“I don’t know how you can overdose smoking them:” 

Illicitly manufactured fentanyl (IMF) remains a critical driver of overdose mortality in the US (Spencer et al., 2024), and there are emerging concerns about its proliferation in other regions of the globe (Friedman & Ciccarone, 2025; Piatkowski et al., 2025). The spread of IMF in the local drug markets in the US has shown increasing complexity with notable regional differences in the types of IMF products available, and associated contamination risks (Kilmer et al., 2022). While powder IMF has been the predominant form in the Eastern part of the US, western states, including Arizona, have seen significant increases in the availability of IMF in counterfeit pill form, most commonly 30 mg oxycodone, referred to as “blues” or “M30s” (Daniulaityte et al., 2022; O’Donnell et al., 2023; Palamar et al., 2022, 2024). For example, between 2017 and 2023, the total number of IMF pill seizures in the US increased by 8509.7 %, and the increase was the steepest in the West (an 11,266.7 % increase) (Palamar et al., 2024). Increases in IMF pill presence have been especially dramatic in Arizona with retail-level seizures of IMF pills increasing from about 1000 in 2017, to 18,004 in 2019, and 155,572 pills in 2020 (Mully et al., 2020). In 2023, Arizona had the highest number of IMF pill seizures in the country (n = 1638), and the second highest in the total number of IMF pills seized (n = 36,525,410) (Palamar et al., 2024).

Along with the increasing availability of IMF in counterfeit pill form, Arizona experienced significant rise in overdoses. Overdose deaths in Arizona increased from 1532 in 2017 to 2550 in 2020, and 2664 in 2022 (Centers for Disease Control & Prevention, 2022). Available data on seized drugs in Arizona indicate that in 2022 seized counterfeit pills contained 2.5 mg of fentanyl on average, with a range of 0.03 to 5.0 mg/tablet (Drug Enforcement Administration, 2024). Nationally, in 2022, an estimated 6 in 10 seized counterfeit pills were found to contain at least 2 mg of fentanyl, which is considered a potentially lethal dose (Glidden et al., 2024). Arizona currently does not have community-based drug checking programs, and there is limited up-to date information on the changes in potency of counterfeit pills or on the types of other substances that may be present in them. Data from other regions suggest that besides fentanyl, the pills may contain other fentanyl analogs, acetaminophen, and other drugs (Wightman et al., 2024).

Prior studies have identified a broad range of behaviors and conditions that are associated with an increased likelihood of opioid overdose. Some of these established risk factors include prior overdose experiences, concurrent use of benzodiazepines or alcohol, returning to high doses after losing tolerance (e.g., individuals recently released from prison or inpatient drug treatment), and physical and mental health comorbidities (Carlson et al., 2020; Darke & Hall, 2003; Darke et al., 2014; Kline et al., 2021; Park et al., 2016). However, established frameworks and “expert knowledge” that guide overdose prevention interventions may not align with the perceptions and experiences of people who use drugs (Chang et al., 2024; Moallef et al., 2019). Risk assessment is not an objective and value free enterprise, but it is embedded in the individual histories and experiences, underlying socio-cultural values, and broader structural and environmental conditions (Agar, 1985; Rhodes, 2002). There is a need for qualitative studies to help increase the understanding of how people who use IMF view, experience and judge their overdose-related risks.

Several prior qualitative studies have examined overdose risks in the era of IMF spread, aiming to characterize how people who use drugs (PWUD) experience IMF risks, what harm reduction strategies they employ, and how broader social and structural factors contribute to the local environments of risk (Abadie, 2023; Bardwell et al., 2021; Beharie et al., 2023; Ciccarone et al., 2024; Collins et al., 2024; Fadanelli et al., 2020; Gunn et al., 2021; Lamonica et al., 2021; Latkin et al., 2019; Macmadu et al., 2022; Victor et al., 2020). Many of the prior studies on IMF-related overdose risk perceptions and experiences were conducted at the initial stages of IMF spread, and primarily focused on overdose risks associated with inadvertent exposures to IMF contaminated heroin or other drugs (Abadie, 2023; Ataiants et al., 2020; Carroll et al., 2017; Lamonica et al., 2021; Latkin et al., 2019; Stein et al., 2019; Victor et al., 2020). More research is needed to understand the perceptions of IMF-related overdose risks in the context of high market saturation with IMF, and among individuals who intentionally seek and use IMF-containing drugs. Further, most prior studies were conducted in the regions where IMF is primarily available in powder form and as a contaminant of or replacement for heroin Carroll et al. (2017); Ciccarone et al. (2024, 2017); Latkin et al. (2019); Mars et al. (2018); Moallef et al. (2019). A few recent studies conducted in California described an increasing trend of individuals who use opioids switching from injection to smoking route of using IMF in powder form. These emerging studies have highlighted health-related benefits that were linked to this transition, including potential reduction in overdose risks (Ciccarone et al., 2024; Kral et al., 2021; Megerian et al., 2024). In the context of these important findings, there remains a lack of data on overdose risk perceptions related to the use of IMF in a counterfeit pill form. This qualitative study, conducted in Phoenix, Arizona, aims to address these key gaps and provide an in-depth understanding of how overdose-related risks are viewed and experienced by people who intentionally seek and use IMF-laced counterfeit pain pills (blues).