Abstract
The US illicit drug market is increasingly unreliable, with new and often harmful adulterants contributing to overdose risk among people who use drugs. In this context, it is crucial to examine whether people who inject drugs (PWID) are aware of these changes and if so, how they are adapting to inform harm reduction interventions and programs. In-depth interviews were conducted with 23 PWID between July 2022 and January 2023. Interviews explored participants' substance use behaviors and perspectives on harm reduction interventions. A combined deductive and inductive thematic analysis was conducted to identify emergent themes. This analysis focuses upon participants' discussions around drug market activity/changes, drug-related harms, drug use risk perceptions, and harm reduction strategies. Participants demonstrated awareness of the increasing volatility and risk associated with illicit substance use. They reported engaging a range of strategies to reduce the risk of these harms, motivated by individual-level cognitions and behaviors, as well as external-level interpersonal relationship dynamics. These findings highlight that perceived risk translates to behavior change amid a changing market, suggesting the need for universal drug testing access, responsive health education/harm reduction programming, peer-based interventions, and structural changes to reduce barriers to harm reduction behavior change.