Overdose deaths are going down: health, harm reduction approaches play a big role

It’s several factors that may be at play, and all point to why public health approaches to drugs and overdose are critical and lifesaving.

1. Naloxone saturation. With naloxone now being available over the counter, and with more funding from public health departments, federal grants, and opioid settlement funds for it – it is saturating more communities than ever. Since most overdoses are witnessed by a friend, family member, or loved one- they are the true responders who are more likely to be armed to respond during emergencies.
2. Fewer people using fentanyl. Many have tragically died over the last few years, so there is a smaller overall population of people using street opioids, like fentanyl. Research suggests that newer users have been deterred from experimentation due to more awareness of potential risks.
3. More widespread harm reduction in places where fentanyl replaced heroin. Fentanyl entered east coast drug supplies over a decade ago and these communities have had more time to establish legal harm reduction, including syringe service programs that distribute safer injecting and smoking equipment, naloxone, fentanyl and xylazine testing strips, and broader drug checking. It could be that access to these supportive tools and harm reduction messaging about safer use strategies could be reducing risky practices. It is still important to acknowledge that overdose deaths still remain far too high in these communities, and we should be scaling up services to maximize impact.
4. People transitioning to smoking could be protective in some places. On the West Coast, smoking is a more common mode of fentanyl consumption, which may be protective. For some people, smoking leads to them consuming less fentanyl or pacing their use. However, this can also be a practice associated with risk if people re-use and share pipes for fentanyl and stimulants, and if users with no opioid tolerance accidentally consume fentanyl or too much. Even though it is a growing mode of consumption, smoking fentanyl still carries risk.
5. More access to medications that cut overdose risk in half could be protective. More settings than ever are providing access to medications, like buprenorphine and methadone, for opioid use disorder (MOUD). Settings include emergency rooms, harm reduction programs, jails, and prisons. This is a sign we need to continue to increase access to these medications. Many people still face barriers such as cost, insurance coverage, or difficulty finding a prescriber. In the case of methadone, a huge barrier is the requirement that it can only be dispensed at special clinics that require near-daily attendance and have strict rules for compliance.

First, it’s important to remember that fentanyl entered our drug supply only after crackdowns on prescription opioids led drug dependent people to seek a new source of opioids. Then the illegal market responded to this enormous demand by cutting heroin with fentanyl to make it stronger. Now, pure fentanyl is the norm, and even stronger drugs are emerging, like xylazine and nitazenes. Evidence and history show that crackdowns only lead to more dangerous drugs. In fact, the federal government criminalized all fentanyl-related substances in 2018, and overdose deaths rose 60%—from 67,367 in 2018 to 107,941 deaths in 2022.

If you look at data from Customs and Border Protection, you’ll see that fentanyl seizures nearly doubled between fiscal year 2021 and 2023. Yet during that time, overdose deaths remained high. Even the DEA claimed that fentanyl was still available on our streets. Then, in fiscal year 2024, fentanyl seizures decreased nearly 19%—and data suggests overdose deaths declined.  Drug seizures often fluctuate on an annual basis, and it is hard to draw a connection between seizures and deaths.

Drug expert Dr. Joseph Palamar from New York University has been quoted as saying we do not have enough information on the drug supply to know how much fentanyl made it into the country. Any claims that try to connect increase in seizures to decrease in overdose deaths are overblown and unfounded.

It’s unclear whether the potency of pills has changed. The only way to potentially answer this question is from the DEA’s testing of a small portion of pills they seize annually. They have used the arbitrary cutoff of 2 mg of fentanyl per pill to indicate a “lethal” amount of fentanyl in samples. DEA Administrator Anne Milgram recently claimed that in 2024, fewer seized pills had a lethal amount of fentanyl in them due to U.S. efforts abroad (yet the public has not been given access to 2023 or 2024 reports).

However, not all counterfeit pills come over the border in that form. Sometimes powders come over the border, and they are then mixed with other adulterants and pressed into counterfeit pills domestically in the U.S. It is impossible to judge the potency of all counterfeit pills circulating in our underground drug supply based on a small sample. It is also difficult to trace the potency of counterfeit pills to U.S. policies targeting cartels in Mexico.

In addition, fentanyl powder remains the dominant form of fentanyl used on the East Coast, where the majority of overdoses occur. Reduced potency in pills may not have as large of an impact as changing potency in powder.

Polysubstance use, or using more than one drug at a time, is also a driver for overdose. So we must also remain aware of the role that other drugs continue to play in overdose deaths, such as methamphetamine, cocaine, xylazine, medetomidine, nitazenes, and others.

In 2019, China scheduled, or criminalized, fentanyl. But U.S. fentanyl overdoses reached record highs in 2020 because China became a supplier of precursors. (Precursors are the chemical building blocks to make certain synthetic drugs.) The Biden Administration finally sat down with Chinese officials in fall 2023, after two years of China not engaging in much domestic drug law enforcement to target people who were selling these precursors abroad.

After these talks, China scheduled some fentanyl precursors, the nitazene class of drugs, and they promised to regulate xylazine. But these changes only went into effect on September 1, 2024. We cannot attribute reduced overdose deaths to any of these changes, since they are very recent.

Yes. While many states saw reductions, some states saw increases in overdose deaths. This is particularly true in the northwest and west—places where fentanyl only arrived recently. And some cities and states saw small reductions, or deaths remained relatively stable—for instance, overdose deaths in NYC only dropped by 1% in 2023.

In some cities, states, and regions, overdose deaths remained high or increased among certain marginalized groups. These include racial and ethnic minorities, unhoused or unstably housed people, people involved with the criminal legal system, and others. These individuals tend to be some of the most vulnerable to overdose deaths. This is why we must make meaningful investments in housing, affordable and evidence-based treatment, as well as harm reduction and overdose prevention services.

While we are still trying to understand the reasons why overdose deaths went down, it’s becoming clearer that public health interventions have played a pivotal role. It is not time to slow down our efforts. People are still dying—more than 93,000 between June 2023 and 2024. This number is still higher than pre-COVID. Our elected leaders must prioritize and go all in on a public health response that keeps our communities safe and provides better access to health, harm reduction, and treatment services.