Drug-related deaths in Hawaii rose a projected 13% for the year that ended in March, and local law enforcement and health officials caution that counterfeit opioids and fentanyl-laced products could quickly contend with methamphetamine as the state’s deadliest drug.

The U.S. Centers for Disease Control and Prevention is predicting 282 drug overdose deaths statewide through the end of March, compared with 249 fatalities during the same period in 2020. Hawaii’s increase mirrors a national trend where a record 99,106 deaths were reported, a 31% increase over the previous year.

Drug overdose deaths are often initially classified as “no cause,” according to the CDC, and autopsies and toxicology reports will change final statistics.

Methamphetamine-­related deaths hit a 22-year high in Hawaii in 2020, with 192 deaths, up from 169 in 2019, according to the state Department of Health. Opioid deaths hit a four-year high last year of 69, up from 54 the year prior.

Deaths from commonly prescribed opioid pain relievers like hydrocodone, oxycodone, morphine and methadone mostly have declined since 2016, according to DOH. Overdoses from heroin and synthetic opioids other than methadone, like fentanyl, generally have increased since 2012.

Over the past two years, fentanyl and synthetic opioid deaths have outnumbered prescription opioids.

“The ongoing increasing trend of overdoses related to meth is certainly a concern,” said Dan Galanis, epidemiologist with DOH’s Emergency Medical Services and Injury Prevention System Branch, in a statement to the Honolulu Star-Advertiser. “Hawaii has always had higher meth usage and related mortality than most any other state, and for probably the longest period of time — going back to the late 1980s. Currently we see the highest fatality rates among residents in the 45- to 64-year-age group, which is probably what most people wouldn’t expect. I think we are seeing the sad end to a ‘cohort’ of long-term users, eventually succumbing to cumulative physiologic effects of meth.”

The record number of overdose deaths nationwide and increasing fatalities in Hawaii concern law enforcement.

The U.S. Drug Enforcement Administration issued its first Public Safety Alert in six years on Sept. 27, warning Americans of the “alarming increase” in the lethality and availability of fake prescription pills containing fentanyl and methamphetamine, according to a news release. A “significant nationwide surge” in deadly counterfeit pills is being mass-produced by criminal drug networks and marketed as legitimate prescription pills.

“Methamphetamine continues to be the biggest drug threat in Hawaii. However, we have been seeing a steady incline in seizures of powder fentanyl and counterfeit pills containing fentanyl. It’s not the pill people think it is,” said Leslie Tomaich, assistant special agent in charge of the DEA’s Honolulu field office. “These counterfeit pills are made in filthy, clandestine labs, typically in Mexico, that have no regulation control. There is a level of deception in the marketing of these fake pills because oftentimes individuals don’t know what’s in the pill and may not have a tolerance for the type of drug or dosing contained in the counterfeit pill.”

DEA agents are also seeing fentanyl taken in conjunction with other drugs, including methamphetamine, by Hawaii consumers.

Gary Yabuta, executive director of the Hawaii High Intensity Drug Trafficking Area and former chief of the Maui Police Department, told the Star-Advertiser that the demand for fentanyl and counterfeit oxycodone on the mainland is “enormous,” and Hawaii has ample supply to fuel a new trend in addiction.

“Those who were addicted to opioid drugs through their own doctors’ prescriptions are faced with a difficulty to legally obtain prescribed painkiller medication due to reluctance from their doctors to prescribe drugs and face criminal charges, and will seek fake painkillers via the black market (pills laced with fentanyl),” said Yabuta. “Opioids and fentanyl-related products will be Hawaii’s greatest drug threat, and furthermore, the threat of our current greatest drug threat (methamphetamine) will not be mutually excluded. We will be faced with two evils.”

Dr. Mark Baker, an emergency room doctor at the Pali Momi Medical Center and founder of End Meth, a Hawaii-based coalition of concerned people and organizations dedicated to reducing meth use, told the Star-Advertiser that on a typical weekend in the emergency room, about one-third of the patients are having problems with methamphetamine. Overuse of the drug is leading to heart failure, trouble breathing and other fatal ailments.

Baker told the story of a patient who occasionally shows up “off the wall, uncontrollable,” on a meth binge after his wife calls 911. Recently, he arrived after 72 hours without sleep, passed out for 12 hours and then returned to his routine.

“It’s just such an addictive drug. He may go home thinking, ‘Man, I should never do that again,’ but the drive to do methamphetamine is so strong,” Baker said. “The message I try to give them is it is possible to stop using it, and there is help out there. I just encourage them to do whatever they can to stop.”

Alan Johnson, president and CEO of Hina Mauka, a residential substance abuse treatment organization that has addressed addiction for more than 50 years, told the Star-Advertiser a substance abuse disorder is a chronic illness like diabetes or heart disease.

“Some people who get treatment make major changes in their lives and live a full life in recovery, while many others struggle with occasional relapses as part of their improving recovery, while others lapse into seriously ill conditions, even death,” said Johnson. “Better than other chronic illnesses, there are services for counseling with medications that give the best hope for people to recover. Residential treatment followed by outpatient counseling is by far the best available treatment for those who suffer with multiple chronic conditions that involve substance abuse or addiction.”

Johnson said he would like to see government help improve data collection, compilation and reporting from hospital admissions, death certificates and other medical data. Better analytics will help conserve resources for prevention and treatment that must be carefully managed.

Ryan Yamane, chairman of the state House Committee on Health, Human Services and Homelessness, told the Star-Advertiser the state continues to work with the counties to address emerging trends in drug-related deaths. He is concerned by methamphetamine and opioids and dangerous over-the-counter drugs, like Spice, that narrowly avoid regulation but can have harmful side effects. State and federal lawmakers must collaborate to fund addiction, treatment and prevention services in an efficient and effective manner, leveraging matching funds when possible and implementing community specific approaches.

“We are always concerned when we see an increase in substance abuse-related fatalities. … That (13% increase) is a concerning number for us,” said Yamane. “It’s about resources. We are looking for proven treatments so we don’t waste precious state dollars. It’s a very comprehensive, widespread issue. It’s not just one drug that we have to deal with.”