Fentanyl use among people who inject drugs in two large Pacific Northwest metropolitan areas

Fentanyl use among people who inject drugs in two large Pacific Northwest metropolitan areas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Fentanyl use among people who inject drugs in two large Pacific Northwest metropolitan areas Lauren Lipira, Sara N Glick, Courtney Moreno, Lalaine Sevillano, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6597345/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Mar, 2026 Read the published version in Harm Reduction Journal → Version 1 posted 11 You are reading this latest preprint version Abstract Background We examined fentanyl use and outcomes among people who inject drugs (PWID) in the urban Pacific Northwest (PNW). Methods We conducted secondary analysis of data from the 2022 National HIV Behavioral Surveillance PWID cycle from Portland, OR and Seattle, WA. We calculated proportions of any fentanyl, injection fentanyl, non-injection fentanyl, and street pill use. Next, we compared characteristics, behaviors, and outcomes by any fentanyl use. Finally, we estimated adjusted relative risk (aRR) of overdose outcomes associated with fentanyl use and injecting less associated with type of street pill use. Results Among 835 PWID, 76% reported fentanyl use, 47% injection fentanyl use, 68% non-injection fentanyl use, and 66% street pill use. Of those who used pills, 94% smoked them. Fentanyl use was crudely associated with age; race; housing; detainment; usual drug injected; injection frequency; syringe service programs, substance treatment, overdose, and naloxone (p<0.05). With adjustment, any fentanyl use (aRR=2.99, 95% CI: 1.55-5.76), injection fentanyl use (aRR=2.98, 95% CI: 1.43-6.19), and non-injection fentanyl use (aRR=2.12, 95% CI: 1.19-3.75) were associated with higher risk of overdose. Participants who smoked street pills were more likely to report injecting less because of pill use (aRR=1.80, 95% CI: 1.23-2.64). Conclusions Fentanyl use was highly prevalent among PWID in the urban PNW. Non-injection fentanyl use was most common and street pills were frequently administered by smoking which was associated with injecting less. All fentanyl use was associated with increased risk for overdose. There is ongoing need for access to naloxone for PWID who use fentanyl. Fentanyl IDU naloxone NIDU overdose PWID Background Considered the “third wave” of the opioid epidemic, illicit fentanyl use is increasingly common among people who inject drugs (PWID) in the United States (US) ( 1 ). Similar to heroin, and sometimes combined with heroin or other drugs, fentanyl is often distributed in powder form which can be injected, snorted, ingested or smoked ( 2 ). Additionally, a growing proportion of fentanyl is in the form of street pills designed to look like prescription opioids ( 3 ). Fentanyl is inherently more potent, faster acting, and generates a shorter high than heroin, lending itself to high risk for misuse, addiction, and opioid overdose ( 4 ). Since the introduction of fentanyl into the US drug market, overdose cases have increased exponentially with fentanyl documented as a growing contributor ( 5 ). Naloxone is an opioid antagonist that safely reverses the effects of opioid overdose and has been critical in reducing opioid-related morbidity and mortality associated with heroin and prescription opioids ( 6 ). However, naloxone has demonstrated variable effectiveness at reducing risk of overdose due to fentanyl, with a frustrating level of failed attempts at resuscitation when compared to heroin overdose response ( 7 ). The high potency and rapid onset of fentanyl may require quicker administration and additional doses of naloxone for consistent successful rescue ( 8 ). Recent evidence indicates that the rise of fentanyl, in injection and non-injection forms, may also be influencing trends in injection frequency among PWID. While some studies suggest people who use fentanyl inject at a greater frequency (potentially due to the short duration of effect) ( 9 ), multiple studies indicate PWID who use non-injection fentanyl may be injecting less ( 10 – 13 ). Though non-injection drug use has its own innate risks, a decrease in injection among PWID could be considered harm reduction as it relates to both overdose and infectious disease risk ( 14 ). PWID in the Pacific Northwest (PNW) of the US may be uniquely affected by the fentanyl crisis. Analysis of the movement of illicit fentanyl through the US drug markets suggests it first emerged on the East Coast and has spread toward the West ( 15 ). So while evaluation of the impact of fentanyl in Eastern US cities has been possible since as early as 2014, a meaningful increase in fentanyl was only observed in Washington and Oregon in 2020 and 2021, respectively ( 16 ). Therefore, to date, no studies have estimated the prevalence of fentanyl use among PWID in these areas nor described associated factors and outcomes ( 17 ). The purpose of this study was to examine fentanyl use among PWID in the urban PNW. The objectives were to 1) quantify and describe fentanyl use and 2) explore the relationships between fentanyl use and key outcomes including overdose, naloxone ownership, and injection frequency. Methods Sample. We used data from the National HIV Behavioral Surveillance (NHBS) project, a program of the Centers for Disease Control and Prevention (CDC) that collects data in US metropolitan areas with high HIV prevalence ( 18 ). In each area, NHBS teams collect cross-sectional data from three annually rotating populations considered to be at increased risk for HIV: men who have sex with men (MSM), low-income individuals at increased risk of HIV through heterosexual sex (HET), and PWID. For this analysis, we used data from the 2022 PWID cycle from Seattle, Washington and Portland, Oregon. Participants in the 2022 PWID cycle were recruited from June through December 2022. Individuals were recruited through respondent driving sampling (RDS), a variation of chain-referral sampling designed to reach marginalized populations ( 19 ). Recruitment began with a small convenience sample of initial participants, or “seeds.” These individuals then recruited new participants from their social networks, who subsequently recruited new participants from their social networks, and so on until the target sample size for each site (N = 500) was reached or the CDC-determined data collection period concluded, whichever came first. Participants were eligible for the 2022 PWID cycle if they were at least 18 years old; resided in a qualifying county, were able to complete the survey in English or Spanish, and reported injecting drugs in the past 12 months. Eligible participants completed an anonymous computer-assisted survey with an off-site interviewer using video-conferencing software. The survey captured information about demographics, social, economic, and behavioral vulnerability to HIV, and access to HIV testing, care, and prevention. Participants were given Visa gift cards (Seattle) or cash (Portland) incentives for participation. Measures. Using supplemental questions to the CDC-mandated core NHBS survey, we operationalized four types of fentanyl use 1) any fentanyl use, 2) fentanyl use via injection, 3) fentanyl use via non-injection, and 4) (presumed) fentanyl use via street pills. Street pills were defined as “pills from the street or online that look like Percocets, are often blue, have an M30 imprint, and may be called “blues,” “percs,” or “M30s.” We next identified participant characteristics and injection drug use behaviors hypothesized to be associated with fentanyl use and our outcomes of interest based on existing literature. Participant characteristics included age ( 20 , 21 ), gender ( 20 , 22 ), race/ethnicity ( 23 ), current source of healthcare ( 24 ), past 12 months houselessness ( 25 ), and past 12 months detention, jail, or imprisonment ( 26 ). For injection drug use behaviors, we considered the drug that participants usually injected in the past 12 months ( 21 , 27 ). Participants could choose one option among heroin, methamphetamine, powder or crack cocaine, speedball [cocaine and heroin], or something else. Participants who answered “something else” specified which drug they used. Based on frequency of report, responses of goofball [methamphetamine and heroin] and fentanyl or other drugs containing fentanyl were coded into their own categories. Other injection drug use behaviors included past 12 months injection frequency ( 9 , 27 , 28 ), past 12 months syringe service program (SSP) use (to acquire sterile syringes) ( 29 ), and past 12 months substance use treatment ( 30 ). We then operationalized three outcomes associated with fentanyl use based on existing literature including opioid overdose ( 31 ), naloxone possession ( 7 , 22 ), and changes in injection frequency ( 9 , 12 , 14 , 32 ). Opioid overdose was measured by a question in the NHBS core survey asked of participants who reported past year opioid use: “In the past 12 months, did you overdose on heroin or painkillers? By overdose, I mean if you passed out, turned blue, or stopped breathing from using drugs.” Questions about naloxone possession were supplemental to the core survey and site-specific. Seattle participants were asked, “In the past 12 months, have you had a naloxone or Narcan kit?” and Portland participants were asked, “Do you currently have any naloxone or Narcan?” Finally, changes in injection frequency were assessed by both sites in a supplemental question specifically for participants who reported street pill use with the question, “In the past 12 months, did you inject less because you used these pills?” This question was specific to participants who reported street pill use because street pill use was hypothesized to be the most likely predictor of decreased injection among PWID in the PNW metropolitan areas. Analysis. Participants missing data from the fentanyl use questions were excluded from analysis. We first summarized participant characteristics and injection behaviors and outcomes for the whole sample and stratified by site. To quantify fentanyl use, we then calculated the percentages of participants who reported different types of fentanyl use (any, injection, non-injection, and street pills) in the past 12 months. For individual types of fentanyl use, we also reported frequency of use, and for participants who reported street pill use, we reported how pills were used. Next, to describe fentanyl use, we stratified the total sample by any fentanyl use and compared proportions of participant characteristics, injection drug use behaviors, and overdose related outcomes, testing for differences across group with χ 2 tests of independence. Finally, to explore relationships between fentanyl use and outcomes of interest, we used generalized linear models with log-links, Poisson distribution and robust standard errors to estimate relative risk of each outcome associated with fentanyl use, adjusting for participant characteristics and behaviors hypothesized to be associated with fentanyl use. For each model, we reported estimates of the adjusted relative risk (aRR) and 95% confidence intervals (95% CI) with statistical significance set a priori at p < 0.05 and assessed using Wald tests. For the first set of multivariable models, we estimated the aRR of past year overdose and naloxone ownership (current or past year) associated with any fentanyl use. In the second set of multivariable models, we included any injection fentanyl use, any non-injection fentanyl use, and an interaction term between injection and non-injection fentanyl use to allow us to estimate the effects of injection and non-injection fentanyl use when compared to no fentanyl use on past year overdose and naloxone ownership. Lastly, using a sub-sample of only participants who reported street pill use, we estimated the aRR of injecting less associated with different forms of street pill administration. Analyses were conducted using Stata/IC v16. Portland and Seattle NHBS data collection and data sharing procedures were reviewed and approved by the Oregon Health Authority Science and Epidemiology Council’s Project Review Team and the Washington State IRB, respectively. Results A total of 835 participants were interviewed and eligible for analysis (500 from Seattle and 335 from Portland). Table 1 summarizes participants in the entire sample and by site. Similar across sites, participants had a median age of 44 years old (IQR = 36–54 years old) and were most commonly cisgender men and white. In terms of social determinants of health, most participants reported experiencing houselessness in the past 12 months (62% in Seattle and 72% in Portland) and 28% reported being held in detention, jail or prison in the past 12 months. A high proportion of the total sample (87%) reported a usual source of healthcare. Table 1 Participant characteristics, injection drug use, and injection-drug use behaviors outcomes among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N = 835) Seattle, WA (N = 500) Portland, OR (N = 335) Total (N = 835) Characteristics N (%) N (%) N (%) Gender Women 184 (37%) 126 (38%) 310 (37%) Men 313 (63%) 203 (61%) 516 (62%) Transgender 3 (1%) 5 (1%) 8 (1%) Age 18–29 29 (6%) 26 (8%) 55 (7%) 30–39 115 (23%) 119 (36%) 234 (28%) 40–49 146 (29%) 95 (28%) 241 (29%) 50–60 136 (27%) 56 (17%) 192 (23%) 60+ 74 (15%) 39 (12%) 113 (14%) Race/Ethnicity* AI or AN 77 (16%) 39 (12%) 116 (14%) Asian 13 (3%) 6 (2%) 19 (2%) Black or AA 116 (24%) 40 (12%) 156 (19%) NHPI 32 (6%) 5 (2%) 37 (4%) White 339 (68%) 284 (86%) 623 (75%) Hispanic 53 (11%) 24 (7%) 77 (9%) Experienced houselessness** 311 (62%) 242 (72%) 553 (66%) Detained/Jailed/Imprisoned** 147 (29%) 85 (25%) 232 (28%) Has a usual source of healthcare** 438 (88%) 287 (86%) 725 (87%) Injection drug use behaviors** Usual drug injected Heroin 213 (43%) 175 (52%) 388 (46%) Methamphetamine 141 (28%) 123 (37%) 264 (32%) Powder or crack cocaine 12 (2%) 4 (1%) 16 (2%) Speedball (cocaine + heroin) 46 (9%) 8 (2%) 54 (6%) Goofball (methamphetamine + heroin) 58 (12%) 14 (4%) 72 (9%) Fentanyl or drugs containing fentanyl 17 (3%) 8 (2%) 25 (3%) Other drugs or combination of drugs 7 (1%) 0 (0%) 7 (1%) Injection frequency More than once a day 284 (57%) 221 (66%) 505 (60%) Once a day 59 (12%) 37 (11%) 96 (12%) More than once a week 77 (15%) 36 (11%) 113 (14%) Once a week or less 77 (15%) 41 (12%) 118 (14%) Syringe service program use 361 (72%) 248 (74%) 609 (73%) Substance use treatment 152 (30%) 105 (31%) 257 (31%) Overdose outcomes Experienced overdose** 122 (27%) 73 (26%) 195 (23%) Naloxone ownership # 406 (82%) 237 (71%) 643 (77%) *Alone or in combination; not mutually exclusive categories, **In past year #Refers to got naloxone in the past 12 months for Seattle and currently has naloxone for Portland Patterns of usual drug injected in the past 12 months were also similar across across Seattle and Portland; the largest proportion reported heroin (43% and 52%, respectively) and the next largest proportion reported methamphetamine (28% and 37% respectively). Fentanyl use was reported as the usual drug injected by 3% of the Seattle sample and 2% of the Portland sample. Fifty-seven percent of the Seattle sample and 66% of the Portland sample reported injecting more than once a day in the past 12 months. Seventy-two percent of the Seattle sample and 74% of the Portland sample reported acquiring sterile syringes at SSPs in the past 12 months. A little under a third of participants in each site reported substance treatment in the past 12 months. Consistent across sites, about one quarter of the sample reported experiencing an opioid overdose in the past 12 months. Eighty-two percent of the Seattle sample reported getting naloxone in the past 12 months and 71% of the Portland sample reported currently having naloxone. Table 2 shows fentanyl use among the entire sample. Over three-fourths of the sample reported some fentanyl use in the past 12 months. Fentanyl was less commonly injected (47%) when compared to any non-injection or street pill use (68% and 66%, respectively). Frequency of non-injection fentanyl use was highly correlated with frequency of street pill use (post hoc Spearman’s correlation = 0.79, p < 0.001), but not identical; 42% reported using non-injection fentanyl once a day or more and 41% reported using street pills once a day or more. Among the 545 participants who reported using street pills, 94% reported smoking them with much smaller percentages reporting injecting (12%), snorting (13%), ingesting (11%), or other forms of administering the pills (1%). Table 2 Fentanyl use among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N = 835) Total (N = 835) Fentanyl use* N (% of total N) No fentanyl use 204 (24%) Any fentanyl use 631 (76%) No injection fentanyl use 423 (53%) Any injection fentanyl use 382 (47%) More than once a day 132 (16%) Once a day or more 31 (4%) More than once a week 82 (10%) Once a week or less 137 (17%) No non-injection fentanyl use 263 (32%) Any non-injection fentanyl use 556 (68%) More than once a day 267 (33%) Once a day 70 (9%) More than once a week 94 (11%) Once a week or less 125 (15%) No street pill use 283 (34%) Any street pill use 545 (66%) More than once a day 279 (34%) Once a day 62 (7%) More than once a week 81 (10%) Once a week or less 123 (15%) How street pills were used** N (% of 545) Injected 67 (12%) Smoked 511 (94%) Snorted 72 (13%) Swallowed/Ingested 61 (11%) Other 3 (1%) *In past 12 months, **Not mutually exclusive categories; column totals will not equal 100% For each type of fentanyl use, the italicized percentages of reported frequency of use sum to the preceding total percent of use. In bivariate analysis (Table 3 ), compared to participants who reported no fentanyl use in the past 12 months, participants who reported any fentanyl use had a younger age distribution, lower representation of Black or African American participants, and higher representation of white participants, and higher proportions of houselessness and detention, jail, or imprisonment (p < 0.001). Participants who reported any fentanyl use also appeared to have different patterns of usual drug use (p < 0.001). Specifically, participants who reported any fentanyl use had higher proportions of participants who usually used heroin and heroin containing polysubstances and lower proportions of participants who usually used methamphetamine when compared to participants who reported no fentanyl use. Injection frequency also differed by fentanyl use (p < 0.001); participants who reported fentanyl use were more likely to inject more than once a day when compared to those who did not (66% vs 45%, respectively). Past year SSP use and substance use treatment were both significantly more common among participants who used fentanyl (p < 0.01 and p = 0.04, respectively). Participants who reported any past year fentanyl use were also more likely to report having experienced an overdose and past 12 months or current naloxone ownership (p < 0.001). Table 3 Participant characteristics, injection drug use, and injection-drug use behaviors outcomes, stratified by any fentanyl use, among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N = 835) No fentanyl (N = 204) Any fentanyl (N = 631) Characteristics N (%) N (%) p-value Gender 0.38 Women 82 (40%) 228 (36%) Men 119 (58%) 397 (63%) Transgender 3 (1%) 5 (1%) Age < 0.001 18–29 3 (1%) 52 (8%) 30–39 25 (12%) 209 (33%) 40–49 51 (25%) 190 (30%) 50–60 65 (32%) 127 (20%) 60+ 60 (29%) 53 (8%) Race/Ethnicity* AI or AN 28 (14%) 88 (14%) 0.94 Asian 3 (1%) 16 (3%) 0.38 Black or AA 69 (34%) 87 (14%) < 0.001 NHPI 10 (5%) 27 (4%) 0.71 White 123 (61%) 500 (80%) < 0.001 Hispanic 19 (9%) 58 (9%) 0.97 Experienced houselessness** 101 (50%) 452 (72%) < 0.001 Detained/Jailed/Imprisoned** 27 (13%) 205 (32%) < 0.001 Has a usual source of healthcare** 184 (90%) 541 (86%) 0.10 Injection drug use ** Usual drug injected < 0.001 Heroin 75 (37%) 313 (50%) Methamphetamine 100 (49%) 164 (26%) Powder or crack cocaine 9 (4%) 7 (1%) Speedball (cocaine + heroin) 13 (6%) 41 (7%) Goofball (methamphetamine + heroin) 6 (3%) 66 (10%) Fentanyl or drugs containing fentanyl 0 (0%) 25 (4%) Other drugs or combination of drugs Injection frequency < 0.001 More than once a day 92 (45%) 413 (66%) Once a day 38 (19%) 58 (9%) More than once a week 38 (19%) 75 (12%) Once a week or less 36 (18%) 82 (13%) Syringe service program use 129 (63%) 480 (76%) < 0.01 Substance use treatment 51 (25%) 206 (33%) 0.04 Overdose outcomes Experienced overdose** 9 (7%) 186 (31%) < 0.001 Naloxone ownership # 124 (60%) 519 (82%) < 0.001 P-value generated from Χ 2 *Alone or in combination; not mutually exclusive categories, **In past year #Got naloxone in the past 12 months (Seattle) or currently has naloxone (Portland) Table 4 shows results of our multivariable analyses. After adjusting for potential confounders, any fentanyl use was associated with an approximately three times higher risk of experiencing an overdose (aRR = 2.99, 95% CI: 1.55, 5.76) and a slightly elevated chance of naloxone ownership (aRR = 1.13, 95% CI: 1.01, 1.27). When modeling the individual and interacting effects of injection and non-injection fentanyl use, all combinations were associated with an increased risk of overdose. Compared to no fentanyl use, just injection fentanyl use was associated with the highest risk of overdose (aRR = 2.98, 95% CI: 1.43, 6.19), followed by injection and non-injection fentanyl use (aRR = 2.48, 95% CI: 1.42, 4.32), and just non-injection fentanyl use (aRR = 2.12, 95% CI: 1.19, 3.75). Naloxone ownership was not associated with injection fentanyl use (aRR = 1.00, 95% CI: 0.78, 1.28) or with non-injection fentanyl use (aRR = 1.12, 95% CI: 1.00, 1.26) and was only weakly associated with injection and non-injection fentanyl use (aRR = 1.17, 95% CI: 1.04, 1.30). Table 4 Adjusted relative risk of overdose outcomes associated with any, injection and/or non-injection fentanyl use, compared to no fentanyl use , among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N = 835) Experienced overdose Naloxone ownership aRR 95% CI aRR 95% CI 4a. Any fentanyl vs none* Any fentanyl use 2.99 (1.55, 5.76) 1.13 (1.01, 1.27) 4b. Injection, non-injection, or both vs none** Any injection fentanyl use 2.98 (1.43, 6.19) 1.00 (0.78, 1.28) Any non-injection fentanyl use 2.12 (1.19, 3.75) 1.12 (1.00, 1.26) Any injection and any non-injection fentanyl use 2.48 (1.42, 4.32) 1.17 (1.04, 1.30) Injection fentanyl use by non-injection fentanyl use interaction term p-value 0.02 0.76 Bold – p < 0.05 *Using 1 model for each outcome. **Using 1 model for each outcome, each including an interaction term injection and non-injection fentanyl use. All models adjusted for city, gender, age, race/ethnicity, past year houselessness, past year detention/jail/imprisonment, usual source of healthcare, age at first injection, usual drug injected, injection frequency, past year SSP use, past year substance use treatment Finally, among participants who reported street pill use, in adjusted analysis, smoking pills was associated with an almost two times higher chance of reporting injecting less because of pill use (aRR = 1.80, 95% CI: 1.23, 2.64). The associations between injecting, snorting, ingesting, and other forms of administering street pills and injecting less were all statistically nonsignificant (Table 5 ). Table 5 Adjusted relative risks of injecting less associated with type of drug administration among people who used fentanyl street pills in two Pacific Northwest metropolitan areas, 2022 (N = 537)* Reported injecting less because of pill use Drug administration for street pills aRR 95% CI Smoked 1.80 (1.23, 2.64) Snorted 1.06 (0.88, 1.27) Swallowed/Ingested 1.02 (0.82, 1.27) Other 1.39 (0.84, 2.29) Bold – p < 0.05 *Using 1 model including individual dummy variables for each type of fentanyl drug administration, adjusted for city, gender, age, race/ethnicity, past year houselessness, past year detention/jail/imprisonment, usual source of healthcare, age at first injection, usual drug injected, injection frequency, past year SSP use, past year substance use treatment, and injecting street pills Discussion In a sample of PWID from two large PNW metropolitan areas in 2022, fentanyl use was highly prevalent. Fentanyl was injected by some PWID, but non-injection fentanyl and/or street pill use were more commonly reported, and street pills were most frequently administered by smoking. In bivariate analysis, fentanyl use was associated with younger age; white race; houselessness; detention, jail, or imprisonment; usually injecting heroin or heroin-containing polysubstances; higher injection frequency; SSP use, substance use treatment, experiencing an overdose, and owning naloxone. In adjusted analysis, any, injection, non-injection, and both injection and non-injection fentanyl use were all associated with meaningfully higher risk of overdose, but only weakly associated with naloxone ownership. Finally, while any fentanyl use was crudely associated with higher injection frequency, in an adjusted analysis among participants who reported street pill use, participants who smoked street pills were significantly more likely to report injecting less because of their pill use than participants who used street pills in other ways. Our finding that fentanyl use was common among PWID in the urban PNW is consistent with recent evidence that fentanyl has quickly and effectively infiltrated the drug markets of the Western US ( 15 , 16 ). Furthermore, our findings corroborate early qualitative work out of Central Oregon and a toxicology study in the Seattle area indicating fentanyl use is specifically impacting PWID in the PNW ( 33 , 34 ). Indeed, our data from this 2022 PWID cycle suggest that fentanyl use among PWID has rapidly increased in just a year. Results from the 2021 Washington State SSP Health Survey showed under half (42%) of participants reported fentanyl use in the past 3 months, much lower than the 76% of our sample who reported fentanyl use in the past 12 months. This type of precipitous growth mirrors what was documented in the Eastern US just a few years prior ( 35 , 36 ), and demonstrates the speed at which fentanyl can inundate a new market. The high level of fentanyl use in our sample should be at least partially attributed to fentanyl’s highly addictive nature ( 37 ). Multiple studies have documented an explicit preference for fentanyl by PWID ( 20 , 38 ), and in a sample of PWID in Vancouver, Canada, many respondents indicated that fentanyl gives a “better” high than other opioids ( 21 ). In addition, research suggests that fentanyl may be particularly easy to manufacture and distribute, increasingly in the form of counterfeit prescription pills ( 2 , 3 ). Two thirds of our sample reported using street pills in the past year. This coincides with a recent study of online pill sales showing a large volume of counterfeit oxycodone pills offered at lower prices than pharmaceutical grade pills and targeted at US and Canadian customers ( 39 ), and anecdotal evidence in Washington State where local experts believe there are high volumes of street pill sales via the internet and social media apps ( 40 ). Unlike some previous studies of fentanyl use among PWID ( 41 ), we found many PWID using fentanyl were not injecting it. In fact, non-injection fentanyl use seemed to be preferred, and among participants who reported street pills use, almost all reported smoking pills (compared to very small percentages of participants who reported injecting or administering pills in other ways). Furthermore, participants who reported smoking pills were significantly more likely to report injecting less because of using pills. These results are similar to findings from longitudinal studies of PWID in San Francisco and San Diego ( 12 , 32 ) and are consistent with national trends, all showing decreases in injection and increases in smoking or inhalation of fentanyl among people who use opioids ( 13 ). Interestingly, participants in our sample who used fentanyl in the past 12 months were more likely to have higher injection frequency when compared to participants who did not. This type of correlation has been reported in previous studies ( 9 , 42 ), but is not necessarily evidence that fentanyl use leads to higher frequency injection. Instead, given our finding that smoking pills is explicitly associated with injecting less, it may be more likely that people who have a high injection frequency at baseline are choosing to smoke fentanyl (or administer fentanyl in other non-injecting ways) because they are trying to reduce risks associated with injecting. This hypothesis aligns with qualitative work out of Canada documenting that PWID are indeed transitioning to smoking fentanyl for harm reduction purposes ( 10 , 11 ). Moreover, PWID in San Francisco have reported beliefs that switching from injecting opioids to smoking fentanyl may reduce their risk of blood born illness transmission, abscesses and other skin infections, stigma associated with injecting, and most prominently, overdose ( 14 , 32 ). In our sample, any modality of fentanyl use was associated with significant increased risk for overdose. However, there did seem to be a slightly lower risk among people who only reported non-injection fentanyl use, providing some empirical evidence to support the idea that switching to non-injection fentanyl use is a strategy for reducing overdose risk. Still, according to a recent national study, in 2022, smoking was the most commonly documented route of use in overdose death ( 43 ). As such, strategies to prevent overdose among people who use fentanyl, even those who do not inject it, should continue to be prioritized ( 7 ). Encouragingly, a significantly higher proportion of participants in our sample who used fentanyl reported naloxone ownership compared to participants who had no fentanyl use. This is similar to findings from the 2018 NHBS-PWID cycle in New York City which found participants who reported recent known or possible fentanyl use were more likely to own naloxone ( 44 ). It is also consistent with findings from qualitative work out of rural Oregon that showed most participants were aware of the influx of fentanyl and expressed anxiety regarding the associated increased risk for overdose ( 33 ). Notably, some research indicates previous standards of naloxone ownership and use may be insufficient for preventing fentanyl overdose ( 45 ). Specifically, the amount of naloxone and the window of time for administration required to reverse a fentanyl overdose is greater and shorter, respectively, when compared to heroin ( 8 ). Simultaneously, the intense symptoms of severe opioid withdrawal associated with rapid fentanyl overdose reversal also require consideration ( 46 ). PWID who use fentanyl may benefit from additional naloxone distribution along with fentanyl-specific overdose training and safe spaces where immediate and tolerable administration of naloxone is consistently possible. A 2018 ethnographic study of a safe consumption site in Vancouver, Canada observed a 100% success rate of fentanyl overdose reversal by naloxone administration ( 47 ). This was achieved through community trainings, vigilant monitoring, immediate response to potential overdose, and multiple doses of naloxone distributed and administered. Historically, SSPs have played a critical role in overdose education and naloxone distribution (OEND) for PWID. A 2022 multi-site US study found most SSPs had substantially increased naloxone distribution and some had adapted overdose education in response to recent fentanyl overdose surges ( 48 ), indicating SSPs will continue to be a key resource in the third wave of the opioid epidemic. Indeed, most PWID in our sample reported accessing sterile syringes from SSPs in the past year, and using SSPs was more common among people who used fentanyl. However, if PWID who use fentanyl are injecting less, or eventually not injecting at all, it will be important for SSPs to broaden their outreach and expand their scope of services to meet the needs of people who use drugs (PWUD) but may not inject them. For example, in the 2021 Washington State SSP survey, 72% of respondents indicated that they would like safe drug smoking supplies ( 49 ). Unfortunately, at the time of publication, distribution of safe smoking supplies is restricted in many states, including Oregon. Still, SSPs are well positioned to provide other auxiliary supplies and services to PWUD who are using fentanyl including fentanyl testing strips, medication for opioid use disorder (MOUD), and linkage to substance abuse treatment and other support services. Limitations . This analysis was subject to limitations. First, data were collected cross-sectionally and typically referenced the past 12 months for reported behaviors. As such, associations cannot generally be interpreted as causal. One exception is our question explicitly asking if participants injected less because they used street pills. Still, we asked that question only to participants who reported street pill use and assumed street pills contained fentanyl. Future research may benefit from asking participants about injecting less because of fentanyl use. Next, the NHBS core survey only asked about overdose if the participant reported using heroin, heroin-containing polysubstances, and/or painkillers so we were unable to assess experiences of overdose among people who used fentanyl but no other opioids. Our multivariable models adjusted for any non-fentanyl opioid use, but future analyses would benefit from inclusion of an overdose question asked to all participants. This analysis was also limited by the difference in naloxone variables across sites. Fortunately, similar proportions within each site sample indicated they were both reasonable proxies for overdose harm reduction via naloxone. Next, past studies have shown fentanyl use associated with injection risk behaviors (e.g., sharing syringes) ( 9 , 28 , 41 ). Based on local observations and anecdotal evidence, we focused on just a decrease in injecting. Our study sample may also be limited in generalizability. Both sites used RDS methods; however, it is unlikely that either site met all assumptions needed for inference to the underlying populations ( 50 ). Furthermore, caution should be taken when applying findings to populations in other regions of the US. Lastly, our sample only included people who injected in the past 12 months. Based on our analysis, it is possible that some former PWID stopped injecting just before they would have been eligible for our study. It may be helpful for future studies to also collect data from people who injected within the past few years. Conclusions In summary, fentanyl use was highly prevalent among PWID in two large PNW metropolitan areas in 2022. Non-injection fentanyl was more commonly reported than injection fentanyl use, and street pills were most frequently administered by smoking. Though smoking street pills was associated with a decrease in injection, our study indicated fentanyl use (including only non-injection fentanyl use) was associated with a substantial increased risk for overdose. Naloxone ownership was high in our sample, but potentially insufficient to counter the risk for overdose associated with fentanyl use. There is a continued need to ensure low-barrier access to naloxone with a particular emphasis on people who use fentanyl and their social networks. Fentanyl-specific overdose education, safe consumptions sites, and SSPs with expanded service provision can all contribute toward ensuring PWID and former-PWID who use fentanyl can reduce their risk for overdose and death. Abbreviations People who inject drugs (PWID), Pacific northwest (PNW), adjusted relative risk (aRR), United States (US), National HIV Behavioral Surveillance (NHBS), Centers for Disease Control and Prevention (CDC), men who have sex with men (MSM), low-income individuals at increased risk of HIV through heterosexual sex (HET), syringe service program (SSP), confidence intervals (CI), overdose education and naloxone distribution (OEND), people who use drugs (PWUD), medication for opioid use disorder (MOUD) Declarations Ethics approval and consent to participate All participants provided verbal, documented, informed consent for study activities. Portland and Seattle NHBS data collection and data sharing procedures were reviewed and approved by the Oregon Health Authority Science and Epidemiology Council’s Project Review Team and the Washington State IRB (WSIRB), respectively. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study may be available from the corresponding author on reasonable request. Competing interests SG reports a relationship with Cepheid that includes funding grants. LS reports financial support was provided by Centers for Disease Control and Prevention. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding This work was supported by the Centers for Disease Control and Prevention National HIV Behavioral Surveillance Project (5 NU62PS924776-03, 5 NU62PS924762-03). Authors’ contributions TM and SG were principal investigators for the study sites in 2022 and lead the sites’ investigations and provided study supervision. LL and CM helped administer the project and coordinated data collection and data management. LL analyzed and interpreted the data and drafted the manuscript. All authors provided feedback on early drafts of the manuscript and all authors reviewed, edited, and approved the final manuscript. Acknowledgements The authors would like to thank the 2022 NHBS project staff and participants in Seattle and Portland for their invaluable contributions to research and public health. References Ciccarone D. The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019;71:183–8. Pergolizzi J, Magnusson P, LeQuang JAK, Breve F. Illicitly Manufactured Fentanyl Entering the United States. Cureus. 2021;13(8):e17496. Palamar JJ, Ciccarone D, Rutherford C, Keyes KM, Carr TH, Cottler LB. Trends in seizures of powders and pills containing illicit fentanyl in the United States, 2018 through 2021. Drug Alcohol Depend. 2022;234:109398. Suzuki J, El-Haddad S. A review: Fentanyl and non-pharmaceutical fentanyls. Drug Alcohol Depend. 2017;171:107–16. 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HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland. AIDS Behav. 2022;26(1):277–83. Packham A. Syringe exchange programs and harm reduction: New evidence in the wake of the opioid epidemic. J Public Econ. 2022;215:104733. Gryczynski J, Nichols H, Schwartz RP, Mitchell SG, Hill P, Wireman K. Fentanyl exposure and preferences among individuals starting treatment for opioid use disorder. Drug Alcohol Depend. 2019;204:107515. O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends in and Characteristics of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls - United States, 2019–2020. MMWR Morbidity and mortality weekly report. 2021;70(50):1740–6. Kral AH, Lambdin BH, Browne EN, Wenger LD, Bluthenthal RN, Zibbell JE, et al. Transition from injecting opioids to smoking fentanyl in San Francisco, California. Drug Alcohol Depend. 2021;227:109003. Shin SS, LaForge K, Stack E, Pope J, Leichtling G, Larsen JE, et al. It wasn't here, and now it is. It's everywhere: fentanyl's rising presence in Oregon's drug supply. Harm Reduct J. 2022;19(1):76. Reinhart AA, Simpson C, Yarid N, Haruff R, Baird GS. Investigation of Fentanyl Usage in the Seattle Area. J Appl Lab Med. 2022;7(5):1164–8. Colon-Berezin C, Nolan ML, Blachman-Forshay J, Paone D. Overdose Deaths Involving Fentanyl and Fentanyl Analogs - New York City, 2000–2017. MMWR Morbidity Mortal Wkly Rep. 2019;68(2):37–40. Lu H, Crawford FW, Gonsalves GS, Grau LE. Geographic and temporal trends in fentanyl-detected deaths in Connecticut, 2009–2019. Ann Epidemiol. 2023;79:32–8. Comer SD, Cahill CM, Fentanyl. Receptor pharmacology, abuse potential, and implications for treatment. Neurosci Biobehav Rev. 2019;106:49–57. Hochstatter KR, Terplan M, Mitchell SG, Schwartz RP, Dusek K, Wireman K, et al. Characteristics and correlates of fentanyl preferences among people with opioid use disorder. Drug Alcohol Depend. 2022;240:109630. Lamy FR, Daniulaityte R, Dudley S Jr., Pressed OXYM, Pills. Great Press, Potent, Fast Shipping!!! Availability of Counterfeit and Pharmaceutical Oxycodone Pills on One Major Cryptomarket. J Psychoact Drugs. 2024;56(1):1–7. UW Medicine Newsroom. 2021. [cited 2024]. Available from: https://newsroom.uw.edu/blog/qa-fentanyls-growth-among-overdoses-stunning Kenny KS, Kolla G, Greig S, Bannerman M, Phillips D, Altenberg J, et al. Association of Illicit Fentanyl Use with Injection Risk Practices Among People who Inject Drugs. AIDS Behav. 2023;27(6):1757–65. Duhart Clarke SE, Kral AH, Zibbell JE. Consuming illicit opioids during a drug overdose epidemic: Illicit fentanyls, drug discernment, and the radical transformation of the illicit opioid market. Int J Drug Policy. 2022;99:103467. Tanz LJ, Gladden RM, Dinwiddie AT, Miller KD, Broz D, Spector E et al. Routes of Drug Use Among Drug Overdose Deaths - United States, 2020–2022. MMWR Morbidity and mortality weekly report. 2024;73(6):124 – 30. Rivera AV, Nolan ML, Paone D, Carrillo SA, Braunstein SL. Gaps in naloxone ownership among people who inject drugs during the fentanyl wave of the opioid overdose epidemic in New York City, 2018. Substance abuse. 2022;43(1):1172–9. Coffin PO, Maya S, Kahn JG. Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin. Drug Alcohol Depend. 2022;236:109478. Lai JT, Goldfine CE, Chapman BP, Taylor MM, Rosen RK, Carreiro SP, et al. Nobody Wants to Be Narcan'd: A Pilot Qualitative Analysis of Drug Users' Perspectives on Naloxone. western J Emerg Med. 2021;22(2):339–45. Mayer S, Boyd J, Collins A, Kennedy MC, Fairbairn N, McNeil R. Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada. Drug Alcohol Depend. 2018;193:69–74. Frost MC, Austin EJ, Corcorran MA, Briggs ES, Behrends CN, Juarez AM, et al. Responding to a surge in overdose deaths: perspectives from US syringe services programs. Harm Reduct J. 2022;19(1):79. Kingston S, Newman A, Banta-Green C, Glick S. Results from the 2021 WA State Syringe Service Program Health Survey. Addictions. Seattle, WA: Drug & Alcohol Institute, Department of Psychiatry & Behavioral Sciences, University of Washington; 2022. Gile KJ, Handcock MS. Respondent-Driven Sampling: An Assessment of Current Methodology. Sociol Methodol. 2010;40(1):285–327. Additional Declarations Competing interest reported. SG reports a relationship with Cepheid that includes funding grants. LS reports financial support was provided by Centers for Disease Control and Prevention. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6597345","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453963263,"identity":"670737c4-985e-4471-be53-ae10a77398ed","order_by":0,"name":"Lauren Lipira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBAC+wYehgMMBgwM/Aw5DAyMDURoMWCAapFsgGlhI6ATpAXCOECCFsbDBQX35I2P5x7+8HGHHYP8/ObnDz4w2OQzSKQ/wOoXoC2HZxgUG2478y5NcuaZZAaDY2yGjTMY0iwbJHIMcDnsMI9BAuO2GzlmzLxtzAwGbAyGzUBBAwaJHJx+AWmx3zwjx/gzb1s9g3wb+8fmP2At2B0G05K4AegMad62wwwMx3gMmxnAWhKwO4wZ7JeE5Bln3phJzmw7zmNwLKdwZo9BmgEbzxusWuzb+x9/LviTYNvfnmP84WNbtZx88/ENH35U2Bjws2N3GAMzGCEALJpA8YMbMOORGwWjYBSMglHAwAAAlTVYNga73uoAAAAASUVORK5CYII=","orcid":"","institution":"Portland State University","correspondingAuthor":true,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Lipira","suffix":""},{"id":453963264,"identity":"c43f97c7-6250-4b88-af52-5b5cf7757684","order_by":1,"name":"Sara N Glick","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"N","lastName":"Glick","suffix":""},{"id":453963265,"identity":"b120a761-e1c4-4ba1-9ab9-62cc5689a811","order_by":2,"name":"Courtney Moreno","email":"","orcid":"","institution":"Public Health – Seattle \u0026 King County","correspondingAuthor":false,"prefix":"","firstName":"Courtney","middleName":"","lastName":"Moreno","suffix":""},{"id":453963266,"identity":"3479ec26-90b5-4093-9ccd-b426c0cf4e56","order_by":3,"name":"Lalaine Sevillano","email":"","orcid":"","institution":"Portland State University","correspondingAuthor":false,"prefix":"","firstName":"Lalaine","middleName":"","lastName":"Sevillano","suffix":""},{"id":453963267,"identity":"7da0cb6c-ea80-481a-b9dd-1e04826b6b24","order_by":4,"name":"Matthew A Town","email":"","orcid":"","institution":"Portland State University","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"A","lastName":"Town","suffix":""},{"id":453963268,"identity":"833b0d70-a229-413d-af66-61c817a79a13","order_by":5,"name":"Timothy W. Menza","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"W.","lastName":"Menza","suffix":""}],"badges":[],"createdAt":"2025-05-05 21:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6597345/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6597345/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-025-01384-9","type":"published","date":"2026-03-12T15:59:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104739985,"identity":"f4f45b2e-a80c-4db6-a0d8-1c57305707ab","added_by":"auto","created_at":"2026-03-16 16:14:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1146991,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6597345/v1/3a6a6fc9-bd32-4c1f-98de-c74ea5a8b3ad.pdf"}],"financialInterests":"Competing interest reported. SG reports a relationship with Cepheid that includes funding grants. LS reports financial support was provided by Centers for Disease Control and Prevention. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.","formattedTitle":"Fentanyl use among people who inject drugs in two large Pacific Northwest metropolitan areas","fulltext":[{"header":"Background","content":"\u003cp\u003eConsidered the \u0026ldquo;third wave\u0026rdquo; of the opioid epidemic, illicit fentanyl use is increasingly common among people who inject drugs (PWID) in the United States (US) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Similar to heroin, and sometimes combined with heroin or other drugs, fentanyl is often distributed in powder form which can be injected, snorted, ingested or smoked (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Additionally, a growing proportion of fentanyl is in the form of street pills designed to look like prescription opioids (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Fentanyl is inherently more potent, faster acting, and generates a shorter high than heroin, lending itself to high risk for misuse, addiction, and opioid overdose (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Since the introduction of fentanyl into the US drug market, overdose cases have increased exponentially with fentanyl documented as a growing contributor (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNaloxone is an opioid antagonist that safely reverses the effects of opioid overdose and has been critical in reducing opioid-related morbidity and mortality associated with heroin and prescription opioids (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, naloxone has demonstrated variable effectiveness at reducing risk of overdose due to fentanyl, with a frustrating level of failed attempts at resuscitation when compared to heroin overdose response (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The high potency and rapid onset of fentanyl may require quicker administration and additional doses of naloxone for consistent successful rescue (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent evidence indicates that the rise of fentanyl, in injection and non-injection forms, may also be influencing trends in injection frequency among PWID. While some studies suggest people who use fentanyl inject at a greater frequency (potentially due to the short duration of effect) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), multiple studies indicate PWID who use non-injection fentanyl may be injecting less (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Though non-injection drug use has its own innate risks, a decrease in injection among PWID could be considered harm reduction as it relates to both overdose and infectious disease risk (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePWID in the Pacific Northwest (PNW) of the US may be uniquely affected by the fentanyl crisis. Analysis of the movement of illicit fentanyl through the US drug markets suggests it first emerged on the East Coast and has spread toward the West (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). So while evaluation of the impact of fentanyl in Eastern US cities has been possible since as early as 2014, a meaningful increase in fentanyl was only observed in Washington and Oregon in 2020 and 2021, respectively (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, to date, no studies have estimated the prevalence of fentanyl use among PWID in these areas nor described associated factors and outcomes (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe purpose of this study was to examine fentanyl use among PWID in the urban PNW. The objectives were to 1) quantify and describe fentanyl use and 2) explore the relationships between fentanyl use and key outcomes including overdose, naloxone ownership, and injection frequency.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eSample.\u003c/b\u003e We used data from the National HIV Behavioral Surveillance (NHBS) project, a program of the Centers for Disease Control and Prevention (CDC) that collects data in US metropolitan areas with high HIV prevalence (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In each area, NHBS teams collect cross-sectional data from three annually rotating populations considered to be at increased risk for HIV: men who have sex with men (MSM), low-income individuals at increased risk of HIV through heterosexual sex (HET), and PWID. For this analysis, we used data from the 2022 PWID cycle from Seattle, Washington and Portland, Oregon.\u003c/p\u003e \u003cp\u003eParticipants in the 2022 PWID cycle were recruited from June through December 2022. Individuals were recruited through respondent driving sampling (RDS), a variation of chain-referral sampling designed to reach marginalized populations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Recruitment began with a small convenience sample of initial participants, or \u0026ldquo;seeds.\u0026rdquo; These individuals then recruited new participants from their social networks, who subsequently recruited new participants from \u003cem\u003etheir\u003c/em\u003e social networks, and so on until the target sample size for each site (N\u0026thinsp;=\u0026thinsp;500) was reached or the CDC-determined data collection period concluded, whichever came first.\u003c/p\u003e \u003cp\u003eParticipants were eligible for the 2022 PWID cycle if they were at least 18 years old; resided in a qualifying county, were able to complete the survey in English or Spanish, and reported injecting drugs in the past 12 months. Eligible participants completed an anonymous computer-assisted survey with an off-site interviewer using video-conferencing software. The survey captured information about demographics, social, economic, and behavioral vulnerability to HIV, and access to HIV testing, care, and prevention. Participants were given Visa gift cards (Seattle) or cash (Portland) incentives for participation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasures.\u003c/b\u003e Using supplemental questions to the CDC-mandated core NHBS survey, we operationalized four types of fentanyl use 1) any fentanyl use, 2) fentanyl use via injection, 3) fentanyl use via non-injection, and 4) (presumed) fentanyl use via street pills. Street pills were defined as \u0026ldquo;pills from the street or online that look like Percocets, are often blue, have an M30 imprint, and may be called \u0026ldquo;blues,\u0026rdquo; \u0026ldquo;percs,\u0026rdquo; or \u0026ldquo;M30s.\u0026rdquo;\u003c/p\u003e \u003cp\u003eWe next identified participant characteristics and injection drug use behaviors hypothesized to be associated with fentanyl use and our outcomes of interest based on existing literature. Participant characteristics included age (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), gender (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), race/ethnicity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), current source of healthcare (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), past 12 months houselessness (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and past 12 months detention, jail, or imprisonment (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). For injection drug use behaviors, we considered the drug that participants usually injected in the past 12 months (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Participants could choose one option among heroin, methamphetamine, powder or crack cocaine, speedball [cocaine and heroin], or something else. Participants who answered \u0026ldquo;something else\u0026rdquo; specified which drug they used. Based on frequency of report, responses of goofball [methamphetamine and heroin] and fentanyl or other drugs containing fentanyl were coded into their own categories. Other injection drug use behaviors included past 12 months injection frequency (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), past 12 months syringe service program (SSP) use (to acquire sterile syringes) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and past 12 months substance use treatment (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe then operationalized three outcomes associated with fentanyl use based on existing literature including opioid overdose (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), naloxone possession (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), and changes in injection frequency (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Opioid overdose was measured by a question in the NHBS core survey asked of participants who reported past year opioid use: \u0026ldquo;In the past 12 months, did you overdose on heroin or painkillers? By overdose, I mean if you passed out, turned blue, or stopped breathing from using drugs.\u0026rdquo; Questions about naloxone possession were supplemental to the core survey and site-specific. Seattle participants were asked, \u0026ldquo;In the past 12 months, have you had a naloxone or Narcan kit?\u0026rdquo; and Portland participants were asked, \u0026ldquo;Do you currently have any naloxone or Narcan?\u0026rdquo; Finally, changes in injection frequency were assessed by both sites in a supplemental question specifically for participants who reported street pill use with the question, \u0026ldquo;In the past 12 months, did you inject less because you used these pills?\u0026rdquo; This question was specific to participants who reported street pill use because street pill use was hypothesized to be the most likely predictor of decreased injection among PWID in the PNW metropolitan areas.\u003c/p\u003e \u003cp\u003e\u003cb\u003eAnalysis.\u003c/b\u003e Participants missing data from the fentanyl use questions were excluded from analysis. We first summarized participant characteristics and injection behaviors and outcomes for the whole sample and stratified by site.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTo quantify fentanyl use, we then calculated the percentages of participants who reported different types of fentanyl use (any, injection, non-injection, and street pills) in the past 12 months. For individual types of fentanyl use, we also reported frequency of use, and for participants who reported street pill use, we reported how pills were used. Next, to describe fentanyl use, we stratified the total sample by any fentanyl use and compared proportions of participant characteristics, injection drug use behaviors, and overdose related outcomes, testing for differences across group with χ\u003csup\u003e2\u003c/sup\u003e tests of independence.\u003c/p\u003e\u003cp\u003eFinally, to explore relationships between fentanyl use and outcomes of interest, we used generalized linear models with log-links, Poisson distribution and robust standard errors to estimate relative risk of each outcome associated with fentanyl use, adjusting for participant characteristics and behaviors hypothesized to be associated with fentanyl use. For each model, we reported estimates of the adjusted relative risk (aRR) and 95% confidence intervals (95% CI) with statistical significance set \u003cem\u003ea priori\u003c/em\u003e at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and assessed using Wald tests.\u003c/p\u003e\u003cp\u003eFor the first set of multivariable models, we estimated the aRR of past year overdose and naloxone ownership (current or past year) associated with any fentanyl use. In the second set of multivariable models, we included any injection fentanyl use, any non-injection fentanyl use, and an interaction term between injection and non-injection fentanyl use to allow us to estimate the effects of injection and non-injection fentanyl use when compared to no fentanyl use on past year overdose and naloxone ownership. Lastly, using a sub-sample of only participants who reported street pill use, we estimated the aRR of injecting less associated with different forms of street pill administration.\u003c/p\u003e\u003cp\u003eAnalyses were conducted using Stata/IC v16. Portland and Seattle NHBS data collection and data sharing procedures were reviewed and approved by the Oregon Health Authority Science and Epidemiology Council\u0026rsquo;s Project Review Team and the Washington State IRB, respectively.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 835 participants were interviewed and eligible for analysis (500 from Seattle and 335 from Portland). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes participants in the entire sample and by site. Similar across sites, participants had a median age of 44 years old (IQR\u0026thinsp;=\u0026thinsp;36\u0026ndash;54 years old) and were most commonly cisgender men and white. In terms of social determinants of health, most participants reported experiencing houselessness in the past 12 months (62% in Seattle and 72% in Portland) and 28% reported being held in detention, jail or prison in the past 12 months. A high proportion of the total sample (87%) reported a usual source of healthcare.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics, injection drug use, and injection-drug use behaviors outcomes among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N\u0026thinsp;=\u0026thinsp;835)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSeattle, WA\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;500)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePortland, OR\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;835)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWomen\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMen\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(62%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTransgender\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e18\u0026ndash;29\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e30\u0026ndash;39\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e40\u0026ndash;49\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e50\u0026ndash;60\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e60+\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace/Ethnicity*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAI or AN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAsian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBlack or AA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNHPI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWhite\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHispanic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperienced houselessness**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDetained/Jailed/Imprisoned**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas a usual source of healthcare**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(87%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjection drug use behaviors**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsual drug injected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHeroin\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMethamphetamine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePowder or crack cocaine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSpeedball (cocaine\u0026thinsp;+\u0026thinsp;heroin)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGoofball (methamphetamine\u0026thinsp;+\u0026thinsp;heroin)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFentanyl or drugs containing fentanyl\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOther drugs or combination of drugs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjection frequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e505\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a week\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a week or less\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyringe service program use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(73%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance use treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverdose outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperienced overdose**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaloxone ownership\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e406\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(77%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*Alone or in combination; not mutually exclusive categories, **In past year #Refers to got naloxone in the past 12 months for Seattle and currently has naloxone for Portland\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatterns of usual drug injected in the past 12 months were also similar across across Seattle and Portland; the largest proportion reported heroin (43% and 52%, respectively) and the next largest proportion reported methamphetamine (28% and 37% respectively). Fentanyl use was reported as the usual drug injected by 3% of the Seattle sample and 2% of the Portland sample. Fifty-seven percent of the Seattle sample and 66% of the Portland sample reported injecting more than once a day in the past 12 months. Seventy-two percent of the Seattle sample and 74% of the Portland sample reported acquiring sterile syringes at SSPs in the past 12 months. A little under a third of participants in each site reported substance treatment in the past 12 months. Consistent across sites, about one quarter of the sample reported experiencing an opioid overdose in the past 12 months. Eighty-two percent of the Seattle sample reported getting naloxone in the past 12 months and 71% of the Portland sample reported currently having naloxone.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows fentanyl use among the entire sample. Over three-fourths of the sample reported some fentanyl use in the past 12 months. Fentanyl was less commonly injected (47%) when compared to any non-injection or street pill use (68% and 66%, respectively). Frequency of non-injection fentanyl use was highly correlated with frequency of street pill use (post hoc Spearman\u0026rsquo;s correlation\u0026thinsp;=\u0026thinsp;0.79, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but not identical; 42% reported using non-injection fentanyl once a day or more and 41% reported using street pills once a day or more. Among the 545 participants who reported using street pills, 94% reported smoking them with much smaller percentages reporting injecting (12%), snorting (13%), ingesting (11%), or other forms of administering the pills (1%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFentanyl use among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N\u0026thinsp;=\u0026thinsp;835)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;835)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFentanyl use*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(% of total N)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e423\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(53%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(47%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e132\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(16%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a day or more\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e31\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(4%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a week\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e82\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(10%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a week or less\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e137\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(17%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo non-injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny non-injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(68%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e267\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(33%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e70\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(9%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a week\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e94\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(11%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a week or less\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e125\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(15%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo street pill use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny street pill use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e279\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(34%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e62\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(7%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a week\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e81\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(10%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a week or less\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e123\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(15%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow street pills were used**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(% of 545)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInjected\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSmoked\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(94%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSnorted\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSwallowed/Ingested\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*In past 12 months, **Not mutually exclusive categories; column totals will not equal 100%\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eFor each type of fentanyl use, the italicized percentages of reported frequency of use sum\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eto the preceding total percent of use.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn bivariate analysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), compared to participants who reported no fentanyl use in the past 12 months, participants who reported any fentanyl use had a younger age distribution, lower representation of Black or African American participants, and higher representation of white participants, and higher proportions of houselessness and detention, jail, or imprisonment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Participants who reported any fentanyl use also appeared to have different patterns of usual drug use (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Specifically, participants who reported any fentanyl use had higher proportions of participants who usually used heroin and heroin containing polysubstances and lower proportions of participants who usually used methamphetamine when compared to participants who reported no fentanyl use. Injection frequency also differed by fentanyl use (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); participants who reported fentanyl use were more likely to inject more than once a day when compared to those who did not (66% vs 45%, respectively). Past year SSP use and substance use treatment were both significantly more common among participants who used fentanyl (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and p\u0026thinsp;=\u0026thinsp;0.04, respectively). Participants who reported any past year fentanyl use were also more likely to report having experienced an overdose and past 12 months or current naloxone ownership (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics, injection drug use, and injection-drug use behaviors outcomes, stratified by any fentanyl use, among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N\u0026thinsp;=\u0026thinsp;835)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNo fentanyl\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;204)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAny fentanyl\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;631)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWomen\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMen\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTransgender\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e18\u0026ndash;29\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e30\u0026ndash;39\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e40\u0026ndash;49\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e50\u0026ndash;60\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e60+\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace/Ethnicity*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAI or AN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAsian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBlack or AA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNHPI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWhite\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHispanic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperienced houselessness**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDetained/Jailed/Imprisoned**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas a usual source of healthcare**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e541\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjection drug use\u003c/b\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsual drug injected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHeroin\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMethamphetamine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePowder or crack cocaine\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSpeedball (cocaine\u0026thinsp;+\u0026thinsp;heroin)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGoofball (methamphetamine\u0026thinsp;+\u0026thinsp;heroin)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFentanyl or drugs containing fentanyl\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOther drugs or combination of drugs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjection frequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a day\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMore than once a week\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOnce a week or less\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyringe service program use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance use treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverdose outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperienced overdose**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaloxone ownership\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eP-value generated from Χ\u003csup\u003e2\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Alone or in combination; not mutually exclusive categories, **In past year\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e#Got naloxone in the past 12 months (Seattle) or currently has naloxone (Portland)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows results of our multivariable analyses. After adjusting for potential confounders, any fentanyl use was associated with an approximately three times higher risk of experiencing an overdose (aRR\u0026thinsp;=\u0026thinsp;2.99, 95% CI: 1.55, 5.76) and a slightly elevated chance of naloxone ownership (aRR\u0026thinsp;=\u0026thinsp;1.13, 95% CI: 1.01, 1.27). When modeling the individual and interacting effects of injection and non-injection fentanyl use, all combinations were associated with an increased risk of overdose. Compared to no fentanyl use, just injection fentanyl use was associated with the highest risk of overdose (aRR\u0026thinsp;=\u0026thinsp;2.98, 95% CI: 1.43, 6.19), followed by injection and non-injection fentanyl use (aRR\u0026thinsp;=\u0026thinsp;2.48, 95% CI: 1.42, 4.32), and just non-injection fentanyl use (aRR\u0026thinsp;=\u0026thinsp;2.12, 95% CI: 1.19, 3.75). Naloxone ownership was not associated with injection fentanyl use (aRR\u0026thinsp;=\u0026thinsp;1.00, 95% CI: 0.78, 1.28) or with non-injection fentanyl use (aRR\u0026thinsp;=\u0026thinsp;1.12, 95% CI: 1.00, 1.26) and was only weakly associated with injection and non-injection fentanyl use (aRR\u0026thinsp;=\u0026thinsp;1.17, 95% CI: 1.04, 1.30).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted relative risk of overdose outcomes associated with any, injection and/or non-injection fentanyl use, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ecompared to no fentanyl use\u003c/span\u003e, among people who inject drugs who participated in NHBS in two Pacific Northwest metropolitan areas, 2022 (N\u0026thinsp;=\u0026thinsp;835)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eExperienced overdose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eNaloxone\u003c/p\u003e \u003cp\u003eownership\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaRR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eaRR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4a. Any fentanyl vs none*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1.55, 5.76)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e(1.01, 1.27)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4b. Injection, non-injection, or both vs none**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2.98\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1.43, 6.19)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(0.78, 1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny non-injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2.12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1.19, 3.75)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(1.00, 1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny injection and any non-injection fentanyl use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2.48\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1.42, 4.32)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e(1.04, 1.30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInjection fentanyl use by non-injection fentanyl use interaction term p-value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0.02\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.76\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eBold\u003c/b\u003e \u0026ndash; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*Using 1 model for each outcome. **Using 1 model for each outcome, each including an interaction term injection and non-injection fentanyl use. All models adjusted for city, gender, age, race/ethnicity, past year houselessness, past year detention/jail/imprisonment, usual source of healthcare, age at first injection, usual drug injected, injection frequency, past year SSP use, past year substance use treatment\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFinally, among participants who reported street pill use, in adjusted analysis, smoking pills was associated with an almost two times higher chance of reporting injecting less because of pill use (aRR\u0026thinsp;=\u0026thinsp;1.80, 95% CI: 1.23, 2.64). The associations between injecting, snorting, ingesting, and other forms of administering street pills and injecting less were all statistically nonsignificant (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted relative risks of injecting less associated with type of drug administration among people who used fentanyl street pills in two Pacific Northwest metropolitan areas, 2022 (N\u0026thinsp;=\u0026thinsp;537)*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eReported injecting less because of pill use\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug administration for street pills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaRR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoked\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.80\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1.23, 2.64)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSnorted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.88, 1.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwallowed/Ingested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.82, 1.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.84, 2.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eBold\u003c/b\u003e \u0026ndash; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Using 1 model including individual dummy variables for each type of fentanyl drug administration, adjusted for city, gender, age, race/ethnicity, past year houselessness, past year detention/jail/imprisonment, usual source of healthcare, age at first injection, usual drug injected, injection frequency, past year SSP use, past year substance use treatment, and injecting street pills\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn a sample of PWID from two large PNW metropolitan areas in 2022, fentanyl use was highly prevalent. Fentanyl was injected by some PWID, but non-injection fentanyl and/or street pill use were more commonly reported, and street pills were most frequently administered by smoking. In bivariate analysis, fentanyl use was associated with younger age; white race; houselessness; detention, jail, or imprisonment; usually injecting heroin or heroin-containing polysubstances; higher injection frequency; SSP use, substance use treatment, experiencing an overdose, and owning naloxone. In adjusted analysis, any, injection, non-injection, and both injection and non-injection fentanyl use were all associated with meaningfully higher risk of overdose, but only weakly associated with naloxone ownership. Finally, while any fentanyl use was crudely associated with higher injection frequency, in an adjusted analysis among participants who reported street pill use, participants who smoked street pills were significantly more likely to report injecting less because of their pill use than participants who used street pills in other ways.\u003c/p\u003e\n\u003cp\u003eOur finding that fentanyl use was common among PWID in the urban PNW is consistent with recent evidence that fentanyl has quickly and effectively infiltrated the drug markets of the Western US (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). Furthermore, our findings corroborate early qualitative work out of Central Oregon and a toxicology study in the Seattle area indicating fentanyl use is specifically impacting PWID in the PNW (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e). Indeed, our data from this 2022 PWID cycle suggest that fentanyl use among PWID has rapidly increased in just a year. Results from the 2021 Washington State SSP Health Survey showed under half (42%) of participants reported fentanyl use in the past 3 months, much lower than the 76% of our sample who reported fentanyl use in the past 12 months. This type of precipitous growth mirrors what was documented in the Eastern US just a few years prior (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e), and demonstrates the speed at which fentanyl can inundate a new market.\u003c/p\u003e\n\u003cp\u003eThe high level of fentanyl use in our sample should be at least partially attributed to fentanyl’s highly addictive nature (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e). Multiple studies have documented an explicit preference for fentanyl by PWID (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e), and in a sample of PWID in Vancouver, Canada, many respondents indicated that fentanyl gives a “better” high than other opioids (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). In addition, research suggests that fentanyl may be particularly easy to manufacture and distribute, increasingly in the form of counterfeit prescription pills (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Two thirds of our sample reported using street pills in the past year. This coincides with a recent study of online pill sales showing a large volume of counterfeit oxycodone pills offered at lower prices than pharmaceutical grade pills and targeted at US and Canadian customers (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e), and anecdotal evidence in Washington State where local experts believe there are high volumes of street pill sales via the internet and social media apps (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eUnlike some previous studies of fentanyl use among PWID (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e), we found many PWID using fentanyl were \u003cem\u003enot\u003c/em\u003e injecting it. In fact, non-injection fentanyl use seemed to be preferred, and among participants who reported street pills use, almost all reported smoking pills (compared to very small percentages of participants who reported injecting or administering pills in other ways). Furthermore, participants who reported smoking pills were significantly more likely to report injecting less because of using pills. These results are similar to findings from longitudinal studies of PWID in San Francisco and San Diego (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) and are consistent with national trends, all showing decreases in injection and increases in smoking or inhalation of fentanyl among people who use opioids (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eInterestingly, participants in our sample who used fentanyl in the past 12 months were more likely to have higher injection frequency when compared to participants who did not. This type of correlation has been reported in previous studies (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e), but is not necessarily evidence that fentanyl use leads to higher frequency injection. Instead, given our finding that smoking pills is explicitly associated with injecting less, it may be more likely that people who have a high injection frequency at baseline are choosing to smoke fentanyl (or administer fentanyl in other non-injecting ways) because they are trying to reduce risks associated with injecting. This hypothesis aligns with qualitative work out of Canada documenting that PWID are indeed transitioning to smoking fentanyl for harm reduction purposes (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). Moreover, PWID in San Francisco have reported beliefs that switching from injecting opioids to smoking fentanyl may reduce their risk of blood born illness transmission, abscesses and other skin infections, stigma associated with injecting, and most prominently, overdose (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn our sample, any modality of fentanyl use was associated with significant increased risk for overdose. However, there did seem to be a slightly lower risk among people who only reported non-injection fentanyl use, providing some empirical evidence to support the idea that switching to non-injection fentanyl use is a strategy for reducing overdose risk. Still, according to a recent national study, in 2022, smoking was the most commonly documented route of use in overdose death (\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e). As such, strategies to prevent overdose among people who use fentanyl, even those who do not inject it, should continue to be prioritized (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eEncouragingly, a significantly higher proportion of participants in our sample who used fentanyl reported naloxone ownership compared to participants who had no fentanyl use. This is similar to findings from the 2018 NHBS-PWID cycle in New York City which found participants who reported recent known or possible fentanyl use were more likely to own naloxone (\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e). It is also consistent with findings from qualitative work out of rural Oregon that showed most participants were aware of the influx of fentanyl and expressed anxiety regarding the associated increased risk for overdose (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eNotably, some research indicates previous standards of naloxone ownership and use may be insufficient for preventing fentanyl overdose (\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e). Specifically, the amount of naloxone and the window of time for administration required to reverse a fentanyl overdose is greater and shorter, respectively, when compared to heroin (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Simultaneously, the intense symptoms of severe opioid withdrawal associated with rapid fentanyl overdose reversal also require consideration (\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e). PWID who use fentanyl may benefit from additional naloxone distribution along with fentanyl-specific overdose training and safe spaces where immediate and tolerable administration of naloxone is consistently possible. A 2018 ethnographic study of a safe consumption site in Vancouver, Canada observed a 100% success rate of fentanyl overdose reversal by naloxone administration (\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e). This was achieved through community trainings, vigilant monitoring, immediate response to potential overdose, and multiple doses of naloxone distributed and administered.\u003c/p\u003e\n\u003cp\u003eHistorically, SSPs have played a critical role in overdose education and naloxone distribution (OEND) for PWID. A 2022 multi-site US study found most SSPs had substantially increased naloxone distribution and some had adapted overdose education in response to recent fentanyl overdose surges (\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e), indicating SSPs will continue to be a key resource in the third wave of the opioid epidemic. Indeed, most PWID in our sample reported accessing sterile syringes from SSPs in the past year, and using SSPs was more common among people who used fentanyl. However, if PWID who use fentanyl are injecting less, or eventually not injecting at all, it will be important for SSPs to broaden their outreach and expand their scope of services to meet the needs of people who use drugs (PWUD) but may not inject them. For example, in the 2021 Washington State SSP survey, 72% of respondents indicated that they would like safe drug smoking supplies (\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e). Unfortunately, at the time of publication, distribution of safe smoking supplies is restricted in many states, including Oregon. Still, SSPs are well positioned to provide other auxiliary supplies and services to PWUD who are using fentanyl including fentanyl testing strips, medication for opioid use disorder (MOUD), and linkage to substance abuse treatment and other support services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e. This analysis was subject to limitations. First, data were collected cross-sectionally and typically referenced the past 12 months for reported behaviors. As such, associations cannot generally be interpreted as causal. One exception is our question explicitly asking if participants injected less because they used street pills. Still, we asked that question only to participants who reported street pill use and assumed street pills contained fentanyl. Future research may benefit from asking participants about injecting less because of fentanyl use. Next, the NHBS core survey only asked about overdose if the participant reported using heroin, heroin-containing polysubstances, and/or painkillers so we were unable to assess experiences of overdose among people who used fentanyl but no other opioids. Our multivariable models adjusted for any non-fentanyl opioid use, but future analyses would benefit from inclusion of an overdose question asked to all participants. This analysis was also limited by the difference in naloxone variables across sites. Fortunately, similar proportions within each site sample indicated they were both reasonable proxies for overdose harm reduction via naloxone. Next, past studies have shown fentanyl use associated with injection risk behaviors (e.g., sharing syringes) (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). Based on local observations and anecdotal evidence, we focused on just a decrease in injecting. Our study sample may also be limited in generalizability. Both sites used RDS methods; however, it is unlikely that either site met all assumptions needed for inference to the underlying populations (\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e). Furthermore, caution should be taken when applying findings to populations in other regions of the US. Lastly, our sample only included people who injected in the past 12 months. Based on our analysis, it is possible that some former PWID stopped injecting just before they would have been eligible for our study. It may be helpful for future studies to also collect data from people who injected within the past few years.\u003c/p\u003e\n\n"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, fentanyl use was highly prevalent among PWID in two large PNW metropolitan areas in 2022. Non-injection fentanyl was more commonly reported than injection fentanyl use, and street pills were most frequently administered by smoking. Though smoking street pills was associated with a decrease in injection, our study indicated fentanyl use (including only non-injection fentanyl use) was associated with a substantial increased risk for overdose. Naloxone ownership was high in our sample, but potentially insufficient to counter the risk for overdose associated with fentanyl use. There is a continued need to ensure low-barrier access to naloxone with a particular emphasis on people who use fentanyl and their social networks. Fentanyl-specific overdose education, safe consumptions sites, and SSPs with expanded service provision can all contribute toward ensuring PWID and former-PWID who use fentanyl can reduce their risk for overdose and death.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePeople who inject drugs (PWID), Pacific northwest (PNW), adjusted relative risk (aRR), United States (US), National HIV Behavioral Surveillance (NHBS), Centers for Disease Control and Prevention (CDC), men who have sex with men (MSM), low-income individuals at increased risk of HIV through heterosexual sex (HET), syringe service program (SSP), confidence intervals (CI), overdose education and naloxone distribution (OEND), people who use drugs (PWUD), medication for opioid use disorder (MOUD)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided verbal, documented, informed consent for study activities. Portland and Seattle NHBS data collection and data sharing procedures were reviewed and approved by the Oregon Health Authority Science and Epidemiology Council\u0026rsquo;s Project Review Team and the Washington State IRB (WSIRB), respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study may be available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSG reports a relationship with Cepheid that includes funding grants. LS reports financial support was provided by Centers for Disease Control and Prevention. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Centers for Disease Control and Prevention National HIV Behavioral Surveillance Project (5 NU62PS924776-03, 5 NU62PS924762-03).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTM and SG were principal investigators for the study sites in 2022 and lead the sites\u0026rsquo; investigations and provided study supervision. LL and CM helped administer the project and coordinated data collection and data management. LL analyzed and interpreted the data and drafted the manuscript. All authors provided feedback on early drafts of the manuscript and all authors reviewed, edited, and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the 2022 NHBS project staff and participants in Seattle and Portland for their invaluable contributions to research and public health.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCiccarone D. The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019;71:183\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePergolizzi J, Magnusson P, LeQuang JAK, Breve F. Illicitly Manufactured Fentanyl Entering the United States. Cureus. 2021;13(8):e17496.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalamar JJ, Ciccarone D, Rutherford C, Keyes KM, Carr TH, Cottler LB. 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Harm Reduct J. 2022;19(1):79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKingston S, Newman A, Banta-Green C, Glick S. Results from the 2021 WA State Syringe Service Program Health Survey. Addictions. Seattle, WA: Drug \u0026amp; Alcohol Institute, Department of Psychiatry \u0026amp; Behavioral Sciences, University of Washington; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGile KJ, Handcock MS. Respondent-Driven Sampling: An Assessment of Current Methodology. Sociol Methodol. 2010;40(1):285\u0026ndash;327.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fentanyl, IDU, naloxone, NIDU, overdose, PWID","lastPublishedDoi":"10.21203/rs.3.rs-6597345/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6597345/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe examined fentanyl use and outcomes among people who inject drugs (PWID) in the urban Pacific Northwest (PNW).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted secondary analysis of data from the 2022 National HIV Behavioral Surveillance PWID cycle from Portland, OR and Seattle, WA. We calculated proportions of any fentanyl, injection fentanyl, non-injection fentanyl, and street pill use. Next, we compared characteristics, behaviors, and outcomes by any fentanyl use. Finally, we estimated adjusted relative risk (aRR) of overdose outcomes associated with fentanyl use and injecting less associated with type of street pill use.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong 835 PWID, 76% reported fentanyl use, 47% injection fentanyl use, 68% non-injection fentanyl use, and 66% street pill use. Of those who used pills, 94% smoked them. Fentanyl use was crudely associated with age; race; housing; detainment; usual drug injected; injection frequency; syringe service programs, substance treatment, overdose, and naloxone (p\u0026lt;0.05). With adjustment, any fentanyl use (aRR=2.99, 95% CI: 1.55-5.76), injection fentanyl use (aRR=2.98, 95% CI: 1.43-6.19), and non-injection fentanyl use (aRR=2.12, 95% CI: 1.19-3.75) were associated with higher risk of overdose. Participants who smoked street pills were more likely to report injecting less because of pill use (aRR=1.80, 95% CI: 1.23-2.64).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFentanyl use was highly prevalent among PWID in the urban PNW. Non-injection fentanyl use was most common and street pills were frequently administered by smoking which was associated with injecting less. All fentanyl use was associated with increased risk for overdose. There is ongoing need for access to naloxone for PWID who use fentanyl.\u003c/p\u003e","manuscriptTitle":"Fentanyl use among people who inject drugs in two large Pacific Northwest metropolitan areas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-10 16:05:57","doi":"10.21203/rs.3.rs-6597345/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-18T03:38:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T23:31:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205955282650442447313587432814948001634","date":"2025-09-17T16:26:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T18:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164970155031154204549499376406415121313","date":"2025-07-12T14:52:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240176861880552698757387958755076301005","date":"2025-07-11T13:26:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144615974204429954325297212144457248463","date":"2025-05-08T19:36:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-06T13:05:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T04:10:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-06T04:10:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-05-05T20:56:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c3dbb61-2364-46a7-adf2-c33d47790bcb","owner":[],"postedDate":"May 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:09:32+00:00","versionOfRecord":{"articleIdentity":"rs-6597345","link":"https://doi.org/10.1186/s12954-025-01384-9","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2026-03-12 15:59:16","publishedOnDateReadable":"March 12th, 2026"},"versionCreatedAt":"2025-05-10 16:05:57","video":"","vorDoi":"10.1186/s12954-025-01384-9","vorDoiUrl":"https://doi.org/10.1186/s12954-025-01384-9","workflowStages":[]},"version":"v1","identity":"rs-6597345","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6597345","identity":"rs-6597345","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}