According to a recent CDC study, more than 109,000 drug overdose deaths occurred in the United States in 2022. The study also revealed that the proportion of overdoses associated with smoking increased over the last few years, while the proportion associated with injection decreased. This demonstrates a need for local health departments (LHDs) and other local harm reduction programs (HRPs) to ensure they are engaging people who smoke drugs to offer naloxone, the overdose reversal medication, as well as overdose prevention and response messaging and education. Distributing smoking supplies is a critical way for HRPs to reach people who smoke with overdose prevention resources, and also presents an opportunity to reduce sharing of smoking equipment, reduce the use of unsafe equipment, and connect people who smoke to other health services.

The study examined the drugs and routes of exposure most associated with fatal overdoses, providing crucial data that can help shape the future of harm reduction services. CDC found that nearly 70% of reported overdose deaths in 2022 involved synthetic opioids other than methadone, of which primarily included illegally manufactured fentanyl and fentanyl analogs (IMFs). Between 2011 and 2018, the estimated number of U.S. adults who inject drugs increased dramatically and corresponded with a shift from use of prescription opioids to heroin and IMFs. In recent years, there appears to have been a shift from injecting heroin to smoking IMFs, based on data from the Western U.S. Overdose trends align with these trends. According to the report, from January-June 2020 to July-December 2022, the number and percentage of overdose deaths with evidence of smoking increased 109.1% and 73.7% respectively. Throughout this period, the primary route of exposure in drug overdose deaths shifted from injection to smoking. In addition to the shift from injecting heroin to smoking IMFs seen in the West, this transition may also be attributable to a reduction in stigma associated with smoking, the fear of wounds or infections associated with injections, and the perception of a lower risk of overdose from smoking compared to injection. Although smoking is generally seen as safer than injecting, smoking still holds significant overdose risk due to rapid drug absorption, and people who smoke drugs are a critical population for HRPs to reach with overdose prevention and other harm reduction supplies.

These findings demonstrate the importance of reaching people who smoke to offer overdose prevention and other health and harm reduction services. HRPs that offer syringes but not smoking supplies may not reach the people in their communities who would most benefit from their services or they may lose existing clients who transition from injecting to smoking. This is extremely detrimental, as HRPs are known for distributing life-saving materials, like naloxone, that don’t necessarily have to do with whatever route a client uses. If people who smoke are dissuaded from coming to a certain facility, they also miss out on other health related opportunities, like STI, HIV, and hepatitis testing, linkage to substance use treatment, and wound care.

NACCHO acknowledges and supports CDC’s 3 action items highlighting the importance of: expanded messaging emphasizing overdose risk associated with smoking and other routes; continued and expanded support for syringe services programs to provide comprehensive, integrated health services; and enhanced outreach and harm reduction services across multiple settings for persons using drugs by smoking and other routes.

As more information regarding drug user health emerges, NACCHO will continue to study this work and help connect organizations with opportunities to learn more about harm reduction trends and services. For additional information about the distribution of smoking supplies, check out this NACCHO webinar highlighting the results of a survey to better understand the implementation of smoking supplies, including the impact and benefits, factors that support this work, and barriers that undermine it. NACCHO is also funding the evaluation of smoking supplies distribution, including its impact on program reach and substance use behaviors, at 7 HRPs across the U.S. and will sharing findings from this project beginning this summer.