After years of relentless rises in overdose deaths, the United States has seen a remarkable reversal. For seven straight months, according to federal data, drug fatalities have been declining.
Addiction experts say many interventions contributed to the declining fatalities, including wider distribution of overdose reversal medications such as Narcan; an uptick in some states in prescriptions for medication that suppresses opioid cravings; and campaigns warning the public about fentanyl-tainted counterfeit pills.
Harm reduction programs that offer sterile syringe exchanges and fentanyl test strips are also saving lives, experts note. Many treatment and support services that were shuttered during the coronavirus pandemic have become more accessible.
But drug policy and medical experts believe there is another, surprising reason: changes in the drug supply itself, which influence how people use the drugs, with some disturbing effects.
Weaker fentanyl
The fentanyl on the street is starting to become weaker.
The Drug Enforcement Administration announced that last year, seven out of 10 counterfeit pills tested in DEA labs contained a life-threatening amount of fentanyl, but that number has dropped to five out of 10. The development was attributed to the government’s crackdown on Mexican cartels and international supply chains.
Dr. Rahul Gupta, the director of the White House Office of National Drug Control Policy, attributed the decrease in overdose deaths in part to law enforcement efforts, including cracking down on the distribution of chemicals used to make fentanyl and other supplies that bring the drug more easily into the street supply. As a result, pure fentanyl is becoming scarcer and more expensive, he said in an interview.
Some public health researchers theorize that the growing prevalence of other drugs, sold on their own and also mixed in with fentanyl, is affecting how people use fentanyl.
Fentanyl is now often diluted with xylazine, an animal tranquilizer that can cause horrific skin ulcers, which have even led to limb amputations. People addicted to fentanyl often need the drug numerous times a day, but xylazine can sedate users for hours. Research has found that patients admitted to emergency departments for fentanyl overdoses had less severe outcomes when xylazine was also detected.
The spread of psychostimulants such as methamphetamine and cocaine may also be playing a role, medical and law enforcement experts say. But teasing apart that impact is difficult. Research suggests that stimulants are not as acutely deadly as fentanyl, though they are still dangerous. They can lead to fatal overdoses and cause chronic cardiac damage.
The ways people ingest fentanyl are also evolving, some researchers have observed, though they are not yet prepared to draw conclusions about how that is affecting fatalities.
Dr. Allison Arwady, the director of the government’s National Center for Injury Prevention and Control, an arm of the Centers for Disease Control and Prevention, said fewer users were injecting fentanyl in favor of smoking or snorting it.
That may be because they are trying to avoid the necrotic wounds that are caused by xylazine and are closely associated with injection. But it may also be related to the mistaken perception that smoking or snorting is less deadly than injection.
In fact, a recent CDC study showed that while injection-related opioid fatalities had dropped, particularly on the West Coast, deaths associated with smoking the drug had risen.
Still alarmingly high
Though the improvements have been significant, drug-related deaths are still alarmingly high. According to the latest provisional data from the CDC, overdose deaths fell to 97,000 in the 12 months that ended in June, 16,000 fewer than in the period a year earlier — a projected drop of 14.5%. Data suggests that in many states, nonfatal overdose rates are falling as well.
But the data also shows uneven progress among racial and ethnic groups and geographic regions. Fatal overdoses among Black Americans generally increased between 2022 and 2023, while they largely decreased among white Americans, according to a recent Georgetown University analysis of state data.
Eastern and Midwestern states saw some of the sharpest fatality drops, a possible reflection of their more seasoned responses to fentanyl, which has plagued them for years. By contrast, in five Western states, where fentanyl arrived later, overdose deaths are still rising.
While the overall fatality decline is welcome news, “it comes with the risk that people will say, ‘We’re doing OK now on drug overdoses, we’re making progress,’” Arwady said.
“There are entire communities that are not seeing that progress,” she continued. “Many families continue to be impacted by it every day. So it has to remain a priority for the CDC and public health across the country.”
Jan Hoffman is a health reporter and Noah Weiland writes about healthcare for The New York Times.
First Published: December 1, 2024, 10:30 a.m.
