‘Unprecedented’ decline in US drug overdose deaths gives experts hope

Experts have welcomed news of a reported drop in overdose deaths in the US and say they are cautiously optimistic about the downward trend, while warning that more work and extra resources will be needed to sustain progress.

Overdose deaths in the US have dropped by about 10%, the largest decline in decades – falling to an estimated 101,168 deaths annually as of April 2024, according to an analysis of state-level data.

Emergency room visits for overdose are down by 24% and 911 first-responder calls for overdoses are down by 16.7%. Some of the biggest changes are being seen in eastern states, while some states in the west are still struggling with higher rates.

Overdoses rose precipitously in the first three years of the pandemic, reaching a peak of 111,029 deaths in 2022. Overdose deaths more than quintupled in the past 25 years, with the majority caused by opioids – especially the powerful drug fentanyl.

Related: Beyond The Tipping Point: Malcolm Gladwell on Covid, Trump and what he got wrong

One in three Americans know someone who has died from drug overdose.

There was a 3% drop in 2023, the first decrease in five years, the US Centers for Disease Control and Prevention (CDC) said in May.

While the reasons for the decline are not immediately clear, researchers and those on the frontlines believe it is driven by changes in the drug supply as well as improved access to treatment and harm reduction programs.

“Looking back over the last quarter-century, there’s been no intervention that has caused a decline in overdose deaths of this magnitude,” said Nabarun Dasgupta, a senior scientist at the University of North Carolina and one of the authors of the analysis . “It’s unprecedented.”

“The recent declines in estimated overdose deaths are unprecedented, robust, and appear to be reflecting real trends,” Dr Nora Volkow, director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, said in an emailed statement. “These data give us hope that we may finally be making significant progress in reducing the devastating loss of life from the overdose crisis.”

But she also highlighted the continued – and increasingly unequal – death toll from the overdose crisis when it comes to who in society is affected the most.

“It’s also important to acknowledge that progress has not been equal for all groups,” she said. “Unfortunately, for the most affected groups, namely Native Americans and Black American men, the death rates are not decreasing and are at the highest recorded levels.”

Leo Beletsky, professor of law and health sciences at Northeastern University, remembers when 12,000 deaths in the US were considered “absolutely catastrophic” – compared with more than 100,000 now. He feels “cautious optimism” about the drop and urges policymakers to continue the momentum by scaling up prevention programs.

“We’re seeing a reversal of a trend that’s been happening for a very long time – we’re still at historic highs,” Beletsky said. “We need to double down on what works and try to move away from things that do not work.”

About 18 months ago, Eric Mockewich decided to get clean after years spent in and out of recovery. He entered treatment and now receives a monthly buprenorphine shot, which keeps him from entering withdrawal and helps him manage his opioid use disorder.

Access to naloxone, the opioid-overdose reversal drug, “definitely helps”, Mockweich said, and so do housing, food, childcare and other social services alongside accessible, affordable treatment options.

“Anything that keeps people alive long enough for them to make a decision to do something else is definitely good,” he said.

In 2021, the Biden administration announced a plan to prevent overdoses by expanding treatment and distributing naloxone, among other steps.

We need to double down on what works and try to move away from things that do not work

Leo Beletsky

After the price of naloxone soared for some harm-reduction groups, it became much more affordable . Narcan, a nasal-spray naloxone, was approved for sale over the counter in 2023, making it more widely accessible.

The administration also relaxed “very outdated” rules about medications like buprenorphine and methadone, Beletsky said. Only a third of people who need those medications can access them because of previous limitations, but access is slowly expanding, he said.

“Distributing naloxone, providing people with substance use treatment, giving folks clear information about the drug supply – all of these efforts work,” Beletsky said. “We know that they are lifesaving.”

Many of the resources offered during the pandemic, like Medicaid expansion and financial assistance, also helped, though those programs have now expired.

Another major factor leading to the overdose drop may be changes in behavior.

Xylazine, a tranquilizer, has become a more common adulterant in street drugs in recent years. Like fentanyl a few years ago, it appeared in the east and is moving west – the same pattern as the fall in overdoses.

People who use drugs laced with xylazine often need to use less frequently than they do with fentanyl-laced drugs, because xylazine binds to receptors for longer. Using less often means “less rolls of the dice” that could result in overdose, Dasgupta said.

But xylazine can cause extensive wounds when it’s injected. “It is pretty brutal,” Mockewich said. “When I went through treatment, there were people showing up – one girl had just lost her arm” due to amputation.

Because of these risks, people who use xylazine may be more inclined to snort or smoke it, rather than injecting it – and those routes of administration may have lower risks of overdosing than injections.

“The market is also maturing. People are kind of tired of fent,” Dasgupta said. The turn to xylazine could represent a desire for something else – especially among those using xylazine to keep from getting dopesick.

“It’s something that maybe helps open a door a little bit for us, and now we need to rush in with all the resources that we have developed over the last decade,” Dasgupta said. “We should be dumping huge amounts of [funding for] medications for opioid disorder treatment and scaling that up orders of magnitude more to give people a better option.”

That’s especially true for communities that aren’t seeing declines, including African Americans and Indigenous Americans in some states, he said.

The options should include harm reduction services and substance use treatment, as well as “broader structural responses” like access to medical care, pain management and mental healthcare, Beletsky said. “All those things play into substance use and overdose.”

Taking action also means stopping harmful actions and policies known to increase overdose risk, like incarceration, which increases the risk of overdose by 120% after people re-enter the community, Beletsky said.

Drug criminalization only deepens stigma, making it harder to prevent overdoses, he said.

“Law enforcement never stopped me,” Mockewich said. “Everything still goes on.”

Dasgupta is worried about the move to classify xylazine as a schedule III drug in the US. “If you were to suddenly cut off the supply of xylazine right now, I guarantee you would see a spike in overdose deaths,” he said.

Drug interdiction at the border does not seem to have an effect on overdose rates, and can even worsen the crisis, experts agreed. Authorities are seizing significantly more meth and marijuana than fentanyl at the border. With lower availability of meth, drug dealers tend to cut it with fentanyl, leading to more overdoses. Authorities should instead focus on making the drug supply safer, Dasgupta said.

Mockewich now works at a treatment facility, and he is planning to become a peer recovery specialist – a “bridge” career between leaving recovery and getting a full-fledged counseling degree for people who want to use their experiences to help other people get well, he said.

“It allows people to get into the field and help put people in touch with services,” Mockewich said. “A lot of treatment has been based on abstinence and telling people how they have to live. In the peer networks, we’re just meeting people where they’re at.”

Work like this is important because with more than 100,000 people dying and more people hospitalized each year, overdoses are “still a big problem”, he said.

“The numbers are still way too high,” Dasgupta said. “You may have put the lid on the top, but we’re still at a rolling boil.”