Smoking Drugs Kills More People Than Injecting Them, US Study Finds

CDC officials opted to investigate this subject following reports from California indicating that smoking fentanyl was increasingly prevalent compared to injecting it. Illicit variations of this powerful painkiller are implicated in more overdose deaths in the United States than any other substance.

According to the study's lead author, Lauren Tanz, preliminary research indicates that smoking fentanyl might be slightly less lethal than injecting it. Any decline in overdose deaths related to injection is considered a favorable outcome.

However, “both injection and smoking carry a substantial overdose risk,” and it remains uncertain whether a transition towards smoking fentanyl leads to a decrease in overdose deaths in the United States," stated Tanz, a CDC researcher specializing in overdose studies.

Illicit fentanyl, infamous for its immense potency, is frequently mixed into heroin or other substances in powdered form. Over recent years, it has been a major contributor to the overdose epidemic in the United States. Despite two significant increases during the pandemic, drug overdose fatalities in the U.S. experienced a slight rise in 2022, and preliminary data for the first nine months of 2023 indicates a further slight increase last year.

Over the years, fentanyl has predominantly been administered through injection, but there has been a growing trend among drug users to smoke it. According to Alex Kral, a researcher at RTI International who focuses on studying drug users in San Francisco, individuals typically place the powder on tin foil or in a glass pipe, apply heat from below, and inhale the resulting vapor.

According to Kral, smoked fentanyl is less concentrated than the version administered via syringe, but some individuals who use drugs perceive advantages to smoking. One benefit noted is that individuals who inject drugs frequently contend with skin abscesses filled with pus and face risks of contracting hepatitis and other infections.

“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 examined the trend by utilizing a nationwide database compiled from death certificates, toxicology reports, and information provided by coroners and medical examiners.

Suitable data was obtained from the District of Columbia and 27 states for the years 2020 to 2022, comprising information on how drugs were consumed in approximately 71,000 out of over 311,000 total overdose deaths in the United States during that period— roughly 23%.

The researchers observed that between early 2020 and late 2022, there was a 74% increase in the proportion of overdose deaths with indications of smoking, while the percentage of deaths involving injection decreased by 29%. Additionally, the study revealed a rise in the number and proportion of deaths associated with snorting, although not as dramatically as those related to smoking.

Experts caution that determining precise percentages of deaths attributed to smoking, injecting, snorting, or ingesting drugs is complex. Some cases involve the use of multiple substances through various methods, while in others, the method of drug consumption remains unidentified.

According to the study, among the deaths where a method of drug intake was identified, 23% resulted from smoking, 16% from injection, 16% from snorting, and 14.5% from swallowing in late 2022.

Tanz expressed confidence in the national representativeness of the data, as it was collected from states across all regions of the country, all of which exhibited increases in smoking and decreases in injection. The report highlighted that smoking emerged as the primary method in the West and Midwest, while in the Northeast and South, it was nearly equal to injection.

Kral praised the study as “mostly good” but highlighted its limitations. Determining the specifics of how and why an overdose occurred can be challenging, especially in the absence of witnesses. Injection cases may be more readily identifiable due to visible injection marks, whereas identifying smoking likely would need to find a pipe or foil on the scene and decide whether to write that down,” he said.

Additionally, Kral noted that individuals who smoke fentanyl often use a straw to inhale vapors, which could potentially be mistaken for snorting by investigators.