A Dose of Truth: A Qualitative Assessment of Reactions to Messages about Fentanyl for People Who Use Drugs

Abstract

Background: Fentanyl-related overdoses are occurring at alarming rates and developing campaigns to increase awareness about fentanyl and harm-reduction strategies is critical. A Dose of Truth is an educational campaign aiming to increase knowledge about the threat of fentanyl and risk of exposure among people who use drugs (PWUD). The current study tests preliminary concepts and messages for the campaign. Methods: Twenty-one one-on-one interviews were conducted with young adults ages 18-35 who use drugs. Participants discussed knowledge of fentanyl and perceived risk of exposure, and provided feedback on four concepts. Thematic analysis of transcripts generated insights about promising approaches and topics. Results: Findings demonstrated that fentanyl awareness is growing among PWUD, but they perceive low risk of exposure because they trust a source. Messaging that challenged that trust, by highlighting that contaminated drug supplies are increasingly widespread, made personal risk salient. Additionally, messaging conveyed through a personal narrative that encouraged carrying naloxone to protect friends was perceived as personally relevant. Conclusions: While opioid- and fentanyl-related campaigns exist, few have used an evidence-based process to guide campaign development. Addressing gaps in knowledge and developing messages that are personally relevant are foundational steps in creating effective campaigns on fentanyl and other substances.

Keywords:

• Fentanyl
• health education campaign
• harm reduction
• risk communication
• young adults

Introduction

The opioid epidemic has evolved in distinguishable phases since its onset in the 1990s (Center for Disease Control and Prevention [CDC], 2021). Initially, opioid deaths were attributed to prescription opioid medications, followed by a “second wave” associated with heroin use and heroin-related overdoses (CDC, 2021). As the crisis continued, the proliferation of synthetic opioids (i.e., fentanyl) in heroin and counterfeit opioid pills marked a new third wave (Ciccarone, 2019; Drug Enforcement Administration [DEA], 2018; Gladden et al., 2019). Fentanyl is a potent synthetic opioid that is deadly in small doses, inexpensive to produce, and commonly unknowingly laced into drugs (Carroll et al., 2017; Center for Disease Control and Prevention [CDC], 2022; DEA, 2018). Recently, researchers have warned that fentanyl is being laced with a growing list of illicit drugs beyond opioids and heroin and causing recent spikes in mortality rates, particularly among young adults (Ciccarone, 2021; Kaiser Family Foundation, 2020; Reed et al., 2022). In 2020, over 91,000 drug-related overdoses occurred in the U.S., and synthetic opioids accounted for more than 60% of those overdoses (CDC, 2022).

The presence of fentanyl-laced drugs in the drug market has important implications. For one, mixing drugs can cause unpredictable effects and be deadly (CDC, 2021). Although people who use heroin are becoming increasingly aware of fentanyl (McLean et al., 2019; Stein et al., 2019), people who use other drugs report low awareness and feel unsure about how to respond to an overdose (Hughto et al., 2022; Moallef et al., 2019). These individuals also perceive their risk of fentanyl exposure to be low (Moallef et al., 2019), particularly young adults (Gunn et al., 2021). Notably, studies have focused on individuals who use opioids or heroin (Ciccarone et al., 2017; Gunn et al., 2021; Kral et al., 2021; Winiker et al., 2020), but limited work has been conducted with people who use various types of illicit drugs (Bardwell et al., 2019; Cicero et al., 2020). This highlights the need to create campaigns that increase awareness of the dangers of fentanyl among people who use drugs (PWUD), particularly young adults (Hughto et al., 2022). To date, numerous interventions and educational campaigns designed to mitigate the opioid overdose crisis have been developed (Bmore POWER, 2022; Frkovich et al., 2022; LIVE. LONG. DC, 2022), but a review conducted by Frkovich et al. (2022) revealed that few conduct formative research or include the audience in the development process. As the landscape evolves, developing campaigns that focus on young adults who use drugs while including them in the development process is critical.

A Dose of Truth Campaign

To address the opioid crisis in Illinois, Prevention First and the Illinois Department of Public Health partnered with Rescue Agency (Rescue) to develop A Dose of Truth (www.adoseoftruthil.com), an educational campaign aiming to increase knowledge about the threat of fentanyl among young adults who use drugs. A Dose of Truth is designed using Rescue’s Decision Blocks framework, which consists of four sequential stages or blocks that guide the development of behavior change health communication. Grounded in the Transtheoretical Model (Prochaska & Velicer, 1997) and the Elaboration Likelihood Model (Petty & Cacioppo, 1986), the framework underscores the importance of behavior change through stages and meeting the audience where they are to guide message development. Decision Blocks also applies learnings on peripheral and central processing of persuasive communication to determine the messaging tactics that will be effective at each block (Petty & Cacioppo, 1986). The first block focuses on peripheral processing and creating an openness to the message by addressing gaps in knowledge with novel and meaningful information, correcting misinformation, and using expert resources. Establishing this is critical for PWUD, as this audience desires factual information to be receptive to a message (Bachhuber et al., 2015; Waye et al., 2018). The next block builds upon foundational knowledge and encourages deeper processing through messaging that focuses on personal relevance. To do this, Bivens (2019) determined that messages must show depictions of PWUD’s realities to build relevance and effectively influence their behavior. Once messaging centered on these initial blocks is established, subsequent blocks focus on behavior change solutions and maintenance strategies. To determine which block to address in messaging, a foundational initial step of an evidence-based approach is to conduct formative research using qualitative methods (Atkin & Freimuth, 2013). This illuminates an audience’s experiences, motivations, and awareness of key information, which in turn inform promising messaging themes. Next, concept testing is necessary to test and refine preliminary concepts and identify approaches that effectively reach the campaign’s goal (Atkin & Freimuth, 2013; O’Keefe, 2018; Waye et al., 2018).

As the initial step of campaign development for A Dose of Truth, formative research was conducted in November 2020 with young adults ages 18–35 in Illinois who reported using drugs. Sixteen in-depth qualitative interviews were conducted to assess key information about fentanyl and identify opportunities for messaging; three primary insights emerged that were used to create the preliminary concepts tested in the current study. First, formative research indicated that young PWUD lacked awareness about fentanyl, and those aware could not comprehensively describe why they should be concerned. This aligned with research showing that people without a history of opioid use report lower awareness than people who use opioids (Hughto et al., 2022). Second, formative research indicated that young PWUD perceive their personal risk of overdosing as low, and trusting a source contributed to that perception. Similarly, Goldman et al. (2019) reported that PWUD place considerable emphasis on the trusted relationship with their supplier, highlighting this is important information to address in messaging. Lastly, formative research suggested that PWUD are not knowledgeable of harm reduction strategies, particularly using naloxone or Narcan®, an opioid antagonist used to rapidly reverse an overdose. Goldman et al. (2019) suggested that focusing on naloxone is an effective harm reduction strategy among younger audiences, and researchers encourage messaging that normalizes naloxone by portraying its utilization (Bennett et al., 2020). Collectively, formative research revealed that PWUD necessitate key information within the first two blocks of the Decision Blocks framework, as they are uninformed about key facts regarding fentanyl (i.e., drugs are laced) and fail to connect the personal relevance of carrying naloxone (i.e., naloxone can be used to save a life). These insights guided the development of preliminary concepts that were tested in the current study.

Study objectives

To address the opioid crisis, there is a need to develop evidence-based educational campaigns, particularly targeting young adults that use various types of drugs (DuPont, 2018; Kimmel et al., 2021). To date, few studies have provided guidance on how to develop fentanyl-related communication and the types of messaging elements that are most promising, while capturing the audience’s perspective during the process (Gunn et al., 2021; Waye et al., 2018). The current research used a qualitative approach to understand knowledge of fentanyl among young adults who use drugs and their reactions to preliminary concepts designed from formative research insights. The study’s aims were to: (1) assess knowledge related to fentanyl; (2) evaluate perceptions of risk; and (3) understand perspectives and reactions to preliminary concepts, extracting insights into promising topics and features to highlight in the execution of an ad. These qualitative insights can guide other campaigns on information to include in fentanyl prevention materials while using best practices for campaign development.

Methods

Participants were recruited from November to December 2021 to participate in individual in-depth interviews (IDIs). To be eligible, study participants had to be young adults between 18 and 35 years old, report illicit drug use, live in Illinois, and provide written informed consent. To focus on drugs recently laced with fentanyl (Jones et al., 2018), illicit drug use was defined as using one or more of the following drugs in the past 12 months: cocaine, Adderall® (used without a prescription), prescription depressant (used without a prescription), ecstasy, LSD, and/or methamphetamines. Prescription opioid use qualified for the study if use of another substance was also reported, but heroin use in the past 12 months was excluded given recent high fentanyl contamination and awareness among users (Jones et al., 2020; Stein et al., 2019). Recruitment was conducted by a panel recruitment agency that used participant panels (i.e., list of individuals interested in research opportunities), snowball sampling, and social media posts. Screening was conducted via phone or an online survey. Advarra, Inc., an independent Institutional Review Board, reviewed and approved formative and concept testing research (Protocol no. PRO 18648).

IDIs were conducted one-on-one by trained facilitators using Zoom video conferencing and lasted approximately 75 minutes. Participants were compensated $100 for their time. Each IDI consisted of a semi-structured discussion that centered around participants’ knowledge of fentanyl and testing facts, while also exploring perceptions of fentanyl risk, relationship with drug sources, and awareness of harm reduction strategies, including naloxone. Next, participants viewed four preliminary concepts and were asked to describe the message, overall reactions (e.g., message appeal, personal relatability), specific likes/dislikes, if they learned new information/facts, and suggested changes. Our analysis is based on participants’ reactions to the concepts.

Materials

The Decision Blocks framework and insights from formative testing guided the development of four concepts (Table 1 describes each concept). The first two concepts, Blind Luck and Farm-to-Friend, aimed to build knowledge and address knowledge gaps by including facts highlighting the potency of fentanyl and contaminated drug supplies. The second two concepts, Decision Maker and Backup Plan, focused on building personal relevance to the messages by depicting realistic scenarios while promoting harm reduction strategies like carrying naloxone (Bachhuber et al., 2015; Waye et al., 2018).

Table 1. Concept title and description.

Concept title	Description
Blind Luck	Blind Luck aims to increase the audience’s knowledge by focusing on facts that fentanyl is potent, lethal, and not easily detected. This concept features a casual exchange at a bar where a character offers the bartender drugs. The bartender refuses and informs the character that pills and powders are being laced with fentanyl and that even a salt-sized amount can be deadly.
Farm-to-Friend	Farm-to-Friend aims to increase the audience’s knowledge by highlighting that even a reliable source can have a contaminated supply. This concept features a character acquiring pills from a trusted drug source at a party, and the scene showcases the extensive supply chain from which the pills originated. This concept also includes information that substances (i.e., pills or powders) can be laced and that fentanyl is inexpensive to produce.
Decision Maker	Decision Maker aims to make a personal connection with the audience by showing the gravity of an overdose and that naloxone can save a friend’s life. This concept depicts a casual exchange of drugs at a party, and friends panic as a young man overdoses. Additional information featured: drugs can be laced, fentanyl can lead to an overdose, and naloxone can reverse an overdose.
Backup Plan	Backup Plan aims to make a personal connection with the audience by eliciting empathy through a personal narrative that shows how naloxone saved a friend’s life. The concept features a testimonial with two friends sharing an emotional story of an overdose. Additional information featured: drugs can be laced, fentanyl can lead to an overdose, and naloxone can reverse an overdose.

Data analysis

All IDIs were audio-recorded and transcribed. During data collection, researchers met periodically to discuss notes and debrief about high-level themes. Data analysis involved an inductive approach in which the research team conducted thematic content analysis of the transcripts referencing themes identified during debrief sessions while continuously adding thematic categories emerging from the analysis (Thomas, 2006). Analysis of transcripts and coding was conducted by researchers using NVivo Qualitative Data Analysis Software Program. Coding queries were used to build content themes around fentanyl and each concept, including: fentanyl knowledge, perceptions of drug sources, knowledge of naloxone, concept (likes), concept (dislikes), concept (fact), and concept (relevance).

Results

Participants included 21 young adults ages 18–35 years old who were mostly male (n = 12). Nine identified as Black/African American, five as white, four as Hispanic, and three as other/biracial. All participants had used one or more drugs in the past 12 months listed in Table 2, which shows the frequency of use. Across participants, 19 had used more than one drug, and 10 had used three or more drugs.

Table 2. Frequency of drug use within the past 12 months.

Drug	0	1–10 times	11–19 times	20–40 times
Prescription opioid medication	5	11	1	4
Cocaine	11	6	1	3
Prescription depressant	12	5	1	6
Adderall®	9	5	2	5
Methamphetamine	18	3	0	0

General awareness and knowledge of fentanyl

When asked if they had heard about fentanyl, nearly all participants had heard of it (n = 18) and reported that using it was a “great risk” (n = 18). Participants discussed learning about fentanyl through media or from friends and often cited that it can lead to an overdose and be deadly. For example, a 27-year-old female participant remarked, “the only real reference I have for [fentanyl] is TV, but I know people might foam at the mouth or they’ll choke if they overdose.” One participant who was very familiar with fentanyl described key characteristics, “I’ve heard that it’s a drug. If you take too much of it, it can definitely kill you. I guess it’s pretty—I’m guessing it’s cheap to get or easy to get because they’ll mix it with the actual drug or they’ll make it with the actual drugs so that it can either increase its strength, or it can supplement it. Yeah, so that’s what I’m hearing about it” (Male, 33). A few had heard of fentanyl but could not describe what made it dangerous. One participant struggled to identify fentanyl’s drug category and said, “I’ve only heard of it. I don’t necessarily know what it is. I think it’s some type of medication in regards to the mental state … Like, maybe it’s a depressant, I believe … I’m not sure” (Female, 25). Therefore, although awareness is generally high, facts about fentanyl’s potency and strength could be highlighted in messaging.

Numerous participants reported hearing that fentanyl is increasingly being laced into substances. Most speculated that lacing was likely common in drugs like heroin, cocaine, or meth and less so in marijuana and prescription medications. Some admittedly were unsure about which substances were laced; a 29-year-old male participant shared, “I’ve heard that other drugs have been laced with it. I don’t know what kind of drugs tend to be laced … or maybe everything could get the fentanyl. But I don’t really know much about it. All I know is that it’s a deadly drug.” Notably, despite awareness of fentanyl-laced drugs, most were not concerned about their own drugs. One 29-year–old female expressed, “I have never even thought about that [personal drugs being laced], to be honest. Since I think my drug use is strictly with cocaine, I’ve never really even thought of what else could be laced with it.” Therefore, although general awareness of fentanyl was higher among this audience than previously observed in formative research and other studies (Hughto et al., 2022), there are opportunities to build knowledge about fentanyl.

Perceptions of fentanyl risk and relationships with drug sources

Most participants were not concerned about their exposure to fentanyl. Exposure and overdosing were associated with obtaining drugs from strangers, using drugs impulsively, and using or mixing large amounts that deviate from typical consumption. Some noted that they use drugs for fun and not often enough to feel their use is risky. Additionally, a predominant theme in formative research was that trusting a source contributed to a low perceived risk of fentanyl exposure. In the current study, this theme reemerged and was the most commonly cited reason for low perceived risk. This sense of trust stemmed from having a long-standing relationship or friendship with a source, perceived consistency in drug quality, and dependability. One 33-year-old male shared that friends also use the same supplier, establishing a sense of security:

I trust my source. I mean, we pretty much all use it from the same guy. And then, I haven’t heard any stories. I remember he warned me about [fentanyl]. He was like, hey, just to let you know if you’re getting stuff from other people, watch out for fentanyl … So, he warned me about it, so that’s what made me know about it. So, if he’s warning people that he serves—then I’m sure he’s doing the right thing.

Filling in information gaps about fentanyl in messaging

The concepts Blind Luck and Farm-to-Friend aimed to build foundational knowledge about the risk of fentanyl. Farm-to-Friend focused on establishing the belief that fentanyl is risky by highlighting that fentanyl can contaminate a drug supply despite trusting a source. One participant noted this was eye-opening: “I definitely agree because literally, you can’t always know. If you think you know where it’s coming from, but you don’t know where it came from before. So I think there is already that risk of not knowing” (Female, 31). This concept also informed participants that fentanyl is contaminating the supply chain worldwide, and a participant shared, “I think the supply chain thing is huge … And I think when you’re doing it with friends, it feels super small and close and safe, and I don’t think you think about the supply chain aspect of it. And I think you don’t think about the cost, and you don’t think about the motive of it all …” (Female, 29). As participants discussed messaging, they also expressed the importance of facts that provided clarity about fentanyl’s recent emergence in the drug scene. Farm-to-Friend cited that fentanyl is inexpensive to produce, clarifying why it is commonly used as a lacing agent. One participant noted this was new information: “And it’s like, okay, I get it now. It’s so much cheaper. They make more money, and they don’t care that it affects people. So, you just understand it a little bit more because right now it feels a little bit like, why would people do that? Whereas now it makes a little bit more—it gives a little bit more background to it” (Female, 29).

Blind Luck focused on the facts that fentanyl is potent, deadly, and used to lace pills. Some participants noted those facts were new information, and appreciated when a visual coincided with the message, such as showing that a salt-sized amount can be deadly. One participant stated, “I think it puts it into perspective. It’s a real thing, like this small … I think it was a nice visual like literally, the tiniest thing can kill you” (Male, 29). Although Blind Luck was rated as informative, Farm-to-Friend provided facts about a significant barrier to feeling personally at risk: trusting a source. This concept featured new and meaningful facts about fentanyl and encouraged participants to consider that fentanyl is contaminating the drug supply irrespective of a source.

Forming a personal connection in messaging

The concepts Decision Maker and Backup Plan featured scenarios intended to elicit an emotional response and encourage harm reduction strategies, like carrying naloxone. To do this, Decision Maker displayed an overdose in a serious and urgent tone to elicit fear that it can happen to anyone, while Backup Plan used a testimonial, storytelling approach to elicit empathy and show that naloxone saved a friend’s life. When comparing these approaches, participants felt that emotional storytelling in Backup Plan made the personal connection to the message strong, and as one 33-year-old male explained, “I think someone sharing their own experiences is going to be more convincing to get a point across because you’re more likely to receive the information, I think.” Another participant noted that storytelling enhanced the potential reality of the situation and stated, “It just seemed more meaningful because they were sharing a life experience. And I think that might get through more people’s heads because they’re like, this is real” (Female, 25). In addition to being perceived as meaningful, many participants described being able to imagine themselves in that situation.

Both concepts communicated that carrying naloxone can save a friend’s life, and participants felt this message was motivating. One participant acknowledged that young adults care more about others than themselves, stating, “It is motivating because sometimes we care about the people around us more than ourselves, especially if it’s someone that’s consistently using illegal drugs. Sometimes our own self-worth and what we think about ourselves is a lot lower than how we would feel about somebody we would care about” (Male, 25). This was particularly relevant as participants expressed greater concern about friends’ drug usage than their own. Participants also noted that this approach encouraged them to consider getting naloxone and wanted to learn more about it. According to one participant (Female, 31):

I like this video because it talks more about preventive measures. And I will say that, honestly, I had a thought that went through my mind that said, maybe I should just have it just to have it because I do go out a lot. And I do have friends that do those things, and that could potentially save them.

Although both ads intended to create personal relevance, Backup Plan was selected as the most motivating because it fostered relevance through an emotional narrative. Findings also showed the importance of framing the message as socially centered (i.e., carrying naloxone to save friends) instead of focusing on individual benefits (i.e., carrying naloxone for oneself).

Realistic details and visuals in messaging

Across concepts, participants identified details and visuals that represented their personal experiences with using drugs. When describing these elements, realistic settings were casual, at a party or gathering, and using with friends. One participant stated that showcasing this type of scenario increased the message’s believability and noted, “I’ve bought drugs from someone like that. It’s been a casual thing in that kind of setting” (Female, 35). Participants also shared that these details helped frame the message in a way that felt personally relevant, particularly because they could envision themselves in those circumstances. One participant commented on the realistic nature of featuring a party, “The setting is spot on because this is casual enough. You’re just at a party and someone is like, ‘hey, I got this stuff.’ That is like, I could see myself in that situation. But yeah, that’s where I think it hit home the most because that’s the most relatable part of it” (Female, 27).

Discussion

As the opioid crisis continues, it is critical to develop campaigns and messages that recognize the audience’s needs by engaging them in the development process (Winiker et al., 2020). This qualitative study identified promising messaging themes and approaches using feedback from the target audience of the campaign A Dose of Truth. The current study serves as a guide for other researchers wanting to use a systematic approach to developing health promotion messaging, and contributes to a growing body of literature on fentanyl (Gunn et al., 2021).

This study shed light that fentanyl awareness is growing among young adults who use drugs, which deviates from past research suggesting that people without a history of opioid use were less aware (Hughto et al., 2022; Moallef et al., 2019). Nearly all participants in the study had heard of fentanyl and could cite that exposure to it is risky and deadly, and this seems to be primarily due to growing media attention on the topic.

Despite this growing awareness, participants in this study did not perceive they were personally at risk of fentanyl exposure, which is consistent with previous work conducted with young adults (Gunn et al., 2021). The current study showed that people were most apt to perceive that risk was related to the quantity consumed, impulsivity, and importantly, a drug source. Participants believed their sources were trustworthy because they were consistent, and building a relationship with their suppliers established a belief that their drugs were safe. This was also consistent with other findings that showed the particular relevance of trusting a source when engaging in risky behavior when using drugs (Goldman et al., 2019). These insights suggest these are knowledge gaps about fentanyl that are necessary to address in messaging in order to establish foundational knowledge about fentanyl, and subsequently be able to create personal relevance for fentanyl risk. Additionally, researchers emphasize that public health messaging should aim to debunk stereotypes about PWUD and focus on societal framing (i.e., a contaminated drug supply), as this framing is less apt to perpetuate negative stereotypes about PWUD (Collins et al., 2018). Farm-to-Friend provided the audience with the directive to question a source and showcased that the contamination of a drug supply is a broader global issue while also providing the audience an explanation as to why fentanyl had become prevalent (i.e., cheap to produce). Based on feedback, participants found these arguments compelling, and this work demonstrates that this was an effective strategic opportunity to educate this audience about fentanyl.

A subsequent critical step in developing effective messaging is establishing personal relevance of the risk. To do this, researchers encourage developing interventions that focus on creating messages that elicit empathy (Bennett et al., 2020) while promoting the use of harm reduction strategies (Mars et al., 2019; McGowan et al., 2018). In the current study an emotional narrative that showcased a harm reduction strategy, carrying naloxone to save a friend’s life, was key to establishing a personal connection. Feedback demonstrated that the testimonial style of Backup Plan, which featured two friends telling an emotional story about unexpectedly overdosing and naloxone saving a friend’s life, was motivating. This approach diverged from Decision Maker, which relied on a more serious, urgent tone when communicating a similar message. Similar to other studies, these findings suggest that effective strategies should be less fear-based (Soames Job, 1988), and more focused on eliciting empathy to enhance persuasion (Shen, 2011).

This study also showed that concern for the safety of friends was an effective approach in messaging. Findings highlighted that young adults were more concerned about friends’ drug use than their own, and participants expressed a greater motivation to carry naloxone to protect friends than themselves. Latkin et al. (2019) reported similar findings in which people expressed greater concern for friends overdosing than personally overdosing. Therefore, the strategic approach to build concern for friends, coupled with the authenticity of the characters and story, was effective in amplifying the personal relevance of the message. Once the audience has established a deeper connection that they can be personally affected, the Decision Blocks framework suggests that messaging can focus on encouraging action by presenting the audience with realistic and achievable solutions that address barriers (i.e., how to obtain and administer naloxone).

These findings illustrate the importance of understanding an audience and involving them in the development of a campaign, as this is essential in forming strategies that will be relevant to their experiences. Winiker et al. (2020) pointed out that creating a message that fails to account for the feasibility of a message decreases the chances the message will be effective. Across all concepts, participants pointed out features that made messages realistic: casual drug exchanges, party settings, and using with friends. For young adults who may use recreationally, displaying use as a social activity may be particularly relevant compared to PWUD alone (Bardwell et al., 2019). For PWUD, the settings and experiences should be realistic in order to establish the personal relevance that an overdose can happen. Therefore, these findings demonstrate that the audience’s feedback was essential in identifying features that represented their personal experiences, and future campaigns should ensure that an audience’s feedback is considered during campaign development.

These concepts promote carrying naloxone as one avenue for messaging, but future investigations can explore other harm reduction strategies. For example, other interventions could focus on promoting testing drugs and the distribution of fentanyl test strips (Carroll et al., 2017). While participants were generally receptive to carrying naloxone in the current study, Bennett et al. (2020) found a variety of barriers that may impede people’s willingness to carry naloxone, including stigma and concerns about being outed as a drug user. This study, however, showed that reframing the focus to be centered on others, specifically carrying naloxone for friends, may lessen stigma related to carrying naloxone for personal reasons (Bennett et al., 2020). Nevertheless, these are considerations when targeting other audiences, as the concern of stigma may be more pronounced among people who are in treatment or who report a high frequency of drug use.

Study limitations

This study relied on a limited sample whose experiences may not reflect those of the general population at risk of fentanyl exposure. Additionally, this analysis did not assess subgroup differences in feedback since such differences would be more accurately evaluated through larger samples. Although it was intended, enrollment criteria included using a variety of illicit substances in the past 12 months; therefore, these findings might not be generalizable to people who use one substance or who might not be polysubstance users. Thus, future campaigns and interventions should ensure that feedback from an intended audience is captured.

Conclusion

The opioid epidemic continues to be a pressing public health issue, and exposure to fentanyl has become increasingly relevant for PWUD, particularly young adults. This research addresses a gap within the literature by exploring young adults’ knowledge about fentanyl, and reactions to preliminary concepts designed to educate an audience about fentanyl and harm reduction strategies. The current study provides tangible guidance for future campaigns on fentantyl and other substances.

Acknowledgments

We are grateful to Gray Abarca, Penny Norman, Farah Kauffman, Michelle Bellon, Jeff Jordan, Molly Barry, Katie Weber, Alex Davis, Laura Gover, Lauren Bozarth, and Rafael Rivera for their support of this work. We also gratefully acknowledge our participants.

Declaration of interest

Priscilla Fernandez and Danny Azucar are employed by Rescue Agency, and Kim Zambole is employed by Prevention First.

Additional information

Funding

This article was supported, in part, by grant number TI-TI083278 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The content of this article does not necessarily reflect the views or policies of SAMHSA or the U.S. Department of Health and Human Services (HHS).