Barriers to, and Facilitators of, Checking Drugs for Adulterants in the Era of Fentanyl and Xylazine: Qualitative Study

Background: Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterantssuch as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increasesrisks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to acombination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to checkdrugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many peoplewho use drugs decline to use them. Objective: We sought to better understand why people in the New York City area do or do not check drugs before use. We planto use study findings to inform the development of technology-based interventions to encourage consistent drug checking. Methods: In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructuredqualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interviewguide examined participants'knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines;using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded,transcribed, and analyzed for emerging themes. Results: Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for notchecking included lacking convenient access to test supplies, or a place to check samples out of the public's view, as well as timeconsiderations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterantsbecause they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sellthem adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agencystaff. Conclusions: New forms of outreach are needed not only to increase people's knowledge of adulterated substances and awarenessof the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. Thisincludes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing andvolatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefitspublic health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted communitymembers including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-costdrug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide.