- Researchers looked at how often people injected fentanyl and shared injecting supplies
- Sharing supplies was more common among people who injected fentanyl than among people who injected other drugs
- Injecting fentanyl may be related to practices that increase risk of hepatitis C and HIV transmission
In recent years, fentanyl and other synthetic opioids have saturated the unregulated drug supply in many parts of Canada. The potency and unpredictability of fentanyl in the unregulated drug supply has been associated with unprecedented increases in drug toxicity and overdose deaths.
Fentanyl is associated with injecting frequently because it has a relatively short duration of action. Injecting frequently may be related to sharing injecting supplies, which can increase people’s risk of infections. To examine the relationship between how often people injected fentanyl and how often they shared injecting supplies, researchers conducted a survey with people who inject drugs in Toronto.
Study details
Researchers analyzed data from a survey of 249 people who inject drugs in Toronto, Ontario. The survey examined a range of topics related to the effects of increasing exposure to overdose in the community. It included questions about experiences with overdoses, naloxone use, practices related to risk of hepatitis C and HIV and needs related to grief and loss support. The survey was developed by academics, peer researchers with lived or living experience of drug use and the study’s community advisory board, which also included people with diverse experiences of drug use.
The survey was administered by peer interviewers between January and February, 2019. Participants were recruited from four organizations that offer harm reduction services (e.g., supervised consumption services, harm reduction supply distribution programs) in different parts of Toronto. People were eligible to participate if they were age 16 or older, if they had injected drugs in the past three months, if they were fluent in English and if they provided verbal consent. Participants received $40 honoraria.
Researchers measured injection-related risk practices in the following ways:
- how often participants reported injecting fentanyl in the past six months (daily, less than daily or none)
- whether or not participants reported sharing syringes, cookers or filters with someone else in the past six months
Results
There were 249 people who participated in the survey. Participant demographic information was as follows:
- median age 42.5 years
- 22.5% identified as women, 45.8% identified as men and 1.6% identified as non-binary or other genders
- 32.5% identified as Indigenous and 55.4% identified as White
- 65.9% reported homelessness
- 25.7% reported being incarcerated in the past six months
The drugs that people reported using most often in the past six months included fentanyl (46.2%), crystal meth (13.7%), heroin (12.5%) and cocaine (11.6%). Nearly half of the participants (47.0%) reported injecting fentanyl daily, compared with 19.7% who injected fentanyl less than daily and 31.3% who did not inject fentanyl.
Fentanyl injection frequency and injection-related risk practices
People who reported injecting fentanyl daily and less than daily reported more injecting-related risk practices than people who injected drugs other than fentanyl.
Compared with people who did not inject fentanyl, people who injected fentanyl daily were significantly:
- more likely to share syringes (25.0% compared with 4.9%)
- more likely to share cookers (42.4% compared with 11.3%)
- more likely to share filters (30.2% compared with 9.7%)
Compared with people who did not inject fentanyl, people who injected fentanyl less than daily were significantly:
- more likely to share cookers (37.2% compared with 11.3%)
- more likely to share filters (30.3% compared with 9.7%)
Overall, the researchers found that people who reported injecting fentanyl shared syringes, cookers and filters more often than people who injected drugs other than fentanyl. There were no significant differences in injection-related risk practices between people who reported injecting fentanyl daily and people who reported injecting fentanyl less than daily.
Risk influenced by factors outside of fentanyl use
While the researchers found that injecting fentanyl was related to increased likelihood of injecting-related risk practices, they did not find any association between fentanyl injection frequency (i.e., daily or less than daily) and injection-related risk practices. This suggests that other factors may be impacting the risk practices associated with fentanyl injection. The authors suggest that the following factors may influence the likelihood of sharing supplies:
- the cost of fentanyl (i.e., high cost may increase the likelihood of sharing supplies as many people pool money to buy and split doses)
- the impacts of criminalization (e.g., creating barriers to harm reduction services)
- practices of care and mutual aid among people who use drugs (e.g., sharing used supplies to make a “wash” to help someone experiencing withdrawal)
Role of cooking drugs to reduce harms
Previous research has shown that injecting fentanyl is associated with increased syringe sharing. However, this study found that injecting fentanyl was also associated with increased sharing of cookers and filters. The researchers note that one strategy that can reduce harms related to sharing cookers and filters is heating (also known as cooking) the drug solution and allowing it to cool before injecting. This is because heating the drug solution until it boils (about 10 seconds) can kill certain viruses (e.g., HIV) and bacteria that may be present, which can reduce the risk of infection. Education about how heating can reduce harms can be included in education about safer substance use, alongside consistent access to new harm reduction supplies.
Need for expanded options in areas with fentanyl in the unregulated drug supply
The researchers also note that, in contrast to previous studies, their research took place in Toronto, where people can access supervised consumption services. Despite access to new harm reduction supplies through the harm reduction supply distribution programs and supervised consumption services where participants were recruited, supplies were still commonly shared. The authors suggest that, when fentanyl becomes the dominant opioid in the unregulated supply, there may be a need to implement and scale up harm reduction services that extend and build on approaches such as supervised consumption sites and harm reduction supply distribution. These approaches may include:
- 24/7 access to harm reduction services, including harm reduction supplies
- injectable opioid agonist therapy and safe supply as alternatives to the unregulated drug supply
- low-barrier access to hepatitis C and HIV testing and treatment
- low-barrier access to prevention for people who inject drugs (e.g., condoms, HIV pre-exposure prophylaxis [PrEP])
Limitations
There are multiple study limitations that need to be considered. Because the study recruited people who inject drugs who access harm reduction services, it is unknown whether the findings apply to people who inject drugs in other areas or who may not have access to harm reduction services. Second, because the results come from one survey, the order of the relationship between fentanyl injection and injection-related risk practices cannot be conclusively determined (i.e., which came first). Third, the results were self-reported, which means that they could be influenced by what people remember and response bias. This is complicated by the fact that people often do not know what exactly is in their drugs. This means that actual fentanyl use and frequency cannot be determined. Finally, more detail about how often people inject fentanyl (e.g., how many times per day) and how frequently they share supplies would help to better understand the relationship between fentanyl and injection-related risk practices.
Resources
Injecting fentanyl and heroin: Steps to safer preparing and injecting
REFERENCE:
Kenny K, Kolla G, Greig S et al. Association of illicit fentanyl use with injection risk practices among people who inject drugs. AIDS and Behavior. 2023;27:1757-1765.