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The main point: In the last decade, U.S. drug consumption behavior has shifted rapidly away from injecting and towards smoking.
The details: Once largely limited to the West Coast, smoking opioids has spread east since COVID, following shifts in the illicit opioid supply.
- Heroin has largely disappeared, while fentanyl has grown to dominate, increasing the toxicity of the drug supply. Xylazine has also proliferated, causing severe skin wounds. These factors have led many people who use drugs to avoid syringes.
Why it’s important: Smoking instead of injection decreases the risks of infections, infectious diseases, skin abscesses, and potentially fatal overdose.
- Early research suggests that overdose rates are lower among those who smoke rather than inject. One possible reason is that smoking allows individuals to consume the drug more slowly and control their intake more precisely. Another is that smoking is often a collective activity, meaning more people are present to administer naloxone or call 911.
- Smoking is so common that it now causes more overdose deaths overall, but the likelihood of overdosing from an individual instance of smoking is far lower than from injecting.
But: Even while syringe exchanges are widely accepted by many states, efforts to distribute pipes and other smoking supplies have faced blowback.
- The Biden administration’s support in 2021 for the distribution of “safer smoking kits,” which often included pipes, became a major controversy.
- Amid frustration with homelessness and public drug use, some areas have wound down their pipe distribution programs.
- Pipes have drawn even stronger public opposition than other treatment and harm reduction services, including new methadone clinics or even supervised consumption sites. This may be a relic of the crack cocaine epidemic, when smoking was the main route of administration.
Read more: Drug injection fades as smoking grows more common, marking sea change in U.S. fentanyl epidemic; Why a change in fentanyl use has helped drive fewer overdose deaths
Published
February 2026