Fentanyl users choosing to smoke the drug

Fentanyl continues to defy conventional wisdom about illicit drugs and poses unforeseen risks to public health.

Research published on May 22 found that people with substance use disorders in San Francisco, Calif., increasingly choose smoking fentanyl over injecting it—likely because of the perception that smoking is a safer way to ingest drugs. An increase in overdoses shows that this may not be the case.

“People kind of dabble in snorting and smoking on their way to injection,” said Nicole Holm, a contributor to the recent research at the University of California, San Francisco. “For a group to leave injection and go backward, so to speak, is really interesting and not happening elsewhere.”

Fentanyl is a synthetic opioid pain reliever with a potency 50-100 times stronger than heroin and morphine. It overran the illicit drug world in the United States in the mid-2010s, causing overdose deaths to skyrocket. In 2021, the number of people who died from a drug overdose of any type was six times higher than it was in 1999. In 2022, of the 110,000 people who fatally overdosed, two-thirds died because of synthetic opioids.

Participants in the recent San Francisco research said they experienced a similar high when smoking versus injecting fentanyl. That is not the case with other drugs such as heroin, which users report has a lower potency when smoked versus injected. Researchers released the documentation about the rise in fentanyl smoking a few months after San Francisco officials issued a 2023 accidental overdose data report that showed the prevalence of fentanyl in the area. The synthetic opioid caused 653 of the 806 total deaths listed in the report.

“You do have this conundrum of all-time high overdoses. And so I think we just have more to learn about the risks associated with smoking fentanyl,” said Holm.

Holm said that the trend of smoking fentanyl appears confined to the West Coast for now, likely due to differing drug supply chains on each coast, but she added that could change.

Pastor Zach Diestler of Bay Area Street Church in Oakland, Calif., has watched the fentanyl crisis develop on the streets of Oakland, where unhoused substance users lie doubled over like jackknives, crippled by their addiction. After several years of trying to supply homeless people with basic necessities such as food and tents, Diestler decided to work toward a certificate in addiction studies and a master’s degree in counseling. He now plans to add a Christian recovery center to his church’s outreach efforts.

“Smoking is a very socially acceptable form of using substances,” said Diestler. “It’s a lot easier to smoke something in a neighborhood versus inject.”

The social aspect of substance use that drives people to smoke may make fentanyl even more dangerous. Users may share, trade, or even steal drug paraphernalia such as foil, glass bubbles, and bongs. Addicts of other drugs could unintentionally inhale fentanyl residue without building up a tolerance to it, risking overdose.

“The residue of fentanyl, what’s left over after you smoke—it’s incredibly similar to meth residue,” said Diestler. “It’s kind of like how needles can pass HIV if they’re not cleaned.”

People who use low-potency or low-purity fentanyl also risk exposure to higher concentrations of illegally made fentanyl from smoking.

“The drug supply is the most dangerous it’s ever been with fentanyl purity just so variable,” said researcher Holm. “A sample could be 5 percent fentanyl or it could be 15 percent fentanyl. You just don’t have any way of gauging that strength.”