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More people die after smoking drugs than injecting them, US study finds

A man is hunched over, using a straw on a device in his hand, with graffiti and items in the background.
U.S. officials decided to study the issue after seeing reports from California suggesting that smoking fentanyl was becoming more common. | Source: Benjamin Fanjoy for The Standard

Smoking has surpassed injecting as the most common way of taking drugs in U.S. overdose deaths, 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.

CDC officials decided to study the topic after seeing reports from California suggesting that 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 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 it’s not yet clear if a shift toward smoking fentanyl reduces U.S. overdose deaths, said Tanz, a CDC scientist who studies overdoses.

Paramedics load a person on a stretcher into an ambulance labeled "San Francisco Fire Department."
A person is loaded into an ambulance near U.N. Plaza, the longtime epicenter of San Francisco’s drug and homelessness crises, in January. | Source: Jason Henry for The Standard

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.

In San Francisco, at least 813 people died from overdoses last year—the worst year on record—according to revised data released by the city on Wednesday. In January, the city recorded 66 overdose deaths, the majority of which were attributed to fentanyl, according to preliminary data.

For years, fentanyl has mainly been injected, but drug users have increasingly smoked it. People put the powder on tin foil or in a glass pipe, heated from below, and inhale the vapor, explained Alex Kral, a 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 upsides to smoking, Kral said. Among them: 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 that 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.

People congregate near the intersection of 7th and Market in downtown San Francisco on Oct. 16, 2023.
People congregate near the intersection of Seventh and Market in downtown San Francisco in October 2023. The intersection is known for its open-air drug trade, where fentanyl and other narcotics are bought and sold. | Source: Loren Elliott for The Standard

It’s complicated to map out exact percentages of deaths that occurred after smoking, injecting, snorting or swallowing drugs, experts say. 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 said she feels 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 said it has limitations.

It can be difficult to ascertain the how and why of an overdose death, especially if no witness was present. Injections might be more commonly reported 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.

Kral also noted that many people who smoke fentanyl use a straw to inhale vapors from the burning powder, and it's possible investigators saw a straw and assumed it was snorted.