{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T20:17:58Z","timestamp":1791404278105,"version":"4.3.3"},"reference-count":49,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2024,5,22]],"date-time":"2024-05-22T00:00:00Z","timestamp":1716336000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000026","name":"National Institute on Drug Abuse","doi-asserted-by":"publisher","award":["DA054190"],"award-info":[{"award-number":["DA054190"]}],"id":[{"id":"10.13039\/100000026","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Illicitly manufactured fentanyls and stimulants are implicated in the escalating US mortality from drug overdose. San Francisco, California (SF) has seen declining fentanyl injection while smoking has increased. Beliefs and behaviors surrounding this development are not well understood.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>The study used rapid ethnography to explore fentanyl and methamphetamine use in SF. The team conducted semi-structured interviews (n = 34) with participants recruited from syringe service programs. Video-recorded smoking sequences (n = 12), photography and daily field notes supplemented interview data.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Difficulty injecting and fear of overdose motivated transitions from injecting to smoking. Fentanyl was extremely cheap\u2014$10\/gram\u2014with variability in quality. Foil was the most commonly used smoking material but glass bubbles, bongs and dabbing devices were also popular. No reliable visible methods for determining fentanyl quality existed, however, participants could gauge potency upon inhalation, and developed techniques to regulate dosage. Several participants reported at least hourly use, some reporting one or more grams of daily fentanyl consumption. Smoking was also very social, with people sharing equipment, drugs and information. Participants raised concerns about hygiene and overdose risk to others arising from shared equipment. Reportedly potent fentanyl \u2018residue\u2019 accumulated on smoking materials and was commonly shared\/traded\/stolen or consumed accidentally with diverse preferences for its use.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>Our data highlight fentanyl residue as a new overdose risk with potential mismatch between the potency of the residual drug and the recipient\u2019s tolerance. Further, large doses of fentanyl are being consumed (estimated at approximately 50 mg of pure fentanyl\/day). Smoking fentanyl has potential health benefits over injecting and may be protective against overdose, but substantial uncertainty exists. However, SF overdose mortality hit a record high in 2023. Recommendations to reduce fentanyl smoking overdose risks through pacing, greater awareness of dosages consumed and checking tolerance of residue recipients are potentially viable interventions deserving further exploration.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0303403","type":"journal-article","created":{"date-parts":[[2024,5,22]],"date-time":"2024-05-22T17:22:27Z","timestamp":1716398547000},"page":"e0303403","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":61,"title":["Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco"],"prefix":"10.1371","volume":"19","author":[{"given":"Daniel","family":"Ciccarone","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-2480-3903","authenticated-orcid":true,"given":"Nicole","family":"Holm","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9954-7932","authenticated-orcid":true,"given":"Jeff","family":"Ondocsin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allison","family":"Schlosser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason","family":"Fessel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda","family":"Cowan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah G.","family":"Mars","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,5,22]]},"reference":[{"key":"pone.0303403.ref001","doi-asserted-by":"crossref","first-page":"109003","DOI":"10.1016\/j.drugalcdep.2021.109003","article-title":"Transition from injecting opioids to smoking fentanyl in San Francisco, California.","volume":"227","author":"AH Kral","year":"2021","journal-title":"Drug Alcohol Depend"},{"key":"pone.0303403.ref002","volume-title":"Addictions, Drug & Alcohol Institute, Department of Psychiatry & Behavioral Sciences","author":"S Kingston","year":"2022"},{"issue":"34","key":"pone.0303403.ref003","doi-asserted-by":"crossref","first-page":"897","DOI":"10.15585\/mmwr.mm6634a2","article-title":"Trends in Deaths Involving Heroin and Synthetic Opioids Excluding Methadone, and Law Enforcement Drug Product Reports, by Census Region\u2014United States, 2006\u20132015.9","volume":"66","author":"JK O\u2019Donnell","year":"2017","journal-title":"Morb Mortal Wkly Rep"},{"key":"pone.0303403.ref004","first-page":"65","article-title":"Fentanyl law enforcement submissions and increases in synthetic opioid\u2013involved overdose deaths\u201427 states, 2013\u20132014.","author":"RM Gladden","year":"2016","journal-title":"MMWR Morb Mortal Wkly Rep."},{"issue":"11","key":"pone.0303403.ref005","first-page":"8","article-title":"Drug and Opioid-Involved Overdose Deaths\u2013United States, 2017\u20132018.","volume":"69","author":"N Wilson","year":"2020"},{"issue":"3","key":"pone.0303403.ref006","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/j.drugpo.2008.08.003","article-title":"Heroin in brown, black and white: Structural factors and medical consequences in the US heroin market","author":"D. 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