Finally, mercifully, the country’s astronomical drug overdose rate appears to be flattening out — even declining. This spring, national data began to show that overdose death rates were, after more than three decades of very steady increases, no longer growing. In fact, they were beginning to drop. By now that fall is clear and striking — suggesting perhaps 10 percent fewer Americans dying from overdoses this year than last, according to a report published last week by NPR. Some leading researchers believe the data is trailing the story, and the decline is even bigger than the backward-looking indicators suggest — perhaps 15 percent year over year.
A 15 percent drop would represent miraculous progress and a windfall of mercy, given just how many Americans have been dying in recent years. But both the spectacular rise and the more modest recent fall of overdose deaths have somewhat complex, even counterintuitive drivers. And the recent good news still leaves the country at levels of overdose that would have once seemed like signs of civilizational collapse — either when compared with America’s deeper past, when drug mortality was a persistent but relatively small-scale problem, or with any of our peer countries, whose own opioid epidemics produce barely one-tenth as many deaths as ours. Over the last decade, Americans have elevated a whole series of social problems into morality tales about the health of the country: homelessness and housing costs, crime and safety, to name a few. But the curves tracing the overdose epidemic tower above them all. In the space of just half a lifetime, the United States entered an entirely new world of drug death.
In 1982, the year I was born, the country officially recorded 6,299 overdose deaths, according to the Centers for Disease Control and Prevention. In 2022, the year I turned 40, the number was 107,941.
My childhood did not take place in some halcyon period of innocence and sobriety; it was pretty well wallpapered with alarmist warnings about drug use and addiction, and in the playground at my elementary school we’d often play games with the empty crack vials we found. The heroin epidemic of the 1970s had subsided, but although crack initiated a new period of national panic, that panic rarely concerned deaths from overdose. In those days, even Americans anxious about drugs focused on other aspects of the crisis — lives shattered or rerouted, crime and violence and social disarray, the apparent menace of Black youth riding intense and short-lived highs — in part because actual deaths from overdose were remarkably rare. Not anymore. Since that time — since DARE and since “This is your brain on drugs,” since Nancy Reagan and very special episodes and national crack-baby panic — the number of American deaths each year from overdose hasn’t just grown, it has grown more than 15 times over.
By and large, Americans have understood this as an explosion in opioid use, one that reflected and expressed a kind of national despair, particularly visible among the country’s left-behind places. In this story, the overdose crisis both foretold the rise of Trump and reminded liberals of the need to repair the country’s threadbare social fabric in the aftermath of the “China shock” and the great financial crisis.
But though overdoses are easier to measure than habitual use, the two are imperfect proxies for each other, and tell quite different stories about the recent past. According to the National Survey on Drug Use and Health, at least, American opioid use has been declining, steadily and significantly, since about 2015.
That year, about 52,000 Americans died of overdoses. Over the next decade, as opioid use declined, deaths more than doubled. How? The answer is very straightforward: fentanyl. In recent years, at least, the opioid overdose epidemic has not been a crisis of demand, powered by a growing number of desperate or despondent Americans, because fewer of them are using opioids now than were a decade ago. It is instead a very obvious and simple matter of supply — what drugs were available where and when, and just how deadly they happened to be.
The country has not been riding an exponential curve upward for opioid use, it seems, just for opioid deaths. And despite what you may have heard or read or thought, that phenomenon does not seem to be primarily about large-scale behavioral change, with many more Americans drawn to addiction than at previous points in the recent past. It’s not primarily because drug decriminalization has opened gateways to casual users, and it is not primarily because “safe injection” sites have proliferated in the country’s big cities, inviting more casual use. It is not primarily because of the villainy or venality of the Sacklers and Purdue Pharma, as villainous and venal as they were in an earlier phase of the epidemic. And it is not primarily because of so-called pill mills, or because American addicts switched from prescription opiates to heroin, as was often emphasized a decade or so ago. All of these are aspects of the longer opioid epidemic story, which has now gone on for more than two decades, long enough to produce several distinct epochs, as distinct as geological eras in the new landscape of opioid death. But the latest era is defined by the introduction of a new drug of extreme lethality, and it is marked by a considerably larger increase in annual deaths than had been recorded in the decades before. At about the same time, in contradictory-seeming patterns that nevertheless may help explain each other, Americans began using opioids less frequently and dying much more often. Just between 2014 and 2021, as fentanyl really entered the U.S. market, death rates from synthetic opioids other than methadone grew 12-fold by some estimates. In 2013, synthetic opioids (consisting mostly of fentanyl) killed less than three thousand Americans. Last year, it was almost 75,000.
A decade ago, it was reasonable to talk about the opioid crisis as a sign that the country was, in some profound way, crying out in pain. But it is hard to know exactly what meaning to extract from the doubling of overdose deaths in the decade since. In fact, these years appear to show increases in the use of methamphetamine.
A recent study published by The Journal of the American Medical Association’s Network Open illustrates the pattern with a suggestive case study. In November 2020, Oregon voters made the state the first in the country to decriminalize small amounts of all drugs, but the backlash was intense enough that, less than four years later, the law was significantly repealed — a sign to many that even in the most liberal states, decriminalization, hands-off policing and harm-reduction public health policies would quickly produce community effects that almost nobody anywhere on the political spectrum would tolerate. And the number of overdose deaths had grown statewide by about 83 percent. But that spike is hard to disentangle from the penetration of fentanyl into local markets over the same period and the displacement of less lethal opioids, the researchers found. When they tried to isolate the two phenomena, their analysis suggested that the program of decriminalization and harm reduction had actually cut overdose deaths in half.
This analysis may appear simplistic, but national reporting seems to corroborate its broad outlines, with experts attributing apparent progress on overdoses to public health interventions, including a dramatic expansion of the availability of Naloxone, which can reverse opioid overdoses and was approved by the F.D.A. for over-the-counter sale last year. Harm reduction outreach and additional spending on treatment programs may have contributed, as well, and though fentanyl is notoriously difficult to police — its concentration means that you can smuggle enough to supply a small city in a saltshaker — the Biden administration has been touting its crackdown on supply and coordination with China to police production, as well.
The full story isn’t yet clear, for the country as a whole or for particular communities, such as Portland, Ore. It’s also not clear how much further interventions like these might drive down overdose deaths in the years ahead. In other words, the progress is uncertain. It is also woefully inadequate, given the scale of ongoing death: Even the encouraging recent reports suggest that as of April, more than 100,000 Americans had died of drug overdoses over the previous 12 months. That has been true now for four Aprils in a row.
These figures — and the supply-side story they suggest — seem to come from almost a different universe than the one in which so much recent national debate around drug policy has unfolded, dominated by questions of decriminalization, safe injection and homelessness policy — and by bad faith actors using overdose deaths as an indictment of liberal politics.
They also caution against our apparent reflex to turn every national crisis into an obvious and sentimental morality tale. The opioid epidemic of the last decades has been, inarguably, an American tragedy, imposing an enormous burden of suffering on the country as a whole and on too many individual families in particular. But mass overdose death was also not exactly a tragedy whose causes aligned so neatly with partisan pieties or ready-made morality tales about either the deprivations of the social welfare state or the criminal depravity of people who use drugs. You can relatively easily imagine an alternative history epidemic of only slightly different shape, in which the same number of Americans were using opioids and the same number became addicted but the novel narcotic was, while just as potent, not nearly as lethal. In that timeline, pervasive drug use might still be wrecking lives, but overdose deaths, while still much higher than in previous decades, would not have reached anything like the heights of the last decade but would have been falling steadily now for years. What story would we be telling about the country then?
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