Smoking illicit substances like fentanyl, cocaine and heroin has replaced injection as the most commonly documented route of use in overdose deaths across the country, according to a federal study released Thursday.
Researchers suggest that the transition might be driven by a perceived decrease in risks. Prior studies have indicated smoking fentanyl results in fewer adverse health effects like abscesses and bloodborne infections, comes at a lower cost than injection, and has “a perception of reduced overdose risk” despite the substantial dangers of rapid drug absorption.
The data supports harm-reduction advocates' years-long effort to transition people away from injecting and toward smoking, according to Rich Baker, the deputy director of prevention at harm-reduction nonprofit Victory Programs.
“It's been really helpful in working with people who are injecting really frequently. Fentanyl makes you inject far more frequently than heroin did, and people had a lot more vein damage, way more abscesses and way more soft tissue infections from injection,” Baker said.
The number of overdose fatalities in Massachusetts reached 2,359 in 2022, the highest record ever set in the state, according to the Department of Public Health.
Despite widespread claims that smoking might be less dangerous than other routes, there’s not enough research to support the possible benefits of this transition, according to Dr. Andrew Kolodny, the medical director for opioid policy research at Brandeis’ Heller School for Social Policy and Management.
“There are some potential benefits from smoking rather than injecting when it comes to injection-related infectious diseases … but then again, with smoking, we may find that there are lung diseases that develop. So we don’t really don't know if this is a positive or negative trend,” Kolodny said. “Certainly from an overdose standpoint, we haven't seen any significant decline in fentanyl-related overdose deaths as more people transition, which suggests that smoking is not safer than injecting.”
Overdose rates remain at historically high levels in Massachusetts and the Northeast.
From 2020 through 2022, the number of overdose deaths with evidence of smoking doubled across all geographic regions, rising by 91% in the Northeast. The biggest increases involved illegally manufactured fentanyl, according to the Centers for Disease Control and Prevention. While smoking has become more prevalent across the nation, injection rates remain high in the Northeast, dropping by about 21% in the study period but remaining one of the most common methods in the region.
Polysubstance use, which involves mixing substances like synthetic opioids with stimulants like cocaine or methamphetamine, was responsible for a substantial uptick in overdose deaths, according to the CDC.
“Polysubstance use has consistently been on the rise,” Baker said. “We always tell people to start low, go slow and not assume that the amount you took when you were injecting is going to equate the amount you would take when you’re smoking. We’re always evolving that messaging.”
While efforts to reduce the harm around using drugs have previously focused on the dangers related to injection, this study presents new challenges for harm reduction experts like Azzy-Mae Ní Mháille, who represents the Eastern branch of the New England Users Union, a local advocacy group for people who use drugs.
"This data is indicative of the need for supervised consumption spaces in the immediate, and the rapid expansion of drug-checking services,” Ní Mháille said. “Substance consumption isn't going anywhere, yet across the country we see heavy-handed tactics forcing people away from resources that would see these rates of overdoses decline.”
The Users Union provides resources for people who use drugs, including guides on how to reduce dangers associated with smoking, which has been shown to intensify the effects of substances and increase the risk of overdose, as opposed to injection.
“We definitely have seen an increase in engagement with distributing injection alternatives, particularly smoking supplies,” they said. The supplies come with warnings: never use alone, don’t share pipes, use a mouthpiece or cover, and test drugs with either fentanyl test strips or, preferably, by bringing them to one of several drug-testing centers around the state.
Despite support from the state’s Department of Public Health, overdose prevention sites remain illegal in Massachusetts. Elsewhere in the Northeast, there are currently two in New York and another is set to open next year in Providence, Rhode Island.
The study has big implications for how future overdose prevention sites might be set up, including safe inhalation areas and an increase of safe smoking equipment, Baker said.
“The current operating overdose prevention sites in New York City have smoking rooms where people can go and smoke their substances in a ventilated room while being monitored by support staff,” he said. “We have to continue to think about people’s preferences as the way they consume drugs shifts.”
