Many people who use drugs in San Francisco have been reducing their injecting of heroin and other drugs and smoking more fentanyl instead, researchers have found. And study participants reported that smoking fentanyl, compared to injecting tar heroin and other opioids, helped them experience better highs, better health, reduced stigma and improved quality of life. The findings contradict some common negative perceptions around fentanyl use—and reflect that how you use it can make a big difference.
The study, conducted by researchers from California and Washington state, was published in the journal Drug and Alcohol Dependence. Its 395 participants were recruited from local organizations working with drug users in San Franciso. Over 24 months between July 2018 and June 2020, the researchers interviewed participants—in person and by phone—and also asked them to complete written surveys. They paid the participants for their time.
The researchers found that over the course of the study, participants began injecting (any kind of drug) much less. An average of 92 monthly injections at the beginning of the study eventually fell to just 13 monthly by the end—a drop of over 85 percent. For opioids specifically (typically tar heroin, which due to its properties is most commonly injected), the participants were injecting about 50 percent less frequently by the end.
The researchers did not find an increase in the number of people who smoked fentanyl over the study period. But people who already smoked it did so more frequently as time went on. In the first half of 2020, those who smoked fentanyl reported doing so on nearly twice as many days per month compared to the first half of 2019. In the same time period, the percentage of people who had smoked fentanyl every day of the past month doubled.
As the researchers make clear, “smoking” fentanyl means heating it on foil and inhaling the vapor, rather than combustion. When they interviewed one local syringe service provider, they learned that the clinic was handing out free aluminum foil so fast that it had trouble keeping it in stock.
“It’s more of a controlled way of getting—you’re not just taking one … big amount and just having it hit you all at once.”
The participants who were smoking fentanyl more often reported fewer opioid injections over time. Between January 2019 to June 2020, fentanyl smokers increased their average frequency of smoking from fewer than 10 days to more than 20 days per month; their average number of opioid injections simultaneously fell from 60 per month to 12.5.
Why did this happen? “Qualitative interviews revealed that people who inject drugs’ main motivation for switching from injecting tar heroin to smoking fentanyl was related to their difficulties finding easily accessible veins,” the researchers wrote.
Participants who were interviewed gave additional reasons for their patterns changing. One described how injecting heroin had always required help from friends. “It was just easier for me to go and buy some fentanyl and smoke it and get high as fuck and not bother anybody to [inject] or have to pay anybody to [inject] me or whatnot,” they said.
Another participant said that smoking shorter-acting fentanyl allowed them to better control their consumption. “It’s when you smoke it, it’s more of a controlled way of getting—you’re not just taking one, like big like amount and just having it hit you all at once,” they said.
One woman said that switching to smoked fentanyl, which is about 30 times more potent than heroin, was a great financial decision for her, because with fentanyl you get more doses for the same price. “So it lasts a lot longer and I can use it a lot more frequently and share it also with my friends more because the [injected] heroin I could only use it for just one time and that’s it,” she said.
“I don’t have the track marks. I don’t have to hide those or anything.”
Participants said they were glad to avoid some of the worst health risks from injecting—which can include abscesses, bacterial infections and the risk of spreading HIV or hepatitis C if needles are shared—as well as the stigmatization and discrimination imposed on people who inject. “And also no more scarring, like I don’t have the track marks. I don’t have to hide those or anything,” one person said.
The researchers cautioned that their study is limited for a few reasons. It only looked at one city, San Francisco. And, California’s unregulated drug market, where tar heroin, for example, has been prevalent, is different from those elsewhere. The fentanyl that researchers observed in the Bay Area was mostly in colored powder form, and easier to smoke. They didn’t see the pressed pills and patches common in other parts of the United States.
And there’s a huge question the study doesn’t answer: Does the switch from injecting to smoking fentanyl have any effect on the risk of overdose? During the time the study ran, San Francisco experienced a 270 percent increase in opioid-involved overdose deaths, and fentanyl has quickly become the primary drug involved in these deaths (72 percent in 2020).
“Yes, the two happened during the same time-period,” Dr. Alex H. Kral, the lead study author and an epidemiologist at RTI International, told Filter. “It is just that fentanyl entered the drug market in a major way in San Francisco (and California in general) about three-to-four years after it did on the East Coast and in Appalachia. We can’t know whether the huge overdose mortality increase would have been less if people had not started smoking fentanyl.”
“Many of the study participants overdosed, some of whom died during the study period,” he said. “Some of these smoked fentanyl and others did not. The sample sizes are too small to make scientific claims.“
The researchers recommend that future studies should examine what effect, if any, fentanyl smoking has on overdose rates. They also caution that smoking fentanyl has its own risks, like lung illness and spreading viruses like COVID-19 and hepatitis C. Harm reduction measures for opioids should include sterile smoking supplies and supervised smoking rooms, they recommend.
Photograph via pxfuel
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