Xylazine exposure and transitions to low-frequency injecting and injection cessation - Project Summary: We propose a two-year qualitative study that will characterize transitions to low-frequency
injecting and injection cessation among people using xylazine-adulterated fentanyl in one of the states
(Connecticut) most impacted by this drug supply change. America's drug supply has grown become more volatile
since the outset of the COVID-19 pandemic, particularly the proliferation of xylazine-adulterated fentanyl in
Northeast and Mid-Atlantic states, and is driving drug-related harms, including increases in non-fatal and fatal
overdoses and severe injection-related soft tissue infections. Amidst the emergence of xylazine-adulterated
fentanyl, researchers have begun to document reductions in injection drug use and injection cessation among
people continuing to use fentanyl. Transitions to low-frequency injecting and injection cessation represent key
strategies for reducing the potential for soft tissue infections associated with xylazine-injecting, as well as the
transmission of infectious diseases (e.g., hepatitis C, HIV). However, the growing proportion of overdose deaths
across the country attributed to non-injection drug use raise significant concerns about overdose awareness and
the responsiveness of harm reduction services to the needs of people transitioning to low-frequency injecting
and injection cessation. Contextualized understandings of how the proliferation of xylazine-adulterated fentanyl
intersects with social, structural, and environmental influences to shape these transitions to low-frequency
injecting and infection cessation and their implications for harm reduction services are urgently needed to
optimize harm reduction approaches. Building on our extensive experience studying the impacts of drug supply
changes, including on drug use behaviors and harm reduction services, we propose the following specific aims:
Aim 1: To characterize how exposure to xylazine-adulterated fentanyl intersects with social-structural influences
(e.g., homelessness, poverty) to shape transitions to low-frequency injecting (≤10 times per month) and injection
cessation (>30 days). Aim 2: To explore perceptions of overdose vulnerability associated with non-injection drug
use of xylazine-adulterated fentanyl, and examine their implications for overdose prevention messaging and
harm reduction service delivery. Aim 3: To explore challenges and opportunities for harm reduction strategies,
including syringe exchange, naloxone, and community health programs, in addressing overdose vulnerability
among people exposed to xylazine-adulterated fentanyl transitioning to low-frequency injection drug use or
injection cessation. Informed by the equity-focused Intersectional Risk Environment framework, we will conduct
qualitative interviews with people using xylazine-adulterated fentanyl across Connecticut (n=50) who have
transitioned to low-frequency injecting or injection cessation (Aims 1&2), as well as focus groups with harm
reduction workers (n=30) from across the state (Aim 3). Findings will be mobilized to develop evidence-informed,
scalable research, policy and program recommendations to address harms associated with xylazine-adulterated
fentanyl, including the design of new interventions.
