Abstract
OBJECTIVE: Fentanyl is a major driver of the overdose crisis in the United States, yet little is known about the intentionality of fentanyl use and its correlates among people who use drugs (PWUD). We examined the intentionality of fentanyl use and associated factors among PWUD. METHODS: We recruited 246 PWUD in New York City in 2023. Participants completed structured interviews and provided urine samples for toxicology screening. Fentanyl use was classified as no use (negative in both self-report and urine toxicology), unintentional use (self-report negative but toxicology positive), and intentional use (positive in self-report with or without positive toxicology). We used multinomial logistic regression to identify factors associated with fentanyl use intentionality. RESULTS: Fentanyl was detected in 40.7%, while 26.0% self-reported intentional fentanyl use. Intentional fentanyl use was significantly associated with chronic pain (RRR: 2.21; 95% CI: 1.02-4.80) and higher Risk Assessment Battery (RAB) scores (RRR: 1.09; 95% CI: 1.01-1.18), and inversely associated with high cannabis use severity (RRR: 0.16; 95% CI: 0.05-0.61). Unintentional fentanyl use was positively associated with older age (RRR: 1.08; 95% CI: 1.02-1.13) and negatively with moderate alcohol use severity (RRR: 0.25; 95% CI: 0.09-0.69). CONCLUSIONS: Unintentional fentanyl use was more common among older PWUD, highlighting the need for targeted outreach and fentanyl education. Intentional fentanyl use, while reflecting awareness of the drug supply, was associated with chronic pain and elevated HIV risk behaviors, indicating a subgroup with greater health and prevention needs. Tailored interventions integrating harm reduction, pain management, and HIV prevention are needed.