In 2022, the US reached [a grim peak](https://nida.nih.gov/sites/default/files/images/fig1-2024.jpg) in drug overdose deaths: Nearly 108,000 people died that year, more than twice the number who died in 2015, and more than four times the number in 2002. Now, in what experts hope is more than a blip, the overdose epidemic that has affected every state in the nation might be showing some signs of abating. The Centers for Disease Control and Prevention’s preliminary data on the [12-month period ending in June](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) showed that [overdoses dropped about 15 percentage points](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) from the previous period. There were still roughly 94,000 overdose deaths, signaling that the public health crisis is far from over, though a positive change could be on the horizon. Understand the world with a daily explainer plus the most compelling stories of the day. Sign up [here](https://www.vox.com/pages/today-explained-newsletter-signup). America’s overdose crisis was exacerbated decades ago by the increasing use of and addiction to synthetic opioids, such as fentanyl, that have proliferated through the nation’s drug supply. Fentanyl was first produced in the 1960s and prescribed by doctors to people seeking relief from severe pain, such as cancer patients. A cheaper, more potent cousin of heroin, the drug soon became a favored commodity of traffickers, who began cutting other drugs with fentanyl and drawing people addicted to prescription painkillers such as oxycodone that have become increasingly more difficult to access. [As my colleague German Lopez wrote in 2017](https://www.vox.com/science-and-health/2017/5/8/15454832/fentanyl-carfentanil-opioid-epidemic-overdose), fentanyl made America’s opioid crisis — already the deadliest drug crisis in US history — even deadlier. So what might have turned the trend around? In the latest episode of Vox’s _Today, Explained_ podcast, we asked Lev Facher, a reporter covering addiction at STAT News. “There’s no one event that happened about a year and a half ago that would explain this sudden significant decrease in drug overdose deaths,” says Facher. “While there’s a lot of optimism in the harm reduction and addiction medicine and recovery world, it’s cautious optimism because people don’t really know what’s happening.” Despite that, Facher says, experts and advocates do have a few potential explanations: The simplest explanation for the drop in overdoses could be the nature of the drugs themselves; they simply may have become less toxic and less potent. Last month, DEA administrator Anne Milgram suggested [that the agency’s crackdowns](https://www.dea.gov/press-releases/2024/11/15/deas-third-annual-national-family-summit-fentanyl-highlights-progress) were having a direct impact on the drug supply. “The cartels have reduced the amount of fentanyl they put into pills because of the pressure we are putting on them,” she said at the National Family Summit on Fentanyl, which gathers people who’ve had loved ones die from drug use. Customs and Border Protection (CBP) data can’t give us the full picture of the effectiveness of cartel crackdowns, but it shows that the [rate of fentanyl confiscation at the border](https://www.cbp.gov/newsroom/stats/cbp-drugs-dosage-value-and-weight) is hardly consistent. In January, CBP confiscated 1.3 million doses of the drug. The number of confiscations dropped significantly in June before rising back to about 1.3 million doses again in August. And data on the potency of illicit drugs is limited, given that drug-tracking systems vary from one community to another, Facher told Vox. “The places that do have really good drug checking, there have been some changes detected in terms of the drugs people are using, but nothing that would explain this sudden drop,” he said. Another explanation could be that harm-reduction efforts are working. Access to [naloxone](https://www.vox.com/even-better/353129/you-can-help-reverse-the-overdose-epidemic), the lifesaving, overdose-reversing drug, expanded significantly in cities across the United States in the last few years. Local governments such as [Los Angeles County](https://laist.com/news/health/los-angeles-naloxone-overdose-deaths) made the drug available at schools, churches, libraries, and jails, and [everyday](https://health.ucdavis.edu/blog/cultivating-health/why-you-should-carry-naloxone-narcan-to-combat-opioid-overdoses/2023/08) Americans are increasingly encouraged to carry naloxone. Harm-reduction campaigns may have also had an impact on those who use recreational “party” drugs, who might favor stimulants but could find themselves unknowingly ingesting fentanyl if a dealer has mixed it into cocaine or MDMA. [Drug testing kits like Overdrive](https://www.amazon.com/Fentanyl-Overdrive-Substances-Detection-Sensitive/dp/B0D936KTKM) are available for less than $15 from retailers like Amazon and provide people with step-by-step directions on testing drugs for fentanyl. Data also suggests that the way people consume drugs might reduce the likelihood of death by overdose. Smoking fentanyl is becoming increasingly more popular than injecting it, and the former is linked to [fewer fatal overdoses and blood-borne infections](https://www.sciencedirect.com/science/article/abs/pii/S0376871623012917?via%3Dihub). The third explanation, floated by some epidemiologists, is the most bleak, and suggests that after hundreds of thousands of people were killed by drug overdoses in a relatively short time span, the [epidemic is essentially burning itself out](https://www.nejm.org/doi/full/10.1056/NEJMe2406359). “It’s a concept called the ‘depletion of susceptibles,’” Facher said. “And that’s just to say that so many people have already died of drug overdoses that there aren’t as many drug users left to die. That’s not necessarily a mainstream theory. And even if it were accepted, it probably wouldn’t explain the full significant sudden decrease in drug deaths.” The staggering number of deaths from the opioid epidemic, however, could be a contributing factor to declining youth drug misuse. [An analysis from KFF](https://www.kff.org/mental-health/issue-brief/teens-drugs-and-overdose-contrasting-pre-pandemic-and-current-trends/#:~:text=In%202023%2C%2010%25%20of%20high,alcohol%20use%20(30%25%20vs.) showed a small drop in opioid misuse among high school students from 2017 to 2023. As [Maia Szalavitz writes for the New York Times](https://www.nytimes.com/2024/12/02/opinion/drug-overdose-deaths-decline.html), “Drug epidemics are often cyclical. Younger generations witness the harm specific drugs have caused their older siblings or parents, leading them to avoid those substances.” The latest data on overdose deaths comes amid a pivotal presidential transition. While the addiction crisis is a marquee issue for both Republicans and Democrats, the incoming Trump administration includes high-level officials who’ve been intimately impacted by it. The vice president-elect, JD Vance, has spoken extensively about how opioid addiction affected his mother and his community of Middletown, Ohio. Trump’s nominee for secretary of the Department of Health and Human Services, Robert F. Kennedy Jr., is in addiction recovery himself and his policy proposals include a network of “[wellness farms](https://www.youtube.com/watch?v=liZq31HLnyA&t=1778s)” to serve [as treatment facilities.](https://www.statnews.com/2024/12/11/rfk-jr-opioid-epidemic-addiction-policy-tough-love/) It remains to be seen whether the administration will focus its efforts on addiction recovery or if it will devote more attention [to law enforcement](https://www.youtube.com/watch?v=NUClE1P8ApI) and [the US-Mexico border](https://www.npr.org/2024/11/18/nx-s1-5187973/fentanyl-trump-cartels-addiction). “There is trepidation about a potential shift toward law enforcement and away from treatment,” Facher said. “Most of my sources talk about harm reduction, treatment prevention, and really just keeping people alive \[by\] meeting them where they are and getting them the services they need to live healthier lives as the cornerstone of ending this drug crisis.” You’ve read 1 article in the last month Here at Vox, we're unwavering in our commitment to covering the issues that matter most to you — threats to democracy, immigration, reproductive rights, the environment, and the rising polarization across this country. Our mission is to provide clear, accessible journalism that empowers you to stay informed and engaged in shaping our world. By becoming a Vox Member, you directly strengthen our ability to deliver in-depth, independent reporting that drives meaningful change. We rely on readers like you — join us.  Swati Sharma Vox Editor-in-Chief See More: * [Criminal Justice](https://www.vox.com/criminal-justice) * [Health](https://www.vox.com/health) * [Policy](https://www.vox.com/policy) * [War on Drugs](https://www.vox.com/drug-war)

 In the past few years, state and local governments across the U.S. have begun spending [billions in opioid settlements](http://www.kffhealthnews.org/opioid-settlements) paid by companies accused of fueling the overdose crisis. But where is that money going, who is getting it and is it doing any good? KFF Health News, partnering with the [Johns Hopkins Bloomberg School of Public Health](https://opioidprinciples.jhsph.edu/) and [Shatterproof](http://www.shatterproof.org/), a national nonprofit focused on addiction, undertook a yearlong investigation to find out. Dozens of interviews, thousands of pages of documents, an array of public records requests and outreach to all 50 states resulted in a first-of-its kind database that catalogs more than 7,000 ways opioid settlement cash was used in 2022 and 2023. It's the most comprehensive resource to date tracking some of the largest public health settlements in American history. _(You can explore the database at the end of this story.)_ Among the findings: * States and localities received more than $6 billion in opioid settlement funds in 2022 and 2023. According to public records, they spent or committed about a third of that amount and set aside about another third for future use. The final third was untrackable, as many jurisdictions [did not produce public reports](https://kffhealthnews.org/news/article/opioid-drugmakers-settlement-funds-50-billion-dollars-khn-investigation-payback/) on the funds. * Reports of spending tracked the minuscule to the monumental, from [$11.74 to buy postage](https://web.archive.org/web/20240811030239/https:/www.azag.gov/issues/opioids/one-arizona-agreement/regions) in Yavapai County, Arizona, to [more than $51 million](https://web.archive.org/web/20240629194551/https:/californiaopioidresponse.org/opioid-settlements/state-funded-projects/) to increase the addiction treatment workforce in California. * States allotted, on average, about 18% of their funds for addiction and mental health treatment; 14% for recovery services such as housing, transportation, and legal aid; 11% for harm reduction efforts such as overdose reversal medications; and 9% for prevention programs that aim to stop people from developing substance use disorders. States committed, on average, about 2% for syringe service programs, through which people can get sterile needles. (A variety of entities received this money, from law enforcement to nonprofit organizations to government agencies.) * Governments reported spending more than $240 million on purposes that did not qualify as opioid remediation. (Most settlements allow states to spend up to 15% of their funds this way.) Most of this tranche went to legal fees, but several jurisdictions funneled money to their general fund. One county even sent funds to its road and bridge department. * Several cities and counties reported expenditures they said addressed the overdose crisis but that would leave an average person scratching their head — [such as](https://www.in.gov/recovery/files/Attachment-A-Local-Units-of-Govt-Report.xlsx) [$33.07](https://www.in.gov/recovery/files/Attachment-A-Local-Units-of-Govt-Report.xlsx) to an anti-abortion pregnancy center in Sandborn, Indiana, and [$30,362 to screen first responders](https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/opioid-settlement-report-fy-22-23.pdf#page=19) for heart disease in Oregon City, Oregon. "When people know that people aren't watching and there's no accountability, then they can kind of do what they want," said [Tonja Myles](https://www.trainedtofightwhilewounded.com/about), a community activist in Baton Rouge, Louisiana, who is in recovery. "That's why we have to have some kind of database and accountability." Despite the [recent decline](https://www.npr.org/2024/09/18/nx-s1-5107417/overdose-fatal-fentanyl-death-opioid) in overall overdose deaths in the U.S., [more than 90,000 people](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) still died in the 12 months ending July 2024 and rates [are rising](https://stateline.org/2024/10/29/overdose-deaths-are-rising-among-black-and-indigenous-americans/) in many [Black and Native American communities](https://oneill.law.georgetown.edu/examining-overdose-inequities-2022-23-data/). "We can't mess up or miss this moment," Myles said. > _Explore more graphics visualizing this data at_ [_KFF Health News_](https://kffhealthnews.org/news/article/opioid-settlement-funds-detailed-database-state-county-city-spending)_._ Opioid settlement payouts are expected to [total about $50 billion](https://www.opioidsettlementtracker.com/globalsettlementtracker) over nearly two decades, paid by more than a dozen companies that made or distributed prescription painkillers, including Johnson & Johnson, Walgreens, and Walmart. Although it's a large sum, it's dwarfed by the size of the crisis, making each dollar that's spent critical. KFF Health News and its partners reviewed hundreds of settlement spending reports, extracting expenditures line by line, and developed a [methodology](https://kffhealthnews.org/wp-content/uploads/sites/2/2024/12/opioid-settlement-expenditures-methodology-121124.pdf) to sort the expenditures into categories like treatment or prevention. States were given an opportunity to review the data and [comment on their spending](https://kffhealthnews.org/news/article/opioid-settlement-funds-detailed-database-state-county-city-spending#statements). To be sure, the database does not capture the full picture of opioid settlement spending nationwide. Some places do not publish spending reports, while others declined to engage with this project. The data presented here is a snapshot as of the end of 2023 and does not account for further spending in 2024. The differences in how states [control](https://kffhealthnews.org/news/article/opioid-settlement-funds-state-council-members-database/), [process](https://kffhealthnews.org/news/article/opioid-settlement-fund-council-meetings-public-comment-closed/) and [report](https://kffhealthnews.org/news/article/state-opioid-settlement-funds-transparency-update/) on the money make apples-to-apples comparisons nearly impossible. Still, the database helps to fill a gap left by a lack of national reporting requirements and [federal government inaction](https://kffhealthnews.org/news/article/biden-administration-opioid-settlements-federal-government/). It is "a tool for those who want to objectively measure whether everything that can be done is being done," said Matthew Myers, a former president of the Campaign for Tobacco-Free Kids, which [compiles similar](https://www.tobaccofreekids.org/what-we-do/us/statereport/) [annual reports](https://www.tobaccofreekids.org/what-we-do/us/statereport/) on tobacco settlement money. ### Funding for treatment is a clear winner The top priority to emerge from early opioid settlement spending was treatment, with more than $416 million spent or committed to residential rehabs, outpatient counseling, medications for opioid use disorder, and more. The state of New York — which spent the most on treatment — allocated about $22 million of that for programs that make the [gold standard](https://www.npr.org/2021/01/15/957115368/trump-administration-will-let-more-doctors-prescribe-drug-to-fight-opioid-addict#:~:text=%22The%20medical%20evidence,a%20statement.) for care as easy as possible for patients: providing same-day prescriptions for buprenorphine, a medication that decreases cravings for opioids. The result was a program that John Greene said changed his life.  Greene, 57, used to live in the woods down the street from Family & Children's Counseling Services in Cortland, N.Y. He cycled through jails and hospitals, overdosing half a dozen times and trying rehab just as many. But now he has four months of recovery under his belt — the longest stint since he started regularly using drugs at 14. He said it's because the counseling center's [new program](https://familycs.org/our-services/substance-use-disorders/rapid-opioid-assistance-in-recovery/) — funded by a mix of state and local opioid settlement dollars — has a different approach. Counselors aren't didactic and judgmental. They don't force him to stop smoking marijuana. Several staff members have experienced addiction themselves. They drive Greene, who doesn't have a car, to doctor appointments and the pharmacy for his buprenorphine prescription. Now Greene lives and works with his brother, looks forward to weekly counseling sessions and is notching small victories — such as buying his nephew toy cars as a stocking stuffer. "It made me feel good to do something for somebody and not expect nothing back," Greene said. [Emily Georgia](https://familycs.org/about/leadership-team/), one of Greene's counselors, said the center has worked with nearly 200 people like him in the past year. Without the settlements, "the program probably wouldn't exist," she said. Across the country, the money supports other innovative treatment approaches: * $21 million for [a new program](https://www.chfs.ky.gov/agencies/dbhdid/Pages/SenateBill90.aspx) in Kentucky that diverts people with mental illness or addiction who face low-level charges away from incarceration and into treatment, education, and workforce training * More than $3 million for, in part, [three new mobile methadone programs](https://www.mass.gov/doc/2023-annual-report-orrf-0/download) in Massachusetts, to bring the medication to rural and underserved areas * Tens of thousands of dollars each in [Iowa](https://www.documentcloud.org/documents/25041561-iowa-jasper-county-2023) and [Pennsylvania](https://www.documentcloud.org/documents/24536886-lehigh-county?responsive=1&title=1) to cover out-of-pocket treatment costs for people without insurance or those with high deductibles [Philip Rutherford](https://www.thenationalcouncil.org/people/philip-rutherford/), an expert on substance use disorder at the National Council for Mental Wellbeing, said these efforts "are really positive" and many have been "historically difficult or impossible to achieve with federal or state funding." But some funds are also flowing to treatment approaches that defy best practices, such as denying people medications for opioid use disorder. [Some in the recovery community](https://www.statnews.com/2024/11/12/opioid-addiction-recovery-narcotics-anonymous-salvation-army/) consider methadone and buprenorphine a crutch. But study after study shows that the medications help people [stay in treatment](https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder#:~:text=In%20this%20study%2C%20the%20treatment,was%20closely%20related%20to%20relapse.) and reduce the [risk of overdose](https://pubmed.ncbi.nlm.nih.gov/32022884/) and [death](https://www.nih.gov/news-events/news-releases/methadone-buprenorphine-reduce-risk-death-after-opioid-overdose). [Research even suggests](https://news.yale.edu/2023/12/19/treating-opioid-disorder-without-meds-more-harmful-no-treatment-all) that treatment without these medications can be more harmful than no treatment at all. Although not everyone will want medication, settlement funds shouldn't "prop up a system that doesn't allow people to have that choice," said [Regina LaBelle](https://gufaculty360.georgetown.edu/s/contact/00336000015ZccgAAC/regina-labelle), a professor of addiction policy at Georgetown University. ### Babies, forgotten victims of the epidemic While treatment received a windfall in early opioid settlement spending, another aspect of the crisis was neglected: [neonatal abstinence syndrome](https://www.nationwidechildrens.org/conditions/neonatal-abstinence-syndrome), a condition in which babies exposed to drugs in the womb experience withdrawal.  Nationwide, more than [59 newborns a day](https://www.cdc.gov/opioid-use-during-pregnancy/about/index.html) are diagnosed with it. Yet only about $8.4 million in settlement money was committed to the issue — less than 0.5% of all funds publicly reported as spent or committed in 2022 and 2023. Experts in public health and addiction, as well as affected families, say it's due to stigma. "A mom using drugs and being a parent is a very uncomfortable reality to face," said Ashley Grant, a 38-year-old mother of three in Mesa, Ariz. "It's easier to just push it under the rug or let them fall through the cracks, as sad as that is." It almost happened to her. Grant learned she was pregnant with her third child last year. At the time, her partner was in jail and she was using drugs after an eight-year period of recovery, was estranged from her family and didn't know how she'd survive the next nine months. During a visit to a methadone clinic, she saw a booth about [Jacob's Hope](https://jacobshopeaz.org/), a specialty nursery that cares for substance-exposed newborns and their moms. Nursery staff connected her with a therapist, helped her enroll in parenting classes and dropped off diapers and a playpen at her home. After delivering at the hospital, Grant and her baby boy stayed at Jacob's Hope for about a week. Nurses showed her how skin-to-skin contact calmed his withdrawal symptoms and more frequent feedings and burpings decreased gastrointestinal discomfort, which is common among substance-exposed newborns. Today, Grant has roughly five months of recovery. She got certified as a peer recovery specialist and hopes to join Jacob's Hope one day to help moms like her. But the nursery's future is uncertain. After opening in 2019, Jacob's Hope [nearly shut down](https://www.azfamily.com/2024/07/29/mesa-nonprofit-caring-infants-with-opioid-withdrawal-risk-closing/) this summer due to low reimbursements and delayed payments from insurers, said [Lyndsey Steele](https://jacobshopeaz.org/our-team/), its associate director. Community donations kept the nursery afloat, but "it's still hanging on by a thread," she said. She's hoping opioid settlement money can help. In 2022, Jacob's Hope [received about $250,000](https://www.azag.gov/sites/default/files/docs/consumer/opioids/FY2023%20STATE%20REPORT%20-%20Revised.xlsx) from Arizona's opioid settlements. But this year, the legislature captured the state's share of remaining funds and, in [a controversial move](https://azmirror.com/briefs/judge-allows-az-opioid-settlement-money-to-go-to-state-prisons/), gave it to the Department of Corrections. Jacob's Hope has now turned to local governments, which control their own settlement dollars. Its home city of Mesa said a first round of grant applications should open in the spring. Steele prays it won't be too late for babies in need — the epidemic's "forgotten victims," she called them.  Some opioid settlement expenditures have sparked fierce disagreement. They generally fall into three buckets: money for [law enforcement](https://kffhealthnews.org/news/article/health-brief-opioid-settlement-spending-debate-law-enforcement/), funding for [youth prevention programs](https://kffhealthnews.org/news/article/opioid-settlement-funds-addiction-prevention-dare-curriculum/) and purchases unrelated to the opioid crisis. Settlement dollars nationwide have bought [body scanners](https://kffhealthnews.org/news/article/using-opioid-settlement-cash-for-police-gear-like-squad-cars-and-scanners-sparks-debate/), [K-9 units](https://www.nj.gov/opioidfunds/documents/reports/P%20-%20NJ%20Subdivision%20Annual%20Opioid%20Abatement%20Report%202023.pdf#page=88), [bulletproof vests](https://www.in.gov/recovery/files/Attachment-A-Local-Units-of-Govt-Report.xlsx), [patrol trucks](https://wyofile.com/wp-content/uploads/2024/04/UintaCounty.pdf) and [laptops and printers](https://www.documentcloud.org/documents/25038460-wisconsin-letter-to-jcf-enclosing-local-osf-reports-may-2024#document/p98) for police and sheriffs. Some spending strayed even further from the spirit of the settlement. In Oregon City, Oregon, [more than $30,000](https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/opioid-settlement-report-fy-22-23.pdf#page=19) was spent on screening first responders for heart disease. Police Chief Shaun Davis said his staff respond to opioid-related emergencies and experience trauma that increases their risk of heart attack. But some people question if settlement funds should be footing the bill. "This looks to me like you're trying to defray other costs" from the police budget, said [Stephen Loyd](https://www.tn.gov/oac/about-us/council-members.html), chair of Tennessee's Opioid Abatement Council. "I don't think that there's any way that this opioid money was earmarked for stuff like that." A second area of contention is youth prevention. Although most people agree that stopping children from developing addictions is important, the execution is tricky. Nearly half a million settlement dollars have gone to the Drug Abuse Resistance Education program, commonly known as D.A.R.E. [Decades of research](https://www.mdpi.com/1660-4601/6/1/267) suggest its original curriculum [is ineffective](https://ajph.aphapublications.org/doi/full/10.2105/AJPH.94.6.1027). Robeson County, N.C., spent about $10,000 in settlement money to buy "[Andy the Ambulance](https://www.robotronics.com/andy-the-ambulance-trade)," a robot ambulance with big eyes and an audio system through which a human operator can discuss the dangers of drugs. EMS Director Patrick Cummings said his team has taken the robot to churches and elementary schools. We "don't have any studies that show it's working," he said, but educating kids seems like a good investment because "if they never try it, they don't get addicted." Then there's the chunk of money — up to 15% of each state's funds — that's a free-for-all. Flint, Mich., spent nearly $10,000 on a sign for a community service center. The city [reported that the expense](https://www.nationalopioidofficialsettlement.com/Home/DownloadDoc?docpath=https%3A%2F%2Fpstoragenationalopioid.blob.core.windows.net%2Fprod%2F6145%2FRemediationForm%2FSysGen%2F5754%2F6145_200609.pdf&docname=Non%20Opioid%20Remediation%20Uses%20Form) did not qualify as "opioid remediation." In other words, it's unrelated to addressing the crisis. But Caitie O'Neill, a city spokesperson, said that "the building sign makes it possible for residents to find" the center, which houses city services, "including Narcan kits, fentanyl testing strips, and substance abuse referrals." Jurisdictions across 29 states reported non-remediation spending in 2022 and 2023. Most opioid settlements require such reports but operate on an honor system. No one is checking if the other 21 states and Washington, D.C., were truthful.  Jackie Lewis, an Ohio mother whose 34-year-old son, Shaun, died of an overdose in October 2022, finds that hard to stomach. "This is blood money," she said. Some people have "lost sight of that." Lewis is raising Shaun's daughter, ensuring the 9-year-old receives counseling at school and can attend the hip-hop music classes she enjoys — all on Lewis' Social Security payments. This year they moved to a smaller town with lower costs. As settlement funds continue flowing, she wants officials in charge of the money to help families like hers. "We still exist and we're still struggling," she said. _KFF Health News' Henry Larweh and Megan Kalata, Johns Hopkins Bloomberg School of Public Health's Sara Whaley and Vivian Flanagan, and Shatterproof's Kristen Pendergrass and Sahvanah Prescott contributed to this article._ [_KFF Health News_](https://kffhealthnews.org/about-us/) _is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at_ [_KFF_](https://www.kff.org/about-us/) _._ _The_ [_Johns_](https://publichealth.jhu.edu/) [_Hopkins Bloomberg School of Public Health_](https://publichealth.jhu.edu/) _has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create_ [_principles for using the money_](https://opioidprinciples.jhsph.edu/)_, which have been endorsed by over 60 organizations._ [_Shatterproof_](https://www.shatterproof.org/) _is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system._ _Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team who worked on this report are not involved in those efforts._ _Lydia Zuraw of KFF Health News created the graphics in this story and Daniel Wood adapted them for NPR._

The middle-aged patient seemed to embody all the twists and contradictions of the opioid crisis. A white-collar professional with a history of addiction, he had become hooked on prescription painkillers again after a knee operation. When doctors would no longer prescribe the opioids, he returned to heroin. But recently he had developed an abscess at an injection site on his leg. Now he was in Highland Hospital, in Oakland, Calif., claiming to have been bitten by a spider. Andrew Herring, a specialist in emergency medicine at the hospital, vividly remembers this man, the first person he would ever treat with the drug buprenorphine. The patient was hoping to receive a few opioid pills to help with his “spider bite.” But he had also caught wind of a trial program Herring was just then starting in the emergency department. He and his colleagues were interested in buprenorphine — itself an opioid — as a way to treat addiction to more powerful opioids like heroin. The patient wanted to try that instead of attempting to finagle pills. Struck by his forthrightness and honesty, and by his evident desire to escape the downward spiral of addiction, Herring sent him home with a prescription. This was in 2016. The previous year, doctors at the Yale School of Medicine published what would come to be seen as [a seminal study in the field of addiction medicine](https://pmc.ncbi.nlm.nih.gov/articles/PMC4527523/). Their study subjects, primarily people who were using heroin or prescription opioids, had been divided into three groups. One received a referral to addiction-treatment services outside the hospital. Another group received a similar referral, along with a brief counseling session at the hospital. And a third group received both the referral and the counseling while also starting on buprenorphine, taken daily as a tablet. After a month, this last cohort was about twice as likely as the other two groups to remain in treatment. This one medicine doubled these patients’ likelihood of staying the course and greatly improved their odds of avoiding a fatal overdose. An unusual aspect of the study was its setting: the emergency room. Addiction treatment usually didn’t happen in the emergency department, a place generally seen as reserved for acute medical issues, not disorders like drug addiction that require long-term treatment. Yet Herring couldn’t stop thinking about the implications of the Yale research — about how many lives might be saved if E.R. doctors embraced this approach. And there was already evidence of buprenorphine’s effectiveness, at the population level, in combating overdose deaths. Although the United States government had partly funded buprenorphine’s development as a treatment for opioid addiction, France was one of the first countries to most fully exploit the drug’s potential. In the 1990s, French health authorities began allowing any doctor to prescribe buprenorphine. By the early 2000s, overdose deaths there from heroin and other opioids had declined by nearly 80 percent. Thank you for your patience while we verify access. If you are in Reader mode please exit and [log into](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2025%2F02%2F16%2Fmagazine%2Fbuprenorphine-opioid-addiction-treatment.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2025%2F02%2F16%2Fmagazine%2Fbuprenorphine-opioid-addiction-treatment.html) for all of The Times. Thank you for your patience while we verify access. Already a subscriber? [Log in](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2025%2F02%2F16%2Fmagazine%2Fbuprenorphine-opioid-addiction-treatment.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2025%2F02%2F16%2Fmagazine%2Fbuprenorphine-opioid-addiction-treatment.html).

 The Trump administration is extending through mid-June [an emergency declaration](https://www.samhsa.gov/newsroom/press-announcements/20250318/secretary-kennedy-renews-public-health-emergency-declaration-address-national-opioid-crisis) linked to the opioid overdose crisis that was set to expire on Friday. In a statement, U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr. acknowledged drug deaths in the U.S. "are starting to decline" but said the Trump administration will continue treating the opioid crisis as "the national security emergency that it is." President Trump has linked fentanyl smuggling to his tariffs against Canada, China and Mexico. In doing so, Trump has [often made factually inaccurate claims](https://www.npr.org/2025/02/02/nx-s1-5283957/fentanyl-trump-tariffs-china-canada-mexico) about the number of drug deaths in the U.S. He's also said repeatedly Canada is a significant source of street fentanyl reaching U.S. communities, which is untrue according to [data gathered by U.S. Customs and Border Protection](https://www.cbp.gov/newsroom/stats/drug-seizure-statistics). In fact, drug overdose deaths have been declining rapidly in the U.S. since the summer of 2023, with fatalities linked specifically to fentanyl down roughly 30 percent. In all, roughly 30,000 fewer people are dying each year from street drugs compared to the peak of the crisis in June 2023. That's [according to the latest data from October 2024 gathered by the Centers for Disease Control and Prevention](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm). According to Kennedy, renewing the public health emergency declaration for 90 days will allow the federal government continued flexibility responding to the crisis. It's unclear why drug deaths are declining so rapidly, though many experts credit public health measures implemented by the Biden administration. Opioid-treatment medications such as buprenorphine, methadone and naloxone, also known as Narcan, are far more widely available now. Under the Affordable Care Act, Medicaid has also emerged as a leading source of insurance coverage for addiction treatment and healthcare related to street drug recovery. Some Republicans have proposed deep budget cuts that could impact Medicaid funding. Democrats in Congress, meanwhile, have criticized the White House for firing roughly 10 percent of federal workers focused on addiction at the Substance Abuse and Mental Health Services Administration.

 Over the past six months, I've been tracking something really cool and mysterious happening on American streets. For the first time in 30 years, drug deaths are plunging at a rate that addiction experts say is hopeful — but also baffling. In the past, even the most ambitious, well-funded efforts to slow drug deaths only helped a little bit. Reducing fatal overdoses by 8% or 9% was seen as a huge win. But now, deaths nationwide plunged more than 26% from the peak in June 2023, according to the latest [preliminary data gathered by the Centers for Disease Control and Prevention](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm). That means roughly 30,000 fewer people a year are dying. Many states are seeing even bigger improvements of 30% to 50%. In some states, progress has been sustained since 2021 and 2022, which suggests this isn't a temporary blip. ### So how did the U.S. finally turn the corner on drug deaths? What's going on? No one knows for sure, but here are eight leading theories I hear from experts. 1\. **Naloxone, also known as Narcan, may be the game-changer**. The Biden administration raced to make this medication, a nasal spray that quickly reverses opioid and fentanyl overdoses, far more widely available. People can buy it now over the counter without a prescription. It's distributed for free in many high-risk communities, and people using drugs often carry it. It's unclear how many lives naloxone is saving each year, but many front-line public health workers tell me the impact is huge. [Learn more here](https://www.npr.org/sections/shots-health-news/2024/10/08/nx-s1-5145832/250-companies-schools-and-organizations-pledge-to-provide-overdose-antidote-naloxone).  2\. **Weaker fentanyl**. Street fentanyl is incredibly potent. But in many parts of the U.S., organizations that test fentanyl doses sold by drug dealers — often in pill form — have found a significant drop in purity. No one's sure why drug cartels have changed their mixtures. Some researchers believe law enforcement pressure in China, Mexico and the U.S. is disrupting the black market fentanyl supply chain. [Learn more here](https://www.npr.org/2024/09/30/nx-s1-5124997/fentanyl-overdose-opioid-btmps-drug-cartel-xylazine-tranq-mexico-china). 3\. **A dangerous but less lethal street drug supply**. In most of the the U.S., gangs are selling complicated "cocktails" of street drugs. The amount of fentanyl appears to be dropping (see above), while the amount of animal tranquilizers, such as medetomidine and xylazine, is rising. These chemicals are highly toxic. They cause skin wounds, severe withdrawal symptoms and other long-term health problems. But doctors and addiction experts generally agree they aren't as immediately lethal as fentanyl. That could mean more chronic illness but fewer fatal overdoses. [Learn more here](https://www.npr.org/2025/03/07/nx-s1-5295618/fentanyl-overdose-drugs#:~:text=Drug%20deaths%20in%20the%20U.S.%20have%20now%20dropped%20from%20a,for%20Disease%20Control%20and%20Prevention.).  4\. **Better public health**. Thirty years after the U.S. opioid crisis began — and a decade after fentanyl spread nationwide — the U.S. has made strides developing better and more affordable services for people experiencing addiction. Medications that reduce opioid cravings, including buprenorphine and methadone, are more widely available, in part because of insurance coverage provided by Medicaid. In many states, roughly $50 billion in opioid settlement money paid out by corporations is also starting to help. Going forward, it's unclear how the Trump administration's deep cuts to public health agencies and grants will affect this new addiction safety net. [Learn more here](https://www.npr.org/2025/03/10/nx-s1-5306937/as-fentanyl-deaths-drop-fast-experts-say-more-survivors-need-help). 5\. **Many of the most vulnerable people have already died**. This theory is discounted by some researchers I talk to, but many addiction experts think it's a factor. Over the past five years, the U.S. has been losing roughly 110,000 people to fatal drug overdoses every year. It's possible drug deaths are declining in part because a heartbreaking number of people using fentanyl and other high-risk street drugs simply didn't survive. [Learn more here](https://www.npr.org/2024/09/18/nx-s1-5107417/overdose-fatal-fentanyl-death-opioid). 6\. **Waning effect of the COVID pandemic**. The isolation, trauma and disruption of addiction treatment programs that followed the onset of COVID in 2020 overlap with the most devastating years of drug overdose deaths. Many public health experts believe the pandemic deepened the catastrophic impacts of fentanyl. According to this theory, as the impacts of COVID continue to fade, deadly overdoses are also declining to a more "normal" level. [Learn more here](https://www.npr.org/sections/health-shots/2021/04/22/989833102/overdose-deaths-surged-in-pandemic-as-more-drugs-were-laced-with-fentanyl). 7\. **People are using fentanyl (and other high risk street drugs) more skillfully**. This is a common theory among people who use street drugs. They often tell me they've adapted to the risks of fentanyl by smoking rather than injecting the drug, which many addiction experts believe is safer (though still incredibly dangerous). People try to never use fentanyl alone and often carry naloxone or Narcan to reverse overdoses. Many people use test strips to identify unwanted contaminants in their drugs and use smaller fentanyl doses. [Learn more here](https://www.npr.org/2025/03/07/nx-s1-5295618/fentanyl-overdose-drugs). 8\. **A decline in young people using drugs**. Street fentanyl has emerged as a leading cause of death among young people in the U.S., age 18 to 45. But research suggests far fewer young people and teenagers are using drugs (other than cannabis). This trend matters because new users have low physical tolerance for opioids such as fentanyl, which means they're more likely to overdose and potentially die. Fewer young users means fewer people taking that risk. [Learn more here](https://nida.nih.gov/news-events/news-releases/2024/12/reported-use-of-most-drugs-among-adolescents-remained-low-in-2024). It's important to emphasize all of these theories are just that — theories. Most researchers, doctors and front-line care providers say they need more data and more time to understand a shift this large. But there is a growing, tentative consensus that the answer may well be "all of the above." A big question going forward is _How low will U.S. drug deaths go?_ We've already seen the biggest, fastest drop in U.S. history. So far, there's no sign the improvement is slowing.

 Fentanyl, the deadly synthetic opioid driving the nation's high drug overdose rates, is also caught up in another serious problem: misinformation. False and misleading narratives on [social media](https://www.instagram.com/p/DAn1odzxc4X/?igsh=eDczdHA0cnJsbGVs&img_index=1), in [news reports](https://www.npr.org/2023/05/16/1175726650/fentanyl-police-overdose-misinformation) and even in popular television dramas suggesting people can overdose from touching fentanyl — rather than ingesting it — are now informing public policy and spending decisions. Some state and local governments, for instance, are investing money from their share of the [billions in opioid settlement funds](http://www.kffhealthnews.org/opioid-settlements) in efforts to protect first responders from purported risks described in fentanyl misinformation. In [2022 and 2023](https://www.npr.org/sections/shots-health-news/2024/12/16/nx-s1-5227987/opioid-settlement-funds-database), 19 cities, towns, and counties across eight states used settlement funds to purchase drug detection devices for law enforcement agencies, spending just over $1 million altogether. [Two mass spectrometers](https://coag.gov/app/uploads/2024/08/Colorado-Opioid-Settlement-Funds-Expenditure-Report-8.1.2024.xls) were purchased for at least $136,000 for the Greeley, Colorado, police department, "to protect those who are tasked with handling those substances." But there is also almost no evidence that law enforcement personnel are at heightened risk of accidental overdoses due to such exposures. Although fentanyl-related deaths have [drastically risen](https://stacks.cdc.gov/view/cdc/135849) over the past decade, [no evidence suggests](https://www.tandfonline.com/doi/full/10.1080/15563650.2023.2259087?casa_token=4bAiQEU-90IAAAAA%3ANGhmsJ06S7Qd3WzD81GcJDoBqqHK0-gqjEJl69I_HI0tEOkkh4f_IUtiSeT1ehEtnM0gRYJz-uL2qQ#abstract) any of these deaths have resulted from incidentally touching or inhaling it, and [little to no evidence](https://www.infodemiology.com/vp-candidate-misleading-claims-fentanyl-marijuana/) that any resulted from consuming it in marijuana products. Recent data indicates that fentanyl-related deaths [have begun to drop](https://www.npr.org/2025/03/24/nx-s1-5328157/fentanyl-overdose-death-drugs). Still, there is a steady stream of reports — which generally [turn out to be false](https://pmc.ncbi.nlm.nih.gov/articles/PMC8810663/) — of officers [allegedly becoming ill](https://www.npr.org/2023/05/16/1175726650/fentanyl-police-overdose-misinformation) after handling fentanyl. But experts say it's unlikely those episodes were caused by the fentanyl itself — more likely, officers' fear and anxiety resulted in panic attacks or similar symptoms. Fentanyl is present in most illicit opioids found at the scene of an arrest, said [Brandon del Pozo](https://vivo.brown.edu/display/bdelpozo), a retired Burlington, Vermont, police chief who researches policing and public health policies and practices at Brown University. But that "doesn't mean you need to spend a lot of money on fentanyl detection for officer safety." If that spending decision is motivated by officer safety concerns, then it's "misspent money," del Pozo said. Overdoses are most commonly caused by ingesting the drug illicitly as a pill or powder. And most accidental exposures occur when people who use drugs, even those who do not use opioids, [unknowingly consume fentanyl](https://www.cbsnews.com/news/reversing-a-fentanyl-overdose-with-naloxone-60-minutes/) because it is so often used to ["cut" street drugs](https://www.tandfonline.com/doi/full/10.1080/00325481.2018.1407618) such as heroin and cocaine. Fentanyl misinformation is affecting policy in other ways, too. Florida [has](https://www.flsenate.gov/Session/Bill/2024/718) a law [on the books](https://www.flsenate.gov/Session/Bill/2024/718) that makes it a second-degree felony to cause an overdose or bodily injury to a first responder through this kind of secondhand fentanyl exposure. Similar legislation has been considered by states such as [Tennessee and West Virginia](https://www.salon.com/2024/04/04/touching-fentanyl-wont-you-why-wont-cops-and-policymakers-get-the-memo/), the latter stipulating a penalty of 15 years to life imprisonment if the exposure results in death. Public health advocates worry these laws will make people shy away from seeking help for people who are overdosing. "A lot of people leave overdose scenes because they don't want to interact with police," said [Erin Russell](https://www.healthmanagement.com/our-team/staff-directory/name/erin-russell/), a principal with Health Management Associates, a health care industry research and consulting firm. Florida does include a [caveat in its statute](https://laws.flrules.org/2024/68) that any person "acting in good faith" to seek medical assistance for someone they believe to be overdosing "may not" be arrested, charged, or prosecuted. And even when public policy is crafted to protect first responders as well as regular people, misinformation can undermine a program's messaging. Take Mississippi's [One Pill Can Kill](https://attorneygenerallynnfitch.com/onepill/) initiative. Led by the state attorney general, Lynn Fitch, the initiative aims to provide resources and education to Mississippi residents about fentanyl and its risks. While it promotes the availability and use of harm reduction tools, such as naloxone and fentanyl test strips, Fitch has also propped up misinformation. At the 2024 Mississippi Coalition of Bail Sureties conference, [Fitch said](https://youtu.be/y1_Ni3SyAsk?t=826), "If you figure out that pill's got fentanyl, you better be ready to dispose of it, because you can get it through your fingers," based on the [repeatedly debunked belief](https://www.kff.org/the-monitor/political-rhetoric-spreads-misinformation-about-fentanyl/#exposure) that a person can overdose by simply touching fentanyl. Officers on the ground, meanwhile, sometimes are warned to proceed with caution in providing lifesaving interventions at overdose scenes because of these alleged accidental exposure risks. This caution is often evidenced in a push to [provide first responders with masks](https://www.cdc.gov/niosh/substance-use/fentanyl-toolkit-emergency-responders/?CDC_AAref_Val=https://www.cdc.gov/niosh/topics/fentanyl/toolkit.html) and other personal protective equipment. Fitch told the crowd at the conference: "You can't just go out and give CPR like you did before." However, as with other secondhand exposures, the risk for a fentanyl overdose from applying mouth-to-mouth [is negligible](https://stopoverdose.org/fentanyl-exposure-faqs/#help-someone-od), with no clinical evidence to suggest it has occurred. Her comments underscore growing concerns, [often not supported by science](https://link.springer.com/article/10.1186/s12954-020-00402-2#Sec1), that officers and first responders increasingly face exposure risks during overdose responses. Her office did not respond to questions about these comments. Health care experts say they are not against providing first responders with protective equipment, but that fentanyl misinformation is clouding policy and risks delaying critical interventions such as CPR and [rescue breathing](https://www.sciencedirect.com/science/article/pii/S0955395924002718). "People are afraid to do rescue breathing because they're like, 'Well, what if there's fentanyl in the person's mouth,' " Russell said. Hesitating for even a moment because of fentanyl misinformation [could delay a technique](https://library.samhsa.gov/sites/default/files/five-essential-steps-for-first-responders.pdf) that "is incredibly important in an overdose response."

Just two years ago, the US was suffering through the worst stretch of its long-running drug overdose crisis. More than 110,000 Americans had [died](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) in the previous 12 months from an overdose — almost twice the number of people who died in all of the Vietnam War. But late last year, the country got some unexpected good news: Overdose fatalities had [fallen](https://www.dea.gov/press-releases/2024/12/16/overdose-deaths-decline-fentanyl-threat-looms) by 10 percent. It was the first drop of any kind since 2018, but here’s the really good news: While in 2018, deaths only plateaued for a few months before rising again, the current decline appears to be sustaining and even accelerating. According to the most recent national data from the Centers for Disease Control and Prevention, deaths in 2024 were [down](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) a whopping 26 percent, to less than 81,000 over the preceding 12 months. New county-level CDC data [reveal](https://www.cdc.gov/nchs/nvss/vsrr/prov-county-drug-overdose.htm) some communities in the states hit hardest by the opioid epidemic — such as West Virginia, New Hampshire, and Ohio — have seen deaths fall by 40 percent to 50 percent over the past year. Too many people are still dying preventable deaths, but the decline nonetheless represents a significant improvement in a problem that has bedeviled public health officials since [the opioid epidemic](https://www.vox.com/the-highlight/2024/1/16/24033590/treatment-opioid-addiction-crisis-2024) began to take off in the 2000s. [Nobody is quite sure](https://www.npr.org/2025/03/24/nx-s1-5328157/fentanyl-overdose-death-drugs) — and several of the experts I spoke to fear the downturn could be temporary. But there are a few plausible explanations. First, the pandemic is over. Overdose deaths [rose sharply](https://pmc.ncbi.nlm.nih.gov/articles/PMC8856931/) during 2020 and 2021, likely for a combination of reasons. People were more isolated, for one, and health care providers were overwhelmed. That’s no longer the case. People who use opioids and other deadly drugs also now know about the particular risks of [fentanyl](https://www.vox.com/science-and-health/2017/5/8/15454832/fentanyl-carfentanil-opioid-epidemic-overdose) and other synthetic opioids and are being more cautious. There is [the contentious theory](https://opioiddatalab.ghost.io/are-overdoses-down-and-why/#5-depletion-of-susceptibles) that the pool of potential victims has shrunk: More than 1.5 million Americans have died from overdoses since 2000, and many of the people who were most vulnerable to becoming dependent on opioids and overdosing may have, sadly, been among that group. It is also possible that people are shifting away from opioids like heroin and fentanyl and toward other drugs that are less deadly. More people are [taking](https://nida.nih.gov/news-events/news-releases/2024/08/cannabis-and-hallucinogen-use-among-adults-remained-at-historic-highs-in-2023#:~:text=Cannabis%20and%20hallucinogen%20use%20among%20adults%20remained%20at%20historic%20highs%20in%202023,-Vaping%20among%20younger&text=Past%2Dyear%20use%20of%20cannabis,the%20Monitoring%20the%20Future%20survey%20.) nonlethal drugs such as cannabis and psychedelics, and the use of cocaine and other illicit stimulants has also been [growing](https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2024/08/stimulant-use-is-contributing-to-rising-fatal-drug-overdoses); they still present a public health risk, especially with [reports](https://www.uclahealth.org/news/release/overdose-deaths-fentanyl-laced-stimulants-have-risen-50-fold) of cocaine laced with fentanyl, but these substances lead to fewer deaths on average. The US has also invested billions of dollars into public health campaigns to reduce overdose deaths. We are not only increasing users’ awareness about fentanyl, for example, but some public health departments have also provided millions of free testing strips so people who use opioids can easily check whether what they are using could quickly and unexpectedly kill them. Access to opioid addiction treatments like methadone and buprenorphine, too, has been greatly expanded through government and philanthropic investments. And perhaps most importantly in the prevention of unnecessary overdose deaths, [naloxone](https://www.vox.com/policy/2023/3/30/23663064/narcan-overdose-fentanyl-drug-where-to-get) — Narcan, the nasal spray that rapidly reverses opioid overdoses — is [omnipresent](https://www.vox.com/even-better/353129/you-can-help-reverse-the-overdose-epidemic). You can find it in vending machines in police stations, libraries, and public schools around the country. Nearly 70,000 lifesaving doses were [administered](https://momentousrecoverygroup.com/rehab-blog/what-is-narcan-the-life-saving-tool-in-the-fight-against-the-opioid-crisis/) in 2021 by emergency responders. “Increased naloxone distribution has saved countless lives by reversing opioid overdoses in real time,” Jessica Hulsey, founder of the Addiction Policy Forum, told Vox. This was a hard-fought public health victory: While some people have at times [objected](https://pmc.ncbi.nlm.nih.gov/articles/PMC7153573/) to placing a drug overdose treatment in a public health setting, the harm-reduction argument that we should make these interventions widely available to save as many lives as possible has largely won out. Even as the good news rolls in, President Donald Trump’s health department is currently working on plans to reduce federal spending on opioid treatments by millions of dollars. A draft budget, recently obtained by [several news organizations](https://www.washingtonpost.com/health/2025/04/16/hhs-budget-cut-trump/), including Vox, would specifically terminate programs that supply Narcan to health centers, doctors, and first responders, as well as programs to train first responders on how to use the drug during an overdose emergency. Other programs focused on drug abuse treatment and support would also be eliminated, according to the document. To be clear, this is only a draft document, and the president’s budget, even when finalized, is rarely adopted exactly as it is written. Congress will have its say, and lawmakers have shown support for substance abuse treatment in recent years. But the proposal nonetheless raises the risk that the US will take a step backward after finally making progress in reducing the toll of opioids. If the programs were to ultimately be eliminated, some day, a health center might not have Narcan on hand when a patient comes through the front door experiencing an overdose. Or an EMT might find their supply runs out, and they don’t have any naloxone spray available when an overdose call comes in. The move by the Trump administration to cut these successful programs would seem to undermine their own goals to curb the opioid crisis. HHS Secretary Robert F. Kennedy Jr., who has spoken openly about his own heroin addiction, [said](https://wpln.org/post/rfk-stumps-for-overdose-prevention-in-nashville-as-tennessees-death-rate-declines/) just days ago that “we need Narcan” — even as his department drafts plans to cut it. In his first term, Trump [promised](https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html) to end the opioid epidemic, and he [signed](https://www.pewtrusts.org/en/research-and-analysis/articles/2018/10/24/president-trump-signs-bipartisan-bill-to-fight-opioid-crisis) some of the first significant legislation to provide federal funding to combat it before the pandemic sent overdose deaths soaring. Now, within the early days of his second term, Trump [framed](https://www.vox.com/politics/402530/trump-tariffs-canada-mexico-explanation) his tariff policy around the goal of stopping fentanyl or its ingredients from being smuggled into the US. “The recent drop in overdose deaths is extremely welcome news, yet there is still a colossal amount of work to be done,” Andrew Kessler, the founder of Slingshot Solutions, a consulting firm focused on mental health and substance abuse, told Vox. “Just as with HIV, Covid, or any other public health emergency, the keys are investments in research, practicing prevention, and evidence-based treatment. It is a tried-and-true formula that should not be deviated from.” See More: * [Health](https://www.vox.com/health) * [Health Care](https://www.vox.com/health-care) * [Policy](https://www.vox.com/policy) * [Politics](https://www.vox.com/politics) * [Public Health](https://www.vox.com/public-health) * [Trump Administration](https://www.vox.com/trump-administration)

In 2020 and 2021, before I came to Vox, I worked as the future correspondent at Axios — yes, that was the actual job title — and I found myself writing almost solely about the Covid-19 pandemic, or major trends that appeared to be driven _by_ the pandemic. One of those trends was an alarming rise in drug overdose deaths. The trajectory was already bad before Covid: Between the widespread prescription and misuse of legal opioids and then the introduction of the ultra-powerful drug [fentanyl](https://www.vox.com/science-and-health/2017/5/8/15454832/fentanyl-carfentanil-opioid-epidemic-overdose) to the illicit drug supply, [overdose deaths in the US began taking off](https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html) in the early 2010s. But the closure of treatment facilities during the pandemic and the isolation of users led to a sudden spike in deaths: In the year leading up to September 2020, as I [wrote in April 2021](https://www.axios.com/2021/04/14/drug-overdose-record-coronavirus-pandemic-opioids), more than 87,000 Americans died of drug overdoses, a higher total than any 12-month period of the opioid epidemic up to that point. After publishing that piece, I received a letter from a reader, who said her son had been one of those 87,000 deaths. She begged me to give this issue more coverage, to remind my readers that behind the Covid pandemic, there was a shadow epidemic of drug deaths, of lost sons and daughters and husbands and wives. People had to stop closing their eyes to the toll of death and pain. In the years that followed, the toll only continued to grow, however, with deaths reaching _110,000_ in 2023. There seemed to be no answer for one of the worst public health crises in a generation. But now, at long last, we finally appear to be turning the corner on the drug overdose crisis. Provisional figures from the Centers for Disease Control and Prevention’s National Vital Statistics System released this week show that some 27,000 fewer [Americans died of a drug overdose in 2024](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm?ck_subscriber_id=2771385781) than in 2023. That year-on-year drop is the [steepest single-year decline](https://apnews.com/article/us-overdose-deaths-opioids-1561a9f189255ad60c533462f10490a2) since the government first began keeping track of overdose deaths 45 years ago. It means that drug deaths are now finally coming back down to pre-pandemic levels — and that we can make progress on what can seem like the most intractable social ills. To put that 27,000 drop in deaths into perspective, think of it this way: It adds up to three lives saved every hour for an entire year. What’s remarkable about the rapid drop in overdose deaths is just how widespread the trend is. Forty-five states recorded declines in deaths, with Ohio and West Virginia — [two states](https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0309938) that have suffered more than almost any other from the opioid epidemic — leading the way. Only a handful of states, mostly in the [Northwest, where the epidemic started](https://www.axios.com/local/seattle/2025/05/16/washington-overdose-deaths-decline-2024) later, experienced increases. While synthetic opioids, which mostly means fentanyl, are still responsible for the vast majority of overdose deaths, [deaths from such drugs are falling](https://www.wsj.com/health/drug-overdoses-2024-3968bc80) faster than any other, declining by 36 percent year over year. One of the biggest factors behind the decline is the growing availability of naloxone, an opioid antagonist. If administered in the immediate aftermath of an overdose, [naloxone has been shown](https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-025-22210-8) to be close to 99 percent effective in preventing death. The key is speed — even the fastest emergency medical responders may not make it to the scene in time to save someone suffering an overdose. But recent policies to [make naloxone available over the counter](https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray), and to advise users to have it on hand, have made it possible to bring back thousands of people who otherwise would have died. While the pandemic directly led to a significant spike in overdose deaths, policies that came out of Covid have helped curb the toll, including [telehealth access to medicine-based treatment](https://www.clinicaladvisor.com/news/cdc-finds-drug-overdose-deaths-declined-in-the-us/) options for addiction like buprenorphine. All of these programs have been paid for in part by the billions of dollars in [opioid-settlement cash](https://nationalopioidsettlement.com/executive-summary/) from drug companies like Johnson & Johnson, which began flowing to state and local governments in 2024. [Tougher enforcement on fentanyl](https://www.statnews.com/2025/05/14/drug-overdose-deaths-drop-27-percent-cdc-says-fentanyl-drops-meth-rising/) has played a role as well. Lastly — and less positively — the sheer number of overdose deaths in the past few years has depleted the number of people at highest risk. Like an infectious disease epidemic that slows down as it begins to run out of new people to infect, the overdose epidemic burned so hot and killed so many that drug users who were left were less vulnerable to fatal overdoses. The news isn’t all good. While synthetic opioids like fentanyl appear to be in a steep decline, deaths actually rose last year from stimulants like meth and [cocaine](https://www.wsj.com/world/americas/cocaine-colombia-industry-production-7f10201b), with production of the latter surging to new highs. The increase in deaths in a handful of states like Alaska and Washington demonstrates that in some parts of the country, at least, there are still populations that remain highly vulnerable to fatal overdoses. Most worryingly, the Trump administration’s draft budget proposes [major cuts to naloxone distribution](https://www.vox.com/public-health/411089/us-drug-overdose-deaths-fentanyl-narcan-rfk), which could take the most potent tool for stopping overdose deaths out of the hands of those who need it most. Still, we should recognize this new data for what it is — evidence that, with effort, we can reverse the course of one of the biggest public health threats the US faces. Thousands of people are alive today who, if nothing had changed since I was writing about this epidemic in 2021, might have suffered a worse fate. Drug addiction is a horrible disease that can destroy futures, families, and lives. But where there is life, there is hope. Every overdose victim brought back by a spray of naloxone has another chance to change their future, and ensure that they won’t become another statistic. _A version of this story originally appeared in the Good News newsletter. [Sign up here!](https://www.vox.com/pages/good-news-newsletter-signup)_ You’ve read 1 article in the last month Here at Vox, we're unwavering in our commitment to covering the issues that matter most to you — threats to democracy, immigration, reproductive rights, the environment, and the rising polarization across this country. Our mission is to provide clear, accessible journalism that empowers you to stay informed and engaged in shaping our world. By becoming a Vox Member, you directly strengthen our ability to deliver in-depth, independent reporting that drives meaningful change. We rely on readers like you — join us.  Swati Sharma Vox Editor-in-Chief

Public health officials across the country working to prevent overdose deaths may have just a month to prepare for up to $140m in funding cuts for the Centers for Disease Control and Prevention (CDC) that the Trump administration [has reportedly withheld.](https://www.npr.org/2025/07/16/nx-s1-5468535/fentanyl-trump-addiction-funding#:~:text=According%20to%20public%20health%20officials,ve%20already%20paused%20new%20spending.) US overdose deaths [began to decline](https://www.theguardian.com/us-news/2025/may/14/us-overdose-deaths-decline) for the first time in 2023 after [climbing for over two decades.](https://www.cdc.gov/nchs/products/databriefs/db491.htm) The CDC’s [Overdose Data to Action (OD2A)](https://www.cdc.gov/overdose-prevention/php/od2a/index.html) cooperative agreement, launched in 2019 during the first Trump administration, provides funding for overdose “prevention and surveillance strategies”. Public health officials emphasized to the Guardian that to effectively reduce fatal overdoses, agencies must work in tandem to track substance use disorders, overdoses and changes in the drug supply, and to implement interventions, like distributing the overdose reversal drug naloxone. OD2A funding made this kind of robust response possible. The Biden administration [expanded the program](https://www.cdc.gov/overdose-prevention/php/od2a/about.html) in 2023, giving five-year grants to 90 state and local public health departments. **“**The funding has largely been used for surveillance, in other words, to obtain data on the opioid crisis that informs a public health response to the problem,” said Dr Andrew Kolodny, medical director for the Opioid Policy Research Collaborative at Brandeis University. “In general, our surveillance data for the opioid crisis is awful. I would even say that one of the reasons that the opioid crisis is as severe as it is, and why, up until recently, overdose deaths have continued to go up pretty much year after year for about 25 years, is because we had very poor surveillance of the problem.” But now, health officials worry the money could run out at the end of the first two-year cycle on 1 September. Dr Jenny Hua, interim deputy commissioner for Chicago’s department of public health (CDPH), which receives $3.4m annually in OD2A funding, says they are preparing for the worst. “We are doing scenario planning. The preferred scenario is that we have the entire award starting the first of August,” she said, though she’s uncertain whether that’s likely. Hua noted that what she had been “told about this money is that at least half of it is available next year. The problem is that for a number of \[the CDC’s\] cooperative agreements with local health departments and state health departments, they’re receiving that money in monthly increments, which has never happened before.” She also said that the CDC now [did not have enough money at once to distribute.](https://www.npr.org/sections/shots-health-news/2025/06/28/nx-s1-5442689/cdc-trump-layoffs-public-health-rescission) A Department of Health and Human Services spokesperson said in a statement that the CDC was committed to the O2DA program and that: “We are working closely with our funding partners to make within the next month, at a minimum, initial grant awards, which may contain less than the full-year of funding in the first incremental award … This incremental funding approach is not specific to OD2A.” Hua said “that sort of fog is making it incredibly difficult for us to make funding decisions, to allocate our resources.” The CDPH has used OD2A funding to make same-day substance use disorder treatment available to patients through telehealth, and had plans to expand recovery housing for treatment. “Do you pull the plug? What tea leaves are we supposed to read, to know what course of action to take?” Hua wondered. Kolodny said it was especially important to keep funding surveillance of multiple factors related to overdose deaths because “right now, you can talk to five different experts, and you’ll get five different explanations for why the deaths are coming down. Nobody really knows, right? And that’s because we don’t have good surveillance data,” he said, “and it’s about to get worse.” Surveillance means tracking not only the number of fatal and non-fatal overdoses in the US, but also the prevalence of substance use disorders, including opioid use disorder. Historically, this has been the mission of the Substance Abuse and Mental Health Services Administration (Samhsa), which also provides a plethora of other addiction and overdose prevention services, but that agency [also faces funding cuts.](https://www.npr.org/sections/shots-health-news/2025/06/06/nx-s1-5424670/rfk-jr-samhsa-mental-health-addiction-overdose-trump-budget-cuts) OD2A funding also went towards surveillance of “emergency drug threats” which often comes in the form of new adulterants in the street drug supply. Unexpected substances, including tranquilizers like xylazine, and potent synthetic opioids like [nitazenes](https://www.theguardian.com/us-news/2024/sep/25/opioid-crisis-nitazenes-fentanyl) and carfentanil, can cause overdoses and poisonings that are more dangerous because they aren’t yet well understood. Still, many health departments across the country [do not monitor the street drug supply](https://opioidprinciples.jhsph.edu/drug-checking/). Street drug surveillance can help officials intervene rapidly when overdoses increase. Partly thanks to OD2A funding, Chicago health officials immediately became aware of a spike in overdoses on the city’s west side last May. Lab analysis revealed the spike was related to the presence of medetomidine, a potent veterinary tranquilizer, in the street drug supply. In June, the CDPH launched the Summer Opioid Response Incident Command System, a coordinated effort involving public messaging [about the contaminated drug supply,](https://www.chicagohan.org/alert-detail?p_p_id=hanalertdetailsweb&p_p_lifecycle=2&p_p_state=normal&p_p_mode=view&p_p_resource_id=download&p_p_cacheability=cacheLevelPage&_hanalertdetailsweb_attachmentId=45704487&_hanalertdetailsweb_priv_r_p_alertId=46684184) distribution of naloxone and drug testing kits, and expanding access to treatment. This effort reduced overdose-related emergency responses by 23% last summer compared to the year before, according [to a report on the program.](https://www.chicago.gov/content/dam/city/depts/cdph/overcome-opioids/resources/2025/ICS-Opioid-AAR-v4.pdf) The Los Angeles department of public health also uses OD2A funding for “community-based drug checking”, according to a statement from a spokesperson; “The Los Angeles County Department of Public Health [recently announced](http://publichealth.lacounty.gov/phcommon/public/media/mediapubdetail.cfm?unit=media&ou=ph&prog=media&cur=cur&prid=5069&row=25&start=1) a 22% decline in drug-related overdose deaths and poisonings in 2024, the most significant drop in LA County history,” adding that “the CDC Overdose to Action LOCAL grant award contributed to these successes.” A spokesperson for the Maryland department of health said that cuts could mean layoffs for 28 public health workers, which would mean they no longer have the capacity to track non-fatal overdoses and will lose most of their capacity to track fatal overdoses. Tracking the number of people who die of overdoses is the “bare minimum” of surveillance, according to Kolodny, who noted that funding cuts are “frustrating” to witness. “Trump has been especially popular in some of the regions of the country that have suffered most from the opioid crisis. So one might think that his administration would be doing everything it can to bring this problem to an end. And in my opinion, this is a step backwards,” he said. Funding overdose prevention doesn’t just save lives, it also saves money, Kolodny said: “The opioid crisis is [a trillion-dollar-a-year problem,](https://www.cdc.gov/mmwr/volumes/70/wr/mm7015a1.htm) and I’m not making up that number. That’s a number that comes in part from the cost analysis on the number of lives that are lost.” Lives will continue to be lost until we can really understand what drives overdose deaths, Kolodny said: “Without the data, we’re shooting in the dark.”

Fewer than [one in three teenagers](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2025.00240) with opioid use disorder receive treatment, according to a study published in this month’s Health Affairs journal that looked at the disorder in minors from 2022 to 2023. In 2023, [557 teens died of opioid overdose](https://www.kff.org/mental-health/teens-drugs-and-overdose-contrasting-pre-pandemic-and-current-trends/), nearly threefold as many as in 2018, while adult opioid deaths only went up by 65% during this time, according to the study. Drug overdoses are now among the [leading causes of death for US teenagers.](https://pmc.ncbi.nlm.nih.gov/articles/PMC10979414/pdf/nihms-1977911.pdf) Manuel Cano, associate professor of social work at Arizona State University and lead author of the study, said it’s hard to know all the reasons opioid deaths have risen so much more among teenagers. One possible explanation is the availability of counterfeit pills that contain fentanyl, manufactured to look just like prescription opioids. “Ten years ago, illicitly manufactured fentanyl was primarily something that people with a history of opioid use were using via injection or smoking,” Cano said, adding that now teenagers who are experimenting with drugs are more likely to encounter these pills or buy them through social media. Fentanyl is highly addictive, but for teenagers who find themselves dependent on it, “there’s just no treatment available in many communities,” says Jessica Calihan, an adolescent medicine physician at Massachusetts general hospital and Harvard Medical School instructor. “I’m in Boston – probably one of the most well resourced medical cities in the country,” Calihan said, but “we still struggle with getting young people into intensive care.” In other parts of the country, even outpatient care and therapy for addiction is unavailable to teenagers, Calihan said. “Even when the care is available, it may not incorporate what we know works,” Calihan added. Medication assisted treatments like naltrexone, suboxone, buprenorphine and methadone [are the most effective available for opioid use disorder.](https://case.edu/news/study-methadone-most-effective-drug-medication-assisted-treatment-opioid-use-disorder) But, as the study notes, less than 10% of the fraction of teenagers who are in treatment for opioid use disorder receive medication assisted treatment. Such treatments are difficult to access even for adults. Methadone, especially, is inconvenient to access due to legal hurdles. The belief that medication for opioid use disorder [compromises true sobriety](https://dmh.mo.gov/media/pdf/challenging-myths-about-medication-assisted-treatment-mat-opioid-use-disorder-oud) also creates hesitation. Still, addiction medicine experts agree that medication is the best way to keep those with opioid use disorder alive. “There’s prejudice and misunderstanding and a sense that we ought to let young people at least try non-medication treatment first,” said Marc Fishman, an addiction psychiatrist at Johns Hopkins University and medical director of Maryland Treatment Centers. “And then maybe if they fail non-medication treatment, we should allow the medication treatment. But that’s nuts. That’s not what the evidence says.” When it comes to fentanyl addiction, failure of treatment can mean a fatal overdose, Fishman said. “That’s hardly an appropriate criteria.” Until 2024, doctors were legally required to try other treatments for minors before prescribing medication assisted therapy, according to the study. “In every other kind of medical treatment, if our loved ones are sick, it’s just intuitive and instinctive and natural that we try to help,” Fishman said. “If Granny won’t take her pills. If she’s not getting to her appointments.” But people think about addiction differently. “That’s secret and shameful,” Fishman said, and often wrapped up in conflict. “Most of these families, when we first meet them, are in crisis. Yelling and screaming and mad, for good reason, right? Because the kid’s in trouble, dropped out of school and had an overdose and nearly died.” He said while this kind of anger is understandable, it’s not an effective strategy for fixing the problem. Research to figure out what does work best for adolescents is still in progress, but we do know that we can’t just treat them as “shorter adults”, Fishman said. “Adolescents have specific developmental needs and generally tend to have different sets of life circumstances, responsibilities, and stressors than adults,” Cano agreed. Fishman says he’s found a few strategies that work in his own practice. One is to get the family and community involved in the adolescent patient’s treatment – with that patient’s input. “Whether it’s their families of origin, or an auntie, a granny, a boyfriend, a girlfriend, whoever it is, you select somebody that you care about, that you’re connected with, to be on your team,” Fishman said. This support person will be on group chats with the patient and their doctor, making sure they get to their appointments. Another effective strategy is to reward patients for adherence to medication, “so you get prizes and money and bonuses if you get your shots or you take your medicine,” Fishman said. This is part of the [contingency management](https://pmc.ncbi.nlm.nih.gov/articles/PMC3083448/) treatment strategy, which addiction treatment providers also use to incentivize adults to get negative drug tests. Calihan says that effectively treating adolescents is vital, not only for preventing overdose deaths, but for helping patients grow into adulthood. Her patients who are most in crisis are almost always those who started using at a very young age. Without early intervention, she worries today’s teens “likely will go on to develop much more severe use disorders”.

Overdose deaths continued to rise in some communities across the US even as they declined nationally in 2024, according to an [exclusive data analysis](https://github.com/mattkiefer/us-overdoses) by the Guardian, which found wide geographical disparities in fatalities linked to the public health crisis. The revelation comes just months after public health officials heralded a 27% drop in overdose deaths, a feat that the Centers for Disease Control and Prevention (CDC) [attributed to factors](https://www.cdc.gov/media/releases/2025/2025-cdc-reports-decline-in-us-drug-overdose-deaths.html) including expanded access to the overdose-reversal drug naloxone and substance-use treatment, and shifts in the drug supply. “This decline suggests more than 81 lives saved every day,” the CDC stated [in a press release](https://www.cdc.gov/nchs/pressroom/releases/20250514.html). On average, 220 US residents still died of overdose each day in 2024. But when the CDC announced the decline in May of 2025, the downward trend in overdose fatalities had already begun to reverse in seven states, according to the Guardian’s findings. [Line chart comparing a few state’s opioid death trends to the US average. West Virginia was earlier and higher, Alaska’s later, and Georgia’s more or less in line with the national total.](https://interactive.guim.co.uk/uploader/embed/2025/10/archive-zip/giv-32554VwRwoVY1TQF2/) [](https://www.theguardian.com/us-news/ng-interactive/2025/oct/17/overdose-deaths-data-analysis#img-2) Line chart comparing a few state’s opioid death trends to the US average. West Virginia was earlier and higher, Alaska’s later, and Georgia’s more or less in line with the national total. Public health experts [were unsure](https://www.npr.org/2025/03/24/nx-s1-5328157/fentanyl-overdose-death-drugs) of [what factors led to the decline](https://www.statnews.com/2025/05/14/drug-overdose-deaths-drop-27-percent-cdc-says-fentanyl-drops-meth-rising/) and whether the reduction in deaths was the beginning of a long-term trend. “You can talk to five different experts, and you’ll get five different explanations for why the deaths are coming down. Nobody really knows,” said Andrew Kolodny, medical director for the opioid policy research collaborative at Brandeis University. In order to better understand how – and why – the overdose epidemic is clearly diminishing in some parts of the country, but progress is waning in others, the Guardian analyzed key data points, including: CDC data on overdose fatalities and the distribution of medication for opioid overdose and addiction; US Census Bureau data on population, poverty, Medicaid and uninsured rates; and drug seizure data from the National Forensic Laboratory Information System. The analysis also reviewed data on patients in substance-use treatment provided by the urinalysis company Millennium [Health](https://www.theguardian.com/society/health), an accredited drug-testing specialty laboratory. [](https://www.theguardian.com/us-news/ng-interactive/2025/oct/17/overdose-deaths-data-analysis#img-3) US county-level opioid overdose map While overdoses declined nationally between August 2023 and December 2024, the most recent month when county-level data is available, they increased by as much as 120% during that time in some US counties. State-level data, which is available through April of this year, showed deaths beginning to rise again in January, reaching near peak levels in Arizona, and climbing more modestly in Delaware, Hawaii, Minnesota, New Mexico and Washington. Overdoses are still the leading cause of death for Americans aged 18-44, according to the CDC, and would be listed as one of the 10 leading causes of death overall were they not lumped together in a single category [with other accidental deaths and injuries](https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm). Overdoses claimed over 80,000 US lives in 2024 – more than [twice as many](https://www.nhtsa.gov/press-releases/nhtsa-estimates-39345-traffic-fatalities-2024) as motor vehicle accidents and nearly three times as many as Covid-19. Yet this was still seen as a major improvement. Marc Fishman, an addiction psychiatrist at Johns Hopkins University who focuses on substance-use disorders in youths, is frustrated at the lack of national attention on addiction treatment. “Who ever would have thought that we’d be applauding 80,000 deaths?” said Fishman. “If 80 goes to 70 goes to 60, that’d be something to celebrate. Let’s see if the trend continues.” **Drug** **supply** ------------------- Of the factors the Guardian analyzed, changes to the amount of fentanyl, and in some cases methamphetamine, in the drug supply, as well as geography, were most strongly linked to changes in overdose deaths. These two factors are likely related, according to recent research and the Guardian’s analysis. According to [a September Lancet study](https://www.sciencedirect.com/science/article/pii/S2667193X25002364#:~:text=Any%20reduction%20in%20the%20number,the%20COVID%2D19%20pandemic%20emergency.): “Starting in 2013, fentanyl began replacing heroin in the eastern US and spread westward, driving profound increases in overdose deaths” that have not yet abated to the same degree as they have in the [east](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835230). The increased prescription of opioids by doctors led many Americans to become addicted starting in the 90s, especially in eastern states such as West Virginia, where physical laborers took pills for their pain. Tightened restrictions on prescription opioids starting in the early 2010s led more people to turn to illegal opioids, such as heroin. Then fentanyl, which is cheaper [and 70 times](https://pmc.ncbi.nlm.nih.gov/articles/PMC6989952/) more potent, began to replace it. [Bar chart showing that western counties had the highest share of people living where overdose deaths increased](https://interactive.guim.co.uk/uploader/embed/2025/10/archive-zip/giv-325547HRvTElTGN24/) [](https://www.theguardian.com/us-news/ng-interactive/2025/oct/17/overdose-deaths-data-analysis#img-4) Eight per cent of the population in western counties included in the analysis were living in areas where overdoses were still increasing by more than 10% since the peak of the crisis, according to the Guardian’s analysis, which also showed that peaks in overdose death rates lined up with peaks in fentanyl prevalence. The percentage of drug seizures containing fentanyl peaked in 28 states in 2023, the same year that overdoses began to decline nationally. **Naloxone** ------------ The overdose-reversal drug naloxone is widely praised as a game changer in the crisis, and is often cited first as a possible explanation for the decline in drug overdose deaths, including in [CDC releases.](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835230) Opioid overdoses occur when the brain’s opioid receptors are overwhelmed and the body neglects to breathe. Naloxone reverses this process by blocking the opioid receptors in the brain, sending the recipient into immediate withdrawal as they awake. Naloxone undoubtedly saves lives, and every public health expert who spoke with the Guardian unequivocally supports its continued promotion. But its necessity is also a grim sign of the severity of the US opioid crisis. Every time someone needed naloxone to reverse an overdose, that person was already on the edge of death – without a friend or bystander with naloxone on hand, their chances of survival would have been slim. People who use opioids encourage one another to “never use alone” and to have naloxone on them at all times. “It is terrifying,” Fishman said. “I’ve been yelling about this for years. You can’t say I’m gonna reverse an acute overdose and then celebrate when you haven’t addressed the disorder.” Substance-use treatment can help prevent overdoses in the longer term, but it requires sustained investment in both addiction and mental health treatment. People who struggle with addiction are often self-medicating for other mental health conditions [such as depression or PTSD](https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107248). It is difficult to tease out how much naloxone has contributed to a reduction in overdose death rates. [Evidence](https://www.bmj.com/content/346/bmj.f174) is [mixed](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835230), and [the few studies](https://pmc.ncbi.nlm.nih.gov/articles/PMC4794468/) that investigate the impact of naloxone on overdose rates were mostly conducted before overdoses began skyrocketing in the wake of Covid-19. **Flying blind** ---------------- Back in 2015, the CDC issued [recommendations](https://stacks.cdc.gov/view/cdc/35133) to address the increasing amount of fentanyl in the drug supply. Some, such as an uptick in the distribution of naloxone, have happened. Many others, like consistent analysis of drugs found on the scene of overdoses, have not. In statements about declining overdose deaths, the CDC touted [its improved data collection and sharing](https://www.cdc.gov/media/releases/2025/2025-statement-from-cdcs-national-center-for-injury-prevention-and-control-on-provisional-2024.html#:~:text=For%20immediate%20release:%20May%2014,efforts%20to%20maintain%20this%20progress.). Experts say it is not enough. “We should have much better data on this,” said Kolodny. “If you think about when Covid was raging, on a county level, on a zip code level, you could find out about Covid positivity rates on tests. You could find out deaths, hospitalization, and it was easily available for everybody. For opioids, we’re almost 30 years into the epidemic, and we still don’t have adequate surveillance.” Kolodny said that CDC overdose death data is “the best we have” to track the crisis – “inadequate as it is. We’re looking at \[data from\] April. That’s crazy. It’s October.” Eric Dawson, vice-president of clinical affairs at Millennium Health, said the company is already working with some health departments to try to “close the gap between what’s happening with fatal overdose today and what we’re being told today happened six, seven months ago”. A [modeling study published in Jama](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835114) this year found that Millennium Health’s urinalysis data for patients in substance-use treatment could be used to accurately predict overdose deaths. The CDC only releases data on a past 12-month basis, so it is not possible to pinpoint spikes. Data about what type of drug caused a death, and the demographics of the fatalities, is available, but extremely limited – there is no way to tease out how many deaths were caused by multiple drugs, for example. The CDC has not yet released data on how death rates among groups hardest hit by the crisis, such as Black and Indigenous men, changed in 2024, and [may never do so under](https://www.kff.org/racial-equity-and-health-policy/disappearing-federal-data-implications-for-addressing-health-disparities/) new Trump administration policies. When overdose fatalities began to decline in 2023, they were still accelerating among Indigenous, Black, Latino and multiracial populations, according to a [June](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835230) _[](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835230)_[Jama study](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835230). The CDC did not respond to the Guardian’s request for comment. [Cartogram of the US, where a series of charts representing states show their overdose death trends.](https://interactive.guim.co.uk/uploader/embed/2025/10/archive-zip/giv-32554cwUe8HPsQW7m/) [](https://www.theguardian.com/us-news/ng-interactive/2025/oct/17/overdose-deaths-data-analysis#img-5) While the Drug Enforcement Administration (DEA) collects data on the drug supply, it does not share detailed data on information such as drug purity. Publicly available drug seizure data is only available [on state and national levels](https://www.nflis.deadiversion.usdoj.gov/) and is currently more than 10 months old. When the DEA does occasionally share alerts and reports, they are often [months or years behind new drug supply trends](https://www.dea.gov/sites/default/files/2020-06/Fentanyl-2020_0.pdf?utm_source=perplexity). In its most recent drug threat assessment report, the DEA announced that the purity of fentanyl [was decreasing](https://www.dea.gov/sites/default/files/2025-07/2025NationalDrugThreatAssessment.pdf). Kolodny noted that this decrease in purity is likely related to the lower prevalence of fentanyl in Millennium Health and drug seizure data. “Fentanyl became more expensive for the [cartels to manufacture](https://www.npr.org/2024/09/30/nx-s1-5124997/fentanyl-overdose-opioid-btmps-drug-cartel-xylazine-tranq-mexico-china), and so less fentanyl is coming into the United States,” Kolodny said. But these trends do not apply evenly across the country. The DEA would not share regionally specific data on fentanyl purity with the Guardian, or respond to requests for comment. Public health officials and researchers who spoke with the Guardian said the DEA doesn’t share this type of data with them either. “I don’t know why they don’t,” Jenny Hua, medical director of the Chicago department of public health, said. “I don’t know if it’s a cultural thing.” “Of course, that data should be more readily available,” Kolodny said, adding that he understands why the DEA might be skeptical of researchers, whose goals don’t necessarily align with those of law enforcement. While drug seizure data for 2025 is not yet available, 2025 Millennium Health data showed that in states where overdoses began to increase again this year, indicators of fentanyl use were also increasing. Fentanyl positivity rates both in urinalysis and drug seizure data were most overwhelmingly tied to overdose death rates, but the picture becomes more nuanced when you zoom in on a local level. [Line charts showing the similar trends of overdose deaths and positive fentanyl testing in three western US states](https://interactive.guim.co.uk/uploader/embed/2025/10/archive-zip/giv-32554KGGe29ktTjPk/) In some states, including Ohio, Washington and Oregon, methamphetamine was also closely tied to overdose death rates, according to the Guardian’s analysis. Data on the drug supply can help inform how to allocate overdose prevention dollars. Many interventions, including naloxone, are exclusively helpful for preventing opioid deaths. Methamphetamine is a stimulant, and stimulant-use disorder requires very different treatment than opioid-use disorder. Katie Strozyk, who manages the opioid and overdose response program in Thurston county, Washington, said that surveys show many residents primarily use methamphetamine, but it can be difficult for them to find treatment because resources are directed toward opioids. Overdose fatalities increased by 6% between the peak of the crisis and December 2024 in Thurston county. **Overdose prevention is critical** ----------------------------------- Kolodny said that if overdose prevention was a priority, it would be possible to get more precise data at the local level much closer to real time. Some US counties are already demonstrating that this is possible. In Cook county, Illinois, for example, drug death toxicology reports can be available within less than a month. Chicago has also ramped up its tracking of the drug supply and other overdose-related information, such as ambulance data, in order to pinpoint overdose spikes at a neighborhood level and understand why they are happening. [ How Chicago succeeded in reducing drug overdose deaths ](https://www.theguardian.com/us-news/2025/oct/17/chicago-reduced-drug-overdose-deaths) But in most of the country, this type of timely and hyper-local response is not happening. Strozyk of the Thurston county, Washington, opioid response program said officials they “may or may not ever know the underlying cause” of a local uptick in overdoses, so they focus on a proactive approach. Hua said there are many factors beyond the control of health departments that influence death rates. It is easier to have a coordinated response in a big city, where people and resources are concentrated. Changes to the drug supply are also affecting different regions differently. A spokesperson for the Georgia department of public health also said they lack local data. Catoosa county, Georgia, saw an 120% increase in overdose deaths since the national peak, the highest among counties with data available in the Guardian’s analysis. Meanwhile, Dougherty county, Georgia, saw one of the largest decreases, by 74%. There is “no clear cause” for the disparity in the statewide data, the spokesperson said. “This is an example of why evolved surveillance and data-sharing strategies are critical to providing local partners with the information they need to focus their efforts on specific counties, populations and overdose risk factors.” Kolodny says it is important to understand why deaths are increasing in certain states, noting that most of these states have high rates of methamphetamine use. “In methamphetamine states, you have a lot of people who are addicted to both drugs \[methamphetamine and fentanyl\],” Kolodny said, “Maybe there’s an increase in purity of methamphetamine that’s causing you more deaths. That’s hard to tease out.” [graphic showing percentage change in US counties’ overdose deaths from August 2023 to December 2024](https://interactive.guim.co.uk/uploader/embed/2025/10/archive-zip/giv-32554JLRuvZ8ln73g/) [](https://www.theguardian.com/us-news/ng-interactive/2025/oct/17/overdose-deaths-data-analysis#img-6) Illustration: Guardian Design A spokesperson for the Medicaid office in Arizona, where overdoses reached near peak rates in 2025, said the rise “is driven largely by synthetic opioids, especially fentanyl, which is increasingly found in combination with stimulants such as methamphetamine. These drug combinations complicate overdose response and increase lethality.” The spokesperson said Arizona faces unique challenges, including “proximity to major trafficking routes”, and that the state was leveraging CDC funding to analyze drug paraphernalia and identify emerging drug threats, and was also working to link more people to substance use treatment. The Guardian’s analysis of Millennium Health data found that the more you zoom in, the more specific trends emerge. In Cook county, there is a much stronger association between cocaine-positive urine samples and overdose deaths than in any state level data. Fentanyl is also associated with overdose deaths in Cook county. Hua’s team is already responding to cocaine’s popularity in the city. “Whether it’s meth or cocaine, we treat these as stimulant-use disorders,” Hua said. As part of this focus, the health department has formed a partnership with Northwestern University to provide “contingency management” – a highly effective treatment strategy in which patients are rewarded for abstaining from drug use. According to Kolodny, one of the reasons that the crisis became so alarming is because the focus is on deaths, rather than prevention. **A** **crisis of addiction** ----------------------------- While death and drug supply surveillance in the US is lacking, there is even less good data on addiction, said Kolodny. “It’s very, very rudimentary, and it was completely useless until a couple of years ago. It’s called the National Survey on Drug Use and Health, so you can extrapolate from about 70,000 face-to-face interviews, but that’s not adequate.” In Portugal, [there is an agency devoted](https://www.euda.europa.eu/drugs-library/government-portugal-2023-portugals-national-plan-reduction-addictive-behaviours-and-dependencies-2030-and-horizon-2024-action-plan_en) to tracking and intervening in addictive behaviors. The agency aggregates data from health agencies, law enforcement, population surveys and even drugs found in wastewater analysis to get a full picture. Portugal’s per capita overdose death rate is less than 1/30 of that in the US. The US national survey is conducted by SAMHSA, an agency whose future under the Trump administration is uncertain. New rules that will require Medicaid recipients to work 80 hours a month could also compromise patients’ ability to access treatment – it can be very difficult to work while in intensive substance-use recovery. These rules will [go into effect in 2027](https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/) under the One Big Beautiful Bill Act, signed into law in July. Deaths should be considered a symptom of the crisis, not the main outcome, Kolodny explained. “At the height of the Aids crisis, tens of thousands of people were dying from PCP pneumonia,” he said, “If you had Aids, it knocked out your immune system, you got this type of pneumonia.” But, Kolodny continued: “We didn’t approach the Aids crisis by calling it a PCP pneumonia epidemic. We realized it was HIV, an infectious disease that can be prevented through clean syringes and condoms, and it can be treated with antiretroviral therapy. But for the opioid crisis,” he said, we have it backwards. “This is a crisis of addiction: if you really understand that most of these deaths are occurring in people who are addicted, not people saying, ‘Hey, shooting up fentanyl would be a fun way to spend a Friday night.’ It’s people who are really struggling.” * **Contributors **Visuals: Andrew Witherspoon Data editing: Will Craft Copy editing: Rusha Haljuci Illustration: Angelica Alzona * _This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2025 Impact Fund for Reporting on Health Equity and Health Systems_

A couple of years ago, I began investigating non-fatal overdoses. Coverage of the US’s opioid crisis has largely focused on lives lost. But through my cousin Mason, I saw another toll of the epidemic: the people who survive overdoses but are left with devastating disabilities. Watching his and his parents’ struggles – and knowing he was not the only young overdose survivor in a nursing home – I wondered: how many people like Mason were out there? What happens to them, and how do their families cope? I quickly learned that no one is tracking these cases. There is no official count of people living with overdose-related brain injuries. But through Facebook groups and GoFundMe pages, I began to connect with families going through similar ordeals. Despite the pain and relentless demands of their situations, many were open and generous with their time. That was especially true of Jessica Pizzitola Jarrett and her son, John-Bryan, who goes by JB and suffered an anoxic brain injury and other complications after overdosing on fentanyl in September 2020. Between managing JB’s 24-hour care, her own workload, and helping other families navigate similar crises, Jessica still made time to speak with me. Last December, she and JB welcomed me into their home in Sugar Land, Texas, where they live with Jessica’s brother. Nothing about their lives struck me as easy – from operating the Hoyer lift to get JB out of bed, to loading up the van for medical appointments and family outings. But being with them in person only deepened my admiration for their strength, five years into their new chapter. I already knew of Jessica’s fierce faith and commitment to JB’s recovery, but what stood out most was the spirit she brings to caring for her son: organizing a tattoo fundraiser in his honor, tracking down a wheelchair in his favorite color (hot pink), finding small ways to inject joy into the daily grind. Love, as much as endurance, sustains them. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-2) Nurse Kenneth Emakpose, uses a Hoyer lift to help JB out of bed in the morning. Luckily, JB did not get added to the US’s tally of overdose deaths – an estimated 81,000 in 2023 – and more than 1m over the past 20 years. The tragedy of his overdose is that having survived, the 29-year-old now lives with profoundly debilitating, life-changing injuries. Nearly five years on, JB cannot walk or talk. After some recent medical setbacks, he also struggles to move, to swallow or to communicate in any way. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-3) Emakpose brushes JB’s teeth during his morning hygiene routine. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-4) Family photographs hang on the wall of JB, before he sustained an anoxic brain injury in 2020, during a fentanyl overdose. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-5) Jessica drives her son to a medical appointment in the family’s handicap-accessible van. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-6) Jessica wipes sweat from JB’s face, trying to keep him comfortable as she and medical staff at the Texas Institute of Rehabilitation and Recovery, better known as TIRR-Memorial Hermann, troubleshoot a non-functioning wheelchair ramp on her van. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-7) Jessica celebrates finding a physical therapist with a portable wheelchair ramp, to help get her son out of her handicap-accessible van – after their electric ramp stopped working outside a medical appointment. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-8) Jessica wheels her son to attend a medical appointment at TIRR-Memorial Hermann, one of the nation’s premier brain rehabilitation centers. The Houston-based hospital has a reputation among the anoxic brain injury community for accepting patients with the most severe injuries and treating them as people with futures and potential. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-9) Jarrett stresses about a broken wheelchair ramp on their family’s van, while at a medical appointment with her son. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-10) Nurse Ngozi Uketui prepares to refill JB’s intrathecal Baclofen pump – a surgically implanted medical device that delivers muscle relaxers directly into his spinal fluid. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-11) Jessica comforts JB, while Uketui refills his intrathecal Baclofen pump. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-12) Dr Cindy Ivanhoe, a professor of physical medicine at UTHealth Houston and director of the spasticity program and associated syndromes of movement at TIRR-Memorial Hermann, consults Jessica and JB. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-13) “It’s a very hard system to navigate. It’s very hard to advocate.” “Some patients get better, some patients get worse,” says Ivanhoe. “We are not great at predicting who’s going to do what, and so I would just not like to take those opportunities away.” But that’s what insurance companies often do, she noted, adding that exasperating phone calls with medical directors over coverage of rehabilitation or other treatments are a routine part of her job. “We teach people to practice based on what the insurance covers, not based on what’s possible,” says Ivanhoe, who has treated thousands of patients over her decades-long career. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-14) Jessica wheels JB from a medical appointment at TIRR-Memorial Hermann. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-15) Brittney Burton, an occupational therapist, works with JB on the motor planning necessary for communication using a head laser and low-tech communication board, in preparation for use of an augmented communication device in the future. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-16) JB answered “yes” when she asked if he was tired, then pointed the red laser beam to “no” when she asked him if he wanted to go to bed. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-17) Burton, uses a Stimpod NMS460 – a neuromodulation device, on JB’s face, to stimulate his nerves to promote neurotransmitter activation and sensory stimulation. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-18) Brittney Burton and Jessica stretch JB’s tightly clenched hands. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-19) JB relaxes in a recliner and watches a baseball game. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-20) Jessica prepares her son for sleep for the night. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-21) JB sleeps under a starry sky nightlight in his bedroom. For peace of mind his mom now sleeps in his bedroom closet, her makeshift bed wedged between the wall and a rack of clothes – close enough to respond to every cry, call, shift of bedsheet, or other sign that JB is in distress. [](https://www.theguardian.com/society/2025/oct/21/opioid-overdose-epidemic-brain-injuries-caretaking#img-22) Jessica embraces her son at night. * Meridith Kohut is a photojournalist based in Houston, Texas, who has documented health, humanitarian and environmental issues in the US and Latin America since 2007