Age-based preferences for risk communication in the fentanyl era: ‘A lot of people keep seeing other people die and that’s not enough for them’

Abstract

Aims

To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age.

Design

A single-site qualitative in-depth interview study.

Setting

Boston, MA, United States.

Participants

The sample included 21 people (10 women, 11 men) who were either 18–25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings.

Measurements

Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content.

Findings

We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl’s lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages.

Conclusions

Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers’ ability to provide compassionate harm reduction communication.

INTRODUCTION

Deaths from illicitly manufactured fentanyl and its analogues (herein referred to as ‘fentanyl’) in the United States have increased 13-fold over the last decade [1]. In 2018, fentanyl was responsible for 67% of opioid-related deaths nationally, but 93% of opioid-related deaths in Massachusetts [2,3]. Fentanyl as the major driver of opioid overdose deaths is likely related to changes in supply, policies that limit opioid prescribing, and contamination of the stimulant and sedative drug supply [4-8]. Since the introduction of fentanyl, people who use drugs are at significantly higher risk of overdose and may have minimal agency to avoid fentanyl use [9-12].

Fentanyl has increased the urgency for expanded access to harm reduction services. Strategies including fentanyl testing strips, using appearance-based drug assessments (e.g. color), overdose prevention counseling, and creating safer spaces for people to use drugs have been reported [10,11,13-17]. Current US strategies to curb overdose emphasize concrete services, like increased naloxone distribution [18] and expanded uptake of medications for opioid use disorder, but focus less on how to change risk behaviors. There remains a gap in the literature on how to most effectively implement harm reduction services to optimize uptake [14,18-20]. The limiting factor may not be only lack of services, but also effective communication that motivates reductions in overdose risk behaviors and increases in harm reduction service use.

Broad-based harm reduction communications have focused on education about the dangers of fentanyl and relied heavily on public health ‘drug alerts’ – flyers from authorities notifying people of an acute outbreak of overdoses [21-23]. Yet these approaches have not achieved widespread changes in opioid-related mortality. Where there are persistently elevated rates of overdose among high risk populations, there are opportunities to improve risk communication [24]. One-on-one risk communication is a complementary approach to community-level messages about the risks of fentanyl with the goal of reducing overdose. One-on-one overdose risk communication can be delivered by a variety of care providers (clinicians, outreach workers, counselors, peers), but is especially relevant for harm reduction providers [25]. Risk communication usually includes both non-directive (informing) messages alongside those that seek to elicit behavior change (influencing), although the balance of these two activities may differ across contexts [26]. One inherent challenge for harm reduction providers is avoiding the perception of coercing behavior change in upholding the principles of harm reduction [27]. Another challenge is that among people at high-risk for overdose prevention messages must compete with other more imminent risks and challenges faced by PWUF, including avoiding arrest and assault, finding money to buy drugs, and securing shelter [28]. Effective risk communication requires an understanding of the context in which messages are delivered and input from the intended audience at all levels of design [29,30]. PWUF’s perspectives have been limited in the design of current communication efforts to reduce overdose and there is limited research on sources of risk communication and resulting perceptions and behaviors [22,31].

Age is an important factor in how people respond to risk information [32], yet few studies directly compare risk behaviors across age groups. One study in Seattle documented that people < 30 years old who use heroin were more likely to re-use and share syringes compared to those over 30 [33]. Other studies among young adults who inject drugs further suggest that they employ few risk reduction behaviors, and knowledge of overdose risk factors does not produce behavior change [34,35]. Lack of behavior change in young adults is sometimes attributed to their developmental stage, characterized by feelings of impulsivity, and increased risk tolerance [36,37]. This is further supported by some data suggesting that younger age is associated with seeking fentanyl over less potent opioids [38]. Young adults may therefore benefit from tailored communication strategies that differ from older adults [32]. Given the paucity of data comparing preferences for risk communication and harm reduction across ages, this qualitative study aimed to characterize 1) how people who use fentanyl and providers engaged in and responded to overdose risk communication interactions, and 2) explore whether these engagements and responses varied by age.

METHODS

Study design

We conducted a single-site qualitative in-depth interview study to describe experiences with and preferences for risk communication among 21 people who use fentanyl-containing opioids (‘PWUF’) and 10 clinical and community providers (‘providers’).

Recruitment

We utilized purposive sampling to target three groups: younger PWUF (ages 18–25), older PWUF (ages 35+), and health care providers. We chose the two age groupings using a purposive maximum variation approach [39], while reflecting CDC age-based groupings [40], enhancing our ability to detect possible age differences by examining two tails on the age spectrum. Flyers and staff referrals recruited PWUF from local syringe service programs, community outreach services, and primary care practices. Most participants were referred from public health-funded community programs serving those who have unstable housing who utilize programs for basic services (syringe services, bathroom facilities, internet access) and represent a group with a high burden of mental health and substance use disorders [16]. We included individuals ages 18–25 or 35+; who were English-speaking, and reported illicit fentanyl use within the last year. We enrolled 21 PWUF, with balanced numbers of men and women in each age cohort. Providers from clinical and community-based settings who worked directly with PWUF were invited by email to participate and 10 enrolled. We defined ‘clinical providers’ as professionals working in medical settings, while ‘Community Health Workers’ (CHWs) were those who practiced outside of institutional medical environments (e.g. outreach programs). All participants were briefed on the study purpose, risks, and benefits and provided informed consent before interviews. This research was reviewed and approved by the Boston Medical Center Institutional Review Board.

Qualitative guide development

We used open-ended, flexible interview guides for all interviews. Guides were drafted by the study team, including two addiction medicine clinicians and a qualitative health services researcher. A risk communication framework (Fig. 1) designed for practitioners communicating about health risks, guided interview development and analysis. The framework describes four elements of risk communication, including: 1) Providing information about the risk (of using fentanyl); 2) Providing information to eliminate risk; 3) counseling about harm reduction; and 4) Reassuring continued care. Each of the four components of risk communication was considered in PWUF’s and providers’ interviews and was used to develop initial codes for analysis. Interview guides were tested prior to study initiation on volunteer community health workers, research staff, and practicing clinicians (n = 6).

Figure 1.

Four elements of risk communication framework

Qualitative interviews

Interviews occurred from May–November 2018. Trained research assistants conducted 40–60 minute interviews with PWUF in-person. Interviews covered: 1) Fentanyl risk communication experience, including what they have learned about fentanyl, how and from whom; 2) Preferences for risk communication, specifically what communications would most impact behavior; 3) Current and preferred harm reduction practices; and 4) Relative concern about fentanyl overdose risk in relation to other concerns. Participants received a $50 debit card at the interview’s conclusion. Provider interviews were conducted in-person or by phone and lasted 30–60 minutes. These covered: 1) Current communication practices about fentanyl and overdose risks; 2) Facilitators and barriers to communicating effectively; and 3) Strategies to improve fentanyl-related risk communication. Providers received $75 compensation. Interviews were audio-recorded and professionally transcribed verbatim. Research assistants reviewed transcripts against audio files for fidelity.

Analysis

Interview transcripts were imported into NVivo qualitative data management software version 12.1 and analyzed using a grounded content analysis [41,42], combining deductive and inductive thematic development approaches. The lead author drafted a codebook with deductive codes based on the risk communication framework and through codebook development with five transcripts, identified inductive codes related to communication factors, fentanyl, and overdose risk perception [43]. Each transcript was coded independently by two coders, examined for agreement [44,45], and discrepancies resolved by the study team. Coding queries were used to build content themes around risk communication and compare strategies that were employed versus those desired. We examined codes by age group to assess commonalities and differences in themes between younger and older participants. Coding and theme development was repeated separately for providers. After analysis within each perspective, themes were compared across the PWUF and provider groups. Names reported in the text below are pseudonyms randomly generated to protect participant confidentiality.

RESULTS

Table 1 displays the demographics of the 21 enrolled PWUF and 10 providers. Of the PWUF, 10 were ages 18–25 and 11 were 35+. More participants who were 35 + reported actively avoiding fentanyl (n = 7) versus those 18–25 (n = 1). Most participants were in treatment or receiving care at the time of the interview (n = 9, 18–25, n = 6, 35+). All PWUF and providers engaged in at least one element of the risk communication framework, although some elements were reported more often by older PWUF (Table 2). Below we present 3 themes characterizing how PWUF and providers engaged in and responded to risk communication interactions as conceptualized in the guiding framework.

Table 1.

Participant characteristics

	PWUF (N = 21)
	Age 18–25 (n = 10)	Age 35+ (n = 11)	Total
Gender
Male	5	6	11
Female	5	5	10
Fentanyl-seeking*
Active	1	1	2
Passive	6	3	9
No	3	7	10
In treatment**
Yes	9	6	15
No	1	4	5
Unsure	0	1	1
	Providers (N = 10)
	Clinical (n = 4)	CHW (n = 6)	Total
Gender
Male	1	2	3
Female	3	4	7

CHW = Community Health Workers.

^*Fentanyl-seeking was categorized as either ‘active’ (a person who wants to use fentanyl), ‘passive’ (a person who uses fentanyl but does not seek it) or ‘no’ (a person who does not want to use fentanyl).

^**Participants were defined as being in treatment if they were on medication for opioid use disorder, were in a detox or residential treatment program or enrolled in a program providing treatment for substance use disorder. PWUF = people who use fentanyl.

Table 2.

Elements of risk communication discussed by participants, reported as n (%)

Communication element	PWUF 18–25	PWUF 35+	All PWUF	Providers
Information about risk	5 (50%)	7 (64%)	12 (57%)	7 (70%)
Eliminate risk	6 (60%)	10 (91%)	16 (76%)	5 (50%)
Discuss harm reduction	8 (80%)	7 (64%)	15 (71%)	10 (100%)
Reassure continued care	1 (10%)	6 (55%)	7 (33%)	4 (40%)

PWUF = people who use fentanyl.

Theme 1: Older PWUF were more concerned with fentanyl-related fatal overdose than younger PWUF and modified their behavior accordingly. Providers perceived greater challenges relaying risk information to young adults.

In responding to messages about the risks of fentanyl, seven older PWUF described an aversion to fentanyl, due to its inconsistent effects, shorter duration, heightened risk of fatal overdose, and potential for long-term health consequences.

‘I hate [fentanyl], a lot of us do not like it… It works for 20 minutes and then it goes away… when you are doing a huge booming shot of fentanyl and your body is not used to it and whatever, you are going down’ (Alana).

‘This is a person that was using for so many years. Look what it did to his liver. Look how much he’s lost of his brain capacity. This is what’s going to happen to you. I wish I would have had that information then.’ (Tim)

Older PWUF who were attempting to avoid fentanyl described switching substances, declining fentanyl when offered, and utilizing discretion when obtaining drugs:

‘I switched over to straight cocaine, I do not mess with heroin cause … it’s fentanyl.’ (Vincente)

‘I do not subject myself to buying drugs just from anyone. If it’s one individual that I have purchased my drug of choice from, I will go to them and only them. If they are not available, I will not go out just jumping and getting some from just anyone … it’s better off to just wait … they do not give two cramps[sic] if they end up killing you.’ (Kathy)

Younger respondents described nonfatal overdose as a primary risk related to fentanyl use, although only half said they were fearful of overdose in contrast to the majority in the 35 + group. Many, like Jared, acknowledged ‘I’m just not scared when I’m out there. I just go all in.’ When most young people described the moments using fentanyl, they did so with feelings of confidence and immunity, dismissing that overdose risk applies to them:

‘I feel like myself and other addicts always think that – ‘Oh, [overdose is] not going to happen to me … Oh, I know how much to do … I know, I’ve been doing this for years. I know how to use. I know how much is too much.” (Anabel)

While all but one younger PWUF recalled a history of at least one overdose, such experiences did not always translate into concerns about future overdose fatality:

‘I overdosed and I came out of it. It did not even phase me in the slightest way. I came very close to death and I just kind of brushed it off, went about my day as usual … And even now I do not look back on it in a traumatic way or like – it honestly did not affect me.’ (Brent)

As Brent stated here, surviving overdose did not catalyze behavior change. Young PWUF either perceived risk of withdrawal as greater than risk of overdose or felt immune to overdose risk. Seven providers similarly perceived that younger PWUF had a sense of immunity that was difficult to overcome, impeding risk communication and behavior change:

‘There’s a lot more arrogance and their sense of immunity to it that I do not find in older, more seasoned users … So, they are a little more resistant to receiving information … Because these new users have started using and come up in the age of fentanyl, they are very aware of what they are using. They’re like, ‘yeah that’s Feddy. Yeah I’ve overdosed this many times.’ (Joyce, Clinical Provider)

Some young people expressed fear, but described being unable to consistently use harm reducing behaviors despite knowing what to do. Savannah described this experience and her desire for overdose response and prevention education:

‘I’d try to have Narcan on me but I would not always… It was all in secret. It was all like me using in the bathroom and coming out like nothing happened. And that’s also why it was so dangerous, because I wasn’t using with people … But I could not use less … There’s something we need to learn about, about how to tell if someone’s having an overdose … Make it like a CPR training, here’s how you check a pulse … this is the color someone’s lips should be… This stuff’s important. If you do not know how someone looks when they are overdosing, all the other shit’s out the window.’

In line with Savannah’s experience, over half of younger PWUF sought to learn actionable skills that minimized short-term risk.

Theme 2: While clinical providers advised treatment as a means of risk reduction, the treatment offered often did not align with PWUF priorities. Limited access to desired treatment types was a barrier from the provider perspective.

While 15 PWUF were in treatment at the time of the interview, all described cycles of relapse and recovery and reflected on how communication affected their engagement with treatment over time. For five providers (3 of 4 clinicians vs. 2 of 6 CHWs), their primary risk communication was encouraging PWUF to engage in treatment (including residential treatment, detoxification, and/or medications), yet PWUF often described not feeling ‘ready’ to consider treatment at the time of communication and/or experienced cumbersome logistics to treatment: ‘She offered me either one or the other, but I have to go through a series of appointments for the methadone … Right now – I don’t know if my readiness is there.’ (Kathy, 35+) Resource-strapped CHWs, while less frequently engaged in promoting treatment directly, discussed their struggle to link PWUF to their preferred treatment options. Antonio said, ‘I know the real problem is we don’t have enough treatment beds … We can do what we can do to keep them alive but there’s not enough’. Four of the providers described that younger PWUF had less social support, which sometimes impeded efforts to support treatment: ‘[People in their twenties], if they’re still using, they mostly feel like they have no help or no one to help them or they feel like everyone has pretty much given up on them … The older population sometimes that happens but it’s rare.’(Lydia). When younger people were connected with family or support networks, involving these supports in efforts to access treatment was critical.

Clinical providers described alternative communication strategies when treatment was not desired. One incorporated personalized goal setting into clinical interactions to retain PWUF in health care:

‘I talk about it up front…and [identify] what are that person’s goals. And some people might say ‘never inject again’. And that’s great. But other people might like to go back to work or not have to put all [their] time seeking out fentanyl; so like using once a week actually is their goal … And so I talk a lot about how it might take time … and our goals generally are in line with whatever their goal is.’ (Maya, Clinical Provider)

Utilizing a partnership rather than a compliance model, this provider identified goal-concordant risk reduction strategies that they felt PWUF were more likely to implement.

Theme 3: PWUF valued risk communication when providers prioritized developing rapport and being compassionate; an approach facilitated in community settings more readily than in clinical care.

PWUF and providers detailed discussing a range of harm reduction strategies including naloxone, starting low and going slow, using in groups, using in public if alone, and safe injection practices. For PWUF across the age spectrum compassionate, trust-building approaches were preferred and conveyed through cultivating personal connections, listening and asking questions, consistent messaging, and balancing honesty with words of encouragement. Messages like ‘[you] are not alone’ (Matteo, 18–25) paired with non-’sugar coated’ language, ‘Pretty much just like they tell you the truth. You’re going to die out there.’ (Leandro, 35+), helped PWUF feel supported and empowered, yet accountable.

CHWs, like Camila below, described a variety of light-touch strategies to initiate risk conversations with a focus on relationship building, which were appreciated by PWUF:

‘So [the tip of the day] is usually around two to three sentences. We make them on a quarter sheet of paper … So if somebody comes in, they do not want to talk, you can just sense by how they said hello or how they just look …we provide them with the syringes and whatever they may need. We’re like – okay, this is our tip of the week – and just staple it to a bag that we give them … And what normally happens is they read it and they ask a question.’

CHWs found displaying active curiosity to be rapport building, helped them learn about fentanyl, and message safe practices in ways that were concordant with PWUFs’ preferences:

‘I would use fentanyl and they’d be like, Feddy. And so, if they use that word in a conversation, I will use it back because I’m using their language .… If you say something I do not understand, I need to ask you what that means. And I think that’s what makes overdose prevention messaging for a specific population so important, is really listening to the people. So that our messaging matches their experience.’ (Denise, CHW)

PWUF valued people who stuck with them, even if relationships with clinicians felt fragile at times when using and reassurance from clinicians was not universal. CHWs suggested that perceived power dynamics between PWUF and clinicians may compromise harm reduction delivery, stemming in part from clinicians holding the power to prescribe medications:

‘When people are on things like Suboxone and Methadone that they do not want to have that discussion with their provider … Every person who sees the doctor is offered Narcan. They do not take Narcan from the doctor. They take it from me. Why is that? The doctor controls the prescription … They do not want to take it. They’ll take it from me when I do group … different power dynamic.’ (Denise, CHW)

Clinical providers, who faced structural barriers such as time-crunched and infrequent PWUF encounters, sometimes described prioritizing compliance-oriented testing over rapport building. One provider, Stephanie, addressed this tension by describing results via open-ended questions and ‘we’ language: ‘So, you said you hadn’t used. We found a surprising result - are you struggling? How can we support you?”

Another trusted source of information for 13 PWUF was people with lived experience, who were considered most credible:

‘If you are about to go skydiving, you do not want to talk about some guy who’s only seen it in movies. You want someone who’s actually jumped out of a plane and can describe to you what’s the best way not to die jumping out of said plane. You know what I mean? So personal experience is always best.’ (Brent, 18–25)

However, participants agreed that messages could be conveyed effectively by anyone displaying compassion. Though structural barriers to compassionate care persist, these obstacles were lessened by individual displays of empathy.

DISCUSSION

This exploratory study used qualitative interviews to characterize how people who use fentanyl and providers engaged in and responded to overdose risk communication. Younger people described fentanyl as posing an immediate risk of non-fatal overdose, but described feeling immune to fatal overdose, and seemed less likely to describe behavior modifications in response to overdose or risk communication. Most older PWUF appeared to perceive fentanyl as heightening risk of death and long-term health consequences, and many avoided fentanyl when possible. Treatment was often offered as the primary means of risk reduction in clinical settings, but options were not consistently aligned with PWUF desires. For PWUF of all ages, compassion was described as integral to successful risk communication.

Risk perceptions identified by younger participants in this study were consistent with research demonstrating that young adults display feelings of immunity to harm, which poses challenges to risk communication, as voiced by providers in the study [32,36,37]. There remains a need to examine factors related to both a sense of immunity and participation in risk-reduction behaviors, which may be attributable to experiential, developmental, biological, environmental and/or social circumstances. Despite some younger participants’ downplaying of their own fatality risk in using fentanyl, they did express a need for concrete information about overdose prevention/response and treatment linkages. For this group, there are a few approaches that may be effective. One approach may be adapting existing short, skills and knowledge-based trainings paired with naloxone distribution [20,46]. Elements of these trainings could be specifically tailored and tested to identify messaging that best targets and overcomes possible barriers to using harm reduction behaviors, including the belief of low risk of fatal overdose. Second, ensuring that substance use providers offer a continuum of overdose prevention services from harm reduction to medication treatment may engage young adults.

Communication strategies characterized as universally preferred and effective by both age groups included individual goal setting, a component of motivational interviewing (MI) methods. MI counseling is used to help individuals negotiate ambivalence and realize personal goals. It is well-studied, although data is mixed about its effectiveness among people who use substances [47-50]. PWUFs’ desires for active listening and honest, direct language reflected MI’s principles of empathy and discrepancy development (how current behavior differs from desired behavior). Provider elicitation of PWUF goals and use of encouraging words can promote self-efficacy [51]. Alignment between PWUF preferences and strategies they endorsed as effective suggest that MI elements may enhance the delivery of fentanyl-related risk communication. Two small randomized controlled trials have demonstrated MI’s effectiveness at reducing overdose risk behaviors in community and health care settings [52,53]. If further demonstrated to be effective, these models will provide pathways to integrating MI into overdose prevention settings.

PWUF also sought risk communicators who conveyed messages compassionately, which is consistent with the longstanding literature on patient-provider communication, where active listening and displays of compassion build trust and promote improved health outcomes [54]. In our sample, a majority of participants sought involvement of individuals with lived experience. Findings suggest that peer engagement may be a favorable conduit for risk communication. Supported by recent government funding, many states are currently implementing peer engagement strategies [55-60]. Though models vary, peers can address a range of needs, including information (e.g. overdose training), affiliation (e.g. social support), and instrumental support (e.g. resource linkage). Peers may also address providers’ perceived lack of social support for young people using fentanyl. While studies illustrate success in peer engagement, limited evidence demonstrates impacts on outcomes such as reduced substance use [61,62]. Future experimental studies should isolate the effects of peer engagement within PWUF communities on harm reduction and overdose outcomes.

From a systems perspective, PWUF in our study highlighted two areas that they perceived as underdeveloped in current treatment models. PWUF described that their preferred harm reduction approaches are more often accessed via community organizations, while treatment is more heavily focused within health care settings. Integrated care models that remove silos between primary care, outreach, harm reduction counseling, and treatment services among people using opioids are needed. Existing integrated care models include core program elements such as primary care coordination, delivering services in community-based settings, and providing substance use specialty support [63,64]. Studies of these models highlight the importance of wrap around services (e.g. transportation, telephone assistance) and in-person hand-offs in PWUF engagement and retention [64,65]. Touchpoints with multiple providers and flexible structures, such as variable clinic hours and group visit models, encourage both efficient care and increased PWUF engagement and could be leveraged more broadly to include community partners [66,67]. Second, some PWUF and CHWs suggested structural barriers in health care relationships may deter engagement and prohibit use of such integrated care models. Hawk et al. have published principles to guide the integration of harm reduction into health care settings [25]. At a minimum, improvements in coordination between organizations providing services along the continuum harm reduction to treatment are critical. The National Harm Reduction Coalition, based in New York, provides trainings for a variety of organizations that seek to scale harm reduction and integrate services across clinical and community settings [68], providing one path for promoting comprehensive services for people at all stages in their addiction.

The scope of this study is both a strength and limitation. By interviewing PWUF and providers, we elucidated the information and delivery preferences of stakeholders involved in traditional risk communication dyads. Examining age differences confirmed that neither PWUF nor provider groups were homogeneous and engaging with diverse perspectives is important for intervention development. This study’s focus on age limited an intersectional analysis of how other identities or circumstances, including gender, race, or housing status, influence risk communication. Further, our age comparisons may be vulnerable to survival bias and cohort effects, such that the older participants may have been risk-averse and thus survived longer, rather than older people become more risk-averse. Fully characterizing the impact of risk communication on behaviors over time requires robust longitudinal approaches. Focusing exclusively on the PWUF-provider relationship hindered interrogation of the full network of actors operating in the overdose risk reduction environment, including caregivers and policymakers. Also, many of our participants were engaged in treatment and/or harm reduction services at the time of interview, which may exclude the perspectives of those most immediately vulnerable to fentanyl overdose. These missing voices limit a holistic understanding of risk communication, and the impact of connection to treatment and support services on risk perceptions remains unknown. The purpose of this study was exploratory in nature, and subsequent work is needed to directly measure and compare potential age-based differences in perceptions and behaviors across time and in various settings. Future research should consider how PWUF can inform comprehensive risk communication at individual, community, and policy levels.

CONCLUSION

This study raises the possibility that PWUFs’ fentanyl-related risk communication experiences and preferences may vary by age. The role of age in risk communication preferences warrants further investigation. Longitudinal approaches that examine risk trajectories and behaviors over time and their role in characterizing the influence of age on engagement in risk communication and overdose prevention. Motivational interviewing techniques and using peers to engage PWUF likely offer promising approaches for enhancing multi-disciplinary risk communication across all ages. Future research should incorporate a diverse sample of PWUFs’ voices in intervention development and explore communication strategies and integrated care systems that address individual and structural barriers to behavior modification and impart practical skills to navigate them.