Smoking “hard” drugs now kills many users

Most people believe that smoking drugs like heroin, fentanyl, methamphetamine or cocaine is much safer than injecting. After all, injecting carries the serious risk of severe skin abscesses, as well as the risk of contracting infections like human immunodeficiency virus (HIV) or hepatitis C (and many other infections) when using shared needles.

But here's some shocking news. According to a 2024 report from the Centers for Disease Control and Prevention (CDC), many heroin and other drug users died of overdoses in 2022 smoked the drug instead of injecting it with needles, a major change in consumption patterns. The CDC reports that the percentage of overdose deaths with evidence of injection reduced from 22.7% of deaths to 16.1%, while the percentage of overdose deaths with evidence of smoking increased from 13.3% to 23.1%. Smoking drugs is therefore extremely dangerous, an important fact that many people are not yet aware of.

According to Brian Fuehrlein, MD, Ph.D., associate professor of psychiatry at Yale and director of the psychiatric emergency department at the VA Connecticut Healthcare System, “Most experts believe that injecting is the fastest way to get the drug to the brain, but smoking comes very close and accomplishes that goal as well. Additionally, crack cocaine (which is smoked) tends to be cheap and affects marginalized populations more often. In addition, smoking drugs is very dangerous because fentanyl is found in stimulants that are smoked. The switch to smoking and the switch to speedballing through smoking are the most startling and disturbing changes in addiction today.” (Speedballing refers to taking stimulants and depressants at the same time, an extremely dangerous practice.)

Why the change of use probably occurred

The recent shift from injecting to smoking drugs and the increased number of smoking-related deaths may be due in part to drug addicts switching from injecting heroin to smoking fentanyl analogues. Smoking is almost always perceived as less invasive than injecting, so users may pat themselves on the back that at least they aren't injecting their drugs without realizing the risks. Smoking may also be less costly and far less stigmatized than injecting.

Because smoking is so easy, more users are trying the drug, which can lead to more frequent use, which in turn leads to rapid addiction and a higher risk of overdose.

Addiction expert James H. Berry, DOProfessor and head of the Department of Behavioral Medicine and Psychiatry at the Rockefeller Neuroscience Institute at West Virginia University, agrees that smoking major drugs has become a major problem today. “In my experience, there has definitely been a change in the way patients are treated in West Virginia over the last 20 years. Fewer patients undergoing treatment today report being 'on the needle' than a few years ago.” Many believe that smoking fentanyl is much safer than injecting it, which explains part of this shift.

“However,” Berry adds, “I suspect a more important reason is the sharp increase in methamphetamine use, which is primarily smoked rather than injected. Methamphetamine has overtaken opioids as the drug of choice for many in our region. Although speedballing is common, most patients report that they would rather take pure methamphetamine but find it difficult to obtain methamphetamine that is not laced with fentanyl..“

Berry reports that “we have also seen a significant increase in crack use over the past year.” Patients who use crack suffer from specific deficits in the brain, gray matter and volume, new data suggest.

James H. Berry, DO

Source: West Virginia University

Vaporize speedballs and other drugs

Some people use vaping devices to smoke the most addictive drugs, such as methamphetamine, cocaine, and many other drugs. Some young people vape methamphetamine, cocaine, and fentanyl, although this is an extremely dangerous practice. The ability to vaporize the drugs has improved due to advances in vaping technology and the availability of particularly potent synthetic versions of the drugs.

Vaporizing methamphetamine

Methamphetamine can be vaporized by heating it in a vaporizer or e-cigarette. The drug is usually dissolved in a liquid or used in its crystalline form, which is then heated to create vapor. Vaporized methamphetamine can have a rapid onset of action and carries an increased risk of addiction and overdose due to the high potency of the drug administered in this manner.

Vaporizing cocaine

Although less common, cocaine can be vaporized. Like methamphetamine, cocaine is dissolved in a liquid that can be vaporized. The effects are similarly intense, with rapid ingestion leading to increased risks, including serious cardiovascular disease and addiction.

Vaporize fentanyl

Vaping fentanyl is particularly dangerous due to the drug's extreme potency. Even small amounts of fentanyl can be fatal, and when vaped, a powerful dose can go straight to the lungs, resulting in a rapid and potentially fatal overdose. There are increasing reports of fentanyl being intentionally or inadvertently mixed with other substances in vape cartridges, which poses significant risks.

Vaping marijuana

Some cannabis users have already hacked or modified vape devices to smoke cannabis. Pharmacologically, the drug's effects when smoked are the same as when injected, as happened when intravenous cocaine was replaced with crack.

A recent study by Yale scientists, published online in Pediatrics showed that up to four in 10 teens and young adults who smoke e-cigarettes modify the devices to secretly use marijuana, potentially risking lung injuries and burns. According to the study, 40.1% of 1,018 teens ages 14 to 29 reported refilling devices that were not designed to be refilled, and 35.8% recharged the battery of e-cigarettes that were supposed to be thrown away after a single use. Others reported mixing nicotine and cannabis liquids in devices designed for nicotine only.

Switching to e-cigarettes significantly changes the risk profile of cannabis, as more THC reaches the brain more frequently and in doses that pose a higher risk of addiction.

Berry says, “There are a growing number of vape shops in our communities that legally sell delta-8 and delta-10 THC. This, along with high-potency delta-9 THC concentrates being processed into illegal nicotine vaporizers, has contributed to a rise in the number of people with cannabis-related mental health issues.”

Summary

More and more people are switching to smoking or starting to use drugs instead of injecting drugs. Smoking may seem significantly safer than injecting, but the ease of use, novel combinations, and use of the most dangerous and addictive drugs – methamphetamine, cocaine, fentanyl – make smoking extremely dangerous. While fear of injecting is a barrier for some, there is no such barrier with vaping or smoking – and smoked drugs have similar effects on the brain as injected drugs. All of this increases the risk of overdose and death from smoking. Unintentional speedballing increases the risk when pipes are shared and/or people smoke multiple drugs in the same pipes.