Drug Overdose Deaths Are Down. Is It a Blip or a Trend?

Last year, the US Centers for Disease Control and Prevention (CDC) reported a 3% decline in the number of drug overdose deaths, the largest decrease in 5 years. Officials called the numbers “heartening” but stopped short of saying the decline was a sign of a larger trend.

But now, as drug overdose deaths have continued to drop through the first 5 months of 2024, public health officials may have reason to believe that the decrease in 2023 is more than just an anomaly.

Predicted provisional deaths from drug overdoses declined by 12.7% between May 2023 and May 2024, dropping to 98,820 from a record high of 111,029 in 2022.

“It’s reasonable to feel optimistic,” Lief Fenno, MD, PhD, chair of the American Psychiatric Association’s Council on Addiction Psychiatry, told Medscape Medical News. “It should provide a little bit of a kick for everybody who’s putting effort in at all levels to try to make a dent in this really terrible overdose crisis that we’ve found ourselves in for the last half decade.”

Despite the drop, close to 100,000 people dying annually is an “insanely high” number of losses, Nabarun Dasgupta, PhD, MPH, a senior scientist at the University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina, told Medscape Medical News.

“It feels like we may have gotten the lid on the pot, but we’re still at a rolling boil,” said Dasgupta, who works at the Opioid Data Lab, an academic collaboration.

And the most recent numbers represent only a patchwork of progress: Some states have seen declines in opioid overdose deaths of as much as 30% during that 12-month period, while others saw increases of up to 36%.

What’s more, researchers still don’t understand the reasons behind the surge in overdoses or the recent decline.

“There’s clearly powers beyond what we traditionally think of in public health and public health interventions that are at play here, and we don’t understand it, and we’re not the ones controlling the direction of the overdoses,” Dasgupta said.

Why the Decrease?

In all likelihood, there are a multitude of factors influencing the decline, said Fenno, who also is an assistant professor of neuroscience and psychiatry at the Dell Medical School, The University of Texas at Austin.

“There hasn’t been a single large-scale change that would explain the sudden reversal,” he said.

One reason for the decline may be that “the susceptible population is no longer growing,” Daniel Ciccarone, MD, MPH, professor of family and community medicine at the University of California San Francisco, told Medscape Medical News.

Since 2015, deaths have largely been driven by the presence of fentanyl in the drug supply. Fentanyl’s lethality hasn’t waned, but the number of new users is declining. Ciccarone suspects this could be because new, younger users have been warned off the drug. Fewer users equate to fewer deaths, he believes.

The decline could also be due to a synergy of greater naloxone availability and a larger number of clinicians prescribing buprenorphine in the wake of a late 2022 removal of restrictions. However, “there’s no data to support that the buprenorphine waiver going away has made a dent yet,” he said.

Government seizures of fentanyl have not likely made a difference, Ciccarone said. The drug remains cheap and easy to find, which suggests the supply has not been impacted, he said.

Dasgupta does not see a decline in new users based on recent data on fentanyl use. “There’s still plenty of 20-year-olds using fentanyl for the first time,” said Dasgupta.

He has seen a shift in the drug supply in the east, where fentanyl is taken mainly to prevent withdrawal. People are taking less fentanyl and adding other drugs — like the animal tranquilizer xylazine, in particular — to get fentanyl’s sedative effect, said Dasgupta.

Xylazine is cheaper, and overdoses of xylazine plus fentanyl are less severe than those with fentanyl alone, he said, and users might add cocaine or methamphetamine to counteract the sedation. All of this adds up to less use of fentanyl, which potentially leads to fewer overdoses.

Impact of Naloxone?

The widespread distribution of naloxone may explain a decrease in overdoses in some geographic areas, Dasgupta said. In mid-2023, the US Substance Abuse and Mental Health Services Administration made grants available to states to increase access to naloxone in communities.

This may have helped curb overdoses in St. Louis, for instance, said Dasgupta. The CDC reported a decline in overdose deaths of more than 20% in Missouri for the year ending May 2024. Using its own data, the University of Missouri–St. Louis reported that statewide deaths are on track for a 30% decline for the first half of 2024.

The university reported that in 2023, its data indicated an 11% decline statewide and a 14% decline in the St. Louis metropolitan area. St. Louis is the epicenter of deaths in Missouri, the report noted, and university experts said increased distribution of naloxone had likely made a difference.

In Texas, overdose deaths declined by about 2% through May 2024, according to the CDC. Fenno said that Texas is doing some things right, such as naloxone vending machines, and an emergency medical technician–driven program that provides buprenorphine on the spot within 24 hours of an overdose to those who are interested.

Needle exchange programs and fentanyl test strips are illegal in Texas. Even so, “there’s more of a conversation at the state level around trying to implement public health strategies to reduce either access to or the harms that are caused by illicit opioids,” said Fenno.

Fentanyl is not going away in Texas just yet. At his opioid treatment program, most of his patients reported that the first opioid they used was fentanyl. “People are starting with fentanyl,” and younger users are not shying away from it, said Fenno.

‘Green Shoots of Progress’

States that have weathered the worst of the opioid epidemic have seen declines in deaths. West Virginia, for instance, had a 15% decrease in the CDC’s latest report, while Ohio experienced a 22% decline, figures Ciccarone calls “impressive.”

Overdose deaths decreased 1% in New York City in 2023 after a doubling of deaths between 2019 and 2022, said Ashwin Vasan, MD, who just stepped down as the commissioner of the New York City Department of Health and Mental Hygiene. In an October press briefing sponsored by the Big Cities Health Coalition, Vasan said the decline “represents the beginnings, the green shoots of progress.”

Vasan credited city initiatives, such as supervised consumption sites (run by contractors and called overdose prevention centers), syringe services, naloxone distribution, and programs that connect people to medication-assisted treatment. He said that the $154 million the city has received from its settlement with opioid manufacturers is “starting to make a difference.”

Western states have not fared as well. Deaths increased by 36% in Alaska, 22% in Oregon, 18% in Nevada, 7% in Utah, and 11% in Washington state.

This is due in part to the east-to-west spread of the fentanyl epidemic, Dasgupta and Ciccarone said.

However, Brad Finegood, who as a strategic advisor oversees the overdose prevention efforts for Seattle and King County, Washington, said that real-time data indicate a 22% decline in deaths for the first 9 months of 2024.

“We’re getting a tremendous uptake in people who use opioids carrying naloxone,” Finegood said on the Big Cities Health Coalition call. Some 85% of people using drugs reported they carry naloxone, he said.

The county has increased access to methadone, buprenorphine, and naltrexone, with an estimated 12,000 Medicaid recipients on one of these medications currently, he added. A new 24/7 hotline that started in January helps people get access to buprenorphine. The service has served around 400 clients so far.

King County also has multiple mobile methadone vans in addition to fixed site methadone clinics and providers are offering long-acting injectable medications for opioid use disorder.

African Americans, Native Americans Still at Risk

There are still disparities in overdose deaths in King County, especially among older individuals of color, Alaskan Natives, and Native Americans, said Finegood.

In New York, older Black men are disproportionately dying, Vasan said. These individuals have faced “the cumulative effects of long-term physical and health neglect, long-term social and economic need and marginalization,” and “the impacts of racism,” along with “fragility in the face of a shifting drug supply,” said Vasan, noting that fentanyl is 40 times stronger than heroin.

“There’s still people dying,” said Dasgupta, adding that “the rates are going up in African Americans and Native Americans.”

But, he added, “we’re at an important inflection point where there is a huge amount of new funding that is going to come into play with opioid settlements. There’s a lot that we can do.”

Ciccarone reported that he is the voluntary medical director for Remedy Alliance/For the People, a large wholesale distributor of naloxone and other medications. Dasgupta reported that he is an uncompensated board member of Remedy Alliance/For the People and a contractor for the US Food and Drug Administration on issues of opioid overdose measurements. Fenno and Vasan reported no disclosures.

Alicia Ault is a Saint Petersburg, Florida-based freelance journalist whose work has appeared in publications including JAMA and Smithsonian.com. You can find her on X: @aliciaault.