As U.S. drug use behavior has shifted away from injecting and toward smoking, public health experts have been almost uniform in their reaction. The development, they’ve said, is almost entirely positive: Smoking drugs like fentanyl, instead of injecting, can help reduce infections, disease transmission, and potentially even overdose rates.
A new paper published this week, however, adds a significant wrinkle to the cost-benefit analysis. People who switch to smoking drugs, the new research shows, may be at risk for severe burns.
People who smoked drugs like fentanyl or methamphetamine were roughly four times more likely than people who don’t consume smokable drugs to be treated at an acute burn care unit, according to the study’s analysis of Medicaid claims data in Oregon between 2016 and 2024. While smoking marijuana was also associated with higher rates of severe burns, the gap was most pronounced among those who smoked either opioids or stimulants.
“A headline is that half of emergency department visits and hospitalizations for burns in Oregon are among people who use smokable drugs,” said Honora Englander, the paper’s lead author and a physician-researcher specializing in addiction at Oregon Health and Science University. “That’s a striking finding: Despite comprising about 15% of the population, 53% of burns were in this group.”
While the study is specific to Oregon, it comes amid a broad shift in drug use behavior across the U.S., where injection has faded and smoking has become more common. The shift has taken place both in response to significant changes in the drug supply and, more recently, efforts from harm reduction organizations to encourage smoking as a means of lowering the risk of common health consequences of injection, like endocarditis, hepatitis, and skin wounds associated with xylazine.
Many of the burns stemmed from the use of cheap but powerful butane torches often found at hardware stores. One feature that is commonly responsible for severe burns, Englander said, is a locking mechanism that still produces a powerful flame even when users remove their hands from the lighter.
People smoking drugs often prefer the torches over “soft” flames, like Bic-style lighters, because they are more powerful and less susceptible to wind, Englander said.
The powerful torches, coupled with drug users’ altered consciousness after using substances like fentanyl, can lead to devastating consequences. One patient interviewed as part of the study reported a friend who “burned right through his hand” without waking up.
Englander said she and her colleagues set out to conduct the study after Mark Thomas, an Oregon surgeon specializing in burns who is also one of the paper’s authors, reported witnessing numerous “devastating, serious, life-altering burns” that appeared to be associated with drug use.
In a separate interview, George Karandinos, a Harvard physician-researcher who has studied the shift from injecting to smoking, said the new research was a valuable addition to the evidence surrounding modes of drug use. But it’s difficult to evaluate, he added, because it’s difficult to directly compare burns with other health risks, like overdose or HIV.
Karandinos also noted that overall burn rates did not increase in the roughly one-decade study period — perhaps surprising, given that overall drug use behavior shifted significantly from injecting to smoking during that stretch.
“Any particular way that people use drugs is going to have its own specific risks, so this research is really important,” Karandinos said. “What we don’t know is relative risk: How does the number of burns compare to other health outcomes?”
But the question isn’t whether smoking is safer, Englander said, but rather how clinicians and harm reduction advocates can encourage smoking behaviors that carry fewer risks of severe burns.
“I tell people, essentially, that soft flame and a lighter is safer than a torch,” she said. “If people are going to use torches, I recommend not using with the locks engaged, and being aware of the risk of the lock being engaged with sedating drugs like fentanyl.”
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