The scale and tragedy of the opioid epidemic in the United States cannot be overstated. Since 2021, more than 100,000 people have fallen victim to overdoses each year, with the potent synthetic opioid, fentanyl, being the primary culprit behind the majority of these deaths.
However, new data from the Centers for Disease Control and Prevention (CDC) suggests that this alarming trend may have peaked: overdose deaths have declined slightly since last fall, including those from opioids, of which fentanyl is central. However, we certainly shouldn't jump to conclusions.
Over the past 12 months, the total number of deaths remains exceptionally high at more than 102,000, well above pre-pandemic levels. For example, between 2017 and 2019, there were over 68,000 overdose deaths each year. Keep in mind, however, that the latest numbers are preliminary and may be an underestimate, according to the CDC.
However, new data from the Centers for Disease Control and Prevention (CDC) suggests that this alarming trend may have peaked: overdose deaths have declined slightly since last fall, including those from opioids, of which fentanyl is central. However, we certainly shouldn't jump to conclusions.
Over the past 12 months, the total number of deaths remains exceptionally high at more than 102,000, well above pre-pandemic levels. For example, between 2017 and 2019, there were over 68,000 overdose deaths each year. Keep in mind, however, that the latest numbers are preliminary and may be an underestimate, according to the CDC.
«It's definitely too early to say that the death rate has peaked and will continue to decline. We've experienced false peaks before. Still, there are many reasons for cautious optimism, although the numbers remain overly high. We can think we're starting to turn the corner» — says Daniel Ciccarone, a professor of family medicine at the University of California, San Francisco, who studies the social, behavioral and medical aspects of the opioid epidemic.
The reasons for the change in overdose death rates are not completely clear, but experts have several hypotheses.
One is that mortality rates may be returning to pre-pandemic COVID-19 average levels. Overdose death rates rose rapidly in the early years of the pandemic, but it is unclear whether the cause was due to increased drug use or because people were more likely to die from overdoses.
Specific data on the number of people using illicit substances such as fentanyl are also not available. Stress and social isolation, exacerbated during the pandemic, may have led some people to start using drugs or to use them more frequently and in more risky ways. Important aspects of treatment for opioid use disorder were disrupted, which meant that help was less available in the event of an overdose.
«Now that the pandemic has largely receded, people can once again go out, socialize and access the services they need. That reduces some of the risk, and I think that's why we're seeing this dynamic» — notes Magdalena Cerda, an epidemiologist and director of the Center for Opioid Epidemiology and Policy at New York University's Grossman School of Medicine.
It also emphasizes that investment in treatment and interventions can have a positive impact. Access to addiction medications such as buprenorphine and methadone has increased, and naloxone (often known by the brand name Narcan), an overdose prevention medication, is now available without a prescription.
The availability of test strips to detect fentanyl and other drug screening equipment has also improved. This allows people who use drugs to more effectively avoid fentanyl, which in much smaller doses can cause overdose than other opioids.
A darker explanation for current trends is that there is a significant decline in the number of people who have used fentanyl and are at risk of overdose, which could lead to a natural decline in the opioid epidemic. As Ciccarone argues, if there aren't enough susceptible people, the epidemic, like every other epidemic, will die out sooner or later.
According to Jay Unique, an assistant professor at the University of Maryland School of Social Work, the older generation suffering from opioid use disorders is leaving, while the younger generation is becoming evidence of how dangerous these drugs are, which may make them less willing to start using. The declining supply of fentanyl in several U.S. states may also explain the decrease in overdoses. Most of the illegal fentanyl in the country comes from Mexican cartels that obtain precursors from China and other countries.
The U.S. Drug Enforcement Agency is targeting the Sinaloa cartel, the main supplier of fentanyl to the eastern part of the country, which could lead to shortages of the substance, Ciccarone notes. He has also heard of a similar decline in fentanyl availability in San Francisco. However, given the low cost of fentanyl production and the availability of precursors, Ciccarone doubts that supply shortages are the sole reason for the drop in death rates.
While eastern U.S. states have seen a decline in overdose deaths, the problem continues to grow in western states. Experts speculate that the differences may be related to when fentanyl first appeared in these regions. In the east, including the Midwest and Appalachians, the drug began circulating around 2014, while on the West Coast it didn't become relevant until 2019. Ciccarone comments that eastern states are «late to the party».
The U.S. Drug Enforcement Agency is targeting the Sinaloa cartel, the main supplier of fentanyl to the eastern part of the country, which could lead to shortages of the substance, Ciccarone notes. He has also heard of a similar decline in fentanyl availability in San Francisco. However, given the low cost of fentanyl production and the availability of precursors, Ciccarone doubts that supply shortages are the sole reason for the drop in death rates.
While eastern U.S. states have seen a decline in overdose deaths, the problem continues to grow in western states. Experts speculate that the differences may be related to when fentanyl first appeared in these regions. In the east, including the Midwest and Appalachians, the drug began circulating around 2014, while on the West Coast it didn't become relevant until 2019. Ciccarone comments that eastern states are «late to the party».
Unick agrees that the different timelines of fentanyl's emergence may explain the discrepancies between East and West. «Fentanyl seems to have already shown itself on the East Coast, while it's still ongoing on the West Coast» — he notes. While the national trend shows a decline in deaths, he emphasizes that the numbers remain at extremely high levels.
The demographics affected by the opioid epidemic have also changed: fewer white people now die from overdoses, while black and indigenous people face them more often. The crisis is also exacerbated by homelessness and mental illness, pointing to deep social inequalities.
Experts are cautiously optimistic about the overall decline in overdose deaths, but emphasize that more work is needed to address the problem. They call for greater access to drugs such as buprenorphine and methadone that are effective in helping people cope with addiction, but the dosage required to do so often exceeds allowable limits under many insurances. Cerda and her colleagues advocate raising those limits for more effective treatment, as well as increasing the availability of naloxone and fentanyl test strips, and investing in prevention programs for youth.
The demographics affected by the opioid epidemic have also changed: fewer white people now die from overdoses, while black and indigenous people face them more often. The crisis is also exacerbated by homelessness and mental illness, pointing to deep social inequalities.
Experts are cautiously optimistic about the overall decline in overdose deaths, but emphasize that more work is needed to address the problem. They call for greater access to drugs such as buprenorphine and methadone that are effective in helping people cope with addiction, but the dosage required to do so often exceeds allowable limits under many insurances. Cerda and her colleagues advocate raising those limits for more effective treatment, as well as increasing the availability of naloxone and fentanyl test strips, and investing in prevention programs for youth.
«We are still at a point where over 100,000 people die from overdoses per year, and that number remains unacceptably high. However, I am heartened by the steady decline in overdose deaths in recent months... and we need to continue to invest in programs that are showing to be effective in saving lives» — concludes Cerda.
What happened in Oregon?
Oregon decriminalized hard drugs in 2021 and re-criminalized them just a couple months ago. New analysis shows the laws likely had little impact on opioid deaths
The opioid epidemic in the US has developed in waves, from prescription painkillers to heroin and eventually fentanyl. However, recent data indicates a decline in overdose deaths, with overall rates dropping 10% and fentanyl deaths dropping 12% from April 2023 to April 2024. Still, the situation can vary from region to region, such as in the West, where fentanyl deaths continue to rise.
Haven Wheelock, Oregon's syringe exchange program manager, noted that the past three years have brought significant changes in the drug situation. In February 2021, Oregon became the first state to decriminalize hard drugs, allowing possession of small amounts of drugs to be punished with a $100 fine rather than arrest.
However, Oregon went back to criminalizing drugs a couple of months ago due to a 41% spike in overdose deaths since Measure 110 was introduced. A new study argues that decriminalization was not the cause of that increase; rather, it can be attributed to the proliferation of fentanyl. Todd Kortheis of the University of Oregon confirmed that fentanyl was a major factor, and the lack of access to treatment exacerbated the situation.
Washington State offered Oregon a unique counterexperiment: both states had fentanyl around the same time, but Washington returned to criminalizing the drug in 2021, after a four-month period in which such crimes were not punished.
If you really believe that decriminalization causes overdoses to increase, you should have seen them become more moderate or stabilize after criminalization was restored. But instead, instead, overdoses only increase «at the expense of fentanyl after decriminalization was lifted in Washington».
Keith Humphries, a psychologist and co-director of the Stanford Addiction Policy Network who was not involved in the new study, cautions against overemphasizing the Washington experiment because its decriminalization period was too short and unusual. He also expressed doubts about the study's key conclusion. Decriminalization may, for example, have increased access to fentanyl throughout Oregon, especially amid the open drug markets that have emerged in recent years.
One of the key lessons Oregon can learn is that decriminalization is not a simple switch and requires careful support in the form of well-funded prevention and treatment programs. For example, Portugal, which decriminalized all drugs in 2001, spent about two years strategizing and building treatment capacity before officially changing its laws. Portugal was also able to strike a balance in regulating drug possession, avoiding the extremes of full legalization or criminalization.
In contrast, Oregon implemented decriminalization too quickly, acting under pressure from supporters who were too enthusiastic and didn't want the existing order to persist even longer. We ended up in the decriminalization mess because people were too quick to do a lap of honor and distracted from other key ingredients for success.
One of the key lessons Oregon can learn is that decriminalization is not a simple switch and requires careful support in the form of well-funded prevention and treatment programs. For example, Portugal, which decriminalized all drugs in 2001, spent about two years strategizing and building treatment capacity before officially changing its laws. Portugal was also able to strike a balance in regulating drug possession, avoiding the extremes of full legalization or criminalization.
In contrast, Oregon implemented decriminalization too quickly, acting under pressure from supporters who were too enthusiastic and didn't want the existing order to persist even longer. We ended up in the decriminalization mess because people were too quick to do a lap of honor and distracted from other key ingredients for success.
For example, in 2020, the National Survey on Drug Use and Health ranked Oregon as the worst state in the nation for access to drug treatment. While Measure 110 allocated more than $300 million to address the problem, most of the funds did not become available until 18 months after the decriminalization law went into effect. Additionally, this money was not directed toward traditional treatment services.
Instead, they have mostly gone to harm reduction programs and initiatives that provide clean needles, syringes and other tools for drug use, testing for infectious diseases such as HIV, the drug naloxone to neutralize opioids and other support services. These interventions can help reach people who are not seeking treatment.
However, without simultaneously increasing access to evidence-based treatments or integrating services, many Oregonians seeking help with addiction have not been able to do so.
Fighting addiction also requires addressing its root causes, such as poverty and homelessness. Addiction is a poorly adapted coping mechanism. People need to be provided with basic needs — food, shelter, and supportive communities where they will not feel fear of violence. All of this is a cynical attempt to dump all the blame on «decriminalization» and the idea that policies alone can solve addiction is «magical thinking».
Whether it's a policy failure or a failed PR project, Oregon's experiment may already be influencing reform efforts at the national level. While studies emphasize that decriminalization had no significant impact on overdose deaths, many remain skeptical of its ability to make a difference because Measure 110 was not put to voters with the mindset that «it shouldn't make things much worse». For a number of these reasons, if we could go backwards, we would surely slow down the decriminalization timeline to get it right.
Whether it's a policy failure or a failed PR project, Oregon's experiment may already be influencing reform efforts at the national level. While studies emphasize that decriminalization had no significant impact on overdose deaths, many remain skeptical of its ability to make a difference because Measure 110 was not put to voters with the mindset that «it shouldn't make things much worse». For a number of these reasons, if we could go backwards, we would surely slow down the decriminalization timeline to get it right.