Background
In unregulated, illicit drug use, transitions from injecting opioids to non-injecting modes of use, e.g. smoking or snorting, are historically unusual. However, this is changing with the potent synthetic opioid fentanyl. We investigate transitions between routes of administration, their patterns, motivations and perceived effects.
Methods
We used rapid ethnography to investigate fentanyl administration routes in San Francisco, California, conducting 32 interviews and ethnography with people using fentanyl in 2022. We conducted thematic analysis using a Grounded Theory approach.
Results
Multiple transition patterns emerged, from: a) injecting to smoking fentanyl; b) injecting other opioids to smoking fentanyl; c) smoking to injecting fentanyl and d) both smoking and injecting fentanyl. Participants who had previously injected other opioids could achieve comparably intense effects from smoked fentanyl. This allowed some to cease injecting entirely, often following vein loss or overdose. Others found smoking fentanyl provided greater choice in how to use and navigate the constraints of an unpredictable supply and the challenges of street living. Smoking was favored over injecting when in public, for convenience, considering sensitivity to non-injecting peers, or when seeking a milder experience enabling productivity or vigilance. Injecting was chosen for intimacy, to avoid sharing drugs/equipment with others or for particular drug batches or combinations.
Implications
Participants capitalized on fentanyl’s versatility for greater control over their health and embodied and social experiences while living in highly constrained conditions. People injecting fentanyl may be receptive to policies promoting smoking as a harm reduction practice.