• Posted February 16, 2024

Smoking Now Fuels More Drug Overdoses than Injecting Does

Despite stereotypical images of addicts injecting heroin and then dying, new government research finds that smoking drugs such as fentanyl is now the leading cause of fatal overdoses.

In the new research, published Thursday in Morbidity and Mortality Weekly Report, scientists from the U.S. Centers for Disease Control and Prevention found the percentage of overdose deaths between January 2020 and December 2022 linked to smoking increased 73.7% -- going from from 13.3% to 23.1% -- while the percentage of overdose deaths linked to injection decreased 29.1% -- going from from 22.7% to 16.1%.

These changes were most pronounced when fentanyl was the drug of choice: In those cases, the percentage with evidence of injection decreased 41.6%, while the percentage with evidence of smoking increased 78.9%.

CDC officials explained in their report that they decided to tackle the topic after seeing reports from California suggesting that smoking fentanyl was becoming the preferred way to use the deadly drug.

Fentanyl accounts for nearly 70% of overdose deaths in the United States, they noted.

Some early research has suggested that smoking fentanyl is somewhat less deadly than injecting it, and any reduction in injection-related overdose deaths is a positive, report author Lauren Tanz, a CDC senior scientist who studies overdoes, told the Associated Press.

However, "both injection and smoking carry a substantial overdose risk,"and it's not clear if a shift toward smoking fentanyl will lower the number of U.S. overdose deaths, Tanz said.

Fentanyl is a powerful drug that, in powder form, is cut into heroin or other drugs. In recent years, it's been fueling the U.S. overdose epidemic. Drug overdose deaths climbed slightly in 2022 after two big leaps during the pandemic, and provisional data for the first nine months of 2023 suggests it inched up again last year, the AP reported.

For years, fentanyl has been injected, but drug users often smoke it now. Users put the powder on tin foil or in a glass pipe, heated from below, and inhale the vapor, Alex Kral, a RTI International researcher who studies drug users in San Francisco, told the AP.

Smoked fentanyl is not as concentrated as fentanyl in a syringe, but some users see upsides to smoking, Kral explained, including the fact that people who inject drugs often deal with pus-filled abscesses on their skin and risk infections with hepatitis and other diseases.

"One person showed me his arms and said, 'Hey, look at my arm! It looks beautiful! I can now wear T-shirts and I can get a job because I don't have these track marks,'"Kral said.

In the new report, investigators were able to cull data from the District of Columbia and 27 states for the years 2020 to 2022. From there, they tallied how drugs were taken in about 71,000 of the more than 311,000 total U.S. overdose deaths over those three years.

By late 2022, 23% of the deaths occurred after smoking, 16% after injections, 16% after snorting and 14.5% after swallowing, the researchers reported.

Tanz said she feels the data is nationally representative because it came from states in every region of the country, and all showed increases in smoking and decreases in injecting. Smoking was the most common route in the West and Midwest, and roughly tied with injecting in the Northeast and South, the report found.

Kral noted the study has some limitations.

It can be difficult to determine the exact cause of an overdose death, especially if no witness was present, he said, and injections might be more reported more often because it is easy to spot needle marks on the body. To detect smoking as a cause of death, "they likely would need to find a pipe or foil on the scene and decide whether to write that down,"he said.

Kral added that many people who smoke fentanyl use a straw, and it's possible investigators saw a straw and assumed it was snorted.

More information

The National Institute on Drug Abuse has more on drug overdose deaths.

SOURCE: Morbidity and Mortality Weekly Report, Feb. 16, 2024; Associated Press