The death certificate for Ryan Bagwell, a 19-year-old from Mission, Texas, states that he died of a fentanyl overdose.
His mother, Sandra Bagwell, said that was wrong.
On an April night in 2022, he swallowed a pill from a bottle of Percocet, a prescription painkiller he and a friend had bought that day at a Mexican pharmacy just across the border. The next morning, his mother found him dead in his bedroom.
A federal law enforcement lab found that none of the pills from the bottle tested positive for Percocet. But they all tested positive for lethal amounts of fentanyl.
“Ryan was poisoned,” said Mrs. Bagwell, an elementary school reading expert.
As millions of fentanyl-laced pills flood the United States masquerading as common drugs, grief-scarred families are pushing to change 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” implies that their loved ones are addicted and responsible for their own deaths, whereas “poisoning” shows that they are victims.
“If I tell someone my son overdosed, they assume he’s a junkie strung out on drugs,” said Stefanie Turner, a co-founder of Texas Against Fentanyla nonprofit organization that successfully lobbied Gov. Greg Abbott to authorize statewide awareness campaigns about so-called fentanyl poisoning.
“If I tell you my son was poisoned with fentanyl, you’re like, ‘What happened?'”, he continued. “It keeps 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 fatalities. It has permeated the vocabulary of news reports and even popular culture. But in the past two years, family groups have challenged its reflexive use.
They are having some success. In September, Texas began requiring death certificates to say “poisoning” or “toxicity” instead of “overdose” if fentanyl is the primary cause. Legislation has been introduced in Ohio and Illinois for a similar change. A proposed bill in Tennessee says that if fentanyl is involved in a death, the cause “must be listed as accidental fentanyl poisoning,” not overdose.
Meetings with family groups helped persuade Anne Milgram, the administrator of the Drug Enforcement Administration, who seized more than 78 million fake pills in 2023, for regular use “fentanyl poisoning” in interviews and in congressional hearings.
At a hearing last spring, Representative Mike Garcia, Republican of California, praised Ms. Milgram, saying, “You’ve done a great job of calling these ‘poisonings.’ These are not overdoses. Victims do not know 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 to emerge in bills and resolutions in several states, including Louisiana, New Jersey, Ohio, Texas and Virginia, according to 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,” said Leo Beletsky, a drug policy enforcement expert at Northeastern University School of Law. In the increasingly politicized field of public health, word choice is imbued with greater messaging power. During the pandemic, for example, the label “anti-vaxxer” fell into disrepair and was replaced by the more inclusive “vaccine-hesitant.”
Addiction is an area undergoing convulsive linguistic change, and words like “alcoholic” and “addict” are often seen today as reductive and stigmatizing. Research shows that terms like “substance abuser” can even influencing the behavior of doctors and other health care workers towards patients.
The word “poison” has an emotional force, bringing with it hymns from the Bible and classic fairy tales. “‘Poisoning’ fits into the victim-villain narrative that some people are looking for,” said Sheila P. Vakhariaa senior researcher at the Drug Policy Alliance, an advocacy group.
But while “poisoning” offers many families a buffer from stigma, others whose loved ones have died from using illegal street drugs are struggling. Using “poisoning” to identify some deaths while letting others be labeled “overdose” creates a judgmental hierarchy of drug-related deaths, they say.
Fay Martin said her son Ryan, a commercial electrician, was prescribed opioid painkillers for a work injury. When he became dependent on them, the doctor cut off his prescription. Ryan turned to heroin. Eventually, he got treatment and stayed sober for a while. But, ashamed of his history of addiction, he hid himself and gradually started using drugs again. Believing he was going to buy Xanax, he died from taking a fentanyl-tainted pill in 2021, one day after his 29th birthday.
Although he, like thousands of victims, died from a fake pill, his grieving mother felt that others were looking at him.
“When my son died, I felt the stigma of people, with the personal responsibility involved because he was using illegal drugs,” said Ms. Martin, from 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’s not trying to die. He’s trying to get high.”
To a increasing number of prosecutors, if someone is poisoned by fentanyl, then the person selling the drug is a poisoner — someone who knows or should have known that fentanyl can be deadly. More states are passing fentanyl homicide laws.
Critics note that the idea of a poison-villain does not take into account the complications of drug use. “That’s a bit of a simplification, because many people who sell substances or share them with friends are also at risk of a substance use disorder,” says Rachel Cooperwho manages the anti-stigma initiative at Shatterproof, an advocacy group.
People who sell or distribute drugs are usually several steps removed from those who mix the batches. They likely didn’t know their drugs contained lethal amounts of fentanyl, he said.
“In a non-political world, ‘poisoning’ would be accurate, but the way it’s used today, it reframes what was probably an accidental event and reimagines it as an intentional crime,” said G Beletsky, who directs Northeastern’s Changing the Narrative project, which examines addiction stigma.
In toxicology and medicine, “overdose” and “poison” have value-neutral meanings, he said Kaitlyn Brownthe clinical managing director of Poison Centers of Americawhich represents and collects data from 55 centers across the country.
“But the public will understand the terminology differently than people who are immersed in the field, so I think there are important differences and nuances that the public might miss,” he said.
“Overdose” describes a larger dose of a substance than is considered safe, Dr. Brown. The effect may be harmful (heroin) or not (ibuprofen).
“Poisoning” means that harm actually occurred. But it can be a poisoning from countless substances, including lead, alcohol and food, as well as fentanyl.
The same terms are used whether an event results in survival or death.
Until about 15 years ago, the Centers for Disease Control and Prevention, a respected source of data on national drug deaths, often used the two terms interchangeably. A CDC report detailing the rising drug-related deaths in 2006 is titled “Unintentional Drug Poisoning in the United States.” It also refers to “accidental drug overdose deaths.”
To streamline the growing data on drug deaths from federal and state agencies, the CDC has moved exclusively to “overdose.” (It also now collects statistics on the reported non-fatal overdose.) The CDC’s Division of Overdose Prevention states that “overdose” refers only to drugs, while “poisoning” refers to other substances, such as cleaning products.
When asked what neutral word or phrase might best characterize the death of drugs, experts in drug policy and treatment battled it out.
Some prefer “overdose,” because it is entrenched in data reporting. Others use “accidental overdose” to emphasize the lack of intention. (Most overdoses are, in fact, accidental.) Occasionally, news outlets use the same, reporting that a drug overdose occurred due to fentanyl poisoning.
Addiction medicine experts take note as most of the street drug supply is now adulterated, “poisoning” is, in fact, the most honest, accurate term. Patients who buy cocaine and methamphetamine die from the fentanyl in the product, they note. Fentanyl addicts succumb to bags containing a more toxic mixture than they expected.
Mrs. Martin, whose son was killed by fentanyl, bitterly agreed. “He was poisoned,” he said. “He got the death penalty and his family was sentenced for life.”
