As America’s drug use behavior shifts from injecting to smoking, the reaction from public health experts is nearly uniform. Researchers say the development is almost entirely positive, saying that smoking drugs like fentanyl instead of injecting them could reduce infections, disease transmission, and potentially even overdose rates.
But a new paper published this week has significant implications for cost-benefit analysis. A new study shows that people who switch to smoking drugs are at risk of severe burns.
A study analysis of Medicaid claims data in Oregon from 2016 to 2024 found that people who smoked drugs such as fentanyl and methamphetamine were about four times more likely to be treated in an acute burn unit than those who did not take smokable drugs. Smoking marijuana was also associated with higher rates of severe burns, but the difference was most pronounced among people who smoked either opioids or stimulants.
“The headline is that half of all emergency department visits and hospitalizations for burns in Oregon are people using smokable drugs,” said study lead author Honora Englander, a physician-researcher specializing in addiction at Oregon Health and Science University. “This is a surprising finding: 53% of burns belonged to this group, even though they represent about 15% of the population.”
Although the study was specific to Oregon, it comes at a time when drug use behaviors are undergoing major changes across the country, with injecting becoming obsolete and smoking becoming more common. This shift is occurring both in response to significant changes in drug supply and, more recently, efforts by harm reduction organizations to promote smoking as a means to reduce the risk of common health effects from injections, such as endocarditis, hepatitis, and skin wounds associated with xylazine.
Injecting drugs is declining as smoking becomes more common, driving a major shift in the U.S. fentanyl epidemic
Many of the burns were caused by the use of an inexpensive but powerful butane torch commonly found in hardware stores. One feature that commonly causes severe burns is the locking mechanism, which produces a powerful flame even when the user takes their hands off the lighter, Englander said.
Mr. Englander said dope smokers often prefer torches to the “softer” flames of Bic lighters because they are more powerful and less affected by wind.
A powerful torch, combined with the altered consciousness of drug users after using substances like fentanyl, can have devastating consequences. One patient interviewed as part of the study reported that his friend “burned his hand” without waking up.
Englander said she and her colleagues began conducting the study after one of the study’s authors, Oregon burn surgeon Mark Thomas, reported seeing numerous “catastrophic, severe, life-altering burns” that appeared to be related to drug use.
George Karandinos, a Harvard physician-researcher who studies the transition from injecting to smoking, said in a separate interview that the new study is a valuable addition to the body of evidence surrounding the mode of drug use. But burns are difficult to assess because it is difficult to directly compare them to other health risks such as overdose or HIV, he added.
Karandinos also noted that overall combustion rates did not increase during the roughly 10-year study period. This is perhaps surprising given that overall drug use behavior changed significantly from injecting to smoking during this period.
“This study is very important because the specific ways people use drugs come with their own risks,” Karandinos said. “What we don’t know is the relative risk. How does the number of burns compare to other health effects?”
However, the question is not whether smoking is safer, but rather how clinicians and harm reduction advocates can encourage smoking behaviors that reduce the risk of severe burns, Englander said.
“I basically tell people that soft flames and lighters are safer than torches,” she says. “If you use a torch, we recommend that you do not use it with a lock on and be aware of the risks that a lock may have in conjunction with sedatives such as fentanyl.”
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