Behavioral Safety and Fentanyl Education: BSAFE

Fentanyl overdose mortality has skyrocketed over the past decade. Most of these deaths also involve stimulants (cocaine or methamphetamine). Multiple investigations have demonstrated a substantial contribution of unintentional fentanyl use (UFU) to medically-attended opioid overdose and opioid overdose mortality. This mostly occurs among people using stimulants (cocaine or methamphetamine). While contamination of drugs contributes to UFU, the mechanism is usually related to how drugs are obtained, prepared, and consumed (e.g., finding a drug that is assumed to be a stimulant, letting someone else prepare a drug for use, or using a pipe that was used by someone else). This mechanism of risk can be readily intervened upon with behavioral and educational strategies. We propose to adapt a successful opioid overdose prevention intervention to address UFU among people who use stimulants and do not intentionally use opioids and adapt that intervention to ensure acceptability among high-risk persons. The repeated-dose intervention, B-SAFE, will focus on developing an individualized UFU prevention plan, augmented with weekly SMS reminders and linkage to care for stimulant use treatment. We will test the intervention against usual care (referrals to low-threshold services and treatment, on-site access to overdose prevention supplies) with attention control in a randomized-controlled trial of 160 persons seen every 4 months over 16 months. Results from this trial, conducted at the San Francisco Department of Public Health, will allow us to evaluate a critical intervention to reduce fentanyl overdose and resultant death among a population that should not be experiencing opioid overdose at all. If the intervention proves effective, the health department is well-positioned to continue providing the service.