Drug Deaths Are Finally Declining. Nobody Really Knows Why.
One thing seems clear: Drug warriors do not deserve credit for the turnaround, although they deserve blame for the previous explosion in fatal overdoses.
Drug-related deaths in the United States—which have risen nearly every year for the last two decades, often by double-digit percentages—are expected to fall substantially this year. According to preliminary data from the Centers for Disease Control and Prevention (CDC), the death toll for the 12-month period ending in April 2024 was 101,168, compared to 112,470 for the 12-month period ending in April 2023. That 10 percent drop, assuming it holds up, is striking when compared to the previous trend.
Since the CDC is still reporting more than 100,000 drug-related deaths a year, compared to 20,000 or so at the turn of the century, it would be premature to celebrate. The current numbers, in fact, are still substantially higher than the death toll recorded in 2020, when drug-related fatalities surged by a record 30 percent. Still, a double-digit annual decrease would be unprecedented and may signal the beginning of a long-awaited reversal in ever-escalating drug fatalities, especially in light of the more modest 3 percent drop between 2022 and 2023.
There are several possible explanations for this development, some more plausible than others. But the bottom line is that no one really knows why this is happening now, although it is clear that we cannot credit the efforts of politicians who have been risibly promising to "stop the flow of illicit drugs" for more than a century.
Nabarun Dasgupta and two other drug researchers at the University of North Carolina found that the downward national trend indicated by the CDC's provisional counts was consistent with state-level mortality data and with overdose cases reported by hospitals and emergency responders. They estimate that nonfatal overdoses are down by 15 percent to 20 percent nationwide, and they note that several states have reported big declines in drug-related deaths, emergency calls, and hospital visits.
"A 15-20% decrease in non-fatal overdose and a 10% decrease in fatal overdose is a major impact," Dasgupta and his colleagues write. "There is barely any public health intervention that has credibly achieved this magnitude of decrease. Our conclusion is that the dip in overdoses is real, and not a data artifact. It remains to be seen how long it will be sustained. If it is sustained, whatever caused it would be one of the strongest 'interventions' ever witnessed in this domain of public health. Therefore, we need to next consider the possible causes."
Dasgupta et al. say it is "unlikely" that anti-drug operations along the U.S.-Mexico border have played a significant role in reducing fatal or nonfatal overdoses. They note that recent border seizures have mainly involved marijuana and methamphetamine rather than illicit fentanyl, which is implicated in around 90 percent of opioid-related deaths and more than two-thirds of all drug-related deaths.
Instead of reducing those deaths, methamphetamine seizures may have had the opposite effect. "We detected a sudden increase in meth adulteration over the Summer, starting in May 2024, exactly corresponding to the increase in border seizures," Dasgupta et al. report. "The number one adulterant of meth was fentanyl. So, the impact of the border seizures may be bi-directional: Decreasing fentanyl-only overdoses and increasing fentanyl-methamphetamine overdoses."
More generally, Dasgupta et al. note that drugs seem to be "getting cheaper and cheaper across the board," citing price and purity trends in North Carolina. "If drug prices have been dropping for the past couple of years," they say, it is hard to credit "any suggestion that drops in [overdose] deaths have anything to do with interdiction efforts or the drug supply being significantly affected," let alone to the extent "where we see hundreds of thousands of people stopping use….If the drug supply is affected in such a way, it would almost certainly cause a rise in drug prices, where we have seen just the opposite."
Dasgupta et al. also think it is "unlikely" that increased access to drug treatment can account for the decline in overdoses. Although "some forms of forced-abstinence treatment increase overdose risk even more than continued drug use," they note, "evidence-based drug treatment"—by which they mean programs that replace street drugs with methadone or buprenorphine—"reduces overdoses." They consider two recent policy changes aimed at making such "medication-assisted treatment" easier to obtain.
In January 2023, the Drug Enforcement Administration eliminated the "X-waiver," an extra licensing requirement to prescribe buprenorphine. Last February, the Department of Health and Human Services announced regulations "making permanent COVID-19 era flexibilities that expand eligibility for patients to receive take-home doses of methadone."
While the timing of the first change makes it plausible that scrapping the X-waiver had something to do with declining overdoses, Dasgupta et al. say, research has shown that the number of prescribers increased while the number of patients did not. And since "the 2024 rule change was a continuation of temporary changes from 2020," they say, the impact "should have been seen earlier."
What about wider distribution of the opioid antagonist naloxone, which quickly reverses heroin and fentanyl overdoses? Dasgupta et al. note several possibly relevant recent developments.
In August 2022, the newly formed Remedy Alliance launched a program that provides "bulk naloxone at low or no cost to harm reduction programs." The following month, the Substance Abuse and Mental Health Services Administration (SAMHSA) started a "massive scale-up of naloxone distribution via state health departments." In March 2023, the Food and Drug Administration (FDA) approved over-the-counter (OTC) sales of Narcan, a naloxone nasal spray. In July 2023, the FDA approved the OTC sale of another brand, RiVive. Meanwhile, Dasgupta et al. say, the availability of generic versions was driving down retail prices.
The researchers think it is "plausible" that the SAMHSA-funded "naloxone saturation plans" had an impact, noting "fairly rapid" declines in overdoses after those plans were implemented. But they note that "implementation in some states started in earnest later than others" and "may now just be getting off the ground."
While "the drop in overdoses seemed to be happening around the time of OTC naloxone becoming available in pharmacies," Dasgupta et al. say, it's not clear how often those products have actually been used to reverse overdoses or how long it would take for the impact to be apparent. While OTC status "increases access to naloxone for worried parents," they note, "family members [are] less likely than peers to be present during [an] overdose."
Dasgupta et al. suggest a few other possible factors that do not hinge on deliberate interventions. If opioid users tend to be more experienced today than they were when fentanyl began proliferating as a heroin booster and substitute a decade ago, they may be less likely to overdose thanks to increased tolerance and/or greater caution. And if the introduction of the animal tranquilizer xylazine as a fentanyl adulterant decreased the typical number of doses per day, which Dasgupta et al. think is plausible given the former drug's pharmacological effects, that could have reduced the risk of overdosing.
Finally, although lower retail prices are the opposite of what drug warriors are trying to achieve, they mean that people are less likely to oscillate between using drugs when they can afford them and abstaining when they come up short. That pattern increases the risk of an overdose because tolerance declines during periods of abstinence, whether they result from arrest and jail, disruption of the local drug supply, or financial factors like high prices.
That is just one way in which the war on drugs increases the hazards it aims to mitigate. Prohibition makes drug use much more dangerous by creating a black market in which quality and purity are highly variable and unpredictable. Efforts to enforce prohibition magnify those hazards by encouraging injection instead of safer consumption methods, creating incentives for adulteration, and driving traffickers toward more potent drugs, such as fentanyl, that are easier to conceal and smuggle.
The crackdown on pain pills made all of this worse by replacing legally produced, reliably dosed pharmaceuticals with iffy street drugs, which became even iffier thanks to the prohibition-driven proliferation of illicit fentanyl. That crackdown succeeded in reducing opioid prescriptions, which fell by more than half from 2010 to 2022. Meanwhile, the opioid-related death rate more than tripled, while the annual number of opioid-related deaths nearly quadrupled.
Whatever the reasons, the upward trend in drug-related deaths finally seems to be reversing. As Dasgupta et al. suggest, drug warriors should not get credit for that turnaround, since nothing they have done recently can plausibly explain it. But they do deserve a large share of the blame for creating a situation in which an annual toll of more than 100,000 drug deaths looks like an improvement.
