALTH STUDY

BRIEF DEMOGRAPHIC SURVEY
Thank you for agreeing to be interviewed. Please be assured any information you give us will be confidential and
will only be identified by a number. Your honesty is critical to the success of this project and is important in
understanding how we can improve community health.

Respondent ID Number_______
RESID
Interview Date______
DATE

A. DEMOGRAPHICS

A1. Age: ___________ A2. Year of Birth: _______________
AGE BIRTHYEAR

A3. Gender (GENDER)
1. Female
2. Male
3. Transgender

A4. Do you consider yourself to be Hispanic or Latino (HISPANIC)?
0. No
1. Yes

A5. What is your Race (RACE)?
1. Black
2. White
3. Other (Specify): _____________________
RACEOTH
A6. Education (EDUCAT):
0. Less than High School
1. High School or GED
2. Some College or More
A7. Relationship Status (RELATION)
0. Single, no main partner
1. In relationship but not living as married
2. Married or living as married
3. Divorced
4. Widowed
A8. Which of the following best describes your sexual orientation (SEXORIE)?
1. Heterosexual
2. Bisexual
3. Gay/lesbian
4. Other (Specify):_________________
SEXORIEOTH
A9. In the past month, how much money did you make from all sources, including legal and illegal sources
(INCOME)?
1. Less than $1,041
2. $1,041 to $1,408

153
3. $1,409 to $2,146
4. $2,147 or more
5. Don’t Know

A10. In the last six months, did you receive income from (EMPLOY): (Check all that apply)
1. Job
2. Unemployment
3. VA benefits
4. Welfare/food stamps/AFDC/GR/SSA
5. Spouse/partner you live with
6. Other family/friends
7. Recycling
8. Illegal or possibly illegal sources (i.e. sex for cash, drug dealing, etc.)
9. Panhandling
10. No Income
A11. Do you consider yourself to be homeless or unstably housed (HOMELESS)?
0. No
1. Yes
If yes how many months?___________
MONTHSHLESS
A12. What zip code do you currently stay/sleep?___________
ZIPCODE
A13. In what kind of place do you currently sleep (LIVE)?
1. Your own apartment or house
2. Your parent or other relative’s apartment or house
3. In a (boyfriend/girlfriend/spouse) apartment
4. In a friend’s apartment or house
5. Rented room
6. A shelter or halfway house
7. On the streets (Car/Van, tent, outdoors)

154
B. DRUG USE HISTORY

Drug B1. Ever
EVERDRUG

0. Never Used
1. Ever Used
B2. Age
First Used
AGE____
B3. Past 30 day Frequency of
Use
SUBSTANCEFREQ

0. Never/None
1. Less than Once a month
2. About 1 to 3 times a month
3. About 1 day a week/4 times
per month
4. About 2 days per week
5. About 3 to 5 days per week
6. About 6 to 7 days per
week/Daily
B4. Mode of Use
SUBSTANCEMOD
E

1. Orally
2. Snort
3. Smoking
4. Injecting
5. Other
a. Marijuana/Cann
abis

b. Alcohol

c. Crack Cocaine

d. Powder Cocaine

e. Heroin

f. Street
Fentanyl/Other
Synthetic
Opioid (Not
Duragesic
Patches)

g. Speedball with
Cocaine and
Heroin/ Street
Fentanyl/Other
Synthetic
Opioid

h. Speedball with
Methamphetami
ne and Heroin/
Street
Fentanyl/Other
Synthetic
Opioid

i. Methamphetami
ne

j. Non-Prescribed
Stimulants
(Adderall,
Ritalin, etc.)

k. Non-Prescribed
Opioids
(Vicodin,
Percocet,
OxyContin, etc.)

l. Non-Prescribed
Tranquilizers
(Xanax,
Klonopin, etc.)

155
m. Non-Prescribed
Methadone

n. Non-Prescribed
Buprenorphine

B5. If Yes to heroin and street fentanyl use: What do you prefer (HERFENTPREF)?
1. Heroin Alone
2. Street Fentanyl Alone
3. Heroin mixed with Street Fentanyl
B6. Based on your experiences in what form is street fentanyl available (FENTAVAIL)?
1. Fentanyl with heroin/Sold as mixed with heroin
2. Fentanyl with heroin/Sold as heroin
3. Fentanyl sold as fentanyl
4. Sold as heroin, is only fentanyl
5. Other(Specify)_________
FENTAVAILOTH
B7. How do you identify if you have purchased street fentanyl (FENTDETECT)? (Select all)

1. Color
2. Taste
3. Texture
4. Smell
5. The way I felt after using it
6. The dealer told me
7. Other(Specify)___________
FENTDETECTOTH
B8. In the last 30 days have you used any drug that you suspected or thought was mixed with street fentanyl or some
other synthetic opioid (SUSPECTFENTOTH)?

0. No
1. Yes

Drug
If YES- What drugs
have you used in the
past 30 days that you
believe were mixed
with street fentanyl or
other synthetic
opioids?

B9. How
frequently was the
drug mixed with
street fentanyl or
another synthetic
opioid in the last
30 days ?
(SUBSTANCESFENT)

0. Never
1. Occasionally- 1%
to 25%
2. Sometimes- 26%
to 74%
3. Usually – 75% to
99%
4. Always – 100%
B10. Past 30 day
Frequency of Use
(SUBFENTFREQ)

0. Never/None
1. Less than Once a
month
2. About 1 to 3
times a month
3. About 1 day a
week/4 times per
month
4. About 2 days per
week
5. About 3 to 5
days per week
6. About 6 to 7
days per
week/Daily
B11. Mode of
Use
(SUBFENTMODE)

1. Orally
2. Snort
3. Smoking
4. Injecting
5. Other
B12. Do you
prefer the drug
alone or mixed
with fentanyl?

0. Alone
1. Mixed with
street
fentanyl/other
synthetic opioids
a. Marijuana

b. Crack Cocaine

c. Powder Cocaine

d. Heroin

e. Speedball with
Cocaine and
Fentanyl

156
f. Speedball with
Methamphetamine
and Fentanyl

g. Methamphetamine

h. Non-Prescribed
Stimulants
(Adderall, Ritalin,
etc.)

i. Non-Prescribed
Opioids (Vicodin,
Percocet,
OxyContin, etc.)

j. Non-Prescribed
Tranquilizers
(Xanax, Klonopin,
etc.)

k. Non-Prescribed
Methadone

l. Non-Prescribed
Buprenorphine

157

C. HARM REDUCTION UTILIZATION

What materials have you obtained from a syringe exchange program or somewhere else in the last 30 days
(HRMATERIALS)? (Select all)

1. Syringes
2. Cookers
3. Fentanyl Test Strips
4. Narcan/Naloxone
5. Condoms
6. None
Where did you get most of the syringes you used for injecting drugs in the past 6 months (MATERIALSWHERE)?
1. Syringe Exchange Program
2. From someone who goes to the syringe exchange
3. Bought from another source (street, friend, etc.)
4. My own prescription for syringes
5. Bought from a pharmacy
6. Other family/friends

Do you regularly carry naloxone or Narcan (NARCAN)?
0. No
1. Yes

Where did you get naloxone/Narcan from most frequently in the past 6 months (NARCANWHERE)? (Choose one)
0. Don’t carry
1. Syringe Exchange Program
2. From someone who goes to the syringe exchange
3. Bought from another source (street, friend, etc.)
4. Bought from a pharmacy
5. Other family/friends
6. Project Dawn
7. Family of Addicts
8. OTHER (Specify) ___________________
NARCANWHEREOTH

Have you used a fentanyl test strip in the last 30 days (FENTTESTSTRIP)?
0. No
1. Yes
If YES: Number of times there was fentanyl in the sample______
TIMESFENT
What did you do following the positive fentanyl test result (POSFENTTEST)? (Mark all that apply)
1. Used as intended
2. Used less than intended
3. Pushed plunger more slowly than usual
4. Pushed plunger partway and waited
5. Use half shot and waiting before injecting more
6. Sniffed/tooted before injecting
7. Sniffed/tooted instead of injecting
8. Smoked instead of injecting
9. Have someone with a higher tolerance use from the batch first
10. Ask someone who bought from the same dealer about potency
11. Threw drug away
12. Sold the drug
13. Shared test results with other people

158
14. Use with other people around

What have you done to reduce your risk of overdose given the potency of street fentanyl (INDIGENOUSHR)?
(Mark all that apply)
1. Used less than intended
2. Pushed plunger more slowly than usual
3. Pushed plunger partway and waited
4. Use half shot and waiting before injecting more
5. Sniffed/tooted before injecting
6. Sniffed/tooted instead of injecting
7. Smoked instead of injecting
8. Use with others around
9. Have someone with a higher tolerance use from the batch first
10. Ask someone who bought from the same dealer about potency
11. Tester shots
12. Buying from a trusted source
13. Avoided withdrawal
14. Started carrying Naloxone/Narcan
15. Started carrying fentanyl test strips
16. Started carrying methadone or buprenorphine
17. I have not made any changes

Withdrawal Prevention Tactics Scale: Friedman (Symbiotic Processes)
In the last six months have you done any of the following to avoid withdrawal episodes (SYMBIOTIC1)?

0. Never 1. Rarely 2. Sometimes 3. Often 4.
Very
Often
a. Saved a hit for the next morning.
SYMBSAVED

b. Put aside additional drugs (e.g.
stashing heroin not as a wake-up) to
resort to in an emergency.
SYMBADD

c. Stored methadone or
buprenorphine.
SYMBSTORE

d. Put aside money for getting the
next hit in an emergency.
SYMBASIDE

0. Never 1. Once 2. 2 to 5 times 3. 6 to 10
times
4. 11
or
more
times
e. How many times did you use
other substances to avoid
withdrawal SYMBIOTIC2

159

D. RISKS
In the last 30 days did you use any of the following items that you know had been used by someone else before you?

Item
SHAREMATERIALS
0. Never
1. Ever
Times in Last 30 days?
____TIMES
Relationship to Person:
RELATIONSHIPSHARE
1. Close Friend
2. Family Member
3. Acquaintance
4. Sex Partner
5. Stranger
Syringe/Needle SHARESYR

Cooker/Spoon SHARECOOKER

Rinse/Mix Water SHAREWATER

Filter/Cotton SHARECOTTON

OVERDOSE
How many times have you overdosed in you lifetime (TXOVERDOSE)?_____
If greater than zero then:

The last time you overdosed were you treated with Naloxone/Narcan (LASTODNARC)?
If yes, how many doses were you given? ___________
TXNARCLASTOD

How many people do you know have died due to a heroin or fentanyl related overdose ? _________
NUMKNOWNOD
HEALTH STATUS
Have you ever been tested for HIV (HIVTEST)? 0. No 1. Yes
Has a doctor, nurse or counselor ever told you that you are HIV positive (HIVPOSITIVE)? 0. No 1. Yes
If Yes, are you currently receiving treatment (HIVTX)? 0. No 1. Yes

Have you ever been tested for infection with Hepatitis C virus or HCV(HCVTEST)? 0. No 1. Yes
Have you ever tested positive for Hepatitis C/HCV infection or been told by
a health care professional that you are HCV positive (HCVPOSITIVE)? 0. No 1. Yes
If Yes, are you currently receiving treatment (HCVTX)? 0. No 1. Yes
Times
overdosed in
the last six
months
TXOVERDOSE6
Times the overdose was
treated with
Naloxone/Narcan?
TXOVERDOSENAR
If Naloxone/Narcan used times
it was administered by
Emergency Services Personnel
(EMT/Police/Fire Department)
TXNARCEMT
If Naloxone/Narcan used times it
was administered by a
community member (Non-
emergency services)
TXNARCNONEMT

Select if you
have witnessed
an overdose
among any of
these individuals
in the past 6
months.
(WITNESSOD)?
Times
Witnessed
Overdose in
Past 6
Months
Times the overdose
was treated with
Naloxone/Narcan?
If Naloxone/Narcan
used times it was
administered by
Emergency Services
Personnel
(EMT/Police/Fire
Department)
If Naloxone/Narcan used
times it was administered
by a community member
(Non-emergency services)
Times that 911
or Emergency
Services were
called
Friend
Family
Member
Acquaintance
Sex Partner
Stranger

160
Qualitative Interview Themes
University of Southern California
Suzanne Dworak-Peck School of Social Work
DAYTON USC HEALTH STUDY
Qualitative Interview
General Themes

1. Family
I would like to know about your family these last 10 years. I want to hear about your family
relationships and some of the problems and events in the family you grew up with.
• frequency of contact with parents and siblings
• quality of relationship with family
• family drug use, treatment, crime, and incarceration (intergenerational)
• family structure and density of relatives living in the neighborhood
• patterns of family reciprocity, obligations and social support
• role of family friendships/street networks in the life of individual
• patterns of family conflict and violence (parental IPV, other adults, siblings, etc.)

2. Intimate Partner Relationships
Tell me about your significant partners or relationships these last 10 years.
• patterns of partner relationships (monogamous, serial)
• quality of relationship with partner(s)
• role of empathy and connectiveness to intimate partners
• characteristics of partner (i.e., age, drug use, incarceration history)
• patterns of conflict and intimate partner violence

3. School and Labor Force
Tell me about your experiences with school, work and the kinds of jobs you have had these last
10 years.
• School attendance
• patterns of labor force participation (part-time, full-time, sector) and types of jobs held
• quality of attachment
• barriers to employment
• labor market discrimination

4. Incarceration and Re-entry Experiences
Tell me about your incarceration and re-entry experiences these last 10 years.
• influences of incarceration on continued use or cessation of drugs, crime and violence
• family support
• influence on parenting role and bonds to children
• influence on partner/husband/wife

5. Drug Use Experiences
Tell me about your drug use experiences these last 10 years.
• history of drug use by specific drugs

161
• patterns frequency of drug use
• mode of administration
• access and availability of heroin
• perceived exposure to fentanyl/synthetic opioids
• description of heroin
• perceived adulterants in heroin supply
• perceived effects of different types of heroin
• rituals before and during use

6. Drug Subcultures and Practices
Tell me about the last time you bought drugs and how this differs from other points during the
last 10 years.
• differences in the style and structures of drug subcultures in Dayton
• the nature and dynamics of drug retail markets in Dayton
• interactions with dealers
• information sharing among peers
• sanctions related to substance use

7. Drug Risk Behaviors
Tell me about your drug risk behaviors these last 10 years.
• overdose experiences
• observed overdoses
• sharing of syringes or other materials related to injection
• actively seeking synthetic opioids

8. Risk Reduction Strategies, Practices, Tactics
Tell me about your risk reduction these last 10 years.
• naloxone
• indigenous strategies
• syringe exchange
• symbiotic processes
• drug testing experiences

9. Involvement with Peers Engaged in High-Risk Infectious Behaviors
Tell me about your relationships with peers who you think are involved with high risk behaviors
like injecting drugs, multiple sex partners, have STDs, and so forth these last 10 years.
• involvement with intimate partners who inject drugs and/or have STIs
• sexual practices with intimate partners who inject drugs and/or have STIs
• knowledge of these peers’ risk behaviors
• risk reduction experiences with these high-risk partners
• risk use experiences with these high-risk partners
• participation in sexual risk networks

10. Substance Abuse Treatment

162
Tell me about your experiences with substance abuse treatment in the community during these
last 10 years.
• availability, access, and barriers to substance abuse treatment
• impact of these services on your family life
• availability and access to medically assisted treatment

11. Health History and Experiences
Tell me about your health history and medical treatment experiences these last 10 years.
• history of major illnesses and infections
• history of major medical treatments and/or hospitalization experiences
• mental health

163
Analytic Process
Analytic Activity Purpose Result
Initial reading of
transcribed interviews
007; 023; 039; 048; 056.
Obtain a broad understanding of
perceptions and experiences of
participants.

Analytic memos recorded.
Gained an understanding of
differences and similarities in
participants experiences. Developed
preliminary research questions for
the three papers. Noted potential
areas for further exploration in
analysis.

Immersion into data In-depth reading of the initial five
transcripts (007, 023, 039, 048,
056).

Creation of initial code lists for
three papers using each study
question.

Analytic memos recorded.
Allowed researcher to become more
familiar with the data to create an
initial code list for the three papers.
Refined research questions and
purpose.

Hybrid approach of inductive and
deductive coding utilized. Initial
codes included 24 codes for Paper
1; 23 codes for Paper 2; and 22 for
Paper 3.
Team review and
Revision of initial Code
List
To refine and clarify each code.
Discuss coding scheme and resolve
any discrepancies by consensus.

Memo recorded.
Received feedback on coding.
Recommended to take a broader
approach and code all transcripts
with revised code list. Total new
code lists of 20 codes for data.
Immersion into data In-depth reading of remaining 55
transcripts

Refined research questions for three
papers. Identified relevant
similarities and differences in
participant responses.
Applied new code list to
all transcripts.
Maintain consistency across
analysis.

Analytic memos recorded.
No new codes were derived
highlighting saturation of data.
Emerging themes identified and
specific quotes were identified as of
interest.
Sorting codes into
categories.
Link codes with themes, utilizing
quotes.
Supported themes by linking quotes
to concepts.
Triangulated data from
brief demographic
surveys and interviews
Provide additional interpretation
and understanding of data
Compared results from brief
demographic data to qualitative
interviews to further understand
participants perspectives and
experiences.

Abstract (if available)

Abstract The emergence of synthetic opioids, such as illicitly manufactured fentanyl, into the illicit opioid supply has presented unique challenges in mitigating opioid-related risks. While epidemiological patterns of risk are known from previous studies of heroin use, what is not clear is how individual behaviors, strategies, and local social and situational factors in the current synthetic opioid/illicitly manufactured fentanyl crisis are promoting risk factors and/or self-protective behaviors in distinct emerging fentanyl “hot spots” such as Ohio. Informed by the Drug, Set, and Setting Framework with concepts from the Symbiotic Model of Risk Reduction, this dissertation explores the impact of the emergence of fentanyl on drug markets, illicit opioid use trajectories, and risk or self-protective behaviors among individuals who use illicit opioids in Dayton, Ohio. ? In recent years the drug supply in Dayton has been increasingly contaminated with fentanyl making this an excellent location to understand the rapidly evolving heroin/fentanyl crisis. People who use illicit opioids in environments with a fentanyl contaminated heroin supply represent a nexus of risk and vulnerability for fatal overdoses and disease transmission and require an in-depth understanding of the conditions and contexts under which these populations live. Designed with this scientific premise in mind, this dissertation is guided by the urgent need for qualitative research in understanding current heroin/fentanyl behaviors and shifts in drug use practices to inform implementation science for innovative harm reduction interventions. This dissertation adds to the emerging literature on the patterns and histories of heroin/fentanyl use and the practices by which fentanyl heightens behavioral risks for people who use illicit opioids and the susceptibility for detrimental health conditions and mortality, such as fatal overdose. The three studies, presented across three distinct chapters in this dissertation, have timely and direct implications for geographically tailored responses to the opioid crisis.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Perdue, Tasha (author)

Core Title A qualitative study of street fentanyl in Dayton, Ohio: drug markets, trajectories, and overdose risk reduction

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Degree Conferral Date 2021-08

Publication Date 07/20/2021

Defense Date 06/16/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag drug use,drug use trajectories,Drugs,Epidemiology,fentanyl,heroin,illicitly manufactured fentanyl,OAI-PMH Harvest,Ohio,opioids,overdose,overdose prevention,overdose response,qualitative,risk and protective behaviors,substance use,synthetic opioids

Format application/pdf (imt)

Language English

Advisor Cepeda, Alice (committee chair), Bluthenthal, Ricky N. (committee member), Valdez, Avelardo (committee member)

Creator Email perdue.112@osu.edu,tperdue@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC15612362

Unique identifier UC15612362

Legacy Identifier etd-PerdueTash-9790

Document Type Dissertation

Format application/pdf (imt)

Rights Perdue, Tasha

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu