The death certificate for Ryan Bagwell, a 19-year-old from Mission, Texas, says he died of a fentanyl overdose.
His mother, Sandra Bagwell, says that’s wrong.
One night in April 2022, he swallowed a pill from a bottle of Percocet, a prescription painkiller he and a friend had bought earlier that day at a Mexican pharmacy just over the border. The next morning, his mother found him dead in his bedroom.
A federal law enforcement lab determined that none of the pills from the bottle tested positive for Percocet. But all tested positive for lethal amounts of fentanyl.
“Ryan was poisoned,” said Mrs. Bagwell, a reading specialist at the elementary school.
As millions of fentanyl-tainted pills flood the United States disguised as generic drugs, grieving families are pushing for a change in the language used to describe drug deaths. They want public health leaders, prosecutors and politicians to use “poisoning” instead of “overdose.” In their view, “overdose” suggests that their loved ones were addicted and responsible for their own deaths, while “poisoning” indicates that they were victims.
“If I tell someone my child overdosed, they’ll assume he was a drug addict,” said Stephanie Turner, co-founder of Texas Against Fentanyla nonprofit that successfully lobbied Gov. Greg Abbott to authorize statewide awareness campaigns about so-called fentanyl poisoning.
“If I tell you my child was poisoned with fentanyl, you’re going to say, ‘What happened?'” he continued. “Keep the door open. But ‘overdose’ is a closed door.”
For decades, “overdose” has been used by federal, state and local health and law enforcement agencies to record drug deaths. It has permeated the vocabulary of news reports and even popular culture. But in the past two years, family groups have questioned its reflexive use.
They have some success. In September, Texas began requiring death certificates say “poisoning” or “toxicity” instead of “overdose” if fentanyl was the primary cause. Legislation has been introduced in Ohio and Illinois for a similar change. A proposed Tennessee bill says that if fentanyl is involved in a death, the cause “must be listed as accidental fentanyl poisoning,” not an overdose.
Meetings with family groups helped convince Anne Milgram, the administrator of the Drug Enforcement Administration, who seized more than 78 million fake pills in 2023, in regular use “Fentanyl Poisoning” in interviews and in congressional hearings.
In a hearing last spring, Representative Mike Garcia, Republican of California, praised Ms. Milgram’s choice of words, saying, “You’ve done a great job calling these ‘poisonings.’ These are not overdoses. Victims are unaware that they are taking fentanyl in many cases. They think they’re taking Xanax, Vicodin, OxyContin.”
Last year, efforts to describe fentanyl-related deaths as poisonings began appearing in bills and resolutions in several states, including Louisiana, New Jersey, Ohio, Texas and Virginia, according to the National Conference on State legislatures. Typically, these bills establish “Fentanyl Poisoning Awareness” weeks or months as public education initiatives.
“Language is really important because it shapes policy and other responses,” he said Leo Beletsky, a drug policy enforcement expert at Northeastern University School of Law. In the increasingly politicized realm of public health, word choice has become imbued with ever greater messaging power. During the pandemic, for example, the label “anti-vaxxer” fell into disrepute and was replaced by the more inclusive “vaccine hesitant.”
Addiction is an area undergoing rapid language change, and words such as “alcoholic” and “addict” are now often seen as reductive and stigmatizing. Research shows that terms like “substance abuse” can they even influence the behavior of doctors and other health workers to the patients.
The word “poison” has emotional power, carrying resonances from the Bible and classic fairy tales. “‘Poisoning’ feeds into this victim-villain narrative that some people are looking for,” he said. Sheila P. Vakhariasenior researcher at the Drug Policy Alliance, an advocacy group.
But while “poisoning” offers many families protection from stigma, others whose loved ones have died from taking illegal street drugs find it problematic. Using “poisoning” to distinguish some deaths while leaving others labeled “overdose” creates a critical hierarchy of drug-related deaths, they say.
Faye Martin said her son, Ryan, a commercial electrician, was prescribed opioid painkillers for a work-related injury. When he became dependent on them, a doctor stopped his prescription. Ryan turned to heroin. Eventually, he entered treatment and stayed sober for a while. But, ashamed of his history of addiction, he kept to himself and gradually started using drugs again. Believing he was buying Xanax, he died from taking a fentanyl-tainted pill in 2021, the day after his 29th birthday.
Although he, like thousands of victims, died from a fake pill, his grieving mother feels like others are looking down on her.
“When my son died, I felt this stigma from people, that there was personal responsibility because he was using illegal drugs,” said Ms. Martin, of Corpus Christi, Texas. “But he didn’t get what he bargained for. He did not ask for the amount of fentanyl in his system. He wasn’t trying to die. He was trying to get high.”
In a increasing number of prosecutors, if someone was poisoned by fentanyl, then the person who sold the drug was a poisoner — someone who knew or should have known that fentanyl could be deadly. More states pass fentanyl homicide laws.
Critics note that the idea of a poisoner-evil does not explain the complications of drug use. “That’s a bit too simplistic because a lot of people who sell substances or share them with friends also have a substance use disorder,” he said. Rachel Cooperwho runs an anti-stigma initiative at Shatterproof, an advocacy group.
People who sell or deal drugs are usually several steps away from those who mix the batches. They would likely be unaware that their drugs contained lethal amounts of fentanyl, he said.
“In a non-politicized world, ‘poisoning’ would be accurate, but the way it is used now, it reframes what is likely a random event and recasts it as a deliberate crime,” said Mr. Beletsky, who directed Changing the Narrative of Northeastern. project, which examines the stigma of addiction.
In toxicology and medicine, “overdose” and “poison” have value-neutral definitions, he said. Caitlin Brownits clinical chief executive Poison Centers of Americawhich represents and collects data from 55 centers nationwide.
“But the public will understand the terminology differently than people who are immersed in the field, so I think there are important distinctions and nuances that the public can miss,” he said.
“Overdose” describes a higher dose of a substance than was considered safe, Dr. Brown explained. The effect can be harmful (heroin) or not (ibuprofen).
“Poisoning” means that harm actually occurred. But it can be poisoning from countless substances, including lead, alcohol and food, as well as fentanyl.
Both terms are used whether an event results in survival or death.
Until about 15 years ago, the Centers for Disease Control and Prevention, a valuable source of data on drug deaths nationwide, often used the two terms interchangeably. CDC report detailing the increasing drug-related deaths in 2006, it was titled “Unintentional Drug Poisoning in the United States.” He also mentioned “you hear about drug overdose deaths.”
To rationalize the increasing drug death data from federal and state agencies, the CDC turned exclusively to “overdose.” (Now also collects statistics on the reported non-fatal overdoses.) The CDC’s Division of Overdose Prevention notes that “overdose” refers only to drugs, while “poisoning” refers to other substances, such as cleaning products.
When asked what unbiased word or phrase could best describe drug deaths, experts in drug policy and treatment struggled.
Some preferred “overdose” because it is entrenched in data reporting. Others use “accidental overdose” to emphasize the lack of intent. (Most overdoses are, in fact, accidental.) News outlets occasionally use both, reporting a drug overdose due to fentanyl poisoning.
Addiction medicine experts note that because most of the street drug supply is now adulterated, “poisoning” is, indeed, the clearest, most accurate term. Patients who buy cocaine and meth are dying because of the fentanyl in the product, they note. Those addicted to fentanyl are succumbing to bags that have more of the toxic mixture than they bargained for.
Mrs. Martin, whose son was killed by fentanyl, bitterly agrees. “Poisoned,” he said. “The death penalty was imposed and his family was sentenced to life.”