Most people have an aversion to injecting drugs, especially intravenously; it’s referred to as “the needle barrier.” For much of the 20th century, this aversion was a powerful deterrent to the use of drugs like heroin and cocaine.
Even among drug users, injecting drugs was perceived as dangerous. Intravenous drug use was associated with addiction, infection, HIV/AIDS, hepatitis, and overdose deaths. Most people—even those using pills or snorting drugs—avoided crossing the line to IV use. The needle barrier limited overdose-prone behaviors, keeping the most potent drugs from causing deaths.
Multiple independent studies confirm a marked increase in injection drug use in the United States over the past decade, driven by factors associated with the unrelenting and progressive opioid epidemic and the proliferation of potent synthetic drugs.
Impaired Physicians
Knowledge of intravenous use dangers is not a protective factor against intravenous use, if you are a drug user. Physicians practice strict sterile techniques when injecting medications. And if they administer an opioid, they have an antidote nearby. The situation changes if doctors themselves abuse drugs, when their behavior becomes dangerous and erratic.
Impaired doctors may self-inject diverted opioids in the bathroom. They might plan to inject cocaine, looking around for sterile water but settling for tap water or, worse, toilet water to hastily inject the drug.
A Journal of Addictive Diseases study found that self-injecting physicians reported awareness of injection risks but could not stop. A report from the Federation of State Physician Health Programs (FSPHP) described IV self-injection among impaired physicians as: “…frequently associated with death or near-fatal overdose, occurring not from ignorance but from disease progression.”
Most people who inject drugs today understand the risks but have lost executive control. Brain imaging shows that people addicted to drugs have reduced activity in the prefrontal cortex (reasoning, planning) and hyperactivity in limbic areas (impulse, reward).
Has the Needle Barrier Broken Down?
John Belushi died after a fatal overdose in 1982 from a “speedball”—a combination of heroin and cocaine—administered intravenously by someone else, later convicted of involuntary manslaughter. Actor Matthew Perry died on October 28, 2023, from an accidental overdose of ketamine, administered intravenously by his personal assistant. Many celebrities have died as a result of using drugs intravenously; often, the first doses were given to them intravenously by others. The needle-barrier stigma that once protected users from escalation to IV use is breaking down.
There has been a significant shift in drugs sold by cartels, with heroin being replaced by fentanyl, which can be synthesized in hours from precursor chemicals; in contrast, opium takes months of growing, harvesting, and processing. As fentanyl has taken over the opioid market, dangers and deaths have increased—along with profits.
More recently, xylazine, an inexpensive veterinary tranquilizer, has been added to fentanyl, increasing profits by reducing the amount of fentanyl needed per dose. Fentanyl is often more than fentanyl; today, xylazine and other synthetics are added by cartels to compete in the intravenous abuse market. Users seek this “zombie drug.”
The opioid epidemic introduced opioids to non-traditional populations, such as suburban youth, many already using pills. Pain medication misuse made opioid use common among some. Individuals began using potent opioids orally or nasally. As prescriptions became harder to obtain and more expensive, many users transitioned to heroin. Once heroin was snorted or smoked, some users moved to injection for a super-potent, immediate effect. Now, fentanyl and its analogs are so powerful that injection is often unnecessary. Yet some users quickly develop a tolerance to fentanyl, pushing some to inject for stronger, faster hits.
Why Has the Overdose Epidemic Not Stopped Fentanyl Overdoses?
“Most overdoses occur in people who already know about the risks of ODs,” says drug expert Robert DuPont, M.D. “Most have experienced ODs themselves, and their friends have had ODs. The risk of an overdose death for an IV drug user is about 2% a year. This loss of life is tragic but too infrequent to change the behavior of users, once addicted.”
Addicted individuals often titrate dangerously close to fatal doses. Death can occur from overdosing on one or multiple drugs, or combined drug intoxication (CDI) from polydrug use. Polydrug use carries more risk than a single drug, from an increase in side effects and drug synergy. For example, the chance of death from overdosing on opiates is greatly increased if consumed with alcohol or other drugs.
Addiction Essential Reads
Smoking Decreased Due to Public Vilification
Decades of lung cancer deaths caused by smoking did nothing to reduce smoking. Not until public health prevention programs vilified smoking was it driven home that deaths were the responsibility of cigarette smokers themselves. This has been a missing issue for intravenous abuse and fentanyl abuse.
Successful prevention requires preventing the first use of drugs, publicizing risks, and reducing use by vilifying exploitation by drug sellers. Already-addicted users may ignore warnings as their own risk-reward calculus is biased towards drug use. However, pre-addicts and occasional users can learn to stop (or never start) using fentanyl, injecting drugs, mixing cocaine and meth, and speedballing.
We Need More Truth
The Truth Initiative is credited with a significant drop in teen smoking rates by exposing the manipulative tactics of tobacco companies and highlighting the disease-related suffering associated with smoking. Following the Truth campaign from 2000 to 2004, 450,000 fewer young people started smoking. Most prevention experts calculate that disgust-inducing Truth campaigns, anti-smoking public health initiatives, and legislation reduced smoking by more than 50%. The initiatives contributed to the denormalization of smoking, shifting public perception and behavior.
Over the past five years, nearly 500,000 people have died of drug overdose, mostly from fentanyl. But no gut-wrenching campaign exists to villify the drug cartels or the actual effects of intravenous drug use or smoking fentanyl or overdosing.
Self-Injection Isn’t Suicide—It’s a Spectrum
Most drug users aren’t trying to die. But fentanyl-adulterated synthetic drug combinations make every injection a gamble. When someone withdraws from drugs, emotionally broken, self-injection can seem like the only relief available. Users balance the risks of overdose against the drug providing immediate relief from physical or emotional pain.
Some behavior becomes quasi-suicidal—linked not to a clear intent to die but to indifference to living. Consider it “passive suicidality”—a state of being too numb or hopeless to care about risk. According to a study of people who overdosed and were rescued, conducted by Hilary Connery, M.D., Ph.D., of Harvard, 46% had some desire to die, and one in five reported intention to die.
“We need to put some of the responsibility for overdose deaths on drug users themselves,” observes Dr. DuPont. “Intravenous drug use, like cigarette smoking, is not just stupid, it is suicidal.”
Summary
Drug overdose is the leading cause of death for Americans aged 18 to 45. Prescription opioids, heroin, fentanyl, and polydrug (opioids+) overdoses have killed approximately 750,000 Americans since the epidemic began with OxyContin in 1996, evolving to heroin, fentanyl, fentanyl + xylazine, and poly drugs or speedballing. The past two decades of death and addiction have shown that we need one strategy to help people with existing substance use disorder and another to prevent new occurrences. We need more Truth Initiatives against drugs. If we prevent people from ever starting dangerous drug use, lives will be saved. Action is needed.
