Abstract
Introduction
Fentanyl, a synthetic opioid, is frequently found as a contaminant in illicit substances, significantly increasing overdose risk. A growing trend toward intentional fentanyl use further complicates the opioid crisis. This study aimed to identify patterns of local fentanyl use and contamination and evaluate harm-reduction interventions provided by psychiatric teams to patients at high risk of opioid overdose.
Methods
This observational study combined prospective surveys with retrospective chart review. Adults with a positive fentanyl urine drug screen within 6 months of a psychiatric hospitalization or emergency department encounter were eligible. Participants completed a 10-question survey on substance use patterns, fentanyl risk awareness, and willingness to engage with harm-reduction tools. Electronic health records were reviewed upon patient discharge for demographic and clinical data, including prescribed harm reduction interventions.
Results
Eighteen participants completed the survey; 77.8% were male with a mean age of 41 years. Intentional fentanyl use was reported by 77.8% of participants. Commonly codetected substances included amphetamines (44.4%), cannabinoids (38.9%), cocaine (33.3%), and other opioids (27.8%). Whereas more than 90% recognized the overdose risk from fentanyl, nearly half did not perceive themselves to be at personal risk. Most participants were discharged with naloxone (88.9%) and/or prescribed medication for opioid use disorder. Willingness to use fentanyl test strips was high (72.2%).
Discussion
The findings of this study underscore the need for the increased availability of harm-reduction strategies, including fentanyl detection tools and tailored education, to address gaps in overdose risk perception and enhance patient safety.
Keywords: fentanyl, harm reduction strategies, opioid use disorder, substance use disorder, naloxone, Narcan, overdose prevention, fentanyl test strips, medication for opioid use disorder
Introduction
Fentanyl is a fast-acting synthetic opioid, approximately 100 times more potent than morphine, originally developed for the management of severe pain.1,2 As an opioid analgesic, fentanyl carries a high potential for euphoria and physical dependence. Its rapid onset and high potency make it an attractive filler in the illicit drug market, in which it is commonly combined with substances such as heroin, methamphetamines, and cocaine.1,2 Fentanyl’s pharmacokinetic properties contribute to its misuse and significantly increase the risk of fatal overdose.
The increasing presence of fentanyl in the illicit drug supply has emerged as one of the most urgent public health threats in the United States. In 2023, an estimated 107 000 people died from opioid-related overdoses with approximately 70% of these deaths attributed to synthetic opioids, such as fentanyl.3 Palamar and colleagues4 note that more than 115 million pills containing illicit fentanyl were seized in the United States by law enforcement in 2023, compared with 49 657 in 2017, highlighting the growing threat of contamination. The adulteration of substances significantly heightens the risk of overdose, particularly when end users are unaware of the presence of fentanyl and its concentration. A study by McKnight and colleagues5 sought to characterize fentanyl use in New York City, demonstrating an 83% fentanyl positivity rate in urine toxicology samples despite only 18% of participants reporting recent intentional fentanyl use. A similar study published in the International Journal of Drug Policy describes that a greater number of participants in the Midwest reported suspected exposure to fentanyl rather than heroin.6 These studies highlight the growing threat of fentanyl contamination across various regions of the United States; however, data remains limited regarding fentanyl use patterns in the Southeastern United States.
In addition to the well-documented increases in unintentional exposure, the opioid crisis is further complicated by the lack of education surrounding the risks of fentanyl among those who use it intentionally. A study conducted in Vancouver, Canada, among adults who inject drugs determined that, when assessing participants with awareness of their fentanyl exposure, only 33% reported knowledge of fentanyl risk. More than half of individuals aware of their exposure still perceived themselves as having no risk or low risk of experiencing an overdose.7
In response to the evolving landscape of opioid use, harm reduction has emerged as a key strategy to mitigate negative health outcomes. Harm-reduction strategies attempt to destigmatize substance use and meet individuals where they are, offering practical tools and education aimed at minimizing adverse consequences of drug use in persons who continue to use substances.8 Common treatment and harm-reduction strategies include prescribing medications for opioid use disorder (MOUD) and distribution of naloxone nasal spray kits, fentanyl test strips, and sterile consumption equipment.9,10 As the opioid crisis continues to shift, particularly with the rise of synthetic opioids such as fentanyl, understanding and optimizing the role of harm-reduction efforts has become more important than ever.
Given the limited data on local fentanyl trends in the Southeastern United States, this study aims to address 2 primary objectives. First, this study aims to characterize patterns of fentanyl use and contamination within a patient population in South Carolina. Second, this study seeks to evaluate interventions made by prescribers for patients identified as being at an elevated risk for opioid overdose.
Methods
This 2-part observational study was conducted at an academic medical center in South Carolina between November 2024 and April 2025. Patients were eligible for inclusion if they were 18 years of age and older, under the care of psychiatry during an inpatient admission or emergency department encounter, and had a urine drug screen (UDS) positive for fentanyl within the preceding 6 months. Patients were excluded if they had any inpatient fentanyl administration prior to the UDS being obtained, were non-English speaking, and/or were unable or unwilling to provide consent.
Patients with a UDS positive for fentanyl were approached by one of their care team members about participating in the study and to obtain permission to refer them to the research team. Eligible participants were then approached by psychiatric pharmacists from the research team. A waiver of signed consent was granted, and participants were asked to provide verbal consent after reviewing an introductory paragraph at the beginning of the survey that outlined the risks of participation and their rights as participants. Participants then completed a paper survey consisting of 10 questions during their health care encounter. The survey assessed participants’ current patterns of drug use, their knowledge of the risks associated with fentanyl use and contamination, and their willingness to engage in harm-reduction strategies. We attempted to mitigate potential bias in responses from education potentially provided during the health care encounter by including survey verbiage specifying “prior to this hospital visit” (Appendix A). Data was extracted from the electronic health record following hospital discharge and included participant demographic information, past medical history, and interventions for opioid use disorder (ie, buprenorphine/methadone initiation, intranasal naloxone prescribing) implemented during the inpatient stay and upon hospital discharge. Survey responses and retrospective chart review data were transcribed and securely stored in the REDCap data collection tool.
Descriptive statistics were calculated for each survey item. Continuous variables were summarized using means and SD for normally distributed data, or medians and IQR for nonnormally distributed data. Categorical variables were reported as frequencies and percentages. The study was approved by the IRB and conducted in accordance with ethical standards.
Results
Participant demographics are summarized in Table 1. Based on the eligibility criteria, 18 individuals completed the survey during the specified study period. The sample was 77.8% male and had a mean age of approximately 41 years. Overall, 77.8% of participants reported intentional exposure to fentanyl. Among those with intentional fentanyl exposure (n = 14), the majority were male (71.4%) and white (85.7%) and most commonly reported intranasal (92.9%) or oral (64.3%) routes of substance use. Participants with unintentional fentanyl exposure (n = 4) were all male and white with intranasal (25.0%) or injection (75.0%) use reported most frequently.
TABLE 1.
Baseline demographics for those who reported intentional versus unintentional fentanyl exposure
| Characteristic | All Participants (n = 18) | Intentional Fentanyl Exposure (n = 14) | Unintentional Fentanyl Exposure (n = 4) |
|---|---|---|---|
| Age, mean (SD) | 41.4 (10.7) | 42.9 (11.5) | 36.3 (5.0) |
| Male, n (%) | 14 (77.8) | 10 (71.4) | 4 (100.0) |
| White, n (%) | 16 (88.9) | 12 (85.7) | 4 (100.0) |
| Stable housing, n (%) | 9 (50.0) | 6 (42.9) | 3 (75.0) |
| Route of substance use, n (%) | |||
| Nasal | 16 (80.0) | 13 (92.9) | 1 (25.0) |
| Oral | 10 (50.0) | 9 (64.3) | 1 (25.0) |
| Smoking | 9 (45.0) | 8 (57.1) | 1 (25.0) |
| Injection | 9 (45.0) | 6 (42.9) | 3 (75.0) |
| >1 route of substance use, n (%) | 11 (61.1) | 9 (64.3) | 2 (50.0) |
| Fentanyl formulation used, n (%) | |||
| Fentanyl tablets | — | 2 (14.3) | — |
| Fentanyl powder | — | 13 (92.9) | — |
| Past psychiatric history, n (%) | |||
| Depression | 9 (52.9) | 8 (61.5) | 1 (25.0) |
| Anxiety | 6 (33.3) | 5 (35.7) | 1 (25.0) |
| Bipolar Disorder | 2 (11.8) | 2 (15.4) | 0 (0.0) |
| Substance Use Disorder | 17 (94.4) | 13 (92.9) | 4 (100.0) |
| Any prior history of naloxone nasal spray prescription,a n (%) | 9 (50.0) | 7 (50.0) | 2 (50.0) |
| Any prior history of MOUD*, n (%) | 10 (55.6) | 7 (50.0) | 3 (75.0) |
| Buprenorphine | 8 (44.4) | 5 (35.7) | 3 (75.0) |
| Methadone | 8 (44.4) | 5 (35.7) | 3 (75.0) |
Patients were considered to have a prior history of receiving a naloxone nasal spray kit and/or medications for opioid use disorder if documentation was present in the medical record (eg, provider note indicating previous receipt, filled prescription).
In combination with fentanyl, the substances most frequently detected on UDS were amphetamines (44.4%), cannabinoids (38.9%), cocaine (33.3%), and other opioids (27.8%). Among participants who reported unintentional fentanyl exposure, the substances detected most often alongside fentanyl were other opioids (75.0%), cannabinoids (50.0%), cocaine (25.0%), and amphetamines (25.0%). These findings were generally consistent with the substances these individuals reported using. Specifically, participant-reported substance use within 30 days prior to survey completion and corresponding UDS positivity for those unintentionally exposed to fentanyl were as follows: cannabis (2 reported, 2 UDS positive), cocaine (1 reported, 1 UDS positive), heroin (2 reported, 1 UDS positive), methamphetamine (1 reported, 0 UDS positive), and prescription opioids (1 reported, 1 UDS positive).
Most participants demonstrated awareness of the risks associated with fentanyl exposure with more than 90% indicating that an overdose would be either extremely likely or likely following fentanyl exposure. The majority of participants also believed their preferred substances were likely to be contaminated with fentanyl. Nevertheless, 45% of participants did not believe they were likely to experience an overdose based on their current patterns of substance use (Table 2).
TABLE 2.
Participant reported awareness of the risk of fentanyl exposure
| Statement, n (%) | Extremely Likely | Likely | Neutral | Unlikely | Extremely Unlikely |
|---|---|---|---|---|---|
| Likelihood of overdose with fentanyl exposure | 12 (66.7) | 5 (27.8) | 1 (5.6) | 0 (0.0) | 0 (0.0) |
| Likelihood of preferred substances to be contaminated with fentanyl | 12 (66.7) | 3 (16.7) | 1 (5.6) | 1 (5.6) | 1 (5.6) |
| Likelihood of overdose given YOUR current patterns of substance use | 7 (38.9) | 3 (16.7) | 2 (11.1) | 5 (27.8) | 1 (5.6) |
Nearly 90% of participants were discharged with a naloxone nasal spray kit, and a similar proportion were prescribed MOUD by the psychiatric care team. Of those discharged on an MOUD, 77.8% were prescribed buprenorphine/naloxone and 11.1% were prescribed methadone. Whereas fentanyl test strips are not currently distributed within our institution, there appears to be strong interest in this harm-reduction strategy as all participants who reported unintentional fentanyl exposure indicated they would be willing to use fentanyl test strips if made available. Notably, this willingness remained high (66.7%) among participants who reported intentional fentanyl use.
Discussion
Whereas fentanyl contamination and overdose are widely documented, limited research explores regional or community-level differences in perceptions, behaviors, and harm-reduction prescribing, particularly in the Southeastern United States.4 At this institution, psychiatric providers incorporate harm-reduction approaches as reflected in the frequent prescribing of naloxone nasal spray alongside the use of MOUD as evidence-based treatment. However, there remains a lack of in-depth, patient-centered data on how individuals conceptualize fentanyl risk, navigate available harm-reduction tools, or access treatment options. Understanding patterns of substance use is essential to developing effective interventions and public health strategies, particularly amid the ongoing opioid crisis.
Providers are uniquely positioned to deliver harm-reduction education and interventions during hospitalizations as patients who use substances often have limited engagement with the health care system outside of these encounters.11,12 Hospitalizations represent critical opportunities to intervene, particularly at a time when patients may be more receptive to change. In addition to promoting safer substance use, harm-reduction efforts also offer an opportunity to reduce the financial burden on health systems by potentially minimizing prolonged hospital stays, readmissions, and early discharges against medical advice—challenges often associated with patients who use substances.13 In this study, high rates of MOUD prescribing at discharge may reflect the proactive involvement of the psychiatry team in identifying eligible patients and initiating treatment, underscoring the opportunity for inpatient teams to facilitate access to evidence-based care. By contributing to this emerging body of knowledge, this exploratory study provides important insight into the social and behavioral dynamics that influence substance use and harm reduction within an urban context in the Southeastern United States.
In this cohort, most participants who tested positive for fentanyl and completed a survey reported intentional use, indicating a high prevalence of purposeful fentanyl exposure among surveyed individuals despite most participants being aware of the risks of fentanyl exposure. Notably, approximately 45% of surveyed patients did not perceive themselves to be at risk of experiencing an overdose based on their current patterns of substance use. This finding highlights a critical gap in awareness and presents an opportunity for targeted education around the risks associated with fentanyl use and contamination. A qualitative study by Fernandez and colleagues14 assessing a fentanyl risk awareness campaign found that, although awareness of fentanyl was widespread among people who use drugs (PWUD), perceived risk of exposure for themselves remained low, often due to a belief that their preferred substances were obtained from a trusted source. However, targeted messaging that emphasized the unknown origins of fentanyl effectively shifted these perceptions. The study also notes that educational strategies incorporating personal connection, such as framing naloxone as a tool to save a friend, were impactful in shifting attitudes toward carrying and using naloxone. Implementing similar educational approaches may improve patients’ understanding of fentanyl-related risks and empower them to make safer decisions regarding substance use. Given the demonstrated effect of personal connection, harm-reduction education may be especially effective when delivered by peer-recovery specialists. One study showed that peer-led interventions increased knowledge about overdose and MOUD, reduced high-risk behaviors, and strengthened motivation to quit.15 Pharmacists also have a critical role to play in these efforts by providing proactive education and counseling on MOUD and other harm-reduction strategies, further supporting patients in navigating substance use more safely.
Participants in this study expressed a strong interest in increased access to fentanyl test strips, highlighting their desire for practical tools to mitigate personal overdose risk. Prior studies also demonstrate positive attitudes toward and a willingness to use fentanyl test strips among individuals who use substances.16,17 Furthermore, fentanyl test strips are associated with meaningful behavioral change among PWUD. A cohort study by Vickers-Smith et al18 found that individuals who used fentanyl test strips were more likely to engage in safer substance use practices, such as having naloxone readily available, testing drug strength, and discarding substances suspected to be contaminated. Similarly, a study conducted in Greensboro, North Carolina, reports that more than 40% of individuals who used fentanyl test strips modified their drug use behaviors as a result, and more than two thirds reported an increased sense of safety regarding overdose risk.19 Taken together, these findings and the expressed interest from participants in our study support the integration of fentanyl test strips into hospital- and community-based harm-reduction initiatives. In South Carolina, possession and distribution of fentanyl test strips were decriminalized in 2023, enabling broader access to this essential harm-reduction tool. Although participant perspectives on naloxone were not directly assessed in this study, providers at this institution frequently prescribe naloxone, and previous literature demonstrates favorable attitudes toward naloxone acceptance and use.20 Naloxone is also available through multiple access points in South Carolina and may be obtained from community pharmacies with or without a prescription under the statewide standing order or over the counter. Additionally, select emergency departments, state-funded drug and alcohol treatment centers, and other community resources provide naloxone kits, fentanyl testing strips, and overdose education at no cost to individuals across the state. Our research highlights the importance of strengthening comprehensive harm-reduction strategies that integrate education, naloxone access, and drug-checking tools to address the ongoing risks of fentanyl contamination in the illicit drug supply.21
Whereas this study offers valuable foundational insight into local patterns of substance use, several limitations must be acknowledged. First, the relatively small sample size may limit the generalizability and reliability of our findings. Second, the study was conducted at a large academic medical center located in a midsize metropolitan area, which may not reflect the experiences of individuals in more rural communities across the Southeastern United States. Furthermore, all patients in this study were under the care of psychiatric providers, and thus, it remains unclear whether harm-reduction prescribing rates are comparable among nonpsychiatric prescribers. Finally, the use of a self-administered survey introduces potential bias as responses were dependent on participants’ comprehension of the questions and their willingness to be forthcoming regarding their patterns of use. This reliance on self-reporting may have been influenced by varying levels of health literacy, potentially affecting the accuracy of the data collected. Future studies should incorporate qualitative interviews or focus groups to provide deeper context to the patterns observed, especially around patient perceptions, barriers to care, and cultural or community influences on substance use. Longitudinal studies could additionally assess the impact of tailored education and outreach on changing risk perception and substance use behaviors over time.
Conclusion
The results of this preliminary study highlight a high prevalence of intentional fentanyl use among a small cohort of patients surveyed within a midsize urban area of the Southeastern United States. Despite this finding, most respondents appeared to underestimate the overdose risk associated with their current patterns of substance use. This study not only sheds light on regional patterns of fentanyl use but also emphasizes the urgent need for localized, patient-centered approaches to harm reduction. By addressing the specific gaps in knowledge, perception, and access identified in this study, health care systems can more effectively respond to the evolving opioid crisis.
Supplementary Material
References
- 1.Ramos-Matos CF, Bistas KG, Lopez-Ojeda W. Fentanyl. [Updated 2023. May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459275/ [PubMed] [Google Scholar]
- 2.United States Drug Enforcement Administration . Facts about fentanyl. [published 2021. Apr 29]. Available from: https://www.dea.gov/resources/facts-about-fentanyl
- 3.Murray E. Overdose deaths decline, fentanyl threat looms. [published 2024]. Available from: https://www.dea.gov/press-releases/2024/12/16/overdose-deaths-decline-fentanyl-threat-looms
- 4.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. 10.1016/j.drugalcdep.2022.109398 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.McKnight C, Weng CA, Reynoso M, Kimball S, Thompson LM, Jarlais DD. Understanding intentionality of fentanyl use and drug overdose risk: findings from a mixed methods study of people who inject drugs in New York City. Int J Drug Policy. 2023;118:104063. 10.1016/j.drugpo.2023.104063 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Daniulaityte R, Carlson RR, Juhascik MP, Strayer KE, Sizemore IE. Street fentanyl use: experiences, preferences, and concordance between self-reports and urine toxicology. Int J Drug Policy. 2019;71:3-9. 10.1016/j.drugpo.2019.05.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Moallef S Nosova E Milloy MJ et al.. Knowledge of fentanyl and perceived risk of overdose among persons who use drugs in Vancouver, Canada. Public Health Rep. 2019;134(4):423-31. 10.1177/0033354919857084 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Substance Abuse and Mental Health Services Administration . Harm reduction. [published 2024. Oct 29]. Available from: https://www.samhsa.gov/substance-use/harm-reduction
- 9.Substance Abuse and Mental Health Services Administration. Federal guidelines for opioid treatment programs. 2024. Available from: https://library.samhsa.gov/sites/default/files/federal-guidelines-opioid-treatment-pep24-02-011.pdf
- 10.Marrazzo JM del Rio C Holtgrave DR et al.. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA. 2014;312(4):390-409. 10.1001/jama.2014.7999. Correction: JAMA. 2014;312(6):652. Correction: JAMA. 2014;312(4):403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Fraimow-Wong L Martín M Thomas L et al.. Patient and staff perspectives on the impacts and challenges of hospital-based harm reduction. JAMA Netw Open. 2024;7(2):e240229. 10.1001/jamanetworkopen.2024.0229 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1-2):23-35. 10.1016/j.drugalcdep.2013.02.018 [DOI] [PubMed] [Google Scholar]
- 13.Fairley M Humphreys K Joyce VR et al.. Cost-effectiveness of treatments for opioid use disorder. JAMA Psychiatry. 2021;78(7):767-77. 10.1001/jamapsychiatry.2021.0247 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Fernandez P, Azucar D, Zambole K. A dose of truth: a qualitative assessment of reactions to messages about fentanyl for people who use drugs. Subst Use Misuse. 2023;58(4):520-7. 10.1080/10826084.2023.2177112 [DOI] [PubMed] [Google Scholar]
- 15.Winhusen T, Wilder C, Lyons MS, Theobald J, Kropp F, Lewis D. Evaluation of a personally-tailored opioid overdose prevention education and naloxone distribution intervention to promote harm reduction and treatment readiness in individuals actively using illicit opioids. Drug Alcohol Depend. 2020;216:108265. 10.1016/j.drugalcdep.2020.108265 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Allen ST, O’Rourke A, White RH, Sherman SG, Grieb SM. Perspectives on fentanyl test strip use among people who inject drugs in rural Appalachia. Subst Use Misuse. 2020;55(10):1594-600. 10.1080/10826084.2020.1753773 [DOI] [PubMed] [Google Scholar]
- 17.Krieger MS Goedel WC Buxton JA et al.. Use of rapid fentanyl test strips among young adults who use drugs. Int J Drug Policy. 2018;61:52-8. 10.1016/j.drugpo.2018.09.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Vickers-Smith RA Gelberg KH Childerhose JE et al.. Fentanyl test strip use and overdose risk reduction behaviors among people who use drugs. JAMA Netw Open. 2025;8(5):e2510077. 10.1001/jamanetworkopen.2025.10077 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: findings from a syringe services program in the Southeastern United States. Int J Drug Policy. 2019;63:122-8. 10.1016/j.drugpo.2018.08.007 [DOI] [PubMed] [Google Scholar]
- 20.Le MH Laschober TC Tross S et al.. Attitudes toward and experience with naloxone among people who use drugs in the Southeastern United States. Int J Drug Policy. 2025;139:104769. 10.1016/j.drugpo.2025.104769 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.South Carolina General Assembly. Overdose Prevention Act. S.C. Code Ann. § 44-130. Columbia, SC: South Carolina Legislature; 2015. [Google Scholar]
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