Decline in overdose deaths reflects fentanyl’s devastation

After Jason Wise’s cousin died from a heroin overdose in 2021, Wise wished he could die the same way. While addicted to heroin, pain pills, and other substances, Wise had overdosed about 25 times. But this time, he didn’t want to wake up.

“I went and got the same drugs that [had] just killed my cousin, and my intention was to overdose,” he said. He took the drugs on a baseball field in Albemarle, N.C. The friends he was with left him there, unresponsive.

A passerby noticed Wise’s prone body on the sports field. And after five days in the hospital, hooked up to a line providing a continuous drip of the anti-overdose drug naloxone, Wise recovered. But during that year, 2021, more than 107,000 people overdosed and died across the United States, nearly 15% more than the number of fatal overdoses in 2020. Deadly overdoses had already jumped 30% from 2019 to 2020.

But last year, those increases seemed to stop in their tracks—and even reverse. Nationally, fatal overdoses fell 14.5% during the 12-month period between June 2023 and June 2024, Centers for Disease Control and Prevention data show. Some states reported an even more notable decline—in North Carolina, overdose deaths dropped by 30%.

Experts say the cause of the drop is still unclear, and they agree there are likely multiple factors at play, ranging from disruptions in the fentanyl supply to the widespread availability of naloxone. And while the decline is something to celebrate, some experts and treatment providers say the death tally has become the only metric of an addiction crisis that’s wreaking havoc in many other ways. Ministry leaders fighting for transformation, not just risk-free addiction, say the battle is far from over.

Despite the marked decline, overdoses have not dropped below pre-2019 levels. Roughly 100,000 people are still dying each year. And overdoses are not declining equally across racial demographics—in at least 22 states, deaths are rising among black Americans. CDC data is roughly four months behind the reality on the ground since overdose deaths often require lengthy investigations and provisional tallies are reported months after the deaths occur.

Keith Humphreys, a Stanford University professor and addiction expert, said that the downward trend in deaths reflects a stark reality: there are simply not as many susceptible drug users left alive.

He also noted that the decrease, in part, reflects the end of the social isolation policies and treatment center closures that exacerbated overdose deaths during the COVID-19 pandemic. “This is a one-time benefit,” Humphreys said. “It doesn’t mean we’re through this.”

But he said the pandemic was not completely to blame for the spike of deaths in 2020 and 2021—years when fentanyl was also rapidly spreading throughout the United States and fatal overdoses were already rising as a result. The drug killed a large number of vulnerable users first—individuals who used it multiple times a day or used alone instead of with friends. Those people would still have died, he argued; the pandemic just accelerated their deaths.

Drug policy researcher and Carnegie Mellon University professor Jonathan Caulkins said it’s impossible to understand the recent decline without understanding the geography of fentanyl’s deadly progression across the United States. “If we looked only at deaths in Ohio or New Hampshire, where [fentanyl] came first, it already peaked and was heading down before 2023,” said Caulkins.

National data didn’t reflect the beginning of this decline, he added, since fentanyl was still making its way across the country, fueling a new spike in deaths every time it flooded a state’s illicit drug market for the first time. Now, the drug is everywhere. “So then this natural decline is no longer hidden by fentanyl reaching yet another state,” Caulkins said.

This explains why, moving further west across the United States, the decrease looks more like a slight variation in the data than a significant drop. In Texas, for instance, deaths only declined by nearly 3%. And in a cluster of Western states, among them Oregon and Nevada, fatal overdoses rose by about 16% and 26% respectively.

Last year, deaths skyrocketed just over 38% in Alaska, which, as Caulkins pointed out, was one of the last states fentanyl invaded. Jason Manalli, who serves as development director for the Christian residential rehab Set Free Alaska, said the sharp uptick in deaths also reflects the state’s inconsistent drug supply peddled by amateur dealers.

Georgia, similar to many Southern states, witnessed an 18% drop in fatal overdoses last year. For Carol Smith at the Christian rehab No Longer Bound, it’s a sliver of hope after the bleak pandemic years, when some of the program’s alumni overdoses and died. “I went to five funerals in 2020,” she said.

Smith, the program’s chief development officer, credits naloxone access laws for a large portion of the recent decline. Two years ago, the program began stocking the anti-overdose drug on campus. Smith, whose son struggled with drug addiction for years, keeps naloxone in her car and her office. “There’s an awareness that fentanyl is fatal, and so people are being more careful,” she said.

Overdose deaths plummeted 20% in Kentucky, where Van Ingram, the executive director of the Kentucky Office of Drug Control Policy, said agencies in his state gave out 160,000 two-dose units of naloxone last year and his office provided jails and prisons with about 17,000 units for inmates upon release.

“We’ve increased every year,” he said of naloxone distribution efforts, “We just see more of a willingness for people to take it now.”

Others attribute the nationwide decline in deaths primarily to U.S. law enforcement activity, including large-scale seizures of the drug at the U.S.-Mexico border, the arrests of top Sinaloa cartel leaders, and efforts to seize fentanyl profits. Earlier this fall, some street drug researchers said it appears the fentanyl pipeline could be drying up in some places and reported instances of dealers diluting the drug more aggressively.

But Caulkins at Carnegie Mellon University has his doubts that recent law enforcement actions against the Sinaloa leaders have obstructed the fentanyl supply chain, arguing that multiple cartels are likely involved in the trade. “It’s really, really hard to stop supply for very long, and the conventional wisdom is that a really big enforcement success can rattle the market, but the market adapts,” he said.

Disrupting the fentanyl network is especially difficult since, unlike plant-based drugs cultivated from crops that take a whole growing cycle to replace, production of the synthetic opioid can happen anywhere and at any time. Also, the United States’ icy diplomatic relations with China could complicate U.S. efforts to stem the flow of the drug into the country. Chinese companies produce the chemical precursors which Mexican cartels then turn into fentanyl and press into pills to be shipped across the border.

Strangely, the animal tranquilizer xylazine, known for disfiguring its users with tissue-rotting wounds, could also be playing a role in the sudden decline in deaths, said Adams Sibley, who is a part of a research team for the Opioid Data Lab at the University of North Carolina. Fentanyl tends to give users an intense but rapid high. Xylazine makes the drug last longer, and as a result, people may end up taking less fentanyl, lowering their risk of overdosing.

Another theory posits the decrease is due to drug users themselves taking more precautions, such as using with a group of people, or changing the way they consume their drugs. Sibley noted more people are smoking fentanyl rather than injecting it, possibly allowing users to control their dose, though some data show smoking can be just as deadly.

Gary Blackard is the president and CEO of Adult and Teen Challenge USA, a network of Christian residential rehabs that hold to an abstinence-based approach to addiction recovery. Like other experts, he acknowledges that it’s too soon to fully understand what’s behind the decline in fatal overdoses. But he argued that efforts to lower overdose deaths without freeing individuals from addiction aren’t enough.

A growing number of recovery organizations, as well as the U.S. government, subscribe to a philosophy known as harm reduction, which prioritizes making it less risky for addicts to use illicit drugs. “The problem with the approach is you don’t get at the root cause,” Blackard said. “You don’t help the person with addiction.”

Wesley Keziah is the executive director of Ground 40, the Christian residential rehab where Jason Wise now serves as intake coordinator after his near-fatal overdose death on the baseball field. “Just looking at death is not a good way to rate your success,” Keziah told me. “There are so many people who are still in bondage.”