- In some provinces, most drug toxicity deaths are now related to smoking, rather than injecting
- A Vancouver study interviewed 31 people who smoke unregulated drugs
- Some had switched from injecting to smoking as they believed it had a lower risk of overdose
Research conducted before the arrival of fentanyl suggested that smoking-related overdose was rare. This characterization may have led to a belief that smoking has a lower risk of overdose than injecting. However, the unregulated drug supply has changed significantly since the time of this research. The unregulated supply is now dominated by fentanyl and other synthetic drugs and has become highly toxic and unpredictable, with sedatives such as benzodiazepines being added. Within this context, peoples’ drug use patterns and preferred routes of consumption have changed.
Smoking has become more common across North America, overtaking injecting in some regions. In British Columbia (B.C.), for example, smoking is the preferred route of consumption among people who use opioids.1 Simultaneously, overdose deaths from smoking have increased. Smoking is now the most common route of consumption leading to overdose deaths in the United States and in parts of Canada.2
This increase in smoking-related overdose deaths is not well understood. Better understanding of people who use drugs’ perspectives and experiences with smoking-related overdose can help to inform policies, programs and practices that aim to reduce harms.
Study details
Researchers interviewed 31 people who smoke unregulated drugs in Vancouver, B.C.2 Participants were recruited from two prospective cohort studies and through the Vancouver Area Network of Drug Users (VANDU). Interviews were conducted between February and March, 2023. People were eligible to participate if they were at least 19 years old and currently smoked drugs (other than cannabis). Interviews were semi-structured and gave participants the opportunity to speak openly about various topics, such as their current drug use and recent experiences with overdose. Interview data were coded and analyzed for themes.
Results
Nearly all participants had been impacted by smoking-related overdose. These experiences included having overdosed from smoking (n = 15), losing friends or family to smoking-related overdose deaths (n = 8) and/or responding to smoking-related overdose (n = 14).
Perspectives on smoking-related overdose
Some participants saw smoking drugs as having a lower risk of overdose than injecting and therefore had switched to smoking. To try to reduce their risk of overdose, one participant explained that they had switched from injecting powder cocaine to smoking crack cocaine, as they believed crack was less likely to be contaminated with fentanyl: “I quit injecting [cocaine] when fentanyl was getting into the drug market.” Participants acknowledged that there was still a risk of overdose with smoking, but they felt that smoking helped to reduce their risk. Some believed drugs were absorbed more slowly when smoked than when injected. Others explained that smoking gave them more control over their dose because it was easier for them to smoke smaller amounts than it was to inject smaller amounts: “…it would take like three [inhalations] compared to one [injection] for them to OD, right?”
Experiences with smoking-related overdose
It was common for participants to have experienced a smoking-related overdose, regardless of whether they used opioids, stimulants or both. Participants mostly attributed overdose either to the unpredictability of opioids in the unregulated drug supply or to cross-contamination of stimulants or drug use equipment with opioids.
Unpredictable drugs
Participants who used fentanyl explained how the varying strength of unregulated drugs led to overdose. One participant described how they had overdosed after one “puff of [their] pipe,” even though they “knew it was [fentanyl] but it was just too strong.” Other participants discussed how they felt that inhaling too much or too deeply led them to overdose when smoking fentanyl.
Cross-contamination
Some participants discussed how they had overdosed after accidentally consuming opioids when intending to smoke stimulants. One participant noted that it is often impossible to tell whether stimulants also contain opioids: “a lot of times you can’t tell you’re getting fentanyl, like if you’re [someone who smokes crack]. That’s why a lot of these deaths have happened because some people never used [fentanyl].”
Participants described some ways that cross-contamination can happen:
- Accidental contamination of stimulants with opioids during weighing and packaging of unregulated drugs.
- accidentally using opioids instead of stimulants in groups where people are using multiple drugs
- smoking stimulants with a pipe that had previously been used to smoke fentanyl
One participant explained how they had overdosed as a result of sharing supplies: “…the first time I [overdosed] it was with a group of friends and…I didn’t realize someone was smoking fentanyl out of their pipe, and just went down...”
Responding to smoking-related overdose
Nearly half of study participants had responded to a smoking-related overdose. Some people expressed surprise about finding people who had overdosed by smoking, as they associated overdose with injecting. Participants who worked in overdose prevention sites (OPS), most of which lack spaces for inhalation, described responding to smoking-related overdoses outside the OPS or in other areas of the building, such as the bathrooms. One participant who worked in an OPS noted that they were seeing “more smoking than injecting as time goes on here” and that “a good 25 percent” of the overdoses they had responded to were from smoking.
Implications
In recent years, smoking has become the preferred route of consumption in many parts of Canada. With the increasingly toxic drug supply and this shift to smoking, smoking-related overdose has increased significantly. Smoking is the most common route of consumption leading to drug toxicity death in some provinces. However, harm reduction programs and education have not kept pace with these changes, leading to significant barriers to care for people who smoke drugs.
The study highlights the importance of adapting harm reduction programs and practices to meet the needs of people who smoke drugs. For example:
- Providing education about smoking-related overdose and safer smoking practices: It is important to raise awareness among people who use drugs that smoking drugs does not provide protection from overdose. It is also important to emphasize safer smoking practices, such as not sharing supplies and instead using your own equipment to smoke drugs.
- Distributing safer smoking supplies: These supplies are available in many, but not all, parts of Canada. Where they are available, quantities are not always adequate. Ensuring that people have access to safer smoking supplies can reduce the risks associated with sharing supplies, such as overdose and infections such as hepatitis C.
- Adapting supervised consumption services (SCS) to permit inhalation: As of November, 2023, only two of 39 SCS operating in Canada allow smoking,2 leaving people who smoke their drugs without access to safer spaces to use in.
- Developing safer supply programs that provide smokable drugs: Access to safer supply is limited in Canada. Most programs do not provide drugs that can be smoked, which excludes people who smoke drugs from benefiting from this approach.
Limitations
Most participants in the study lived in downtown Vancouver and their experiences and perspectives may not necessarily be representative of people who use drugs in other parts of Canada, including rural and remote areas. The authors also noted that the sample was not necessarily representative of certain groups who have been disproportionately affected by smoking-related overdose, such as Black and Indigenous people who use drugs.
REFERENCES:
- Parent S, Papamihali K, Graham B et al. Examining prevalence and correlates of smoking opioids in British Columbia: opioids are more often smoked than injected. Substance Abuse Treatment, Prevention, and Policy. 2021;6:1-9.
- Ivsins A, Bonn M, McNeil R et al. A qualitative study on perceptions and experiences of overdose among people who smoke drugs in Vancouver, British Columbia. Drug and Alcohol Dependence. 2024 May;258:111275.