From Needle to Smoke: How People Take Illegal Fentanyl Changed Across the U.S., 2017–2023

U.S. overdose deaths involving fentanyl more than doubled from 2019 to 2023, from an estimated 35,474 to 72,219. Among deaths where only illegally manufactured fentanyl (IMF) was found, those with evidence of smoking rose 78.9% from 2020 to 2022, while those with evidence of injection fell 41.6%. Death records could not show the route when several drugs were involved, though, so CDC looked at the living: adults assessed for substance-use treatment who had used IMF in the past 30 days.

The data

Assessments made with the Addiction Severity Index–Multimedia Version between July 1, 2017, and June 30, 2023 — a convenience sample — in the 14 states with at least 100 assessments reporting recent IMF use: 16,636 in all. Routes were counted by six-month period and census region; one person could report more than one route.

What changed

Injection fell in every region, but at different times and by different amounts — and something different replaced it.

End points are January–June 2023. In each region the rise of the new route was strongly negatively correlated with the fall in injection (r from −0.74 in the West to −0.98 in the South).

Routes of IMF use among people assessed for substance-use treatment, by census region, 14 states, July 2017–June 2023. CDC.

Why the route matters

Some people who use IMF reportedly believe smoking is safer than injecting. In one way it is: avoiding injection likely reduces the risk of HIV, hepatitis C and soft-tissue infections. But other routes still carry overdose risk and other harms — snorting, for instance, is linked to sores in and around the mouth and face — and compared with injecting, smoking IMF is associated with using more often through the day and possibly at higher daily doses.

Because the shifts differ so much by place — to smoking in the Midwest, South and West, to snorting in Massachusetts — the authors call for knowing local drug-use trends and tailoring messages, outreach and links to medical care, including effective treatment for opioid use disorder, for people who use IMF without injecting.

Sources

Based on Chen Y, Jiang X, Gladden RM, Nataraj N, Guy GP Jr, Dowell D, "Notes from the Field: Geo-Temporal Trends in Fentanyl Administration Routes Among Adults Reporting Use of Illegally Manufactured Fentanyl When Assessed for Substance-Use Treatment — 14 U.S. States, 2017–2023," MMWR Morbidity and Mortality Weekly Report volume 73, number 50, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The imported copy was cut short; the missing text is from the report's full text in PubMed Central (PMC11658401).