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Background  Exposure to potent synthetic opioids such as illicitly manufactured fentanyl (IMF) has fueled the escalating overdose crisis in the USA, particularly in the east coast. Drug checking services, which allow people who use drugs (PWUD) to learn about the contents of their drugs, remain limited and even criminalized in many states. Further, there is a persistent belief that PWUD are not willing or able to change their behaviors despite being aware of their potential exposure to fentanyl through drug use.    Methods  We conducted a multi-site cross-sectional study among PWUD to assess what behaviors, if any, were employed in the case of suspected fentanyl exposure, and the correlates of engaging in harm reduction behaviors (HRB). PWUD ( N  = 334) were recruited in Boston ( n  = 80), Providence ( n  = 79), and in Baltimore ( n  = 175). At the time of the survey, no legal drug checking services were available in these cities.    Results  The majority of PWUD (84%) expressed concern about fentanyl. Among those who suspected fentanyl exposure prior to using their drugs ( n  = 196), 39% reported employing HRB including using less of the drug (12%) or abstaining altogether (10%), using more slowly (5%), and doing a tester shot (5%). In adjusted logistic regression models, the odds (aOR) of practicing HRB after suspecting fentanyl exposure were increased among PWUD who were non-White (aOR 2.1;  p  = 0.004) and older (aOR 1.52 per decade of age;  p  < 0.001). Daily injection (aOR 0.50;  p  < 0.001), using drugs in public (aOR 0.58;  p  = 0.001), using drugs alone (aOR 0.68;  p  < 0.001), and experiencing multiple recent overdoses (aOR 0.55;  p  < 0.001) were associated with decreased odds of practicing HRB.    Conclusions  These data illustrate that PWUD employ a number of practices to reduce overdose risk in a context of unknown drug purity and content. Results may also guide efforts to identify early adopters of drug checking services and engage them in peer-outreach to target the most socially and structurally vulnerable PWUD, who are not reporting behavior change, with harm reduction messaging.

Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence