Image from CDC's report
More than 109,000 people died of drug overdoses in the United States in 2022, and nearly 70% of those deaths involved illegally made fentanyl and fentanyl analogs (IMFs). Reports from the West suggested people were switching from injecting heroin to smoking IMFs. CDC looked at whether that shift was happening nationwide.
The data
CDC's State Unintentional Drug Overdose Reporting System gathers death certificates, toxicology results and medical examiner or coroner reports. The study covered 28 jurisdictions — 27 states and D.C. — from January 2020 to December 2022: 139,740 overdose deaths, with deaths rising 20.2% between the first and last half-years. Scene investigations, witnesses or autopsies showed at least one route of drug use in 51.2% of deaths.
Smoking took the lead
Overdose deaths with evidence of each route, January 2020–December 2022. Image from CDC's report
| Route | Early 2020 | Late 2022 | Change in share |
|---|---|---|---|
| Smoking | 13.3% | 23.1% — now the most common | up 73.7%; the number of deaths more than doubled, from 2,794 to 5,843 |
| Snorting | 13.6% | 16.2% | up 19.1% |
| Injection | 22.7% — then the most common | 16.1% | down 29.1% |
| Swallowing | 15.2% | 14.5% | down 4.6% |
By late 2022, most deaths with evidence of smoking (79.7%), snorting (84.5%) or swallowing (86.5%) showed no sign of injection, and 81.9% of deaths with route information involved a non-injection route.
Every region
Routes of drug use in overdose deaths by region. Image from CDC's report
Smoking rose and injection fell in all four regions:
| Region | Smoking, early 2020 → late 2022 | Injection, early 2020 → late 2022 |
|---|---|---|
| Northeast | 8.9% → 17.0% | 21.2% → 16.7% |
| Midwest | 12.4% → 21.7% | 21.8% → 13.9% |
| South | 12.5% → 18.5% | 25.9% → 18.7% |
| West | 25.1% → 42.4% | 19.8% → 13.0% |
By late 2022, smoking led in the Midwest and West; in the Northeast and South, smoking and injection were about even.
Driven by fentanyl
Routes of drug use by drugs detected. Image from CDC's report
The shift was sharpest where IMFs were found:
| Drugs detected | Smoking | Injection |
|---|---|---|
| IMFs only | 10.9% → 19.5% | 20.9% → 12.2% |
| IMFs and stimulants | 17.9% → 29.6% | 28.6% → 21.3% |
| Stimulants only | 15.5% → 20.1% | 10.2% → 7.9% |
| Neither | no change | 11.6% → 6.7%; swallowing most common |
Likely drivers: the move from injecting heroin to smoking IMFs, more deaths involving IMFs with stimulants that may be smoked, and more counterfeit pills, which often contain IMFs and are often smoked. People who switch say smoking causes fewer abscesses, costs less, carries less stigma, and lets them control the dose better — and feel it's safer. But smoking still carries substantial overdose risk because drugs are absorbed quickly, and compared with swallowing it can intensify effects.
What it means for prevention
- People who smoke but don't inject may never visit syringe services programs, where harm reduction supplies and messages are usually offered. Some places now provide safer smoking supplies or health hubs for people using drugs by other routes.
- Peer outreach, fentanyl test strips, naloxone, smoking-specific messages and links to treatment can be built into emergency departments and public safety settings.
- Injection still figured in more than 4,000 deaths in late 2022, so syringe services — sterile supplies, harm reduction tools, and treatment including medications for opioid use disorder — remain important.
Sources
Based on Lauren J. Tanz, R. Matt Gladden, Amanda T. Dinwiddie and colleagues, "Routes of Drug Use Among Drug Overdose Deaths — United States, 2020–2022," MMWR, volume 73, Centers for Disease Control and Prevention; a work of the United States government in the public domain.
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