Cocaine's Silent Killer: Fentanyl Lurks in 62% of Vermont Overdoses, Trapping Recreational Users
Understanding Vermont's Overdose Crisis: What the 2025 Social Autopsy Reveals
What is a Social Autopsy?
While a medical autopsy explains how someone died, a social autopsy examines why. The 2025 Vermont Social Autopsy Report, published by the Vermont Department of Health, systematically reviewed the lives of 491 Vermonters who died from drug overdoses in 2022 and 2023. The goal was to identify patterns and missed opportunities for intervention in the months and weeks before these deaths occurred.
Three Major Findings
1. The Drug Supply Has Become More Dangerous and Unpredictable
The overdose crisis is no longer primarily about heroin or prescription opioids. According to the report, fentanyl was present in 84% of fatal overdoses in 2022 and 85% in 2023. But two new threats have emerged that make the situation even more dangerous.
The Cocaine Crisis
One of the most alarming findings is the dramatic spike in cocaine-involved deaths. Cocaine was a factor in 49% of deaths in 2022, jumping to 62% in 2023. The most common drug combination found in victims was cocaine and fentanyl—present in 43% of deaths in 2022 and surging to 54% in 2023.
This means the crisis is now killing people who may not think of themselves as opioid users. Someone using cocaine recreationally faces extreme risk of a fatal fentanyl overdose, often without knowing it. These individuals are less likely to carry naloxone (Narcan), understand opioid overdose signs, or access harm reduction services.
The Xylazine Complication
Xylazine, an animal tranquilizer, was found in nearly one-third of all fatal overdoses in 2023. The critical danger: xylazine is resistant to naloxone reversal. When someone overdoses on a substance containing both fentanyl and xylazine, naloxone can reverse the fentanyl’s effects but cannot address the heavy sedation from xylazine. A person may not “wake up” even after naloxone is administered, which can cause bystanders to incorrectly assume the person is beyond help.
2. People Are Dying Alone
In both 2022 and 2023, 35% of individuals died without anyone present who could administer naloxone or call for help. Even more concerning, nearly one in five people had not been seen or heard from for at least two days before their overdose was discovered.
The report also identified a shift in how people use drugs. In 2023, smoking (44%) surpassed injection (38%) as the primary method of drug use among those who died. Many users incorrectly believe smoking fentanyl is safer than injecting it. The data proves this perception is deadly wrong—fentanyl’s potency makes smoking just as fatal.
3. Most Victims Were Recently in Contact with State Systems
The report’s most significant finding is that victims were not “off the grid.” In 2023, 80% had interacted with the Department of Vermont Health Access (Medicaid), and 74% appeared in the Vermont Prescription Monitoring System. They were patients in hospitals, clients in social service programs, and individuals known to healthcare providers.
The challenge is not finding people who need help—it’s ensuring systems can effectively connect them to care and keep them engaged in treatment.
Who Is Most at Risk?
Demographics and Social Factors
Those who died were disproportionately male, white, and between ages 25 and 44. Most were unmarried with limited secondary education. The unemployment rate among victims was 20-25%, compared to just 3-4% in the overall Vermont adult population. The highest-risk industries for employment were construction and food service—often labor-intensive, low-wage jobs with limited benefits.
Housing instability also emerged as a significant factor. The percentage of victims without housing at the time of death rose from 5% in 2022 to 11% in 2023. Meanwhile, overdoses in motels declined from 13% in 2021 to 6-7% in 2022-2023, aligning with changes to the General Assistance Emergency Housing Program. The data suggests this policy change may have displaced at-risk individuals from semi-private motel rooms to more isolated settings, increasing their risk of fatal, unwitnessed overdoses.
The Mental Health Connection
About six in ten victims (60% in 2022, 61% in 2023) had a mental health diagnosis—more than double the rate of the general Vermont adult population (27%). This means the majority of victims were known to the healthcare system for mental health conditions. Their deaths represent a failure to integrate care across mental health, substance use, and physical health services.
Critical Missed Opportunities
The Danger of Institutional Release
Between 13-14% of victims had been released from an institution within one month of their death. Notably, the majority of these releases (65-71%) were from hospitals, not correctional facilities. Additionally, 60% of those with an incarceration history who died by overdose did so within five months of release.
This data reveals the extreme danger of returning to substance use following abstinence. In controlled settings, physical tolerance for opioids drops dramatically. If someone uses their previous dose upon release, it can now be fatal. The report notes that 16% of all victims had recently returned to use, many within two weeks of their death.
The Treatment Retention Problem
Perhaps the most heartbreaking finding: 37% of victims in both 2022 and 2023 had an active prescription for Medication for Opioid Use Disorder (MOUD, like buprenorphine) within five years of their death. However, only 9-12% had an active prescription at the time of death.
This means roughly two-thirds of people who engaged with the most effective treatment available eventually stopped. The primary challenge is not just getting people into treatment—it’s keeping them in treatment.
The Childhood Trauma Link
A significant portion of those who died (26% in 2022, 37% in 2023) had involvement with the Department for Children and Families when they were children. For many victims, fatal overdose was the tragic outcome of a lifetime of trauma that began in childhood.
What You Can Do
If You or a Loved One Needs Help
VT Helplink is a statewide, confidential, and free resource for finding treatment and recovery services. Call them first if you’re seeking help.
For Friends, Family, and Community Members
Carry naloxone (Narcan) and learn to use it. It’s available at pharmacies and harm reduction agencies.
Understand the new protocol. Because xylazine is resistant to naloxone, you must always call 911 and be prepared to provide rescue breathing. The person may remain sedated even after naloxone is administered.
Reduce stigma. Have non-judgmental conversations about safety. Ask loved ones: “How can I best support keeping you safe when you are using substances?”
Vermont’s Six Official Recommendations
Based on the findings, the Vermont Department of Health developed six key recommendations:
Invest in primary prevention to increase protective factors for Vermont’s youth
Expand education and communication campaigns to decrease the number of people using substances alone and increase messaging on how to get treatment
Strengthen services to support those leaving institutions, including hospitals and correctional facilities
Further integrate substance use, mental health, and physical health care services
Expand connection to those experiencing unstable housing and social isolation
Evolve terminology from syringe services programs to harm reduction agencies
What Happens Next
The 2025 Social Autopsy provides Vermont with a data-driven blueprint for reducing overdose deaths. Implementation of these recommendations will require coordinated action from state agencies, healthcare providers, community organizations, and citizens.
The Department of Health will work with partners to strengthen discharge protocols from hospitals and correctional facilities, integrate mental health and substance use treatment, expand harm reduction services to include safer smoking supplies and drug testing, increase access to MOUD and improve treatment retention, and launch targeted education campaigns about the cocaine-fentanyl crisis.
Community organizations and harm reduction agencies will adapt their services to reflect current drug use patterns, particularly the shift from injection to smoking. Legislative action may be needed to address housing instability, fund expanded services, and support primary prevention programs for youth.
For individual Vermonters, the path forward involves reducing stigma through open conversations about substance use safety, carrying naloxone and learning proper overdose response protocols, connecting people to resources like VT Helplink, and supporting policies that treat substance use as a public health issue rather than a criminal justice matter.
The 491 Vermonters who died in 2022 and 2023 were seen by state systems—they were patients, clients, and community members seeking help. Their deaths represent system failures, not individual failures. This report provides the roadmap to ensure Vermont’s healthcare, social service, and community systems can effectively save lives at the critical moments when intervention is possible.
Source: 2025 Vermont Social Autopsy Report, Vermont Department of Health