In 2016, synthetic drugs like fentanyl were responsible or involved in nearly 50% of opioid related deaths within the United States (The Recovery Village Columbus Drug and Alcohol Rehab, n.d.). In 2017, fentanyl completely dominated the east coast of the country, while epidemics of prescription opioids and fentanyl, and heroin and fentanyl predominated in the Midwest. In 2022, there were 4,915 unintentional drug overdose deaths in Ohio, which was a 5% decrease from 2021 (Ohio Department of Health, n.d.).

According to the Ohio Department of Health (n.d.), fentanyl was involved in 81% of overdose deaths in 2022, often combined with other drugs. Ohio overdose deaths associated with fentanyl rose from 71%, to 73%, to 76% in 2017, 2018, and 2019, respectively (Ohio Department of Health, n.d.). Fentanyl was also involved in 87% of all heroin-related overdose deaths, 82% of all cocaine related overdose deaths, and 81% of all psychostimulant/methamphetamine related overdose deaths in the state of Ohio (Ohio Department of Health, n.d.).

According to the Cuyahoga County Board of Health Drug Related Deaths by Drug Type table on the Overdose Data Dashboard, 2022 data shows a slight decrease in drug related deaths from 2021.

The Cuyahoga County Medical Examiner estimates that Cuyahoga County is on track to top over 700 overdose deaths in 2023. Furthermore, overdose deaths are striking in Northeast Ohio suburbs (Mitchell, 2022; Pagonakis, 2022). People are buying counterfeit pills that are laced with fentanyl. These counterfeit pills have been described as incredible forgeries that look exactly like the real pills. Fentanyl is added to heroin to increase its potency and is disguised as highly potent heroin. Many people are under the impression that they are purchasing heroin, when it actuality they are purchasing fentanyl, which is positively associated with overdose deaths (DEA, 2020).

**Geographic Region: Cuyahoga County, Ohio

According to the Cleveland National Drug Early Warning System Hotspot Report (2019) provided by Case Western Reserve University, participants reported fentanyl being sold more than heroin. Within the past five years, these two drugs are now being sold together as a mixed substance by some drug dealers and is passed off as ''dope'', leaving the buyers completely unaware of the contents of the drug. Sales of fentanyl have pushed out heroin in Cleveland (Hoffer, Schlosser, & Buckelew, 2019).

Substance Use and Overdose Deaths in Cuyahoga County