While marijuana is the most used drug in Hawaii, persistently high methamphetamine hospital admissions and increasing fentanyl overdoses and penetration are identified as the greatest threats to the drug problem in Hawaii, according to the National Drug Intelligence Center.
Methamphetamine (crystal meth or ice) Between July 2020 and December 2021, 263 drug-related deaths were recorded in Hawaii. Methamphetamine toxicity accounted for 64.3% of those deaths. In 2022, 64% of overdose deaths in the state involved psychostimulants, mostly methamphetamine. Meth addiction in Hawaii has been a persistent problem since the 1980s. Some estimates place the number of addicts in the state as high as 120,000. Hawaii has more residents who use meth than the national average.
Dr. Rainier Dennis D. Bautista, Clinical Professor, University of Hawaii John A. Burns School of Medicine, told the Hawaii Filipino Chronicle, methamphetamine, or “ice,” remains one of the most significant substance use issues in Hawaii. “It continues to cause widespread harm, contributing to psychiatric crises, domestic instability, and chronic medical conditions. Based on recent state data, methamphetamine was involved in 222 overdose deaths in 2023, showing a continued and devastating presence in our communities,” he said.
The social cost of methamphetamine is between $41-68 billion dollars, studies show, which includes lost potential from meth use, meth-related impacts, and the burden of addiction on dependent users and their premature mortality.
Health risks of meth use According to the Mayo Clinic, methamphetamine is a highly addictive stimulant that dramatically increases dopamine levels, leading to intense euphoria, rapid dependence and severe health risks, including heart problems, psychosis and death. Users experience emergent, acute, subacute, and chronic injuries to neurologic, cardiac, pulmonary, dental, and other systems. The long-term effects include damage to the heart, liver and brain. Producers can sustain life-threatening injuries in the frequent fires and explosions that result when volatile chemicals are combined. Methamphetamine both increases libido and reduces inhibition, a synergy that increases the risk of STD for users and their partners.
Fentanyl Since 2020, fentanyl related deaths in the state have quadrupled. In 2020, the state had 26 deaths; in 2021 there were 48 fentanyl-related deaths; in 2022 there were 79 and in 2023 there were 107. Experts warn a more powerful form of fentanyl – 100 times stronger – has reached Hawaii.
Gary Yabuta, executive director at Hawaii High Intensity Drug Trafficking Area, said law enforcement in Hawaii seized 20 pounds of Carfentanil, “that’s enough to kill every citizen or resident in the City and County of Honolulu, that’s how powerful it is,” Yabuta explained. Fentanyl’s potency is 50-100 times stronger than morphine and 25-40 times stronger than heroin.
Health and drug enforcement officials say fentanyl is a growing problem because it is being laced with methamphetamine, heroin, oxycontin, cocaine and marijuana. Dr. Christina Wang of the Hawaii Health and Harm Reduction Center said, “We’ve seen a real shift in drug supply to include fentanyl in almost anything. It took a little longer to see fentanyl hit our shores, but it’s here and so we really need to be proactive about how we’re managing and saving our community. Fentanyl is such a dangerous drug,” Dr. Wang said. “This is what’s causing the majority of overdose and deaths.”
Dr. Seiji Yamada, Professor in the University of Hawaii Department of Family Medicine and Community Health, said the medical community is concerned about how other drugs are laced with fentanyl, as 2 milligrams of fentanyl is fatal. He said as a method of harm reduction, fentanyl test strips are being used to detect the presence of fentanyl in other drugs.
Fentanyl-related deaths rose by 35% in 2023, accounting for 107 confirmed fatalities, Dr. Bautista said. “Many overdoses involve fentanyl mixed into other drugs without the user’s knowledge, increasing the danger of accidental death. Certain areas, such as Honolulu’s ‘fentanyl triangle’ encompassing parts of Chinatown, Iwilei, and Ala Moana, have seen especially high rates of EMS overdose responses. The evolving landscape of substance use in Hawaii now involves both longstanding methamphetamine dependence and a disturbing rise in synthetic opioid fatalities,” he said.
Health risks of Fentanyl Fentanyl is a fully synthetic opioid sometimes prescribed for legitimate medical reasons but is also commonly synthesized in illicit labs and sold on the black market. Fentanyl carries many potential health risks when used by itself or in combination with other drugs. According to the American Addiction Center, Fentanyl misuse can include (but are not limited to):hallucinations and visual disturbances, drowsiness and nausea, confusion, constipation, respiratory distress, muscle rigidity, unconsciousness or sedation, seizures and overdose. Fentanyl can cause permanent brain damage due to hypoxia, which can occur due to overdose and can lead to reduced oxygen in the brain, as well as damage to other organs. It can worsen or cause new mental health conditions such as depression or anxiety, and in some cases, can be associated with a higher risk of suicide.
Drug rehabilitation There are over 150 addiction treatment outpatient rehabs, 49 inpatient rehabs and 36 detox clinics in Hawaii. For assistance to accessing state resources, contact the Hawaii Department of Health’s Alcohol and Drug Abuse Division at 808-692-7506.
Dr. Bautista said he works closely with social workers and behavioral health colleagues to connect patients to rehabilitation programs that match their needs — whether inpatient, outpatient, or harm-reduction models. “In Hawaii, we often refer to Hina Mauka, The Queen’s Medical Center’s chemical dependency services, and other community-based providers. When possible, I also try to align patients with culturally appropriate care, particularly for Native Hawaiian and Filipino patients who may benefit from programs rooted in cultural identity and family involvement,” he said.
The Hawaii State DOH created the Hawaiʻi Coordinated Access Resource Entry System (Hawaii CARES), a statewide 24/7 coordination center for support with substance use, mental health, and crisis intervention services. The State of Hawaii adopted the 988 dialing code. Calling the simple three digit number, 988, directs an individual to the Hawaiʻi CARES line.
Dr. Bautista said primary care providers can screen for substance use risk factors, provide trauma-informed counseling, and intervene before patterns of addiction take root.
Substance abuse treatment reduces costs for society, reduces crime and health care costs.
Risk Factors Breaking New Ground for Youth at Risk: Program Summaries identified several risk factors for potential drug abuse.
Community Environment: Living in an economically depressed area with:
High unemployment
Inadequate housing
High prevalence of crime
High prevalence of illegal drug use
Minority Status Involving:
Racial discrimination
Culture devalued in American society
Differing generational levels of assimilation
Cultural and language barriers to getting adequate health care and other social services
Low educational levels
Low achievement expectations from society
Family Environment:
Alcohol and other drug dependency of parent(s)
Parental abuse and neglect of children
Antisocial, sexually deviant, or mentally ill parents
High levels of family stress, including financial strain
Large, overcrowded family
Unemployed or underemployed parents
Parents with little education
Socially isolated parents
Single female parent without family/other support
Family instability
High level of marital and family conflict and/or family violence
Parental absenteeism due to separation, divorce, or death
Lack of family rituals
Inadequate parenting and little parent/child contact
Frequent family moves
Negative Adolescent Behavior and Experiences:
Lack of bonding to society (family, school, and community)
Rebelliousness and nonconformity
Resistance to authority
Strong need for independence
Cultural alienation
Fragile ego
Feelings of failure
Present versus future orientation
Hopelessness
Lack of self-confidence
Low self-esteem
Inability to form positive close relationships.
Vulnerability to negative peer pressure
Dr. Yamada said, “from the revolutionary medicine perspective, we need to work with the man, the woman, their workplaces, and their societies to combat alienation, addictions, and violence against women and children. Revolutionary medicine is the medicine wherein health workers understand the social origins of illness and the need for social change to improve health conditions. It is created from the practice of the people’s struggles against their oppressive conditions.
“In both the literature and clinical practice, we see that drug use often begins as a response to deeper pain,” Dr. Bautista said, “Many individuals turn to substances to cope with trauma, mental health disorders, poverty, or social isolation. Some start using drugs recreationally or under peer pressure but quickly find themselves dependent due to how these substances alter brain chemistry and decision-making.
“In Hawaii, structural and socioeconomic issues such as housing insecurity, multigenerational poverty, and limited access to behavioral health care compound the problem. We also see intergenerational cycles of substance use in some families, and the effects of cultural displacement, particularly in immigrant and Native Hawaiian communities. Addiction is rarely just about the substance—it’s a reflection of broader unmet needs. Understanding this helps us treat the root causes, not just the symptoms,” Bautista said.
Clinical care and community outreach Dr. Bautista said the first step is to approach the patient with compassion, free of judgment, and to recognize addiction as a treatable medical condition—not a moral failing. “I assess for the specific substances being used, evaluate for withdrawal risks, and identify any coexisting mental health or social issues that may need to be addressed. For opioid use, medications such as buprenorphine (Suboxone) can be life-saving and are often the cornerstone of treatment. For methamphetamine or polysubstance use, treatment tends to rely more on behavioral therapies, intensive counseling, and structured recovery programs.”
Dr. Fortunato Elizaga, a primary care physician, said to help reduce the prevalence of drug addiction, one way is for primary care providers to avoid prescribing narcotics to our patients for moderate to severe pain. “An excellent substitute, and as effective as narcotics, is the combination of Tylenol and ibuprofen. We can educate our patients — not only to those who are addicted but to all patients — about the risk and danger of opioid use and the consequences of drug addiction would also help,” he said.
“Beyond clinical care, the medical community can engage with schools, youth organizations, and cultural groups to provide education, mentorship, and community support. We need to help build resilience and protective factors in our keiki before they ever encounter substances,” Dr. Bautista said. “And we must advocate for systems that promote mental wellness, reduce stigma, and support recovery as part of comprehensive care. When patients are seen, supported, and surrounded by access, not barriers, our entire community becomes stronger and safer,” he said.
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