A look at overdose death by drug

The role of fentanyl in overdose death

The final overdose death numbers for last year are now complete and available by analyzing the Ohio Department of Health mortality database.

In the following charts, Harm Reduction Ohio documents the evolution of Ohio’s overdose epidemic from 2007 – 2021. We examine total overdose death, race, gender and drugs involved in overdose deaths.

First, total overdose deaths. Ohio set another records in 2021.

Fentanyl or a fentanyl analog were involved in 4,134 of 5,174 overdose deaths in 2021, or about 80%.

First, let’s look at how overdose deaths have changed for all drugs, without considering the role of fentanyl. Then, we’ll examine the role fentanyl has played.

(Note: Marijuana-fentanyl numbers aren’t shown because marijuana-fentanyl claims are false, no matter who says it or how many times it is said. Marijuana is the only drug that carries no risk of overdose death.)

Overdose deaths by drug

Ohio cracked down on prescription opioids to reduce overdose deaths. In fact, the policy had the opposite effect. Never has the saying “the road to hell is paved with good intentions” been more apt.

Heroin deaths (and total overdose deaths) increased after the prescription drug crackdown because people who used drugs turned to more dangerous alternatives. Heroin is more dangerous than prescription opioids because heroin is more powerful by weight, unpredictable in dose when obtained on illicit markets and fast-acting when injected rather than consumed by swallowing a pill.

In this chart, we see how heroin use and deaths increased in response to the crackdown on prescription pills. A few charts later we’ll see how heroin deaths plummeted as cheaper, easier-to-make and smuggle fentanyl crowded heroin out of the opioid market.

Cocaine is the most popular prohibited drug, other than marijuana. Cocaine overdose deaths were relatively uncommon despite its frequency of use before fentanyl entered the cocaine supply starting in late 2014.

Meth is a powerful stimulant and an often problematic drug. However, before fentanyl, death was rarely the problem. The increased meth death toll in recent years partly reflects an increase in meth use but mostly is the result of an influx of fentanyl into Ohio’s meth supply.

Now let’s put all the drugs together in one chart. You’ll see dramatic changes in what drugs are involved in overdose deaths.

In this chart, fentanyl-only is a count of when fentanyl was found by itself, mixed with no other major drug (heroin, cocaine, meth or benzodiazepines).

In short, the chart shows that fentanyl has almost entirely displaced heroin (and kills at a much higher rate). Also, people who use cocaine and meth — both stimulants — are suffering from soaring death rates. We are in a stimulant crisis today. Fentanyl is the drug killing 80% of stimulant users, but we must remember that stimulants are the drug most people who die are choosing to use.

Poly-drug use is a complicated subject and every situation is different, but trying to reduce stimulant-driven overdose deaths by throwing more money and buprenorphine at the problem won’t work (and isn’t working). We have an overdose epidemic, not an epidemic of opioid use.

The role of fentanyl

If you think fentanyl is at the heart of Ohio’s overdose crisis, you are correct.

Changes in the level of fentanyl in the drug supply explain almost all changes in overdose deaths, both up and down. Most people don’t know this fact: Ohio has lower than average drug use levels. (Read that sentence again.)

Ohio has a drug adulteration problem, not a drug use problem. Ohio had average drug overdose death levels before the crackdown on prescription drugs, just as you’d expect in a state that has average drug use levels (and average income and is average in most categories).

The prescription drug crackdown disrupted drug markets in unintended and unexpected ways that have proved catastrophic.

We’ve already seen how the prescription drug crackdown lead to more heroin opioid deaths. But the introduction fentanyl and its analogs — first into heroin market in 2014 and then into all drugs as time went along —  created the period of mass death that is nearly a decade old.

This chart shows death counts for drugs containing fentanyl — heroin-fentanyl, cocaine-fentanyl, meth-fentanyl and fentanyl-alone without other common drugs.

Each drug and its connection to fentanyl has a different story arc. Let’s look at those more closely.

First, let’s look at heroin overdose deaths with and without fentanyl. You’ll see overdose deaths from heroin alone defined the overdose epidemic from 2010-2015, the era when the prescription drug crackdown rolled on. Then super-potent/super-cheap fentanyl came into the market and displaced heroin so completely that heroin-only overdose deaths have nearly disappeared and even heroin-fentanyl deaths are rare. Today, the illicit opioid market consists almost entirely of fentanyl and fentanyl analogs.

When one drug displaces another in illicit markets, the new alternative is invariable cheaper, more powerful, dangerous and deadly. That’s why the drug war kills so many. Cracking down on Drug X doesn’t make the world safer; it makes it more dangerous because replacement Drug Y is…well, it’s fentanyl, the perfect market response to how drug prohibition regulates consumer drug markets.

The cocaine-fentanyl overdose death chart may be the most heartbreaking of all. You’ll see that cocaine overdose deaths without fentanyl are essentially unchanged over the last 15 years. That makes sense because cocaine use has changed little, according to the National Survey on Drug Use and Health. The influx of fentanyl into the cocaine supply accounts for the entire increase in cocaine-related overdose deaths.

No one predicted it at the time, but, in hindsight, we now know that: the prescription drug crackdown has resulted in the deaths of hundreds of Ohio cocaine users. More than 1,000 cocaine users died in Ohio last year alone from the law of unintended consequences.

The unintended victim of this policy blunder was Black Ohioans. We’ll explain that in the next section.

But first…look at meth-fentanyl deaths. Although meth use has increased dramatically in Ohio in the last  five years, meth-only deaths have hardly changed. Nearly all the increase in meth deaths are related to fentanyl.

The danger of the drug supply — not unusually high levels of drug use — is the cause of mass overdose death in Ohio. That’s why we can’t prevent our way out of the problem or treat our way out. We must make the drug supply safer so we stop slaughtering people who use drugs.

Benzodiazepines, such as the anti-anxiety drug Xanax, gets less attention, but the story is the same. Adulteration is killing far more people than the drug itself

Race and overdose death

For decades, White Ohioans have died of opioid overdoses at high rates than Black residents. Comedian Dave Chappelle even did a comedy routine about this in 2018.

For decades, though, Black residents of Ohio and the United States as a whole have died at higher rates from cocaine overdoses than White residents. So when fentanyl came into the cocaine and cocaine became more dangerous, overdose deaths among Black residents of Ohio soared

Today, Black Ohioans have much higher overdose death rates than White Ohioans and the racial gap is growing each year.

Black residents account for 13% of Ohio’s population and about 20% of overdose deaths.

White Ohioans still die in greater numbers, although at lower rates than Black Ohioans.

The flat level of overdose deaths among White Ohioans is an interesting mix of two things. First, opioid use has declined in Ohio and deaths of people who use opioids has declined somewhat, too, although the death rate remains alarmingly and aberrantly high. But this declined is hidden by an increase in meth-fentanyl overdose deaths. Meth use is still an overwhelmingly White phenomenon, so, although the number of White overdose deaths in 2017 and 2022 is almost the same, the drug that people were using before suffering a fatal overdose is markedly different.

White deaths are now skewing heavily to meth users. See the chart higher in this article for a reminder of how meth deaths are soaring

Lastly, let’s remember 5,000 deaths a year is not normal. Without the drug war and the dangerous adulteration it causes, Ohio would suffer fewer than 1,000 accidental overdose deaths a year, likely fewer than 500  Today’s overdose epidemic is self-inflicted  We’ve made a policy mistake. We can fix it.

Thanks for reading. Thanks for caring.

— Dennis Cauchon, President, Harm Reduction Ohio