Preference for drugs containing fentanyl from a cross-sectional survey of people who use illicit opioids in three United States cities

•A quarter of surveyed street-based people who use drugs reported a preference for fentanyl.•Fentanyl preferers were younger, non-Hispanic white, and daily users of drugs.•Frequency of use, not route of administration, indicated fentanyl preference.•Exposure to fentanyl among daily users was not differentiated by fentanyl preference. Death from fentanyl-related overdose is now a leading cause of mortality among US adults. We sought to characterize fentanyl preference among street-based people who use drugs (PWUD). Cross-sectional surveys were administered to PWUD (N = 308) who illicitly used heroin or prescription opioids in the prior six months. Recruitment occurred in 2017 in three US east coast cities with high overdose mortality: Baltimore, Boston, and Providence. Our main outcome was preference for fentanyl (yes/no); exposures included sociodemographics, drug use, and overdose history. Pearson’s χ2, Shapiro-Wilk-Mann rank-sum tests, and tiered log-binomial regression determined sociodemographic and exposure-related factors associated with fentanyl preference. Preference for nonmedical use of fentanyl was reported by 27% (n = 83) of the sample. Fentanyl preference was associated with non-Hispanic white race (adjusted risk ratio (ARR) = 1.68, 95% confidence interval (CI):1.18–2.40), daily illicit drug use (aRR = 2.2, CI:1.71–2.87), and overdose ≥1 year ago (aRR = 1.33, CI:1.18–1.50). Age (in decades; aRR = 0.77, CI:0.61–0.98) and overdose