University of Washington (UW) researchers recently interviewed individuals who use fentanyl in an attempt to gather insight to help address the public health crisis spurred by the drug.
Opioid overdose deaths in Washington continue to rise and are primarily driven by unregulated fentanyl. The opioid overdose death rate in the state more than doubled from 2019 to 2022. Washington had 11.3 deaths per 100,000 residents in 2019, and 24.9 deaths per 100,000 residents in 2022. Most of that increase was due to fentanyl. In 2022, fentanyl was involved in 90 percent of opioid overdose deaths in the state, and 65 percent of all overdose deaths.
UW researchers interviewed 30 people who use fentanyl at four Washington syringe services programs. They issued a report about their findings, and discussed them during a webinar on Wednesday. Teresa Winstead, PhD, said participants discussed a rapid change in the drug supply, which switched from a primary use of heroin to fentanyl, and how it affected their substance use.
“The emergence and dominance of fentanyl over heroin has fundamentally changed the context of opioid use,” Winstead said. “That underscores what we feel is the importance of this work.”
A comment from a fentanyl user in the report states that, “It’s a mess. But at the time I thought it was a good idea switching from heroin to that. It wasn’t a good idea. I should have just stuck with heroin because I wasn’t dying from heroin.”
Another fentanyl user said, “It just took over my heroin addiction without me even realizing it. All of a sudden, one day, I was just addicted to fentanyl instead of heroin. It was weird. And then I tried heroin again, and it didn’t do the same thing it used to do for me.”
Researchers’ interview questions centered on drug users’ treatment history and experience, their fentanyl/substance use patterns, their interest in stopping fentanyl use, and the ideal type of care that would support their wellness, Winstead said.
“The interviews took place between September and October 2022,” she said. “Participants were offered a small gift card for their participation.”
Interviews were held at Clallam County Harm Reduction Health Center in Port Angeles, Tacoma Needle Exchange, Thurston County Syringe Services Program in Olympia, and Spokane Regional Health District Syringe Services Program. They took between 30 and 60 minutes to conduct, Winstead said.
“Over half (of the participants) were white, the average age was 37, and only 13 percent reported having stable housing. The vast majority were using fentanyl every day, and had been using it for 13 months. Two-thirds (of them) had tried some kind of treatment.”
— Teresa Winstead, report author, University of Washington
Almost all interview participants smoked fentanyl, and a few also injected it. Many interview respondents had previously injected heroin, and switched to smoking fentanyl due to fentanyl’s potency and a perceived lower overdose risk from smoking it.
“I’m just too scared to shoot it, because there’s been a lot of people that had,” a fentanyl user stated in the report. “Even with melting the pills down to shoot it, they overdosed off of one pill, and died even though they have been on it for years. So, I’m too terrified to do it that way. I’m not looking to die. I’m just looking for some pain relief.”
Report author Everett Maroon said most participants smoked the drug because they said it’s easier than injecting it, and they had a sense that it reduced overdose risk.
“There were many moments that they were trying to mediate overdose risk,” Maroon said. “Even in an environment lacking care, they were still focused on supporting their own health. People are nervous about the risk of overdose, and smoking lets them consume a little bit at a time. Once you inject it, it’s hard to control how much (they’re doing).”
Participants reported complex motivations for using fentanyl, including physical pain, mental health issues, trauma, homelessness, opioid use disorder, and easy access to the drug. The majority of respondents were unhoused and said meeting basic needs like housing, food, and employment were a priority.
“Seventy percent of respondents cited pain as a motivation for use. Many said fentanyl helped them function through the pain they were having. But they still had a chronic pain issue that needed attention. A couple people suggested pain happened after use. There was leg and (foot) pain.”
— Everett Maroon, report author, University of Washington
The majority (70 percent) of participants were interested in reducing or stopping their fentanyl use. They said there were many barriers to doing so, however, including the unavailability of services, and being unaware of what might work for them. They also had a fear of withdrawal, and expressed challenges accessing and staying on medications like buprenorphine or methadone.
“The [high] potency of fentanyl brings on withdrawal symptoms,” Maroon said. “Withdrawal was something people were trying to avoid, especially when they don’t have housing and are out in public.”
Many respondents were interested in, or had previous positive experiences with methadone or buprenorphine for opioid use disorder. But administrative services and other barriers limited their access to medications. The regulations for dispensing methadone and the need for daily dosing were particularly challenging barriers, especially for respondents experiencing housing insecurity.
“I’m stuck on the street, so I can’t get out of here, and I’m not going to be sober being here,” a fentanyl user stated in the report. “I do want to stop. I want a normal life, but I can’t get it. I can’t get it back again. I want to be going to work, going home, going to work, going to the grocery store. I miss it.”
When asked about the “ideal place” to receive medical care or help with their substance use, participants said they preferred holistic, individualized care that was affordable and easy to access. Their specific services of interest included programs to help meet their basic needs, medical care, mental healthcare, care navigation, and support from people with lived experiences with substance use.
Report author Alison Newman said participants want care that is accessible and nonjudgmental.
“People were interested in housing, cash assistance, and contingency management,” Newman said. “They were least interested in (substance use disorder) counseling. Many people describe wanting care in a homey/cozy space. Two people wanted care at home with their families. People were generally interested in methadone and buprenorphine, but experienced barriers in accessing them. They were interested in methadone and said they would try it if they could get it just like any other drug in a pharmacy.”