In a significant shift in drug consumption behavior, the United States is witnessing a marked decline in injection drug use, particularly amid the ongoing fentanyl epidemic. Harm reduction advocates are increasingly promoting smoking as a safer alternative, leading to a surge in the distribution of smoking supplies across various communities. This change is particularly notable in cities like Philadelphia, which have been severely impacted by opioid use.
Megan Merrill, a harm reduction worker affiliated with SOS Recovery, exemplifies this trend. While distributing supplies at a homeless encampment in Rochester, New Hampshire, she highlighted the health benefits of smoking over injecting. “You’re going to see less vein damage, you’re not going to get abscesses on your arm or infections,” Merrill explained, emphasizing that smoking significantly reduces the risk of overdose and the transmission of blood-borne diseases such as hepatitis C and HIV.
The shift from injecting to smoking has evolved organically over the past decade, particularly following the COVID-19 pandemic. Previously, injection was the dominant method of drug use, but the increasing toxicity of street drugs, including the presence of xylazine, an animal tranquilizer linked to severe skin lesions, has compelled many users to seek alternatives. As the opioid landscape has transformed, with fentanyl largely replacing heroin, the ease of smoking this potent substance has become more appealing.
This behavioral change is not isolated. Harm reduction organizations nationwide are adapting their strategies to meet the needs of users. They are now including foil, glass pipes, and mouthpieces in their distribution efforts, aiming to facilitate a safer drug consumption experience. Merrill, who has transitioned from being an injection drug user to a harm reduction advocate, noted, “When I was using three years ago, everyone was injecting their drugs. Now, people are switching to smoking and sniffing.”
While the overall number of opioid overdose deaths remains alarmingly high, with more than 45,000 fatalities reported each year, some experts view the trend toward smoking as a potentially positive development. Caty Simon, a member of the leadership team at the National Survivors Union, a nonprofit that advocates for those who use drugs, stated, “One of the basic mottos of harm reduction is ‘any positive change.’” The transition to smoking is seen as a protective measure that could reduce the health risks associated with drug use.
Research indicates that individuals who smoke drugs may be as much as 30% less likely to experience an overdose compared to those who inject. This is attributed to several factors, including the ability to control intake more effectively and the social nature of smoking, which often occurs in groups. In contrast, injection drug use frequently takes place in isolation, limiting the chances for timely intervention in the event of an overdose.
Despite the growing acceptance of smoking as a harm reduction strategy, challenges remain. Some regions have faced backlash against the distribution of smoking supplies, particularly under the previous administration, which raised concerns about public health implications. In 2021, the Biden administration’s endorsement of “safer smoking kits” sparked controversy, highlighting the ongoing debate surrounding harm reduction policies.
Organizations like Smoke Works, based in Massachusetts, have emerged as significant players in this landscape. Initially part of a syringe exchange program, Smoke Works shifted focus to distributing pipes as an alternative to injection. Executive Director Jim Duffy noted a notable increase in demand for smoking supplies, with many participants opting for pipes over syringes. “Not everybody wanted to inject,” Duffy remarked, illustrating the changing preferences among drug users.
The trend toward smoking as a primary method of drug consumption is particularly pronounced among younger users and in regions where fentanyl is prevalent. Research by Dan Ciccarone, a physician-researcher at the University of California San Francisco, indicates that smoking rates are growing steadily. In some West Coast areas, smoking is now the predominant consumption method, while Eastern cities are also seeing a rise, albeit at a slower pace.
Despite the dangers associated with all forms of drug use, experts express cautious optimism about the potential benefits of smoking over injecting. George Karandinos, a physician-researcher at Harvard, emphasized, “These are all pieces of data that agree with each other and suggest that there may be a lower risk of overdose.”
As harm reduction advocates like Merrill continue their outreach, they remain dedicated to providing users with the tools necessary to minimize risks. Upon leaving the encampment, Merrill reflected on the significant shift in behaviors and attitudes regarding drug use. “We call it safer because you’re not always going to be 100% safe in everything you do, but we can make it safer,” she said, reiterating the importance of offering users choices that prioritize their health and well-being.
While the challenges posed by the opioid crisis are immense, the emerging trend of smoking as a safer alternative to injecting presents a valuable opportunity for harm reduction efforts. As communities adapt to these changes, the focus remains on saving lives and preventing the devastating consequences of substance use.
