Smoking surpasses injecting in fatal overdoses

New government study of fentanyl deaths identifies changing trend in delivery

NEW YORK — Smoking has surpassed injecting as the most common way of fatally overdosing on drugs in the U.S., a new government study suggests.

The Centers for Disease Control and Prevention called its study published Thursday the largest to look at how Americans took the drugs that killed them. The impetus came from California reports suggesting smoking fentanyl was becoming more common than injecting it.

Potent, illicit versions of the painkiller are involved in more U.S. overdose deaths than any other drug.

Some early research has suggested 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 it’s not yet clear if a shift toward smoking fentanyl reduces U.S. overdose deaths, said Tanz, a CDC scientist.

Illicit fentanyl is an infamously powerful drug that, in powder form, increasingly has 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 big leaps during the pandemic, and provisional data for the first nine months of 2023 suggests it inched up last year.

To smoke fentanyl, people put the powder on tin foil or in a glass pipe, heated from below, and inhale the vapor, said Alex Kral, a researcher with RTI International who studies drug users in San Francisco.

Smoked fentanyl is not as concentrated as fentanyl in a syringe, but 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 by using a national database built from death certificates, toxicology reports and reports from coroners and medical examiners.

They were able to get suitable data from the District of Columbia and 27 states for the years 2020 to 2022. From those places, they got information on how drugs were taken in about 71,000 of the more than 311,000 total U.S. overdose deaths over those three years — or about 23%.

The researchers found between early 2020 and late 2022, the percentage of overdose deaths with evidence of smoking rose 74% while the percentage of deaths with evidence of injection fell 29%. The number and percentage of deaths with evidence of snorting also increased, though not as dramatically as smoking-related deaths, the study found.

Determining percentages of deaths that occurred after smoking, injecting or snorting is complicated. In some cases, a person may have used multiple drugs, taken different ways. In other cases, no drug-taking method was identified.