Drug overdose deaths fell by an estimated 14.5 percent from June 2023 to June 2024 — the most significant decline recorded in the 21st century. When I first heard the news, however, I was saddened.
Like many others, I feared this might reflect what epidemiologists call a depletion of susceptibles, a grim term that can describe the waning of an epidemic because the most vulnerable people have perished. Over one million friends, family members, partners and children have died of overdose since 2000, mostly because of illegally manufactured fentanyl.
That could be one element playing a role, but it’s far from the whole story. The United States urgently needs to identify which factors beyond the tragedy of mass death are causing fatalities to fall. Understanding what determinants matter most could not only help prevent rises in overdoses but may also explain why some groups continue to experience sharp increases in overdose deaths and how to end these disparities.
An undeniably positive trend is that far fewer people are becoming addicted to opioids. Most addictions begin during adolescence, and data shows that opioid misuse by teens and young adults has dropped sharply in the past decade. In 2013, 9 percent of adults ages 18 to 25 reported misusing a prescription painkiller in the previous year. In 2023 that figure dropped to just 2.5 percent. Reported misuse of street opioids like heroin has also declined.
Drug epidemics are often cyclical. Younger generations witness the harm specific drugs have caused their older siblings or parents, leading them to avoid those substances. That fewer people are starting to use the most dangerous drugs is nothing but heartening.
The significant, if uneven, rise in the availability of the overdose antidote naloxone has been another major factor in reducing deaths. One nonprofit reported distributing over 1.6 million doses between August 2022 and July 2023 to groups dedicated to drug-related harm reduction. A study of 911 calls between 2020 and 2022 found a 44 percent rise in the number of overdose victims who received naloxone before emergency services arrived. The federal government also significantly funded naloxone expansion and finally made the drug available over the counter in 2023. While some states without much naloxone distribution also saw declines in overdose deaths, research shows that greater availability is associated with fewer deaths.
An ongoing shift from injecting fentanyl to smoking it may also be a factor in declining overdose deaths. At least one important study has found that it may be less deadly than injecting fentanyl. Some people are also using methamphetamine instead of opioids, which carries lower overdose risk because that drug is less deadly and because drugs sold as stimulants are less likely to contain fentanyl.
Changes made by suppliers also appear to have had an impact. In recent years, dealers have started adding the veterinary sedative xylazine to street opioids. While xylazine can be deadly, it also extends the effects of fentanyl, so people take fewer doses. Fewer doses mean fewer chances to overdose.
The Drug Enforcement Administration recently announced that for the first time since 2021, the potency of fentanyl pills appears to be decreasing. There’s disagreement as to why: The agency credits the pressure it has put on drug cartels through arrests and seizures, but the cartels may be trying to produce a less lethal product to avoid killing their customers. Either way, the lower doses are probably saving lives.
Some have argued that expanded efforts to treat addiction are largely responsible for the decline in overdose deaths, but this doesn’t appear to be the case. It’s well known that long-term treatment with the addiction medications methadone and buprenorphine can cut overdose death risk in half. The number of people taking medication for opioid use disorder more than doubled from 2010 to 2019.
But prescriptions had plateaued by the time overdose deaths started falling in 2023, which suggests that greater treatment access played a limited role. Moreover, there are still strict regulations on these prescriptions, and many 12-step-based rehabs refuse to permit or provide medication. Even now, only about one-seventh of people with opioid addiction receive effective medications.
Whatever the reason for the decrease in deaths, some groups are still not benefiting. Understanding why may clue us into how we can save them. The decline started in Eastern states before moving west (in the same path that rises in deaths took). This could be because Eastern states, exposed to fentanyl earlier, have had more time to adapt and develop strategies to reduce its harm — while Western states, some of which are seeing increases in deaths, are still learning.
More distressing are worsening racial disparities in overdose deaths. A recent analysis shows that while such deaths are falling sharply among white people, they are still skyrocketing among Black people and Native Americans. Why? Because, contrary to claims that arrests push people into recovery, research shows that Black people, who are far more likely to be arrested in connection with drugs than white people are, despite similar rates of drug use and sales, are less likely to ever receive addiction treatment. Black people and Native Americans are also more likely to be incarcerated after arrest, which significantly raises overdose death risk. And people of color tend to have less access to naloxone.
Ricky Bluthenthal, a professor of public health at the University of Southern California and a longtime harm reduction leader for Black communities, argues that reducing these racial disparities must start with tearing down restrictions on addiction treatment medications and having local governments support targeted distribution of naloxone to communities of color.
President-elect Donald Trump wants to crack down on drug smuggling at the border and has suggested executing dealers. Republicans campaigned on attacking harm reduction programs that have done the most to distribute naloxone. Reversing these programs and strengthening punitive measures that failed to prevent the crisis won’t extend this positive trend and save more lives; it will merely do the opposite.
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