Table 1.

Key Indicators Identified by PWID of a Rapidly Changing Illicit Opioid Market

Key Themes	Exemplar Quote
Sudden change in product’s appearance	Male, 33: This guy said he had ten pounds of heroin and just ran out. He went out of state and got some stuff, came back, and this is what he’s got—pure white. China White is what they called it.
Saturation of illicit opioid market with fentanyl	Male, 36: I do fentanyl because I don’t have a choice. The heroin that I buy, the heroin that everyone buys, has fentanyl in it. Therefore, if you want to do heroin, you have to do fentanyl. That’s the way it is.
Unusual overdose presentations	Male, 23: We told him, ‘Look, this shit’s strong. He was sitting there and he was good, ya know—he got up and sat down in a chair. And I’m sitting there just staring at him the whole time and I’m seeing it [the overdose] happen. And I’m like, ‘He’s overdosing right now!’ Right in front of me. Male, 36: And all of a sudden, I watched his eyes go back in his head and he tipped right over and his mouth starts foaming. His mouth was blue and was foaming. I’ve never seen anything like that. So suddenly. Male. 23: And we had to Narcan him three times.*
Inconsistent Potency	Female, 25: The same dope will last about maybe a month and then it changes, and it’s either stronger or weaker.
Change in physical sensations	Male, 36: Once in a while, when I will shoot the stuff I’m getting now, I’ll get kind of a tingly sensation in my head. And come to think of it, the dope I was doing back then [before fentanyl] didn’t do that at all.
Scarcity of prescription opioids	Male, 46: The market here in Greensboro has went from where anywhere you could go, you could find [opioid] pills, to where, of course, now, because the pills have depleted, the heroin has become more popular. I mean, it’s everywhere.
Changes in physical sensations	Male, 57: Well, it’s changed, you know, quite a bit since then. The stuff you get nowadays … you go to see the man one day, he’s got something, and the next day he’s got something totally different. But what I noticed was when you got some back in the day, it seemed more potent. It was more of a classic high with an opiate.
Increased overdose risk	Male, 57: I think the stuff that’s out nowadays is actually more dangerous than what it was back then. I mean, I see more people dying, especially young people, and it’s because they’re doing it, coming down and doing it, and then they’re going to get some one time that’s a stronger, or a little different, and it’s going to kill them.
Increased overdose risk	Female, 44: We dealt with the same guy [drug seller] for a year and we noticed that fentanyl was slowly being introduced. We didn’t know anything about fentanyl; what we had heard about fentanyl was scary as hell. It’s ten times stronger than morphine, that’s what we kept hearing. And we just kept hearing that people were dying from it and that it was scary.

^*These statements were from a single interview involving two PWID who were intimate partners and recorded together. They recounted their experiences by joining and finishing each other’s statements and thus included here as a joint quotation.