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 lower-frequency injecting and injection cessation among people using xylazine-adulterated fentanyl in two of the states (Connecticut, Massachusetts) most impacted by this drug supply change. America’s drug supply has grown become more volatile since 2020, 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 lower-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 substance use services to the needs of people reducing their injecting frequency or stopping injecting altogether. Understandings of how the proliferation of xylazine-adulterated fentanyl is influencing transitions to low-frequency injecting and injection cessation and their implications for substance use services are urgently needed to optimize overdose prevention approaches. Building on our extensive experience studying the impacts of drug supply changes, including on drug use behaviors and overdose prevention approaches, we propose the following specific aims: Aim 1: To characterize how exposure to xylazine-adulterated fentanyl shapes transitions to lower-frequency injecting (≥ 50% reduction in injecting frequency) and injection cessation (>30 days). Aim 2: To explore perceptions of overdose risks associated with non-injection drug use of xylazine-adulterated fentanyl and examine their implications for overdose prevention messaging and substance use service delivery. Aim 3: To explore challenges and opportunities for overdose prevention strategies in addressing overdose risks among people exposed to xylazine-adulterated fentanyl transitioning to lower-frequency injection drug use or injection cessation. To generate understandings of the dynamics underlying these changes to drug use behaviors, we will conduct qualitative interviews with people using xylazine-adulterated fentanyl across Connecticut (n=40-50) who have transitioned to lower-frequency injecting or injection cessation (Aims 1&2), as well as focus groups with substance use services workers (n=25-30) from across CT and MA (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.
