Smoking Hard Drugs Is Now Killing Many Users

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

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 who died from overdoses in 2022 smoked the drug rather than injected it with needles, a major change in use patterns. The CDC reports that the percentage of overdose deaths with evidence of injection decreased from 22.7 percent of deaths to 16.1 percent, while the percentage of overdose deaths with evidence of smoking increased from 13.3 percent to 23.1 percent. Thus, smoking drugs is extremely dangerous, an important fact many do not yet realize.

According to Brian Fuehrlein, M.D., Ph.D., associate professor of psychiatry at Yale and director of Psychiatric Emergency Room, VA Connecticut Healthcare System, “most experts assume that injecting gets the drug to the brain fastest, but smoking is close and also accomplishes that goal. Also, crack cocaine (which is smoked) tends to be cheap and affects marginalized communities more frequently. In addition, with fentanyl being found in stimulants that are smoked, smoking drugs is very dangerous. The shift to smoking and the shift to speedballing by smoking are the most newsworthy and troubling changes in addiction today.” (Speedballing refers to using both stimulant and depressant drugs at the same time, an extremely dangerous practice.)

Brian Fuehrlein, MD, PhD

Source: Yales

Why the Use Change Likely Occurred

The recent change from injecting to smoking drugs and the increase in deaths from smoking might be partially driven by substance abusers switching from injecting heroin to smoking fentanyl analogs. Smoking is almost always perceived as less invasive than injecting, so users may pat themselves on the back for at least not injecting their drugs, oblivious to the risks. Smoking may also be less costly and carries far less stigma than injecting.

The ease of smoking also allows more users to try the drug and may lead to more frequent use, causing rapid addiction and a higher risk of overdose.

Addiction expert James H. Berry, D.O., Professor and Chair 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 key issue today. “In my experience, treating patients in West Virginia for the past 20 years, there certainly has been a shift. Fewer patients entering treatment report being ‘on the needle’ today compared to several years ago. Many believe smoking fentanyl is much safer than injecting, which accounts for some of the shift.

"However," adds Berry, "I suspect that a more significant reason is the sharp rise in the use of methamphetamine, 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 they would prefer to use pure methamphetamine, but they find it difficult to obtain any not adulterated with fentanyl."

Berry reports that "we are also seeing a marked increase in crack cocaine this past year.” Patients with crack cocaine use experience specific brain, gray matter, and volume deficits, new data suggests.

James H. Berry, DO

Source: West Virginia University

Vaping Speedballs and Other Drugs

Some individuals use vaping devices to smoke the most addicting drugs, such as methamphetamine, cocaine, and multiple drugs. Some young people vape methamphetamine, cocaine, and fentanyl, although it is an extremely dangerous practice. The ability to vaporize the drugs has increased due to advancements in vaping technology and the availability of particularly potent synthetic versions of the drugs.

Vaping Methamphetamine

Methamphetamine can be vaped by heating it in a vaporizer or e-cigarette. The drug is typically dissolved in a liquid or used in its crystalline form, which is then heated to produce vapor. Vaped methamphetamine can have a rapid onset of effects and carries a heightened risk of addiction and overdose due to the high potency of the drug delivered in this manner.

Vaping Cocaine

While less common, cocaine can be vaped. Like methamphetamine, cocaine is dissolved in a liquid that can be vaporized. The effects are similarly intense, with rapid absorption leading to heightened risks, including severe cardiovascular events and addiction.

Vaping Fentanyl

Vaping fentanyl is particularly dangerous due to the drug's extreme potency. Even small amounts of fentanyl can be lethal, and vaping can deliver a potent dose directly to the lungs, leading to a rapid and potentially fatal overdose. There are increasing reports of fentanyl being mixed with other substances in vape cartridges, either intentionally or unintentionally, posing significant risks.

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Vaping Marijuana

Some users of cannabis have already hacked or modified vape devices to smoke cannabis. Pharmacologically, as happened when intravenous cocaine was replaced by crack cocaine, the effects of the drug by smoking are equivalent to those by injection.

A recent study authored by Yale scientists published online in Pediatrics showed that as many as four out of every 10 teenagers and young adults who vape will modify the devices, allowing for covert use of marijuana and potentially risking lung injury and burns. According to the study, 40.1 percent of 1,018 adolescents between the ages of 14 and 29 said they refilled devices not intended to be refilled, and 35.8 percent recharged the battery of vaping pods meant to be thrown out after one use. Others reported mixing nicotine and cannabis liquids in devices designed only for nicotine.

E-cigarette conversion is significantly changing the cannabis risk profile as it delivers more THC to the brain more often in doses most likely to have addiction liability.

Says Berry, “There is a proliferation of vape shops in our communities that sell legal Delta 8 and Delta 10 THC. Along with high-potency Delta 9 THC concentrates fashioned into ‘bootleg’ nicotine vapes, this has contributed to an upsurge in people presenting with cannabis-related psychiatric problems.”

Summary

Increasing numbers of individuals are switching to or initiating drug use by smoking versus injecting drugs. Smoking may seem dramatically 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 the fear of injecting has served as a barrier for some, no such barrier attaches to vaping or smoking—and smoked drugs have similar effects on the brain as injected ones. All contribute to increased risks of overdose and death by smoking. Inadvertent speedballing adds to the risk if pipes are shared and or people are smoking multiple drugs in the same bowls.