Smoking has now surpassed injecting as the most common way of ingesting drugs in U.S. overdose deaths. This is according to a new government study from the Centers for Disease Control and Prevention.
The institution called its study published Thursday the largest to look at how Americans took the drugs that killed them. CDC officials studied the topic after seeing reports suggesting that smoking fentanyl was becoming more common than injecting it.
Potent, illicit versions of the painkiller have connections to more U.S. overdose deaths than any other drug. Some early research suggested that smoking fentanyl is somewhat less deadly than injecting it, and any reduction in injection-related overdose deaths is a positive, said the study’s lead author, Lauren Tanz.
But “both injection and smoking carry a substantial overdose risk.” And Tanz, a CDC scientist who studies overdoses, believes it is still unclear if smoking fentanyl reduces overdose deaths.
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Illicit fentanyl is a powerful drug that, in powder form, has increasingly been cut into heroin or other drugs. In recent years, it’s been a primary driver of the U.S. overdose epidemic. Drug overdose deaths in the U.S. went up slightly in 2022 after two giant leaps during the pandemic, and provisional data for the first nine months of 2023 suggests it rose last year.
For years, people ingested fentanyl mainly via injection, but drug users have increasingly been smoking it. Alex Kral explained that people put the powder on tin foil or in a glass pipe, heat it from below, and inhale the vapor. He is an RTI International researcher who studies drug users in San Francisco.
Smoked fentanyl is not as concentrated as fentanyl in a syringe, but some drug-takers see advantages to smoking, Kral said. One advantage is the lack of scars. People who inject 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.
CDC investigators studied the trend with a national database built from death certificates, toxicology reports, and reports from coroners and medical examiners. They got suitable data from the District of Columbia and 27 states from 2020 to 2022.
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There was information on how people took drugs in about 23% of the total U.S. overdose deaths over those three years. What they found was that between early 2020 and late 2022, the percentage of overdose deaths with evidence of smoking rose by 74%, while the percentage of deaths with evidence of injection fell by 29%.
The number and percentage of deaths with evidence of snorting also increased, though not as dramatically as smoking-related deaths. It’s challenging to map out the exact percentages of deaths that follow the smoking, injecting, snorting, or swallowing of drugs.
In some cases, a person may have used multiple drugs taken different ways. In other cases, no drug-taking method was identified. The study found that in late 2022, of the deaths for which a method was identified, 23% of the deaths occurred after smoking, 16% after injections, 16% after snorting, and 14.5% after swallowing.
Tanz believes the data is nationally representative. Data came from states from 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 said.
Kral described the study as “mostly good” but admits it has limitations. It can be difficult to determine the how and why of an overdose death, especially if there were no witnesses.
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Injections might be more common because of injection marks on the body. To detect smoking, “they likely would need to find a pipe or foil on the scene and decide whether to write that down,” he said.
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