A liquid dose of methadone at the clinic in Rossville, Ga. The medication is only available at designated opioid treatment centers and that won't change. But more clinicians will be able to prescribe it. Kevin D. Liles/AP As drug deaths surged above 112,000 a year in the U.S., driven by the spread of the synthetic opioid fentanyl, addiction experts have pointed to a troubling paradox. Proven medications, including methadone, have been shown to save lives, [cutting the risk of relapses and fatal overdoses by nearly 60%](https://www.nih.gov/news-events/news-releases/methadone-buprenorphine-reduce-risk-death-after-opioid-overdose). Yet they are rarely prescribed. Despite the growing risk of death, [only one-in-five people experiencing opioid addiction](https://nida.nih.gov/news-events/news-releases/2023/08/only-1-in-5-us-adults-with-opioid-use-disorder-received-medications-to-treat-it-in-2021#:~:text=Researchers%20found%20that%20in%202021,medications%20for%20opioid%20use%20disorder.) gain access to medications. Clinicians and treatment advocates say that's due in part to the fact that methadone is heavily regulated. Now for the first time in more than 20 years, the Biden administration is publishing new federal rules for methadone treatment aimed at widening access for more patients. "The easier we make it for people to access the treatments they need, the more lives we can save," said HHS Deputy Secretary Andrea Palm, [in a statement](https://www.hhs.gov/about/news/2024/02/01/biden-harris-administration-marks-two-years-advancements-hhs-overdose-prevention-strategy-new-actions-treat-addiction-save-lives-press-release.html). "With these announcements, we are dramatically expanding access to life-saving medications." Under the [revised rules](https://www.federalregister.gov/public-inspection/2024-01693/medications-for-the-treatment-of-opioid-use-disorder), methadone will still only be available through a [limited number of roughly 2,000 federally-approved opioid treatment programs](https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/07/opioid-treatment-programs-a-key-treatment-system-component#:~:text=As%20of%20March%202021%2C%20there,medication%20can%20currently%20be%20accessed.) (OTPs) nationwide. But patients accessing those clinics will now be able to receive more take-home doses of the medication; they'll be able to receive care more frequently after a telehealth consultation; and nurse practitioners and physicians assistants working at OTPs will be able to order the medication. The new rule also eliminates a long-standing restriction that required patients to experience opioid addiction for at least a year before receiving methadone. The new actions will take affect within six months, the government says. In a statement, White House drug czar Dr. [Rahul Gupta](https://www.whitehouse.gov/ondcp/briefing-room/2021/10/28/united-states-senate-confirms-dr-rahul-gupta-as-director-of-national-drug-control-policy/) said the new rules "can mean the difference between life or death" for people addicted to fentanyl and other opioids. The changes, which take effect this summer, drew praise from addiction policy experts, but some critics said they don't go far enough. In a statement to NPR, the head of the American Society of Addiction Medicine said it should be easier for qualified doctors not employed by OTPs to dispense opioid treatment medications, including methadone. "Now it is time for Congress to act," said [Dr. Brian Hurley](https://www.asam.org/about-us/leadership/board-of-directors/biography-brian-hurley). "\[A\]llow addiction specialist physicians to prescribe methadone...that can be dispensed from a local pharmacy." Sen. Edward Markey, a Democrat from Massachusetts, also supported the Biden administration reforms, but criticized the regulatory bottleneck requiring opioid treatment programs to distribute methadone. "Ultimately, tethering methadone exclusively to opioid treatment programs is less about access, or health and safety, but about control, and for many investors in those programs, it is about profit," Markey said in a statement. "The longer we leave this antiquated system in place, the more lives we lose." The American Medical Association also supported the new rules, in part because they will liberalize access to buprenorphine, another proven opioid treatment medication. "Prescribing buprenorphine through telehealth visits provides the opportunity to reach remote and underserved communities and patients who may be unable to travel daily to in-person appointments," said the AMA's [Dr. Bobby Mukkamala](https://www.ama-assn.org/about/board-trustees/bobby-mukkamala-md) in a statement. These new rules are part of a wider strategy by the Biden administration over the last two years aimed at curbing [unprecedented overdose death rates](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm).

#### [Analysis](https://www.npr.org/sections/analysis/) ### [Consider This from NPR](https://www.npr.org/podcasts/510355/considerthis)   Drug consumers line up outside of the SAOM van for a methadone cocktail and supplies in the city center of Porto, Portugal last spring. There are very few overdose deaths in the country where drug addiction is treated as an illness rather than a crime.[](https://www.gettyimages.com/license/924064702?adppopup=true) Photo by Demetrius Freeman/The Washington Post /Getty Images Brian Mann covers the U-S opioid and fentanyl crisis for NPR. That means he talks to a lot of people struggling with addiction. Again and again, he's heard stories of people who have succumbed to their addiction — last year 112, 000 — more than ever in history. But when Mann traveled to Portugal to report on that country's model for dealing with the opioid crisis, he heard a very different story. Overdose deaths in Portugal are extremely rare.The country has taken a radically different approach to drugs – decriminalizing small amounts and publicly funding addiction services – including sites where people can use drugs like crack and heroin. Portugal treats addiction as an illness rather than a crime. No one has to pay for addiction care, and no one scrambles to navigate a poorly regulated recovery system. Could Portugal's approach help the U-S fight its opioid epidemic? For sponsor-free episodes of _Consider This_, sign up for _Consider This+_ via Apple Podcasts or at [plus.npr.org](http://plus.npr.org/). Email us at [[email protected]_](mailto:[email protected])_._ _This episode was produced by Connor Donevan and Megan Lim. It was edited by Courtney Dorning and Andrea DeLeon. Our executive producer is Sami Yenigun._

Ibogaine, a formidable hallucinogen made from the root of a shrub native to Central Africa, is not for the timid. It unleashes a harrowing psychedelic trip that can last more than 24 hours, and the drug can cause sudden cardiac arrest and death. But scientists who have studied ibogaine have reported startling findings. According to a number of small studies, between a third and two-thirds of the people who were addicted to opioids or crack cocaine and were treated with the compound in a therapeutic setting were [effectively cured](https://pubmed.ncbi.nlm.nih.gov/30272050/) [of their](https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2018.00529/full) [habits](https://journals.sagepub.com/doi/10.1177/0269881114552713#:~:text=We%20observed%20no%20serious%20adverse,a%20median%20of%208.4%20months.), many after just a [single session](https://pubmed.ncbi.nlm.nih.gov/28402682/). Ibogaine appears to provide two seemingly distinct benefits. It quells the agony of opioid [withdrawal and cravings](https://pubmed.ncbi.nlm.nih.gov/29608409/) and then gives patients a born-again-style [zeal for sobriety](https://pubmed.ncbi.nlm.nih.gov/29922156/). Now, after decades in the shadows, and with opioid overdose deaths exceeding [100,000](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) a year, ibogaine is drawing a surge of fresh interest from researchers who believe it has the potential to [treat opioid use disorder](https://pubmed.ncbi.nlm.nih.gov/37927218/). “It’s not an exaggeration to say that ibogaine saved my life, allowed me to make amends with the people I hurt and helped me learn to love myself again,” said Jessica Blackburn, 37, who is recovering from heroin addiction and has been sober for eight years. “My biggest frustration is that more people don’t have access to it.” That’s because ibogaine is illegal in the United States. Patients have to go abroad for ibogaine therapy, often at unregulated clinics that provide little medical oversight. 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%2F2024%2F03%2F05%2Fhealth%2Fibogaine-psychedelic-opioid-addiction.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F03%2F05%2Fhealth%2Fibogaine-psychedelic-opioid-addiction.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%2F2024%2F03%2F05%2Fhealth%2Fibogaine-psychedelic-opioid-addiction.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F03%2F05%2Fhealth%2Fibogaine-psychedelic-opioid-addiction.html).

SACRAMENTO, Calif. -- California will soon begin selling its own generic version of Narcan — the drug that can save someone's life during an opioid overdose — under a deal announced Monday by Democratic Gov. Gavin Newsom as part of his effort to offer less expensive, state-branded options of medication. The New Jersey-based Amneal Pharmaceuticals will sell naloxone to California for $24 per pack, or about 40% cheaper than the market rate. California plans to give away many of the packs for free to first responders, universities and community organizations through the state's Naloxone Distribution Project. But it will also sell some of the packs at the discounted rate to California businesses and local governments — as long as they agree not to mark up the prices and sell it for a profit. The goal is to expand the distribution beyond schools and public health departments and into places including restaurants, entertainment centers and ride-hailing services such as Uber and Lyft. “Anywhere that has a first aid kit, we hope that this product will be available as part of that,” said Elizabeth Landsberg, director of the California Department of Healthcare Access and Information, which is overseeing the program. The naloxone nasal spray will be the first drug to carry the CalRx label, Newsom's effort to force drug companies to lower their prices by offering much less-expensive competing versions of life-saving medication. Newsom first announced this idea in 2019, and signed a law giving California the authority to do it in 2020. This isn't the first time California will have made its own medication. Since 2003, the California Department of Public Health has manufactured a treatment for the rare disease of infant botulism. But state officials say they believe California will be the first state to distribute a generic medication under a state label. “Federal and state governments can and should use their power as regulators and as purchasers,” said Anthony Wright, president of the consumer advocacy group Health Access California. "Americans paying out-of-pocket for prescription drugs pay more than anyone else in the world, but if government can use our collective power of the purse through direct contracts and manufacturing, we can get better deals not just for taxpayers, but patients and the public as a whole.” Naloxone has been available in the U.S. without a prescription since March of 2023, when the U.S. Food and Drug Administration approved Narcan, a nasal spray brand produced by the Maryland-based pharmaceutical company Emergent BioSolutions. Amneal Pharmaceuticals makes a generic equivalent to Narcan that won FDA approval last week. The naloxone packs purchased by California initially will be available under the Amneal label. The naloxone will move to the CalRx label once it's approved by the U.S. Food and Drug Administration, a process the Newsom administration said could happen by July. “We’ve enabled through CalRx the manufacturing of a low-cost (over the counter) Naloxone option that without us may not have come to market this quickly or at this volume,” said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency. The deal is significant because it means California will be able to buy a lot more naloxone — 3.2 million packs in one year instead of 2 million — for the same total cost. Opioid overdose deaths, which are caused by heroin, fentanyl and oxycodone, have increased dramatically in California and across the country. Annual opioid overdose deaths in California more than doubled since 2019, reaching 7,385 deaths at the end of 2022. California began giving away naloxone kits for free in 2018. State officials say the Naloxone Distribution Project has given out 4.1 million kits, which have reversed a reported 260,000 opioid overdoses. The money has come from taxpayers and portions of a nationwide settlement agreement with some other pharmaceutical companies. Last year, California lawmakers agreed to spend $30 million to partner with a drug company to make its own version of naloxone. But they ended up not needing to spend that money on this deal, since Amneal Pharmaceutical was already so far along in the FDA approval process it did not require up-front funding from the state. Instead, California will use a portion of the revenue it receives from a national opioid settlement to purchase the drugs. Naloxone is just one drug the Newsom administration is targeting. Last year, California signed a 10-year agreement with the nonprofit Civica to produce CalRx branded insulin, which is used to treat diabetes. California has set aside $100 million for that project, with $50 million to develop the drugs and the rest set aside to invest in a manufacturing facility. Newsom said a 10 milliliter vial of state-branded insulin would sell for $30. Civica has been meeting with the FDA and “has a clear path forward,” the Newsom administration said. “As we continue the effort to bring $30 insulin to the market, the state is now set to purchase life-saving naloxone for almost half of the current market price — maximizing taxpayer dollars and saving more lives with this miracle drug,” Newsom said in a statement provided by his office.

 This image provided by the Los Angeles County Sheriff's Department shows suspected fentanyl pills seized at Los Angeles International Airport in 2022. AP A new study shows a dramatic spike in the number of counterfeit fentanyl pills being seized by law enforcement, an indication of the growing illicit drug supply driving the country's historic opioid crisis. Last year, more than 115 million pills containing illicit fentanyl were seized by law enforcement, compared to over 71 million in 2022, according to the study published Monday in the _International Journal of Drug Policy._ The study found that the number of pills seized last year was 2,300 times greater than the roughly 50,000 seized in 2017. The counterfeit pills are made to look like legit prescription opioid medications — like oxycodone or benzodiazepines — but are often far deadlier. Public health officials have been warning about the presence of fentanyl, a potent synthetic opioid, in the illicit drug supply for more than a decade. The new report highlights the rising threat of cheap and highly potent counterfeit pills, especially in the western U.S. "Availability of illicit fentanyl is continuing to skyrocket in the U.S., and the influx of fentanyl-containing pills is particularly alarming," said Joseph Palamar, an associate professor in the Department of Population Health at the NYU Grossman School of Medicine, who was the lead author on the study. "Public health efforts are needed to help prevent these pills from falling into the hands of young people, and to help prevent overdose among people taking pills that unsuspectingly contain fentanyl." The study was led by researchers who participate in the National Drug Early Warning System, a federal program that monitors drug seizures in [33 so-called High-Intensity Drug Trafficking Areas](https://www.whitehouse.gov/wp-content/uploads/2023/06/HIDTA-map-May-2023.pdf) across the country. The data comes from a mix of federal, state and local law enforcement organizations. It does not include seizures made by U.S. Customs and Border Protection. ### 4-in-10 drug overdose deaths involve fentanyl Among the factors fueling the spread: The counterfeit pills are cheap to make and buy, and social media and the dark web have made them easier to buy online. Fentanyl also delivers a very powerful but very brief high, so people consume more of it than they would other opioids. It's also faster-acting and many times more potent than heroin and morphine, making it highly addictive and much easier to overdose. In fake prescription pill form, it can be mistaken for a safer drug. In reality, there's no telling how much fentanyl is in them. "It's like Russian roulette," said Dr. Samuel Beckerman, an emergency medicine physician in Los Angeles. "One pill might be enough to make you stop breathing. Another pill might just be enough to get you high." In 2021, illicit fentanyl was the sole drug involved in 41% of drug overdose deaths with evidence of counterfeit pill use, [according to the Centers for Disease Control and Prevention](https://www.cdc.gov/mmwr/volumes/72/wr/mm7235a3.htm). The fake pills account for an increasing chunk of overall fentanyl seizures, the study found. Fentanyl seizures more than quadrupled between 2017 and 2023. Almost half of last year's fentanyl seizures were in fake pill form, compared to just 10% of fentanyl seizures at the start of that period. ### Most fentanyl pill seizures were in western U.S. states  A member of the Portland Fire and Rescue Community Health Assess & Treat team pushes a patient into an ambulance for medical care after they were administered naloxone nasal spray for a suspected fentanyl drug overdose in Portland, Ore., on Jan. 25. Patrick T. Fallon/AFP via Getty Images The study highlights how the opioid epidemic, which has been historically worse in eastern states, has taken deeper root in the West. While the most fentanyl seizures in 2023 — powder and pill form — took place in Florida, the second- and third-most seizures came in Arizona and California, respectively. When looking at the number of seizures of illicit fentanyl pills specifically, researchers again found the highest numbers occurring in western states. There, the pills accounted for nearly 78% of all fentanyl seizures in the region last year. The total number of pill seizures were greatest in California, followed by Arizona and Colorado. "Most of the fentanyl that we're seeing, on the West Coast at least, is coming from Mexico. A lot of the precursors are getting shipped there from China and then it's getting manufactured in Mexico," said Caleb Banta-Green, a research professor at the University of Washington's School of Medicine who studies drug use epidemiology and was not part of the study. Banta-Green, who also directs UW's Community-Engaged Drug Education, Epidemiology & Research Center, says an increase in the fentanyl supply out West, as the study suggests, would reflect what he's seen happen in Washington state. Within the past two years alone, fentanyl overtook heroin as the most used opioid in the state, according to a [community survey](https://adai.uw.edu/cedeer/community-surveys/) conducted by the center. The spread of fentanyl-laced fake prescription pills has also meant that many people who don't normally use opiates — and never intended to — end up getting hooked on them. In Los Angeles, Dr. Beckerman, who works at Huntington Hospital and LA General Medical Center, said it's become common to see patients who overdosed on what they thought was Adderall or MDMA from a friend and didn't know they ingested fentanyl. "But the friend got it from somebody else who got it from somebody else and it didn't come from a pharmacy," he said. "That pill probably has like a 60 to 70% chance of containing a potentially lethal dose of fentanyl." Accidental fentanyl overdose deaths in the region jumped from 109 in 2016 to 1,910 in 2022, [according to the LA County Department of Health](http://publichealth.lacounty.gov/sapc/MDU/SpecialReport/FentanylOverdosesInLosAngelesCounty.pdf). "The language that I like to use is that these are not just accidental overdoses, these are fentanyl and opiate poisonings," Beckerman said. "These are people who have never done opiates in their life. They're not taking them because they want to take fentanyl." To combat the opioid crisis, experts say Americans need greater access to [medications that are considered the gold standard](https://www.npr.org/sections/health-shots/2023/08/07/1192423154/only-1-in-5-people-with-opioid-addiction-get-the-medications-to-treat-it-study-f) for treating opioid use disorder, such as methadone, buprenorphine and naltrexone. Stigma about addiction often limits the use of these life-saving drugs. "Until we make effective treatment and harm reduction easier to get than fentanyl, people keep using fentanyl," Banta-Green said. "And we are doing it, but we need to take it to a massive scale in the United States."

An estimated 107,543 people died of drug overdoses in the US in 2023, a shocking figure that obscures a glimmer of hope – this is the first annual decline in drug overdose deaths since 2018. The grim toll represents Americans’ struggle with powerful synthetic drugs, in particular the synthetic opioid fentanyl, known to be up to 100 times stronger than morphine. More than 1 million people have died of a drug overdose [since 2001](https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=Drug%20Overdose%20Deaths%20Remained%20High,1999%20from%20a%20drug%20overdose.&text=In%202021%2C%20106%2C699%20drug%20overdose,2021%20(32.4%20per%20100%2C000).), according to the Centers for Disease Control and Prevention. The National Center for Health Statistics (NCHS), which [tracks overdose deaths](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm), attributed more than 74,000 deaths to fentanyl, followed by more than 36,000 deaths from methamphetamine. Often, overdose deaths involve more than one drug. Drug overdoses declined 3% in 2023. “We are encouraged to see the preliminary data that shows a decrease in the overdose death rate for the first time in five years, especially following the period of rapid double-digit increases from 2019-2021,” said the White House Drug Control Policy director, Dr Rahul Gupta. The west was hit particularly hard by drug overdoses, according to the data from the NCHS. Alaska, Oregon and Washington all saw increases in drug overdose deaths of more than 27%. The increases may reflect how illicit drugs have moved across the US, after primarily emerging in states east of the Mississippi in the early 2010s. Other states saw notable declines: Nebraska, Kansas, Indiana and Maine all saw declines of 15% or more. Recent reports by the Drug Enforcement Agency (DEA) and a study supported by the National Institutes of [Health](https://www.theguardian.com/society/health), both released this week, paint an increasingly complex picture of the US’s illicit drug supply, with fentanyl-laced pills appearing to make up an increasing proportion of the illicit drug market. “Pills are flooding the market,” said Joseph J Palamar, associate professor in the department of population health at New York University, and the lead author of the NIH-supported study released this week in the International Journal of Drug Policy. According to Palamar’s study, law enforcement seized more than 115m fentanyl pills in 2023, compared with about 49,000 in 2017, a 2,300% increase, while new synthetic drugs such as xylazine have posed new threats. Palamar also said he believes the arc of drug use has changed over time. In the early 2000s, a person might have developed substance use disorder by starting with a prescription opioid, such as Oxycontin, and moving to heroin. By the early 2010s, it was common for heroin to be laced with fentanyl. Today, fentanyl may be preferred by some people and appears as an adulterant in many different types of illicit drugs. It is also pressed to look like prescription benzodiazepines or opioids, raising the possibilities that people believe they are taking prescription drugs, or may begin using with fentanyl. “The most serious thing is you get these young people who think they’re going to take a Xanax or a Adderall or an Oxycontin and then they find out there’s fentanyl in it,” said Palamar. “You have some kid who thinks he’s getting an Adderall from Snapchat or whatever – that kid could overdose and die.” [skip past newsletter promotion](https://www.theguardian.com/us-news/article/2024/may/15/drug-overdose-deaths-2023#EmailSignup-skip-link-12) Sign up to First Thing Our US morning briefing breaks down the key stories of the day, telling you what’s happening and why it matters **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion The illicit drug supply is primarily controlled by Mexican cartels, according to the DEA’s [National Drug Threat Assessment](https://www.dea.gov/sites/default/files/2024-05/NDTA_2024.pdf). Cartels ship fentanyl, methamphetamine and synthetic drugs into the US through expansive networks, often with the backing of illicit Chinese chemical suppliers, pill presses and bankers. The toll also reflects broader struggles within American society. An estimated [2.5 million people](https://nida.nih.gov/news-events/news-releases/2023/08/only-1-in-5-us-adults-with-opioid-use-disorder-received-medications-to-treat-it-in-2021) suffer with opioid use disorder, but only one in five are in treatment, even though the disease has increasingly come into [public view](https://www.theguardian.com/us-news/2024/feb/21/oregon-drug-law-measure-110-backlash) because of a [housing affordability crisis](https://www.theguardian.com/us-news/2024/feb/22/los-angeles-unhoused-deaths-increase-housing-crisis-fentanyl-overdoses). Experts attribute the low number of Americans in treatment to [systemic barriers](https://www.statnews.com/2024/03/05/opioid-addiction-treatment-methadone-buprenorphine-restrictions/#:~:text=The%20evidence%20supporting%20the%20use,to%20those%20not%20receiving%20medication.), including a focus on abstinence, [insurance company policies](https://www.theguardian.com/us-news/2024/feb/03/opioid-treatment-prior-authorization-health-insurance-edited-) and laws out of step with science and those of peer western nations. At the same time, addiction and the overdose crisis have become a new front in the culture war. Republicans have criticized Joe Biden for failing to focus on [interdiction of illicit fentanyl](https://www.presidency.ucsb.edu/documents/op-ed-nikki-haley-ending-the-fentanyl-crisis-starts-securing-the-border) at the border, even as many [Republican policies](https://www.theguardian.com/us-news/2024/feb/03/opioid-treatment-prior-authorization-health-insurance-edited-#:~:text=In%20her%20analysis%2C%20Andrews%20said,harmful%20in%20one%20program%3A%20Medicaid.) make treatment harder to access.

Last week brought some rare good news on drugs: Overdose deaths [declined in 2023](https://www.nytimes.com/2024/05/15/health/drug-overdose-deaths.html). And while the opioid crisis has taken some surprising and terrible twists over the years, it may finally be turning around. There are two main causes. First, drug epidemics tend to follow a natural course in which the drugs enter a market, spread and then fade away, at least for some time. The opioid epidemic appears to have entered that final phase. Second, policymakers have increased access to both Narcan, a medication that reverses opioid overdoses, and addiction treatment. These changes have saved lives. Today’s newsletter will explain both causes. Drugs are often faddish; epidemics tend to ebb on their own. Why? Users die. People see the damage that a drug does, and they shun it. Surviving users move on to other drugs that they see as better or safer, sometimes incorrectly. Think of all the drugs that have come and gone over the past several decades, such as crack, meth and synthetic marijuana. (In the case of meth, [a comeback is underway](https://www.nytimes.com/2023/11/13/briefing/drug-crisis.html). Even the worst fads can return.) The opioid epidemic is no exception. In fact, it has arguably been a succession of three different fads — first opioid painkillers, then heroin and finally fentanyl — that have felt like one. A chart shows the annual drug overdose death count in the United States. In 2022, the predicted provisional number of deaths was 111,026, and in 2023, the number of deaths was 107,543.   Note: The chart shows predicted provisional death counts. Source: C.D.C. By The New York Times 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%2F2024%2F05%2F21%2Fbriefing%2Fhas-fentanyl-peaked.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F05%2F21%2Fbriefing%2Fhas-fentanyl-peaked.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%2F2024%2F05%2F21%2Fbriefing%2Fhas-fentanyl-peaked.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F05%2F21%2Fbriefing%2Fhas-fentanyl-peaked.html).

Alissa Zhu, Nick Thieme and Jessica Gallagher are reporters for The Baltimore Banner. They spent a year reporting on the city’s response to its overdose crisis as part of a [New York Times Local Investigations Fellowship](https://www.nytco.com/careers/local-investigations-fellowship/).     Across Baltimore, the death toll has mounted. Across Baltimore, the death toll has mounted. Fatal drug overdoses have occurred on a third of the city’s blocks. Fatal drug overdoses have occurred on a third of the city’s blocks. Bodies have been found in motels and vacant houses, at parks and the football stadium, around the corner from City Hall and outside the Health Department. Bodies have been found in motels and vacant houses, at parks and the football stadium, around the corner from City Hall and outside the Health Department. In one grim month alone, 114 people succumbed. In one grim month alone, 114 people succumbed. _This is the first part in a series exploring Baltimore’s overdose crisis._ People in Baltimore have been dying of overdoses at a rate never before seen in a major American city. In the past six years, nearly 6,000 lives have been lost. The death rate from 2018 to 2022 was nearly double that of any other large city, and higher than nearly all of Appalachia during the prescription pill crisis, the Midwest during the height of rural meth labs or New York during the crack epidemic. A decade ago, 700 fewer people here were being killed by drugs each year. And when fatalities began to rise from the synthetic opioid fentanyl, so potent that even minuscule doses are deadly**,** Baltimore’s initial response was hailed as a national model. The city set ambitious goals, distributed Narcan widely, experimented with ways to steer people into treatment and ratcheted up campaigns to alert the public_._ But then city leaders became preoccupied with other crises, including gun violence and the pandemic. Many of those efforts to fight overdoses stalled, an examination by The New York Times and The Baltimore Banner has found. Health officials began publicly sharing less data. City Council members rarely addressed or inquired about the growing number of overdoses. The fact that the city’s status became so much worse than any other of its size was not known to the mayor, the deputy mayor — who had been the health commissioner during some of those years — or multiple council members until they were recently shown data compiled by Times/Banner reporters. In effect, they were flying blind. Baltimore’s fatal overdose rate has quadrupled since 2013. It dipped in 2022, but preliminary data for 2023, not shown below, indicates overdoses were on track to rise again. Source: Centers for Disease Control and Prevention By Molly Cook Escobar From 2018 to 2022, Baltimore’s fatal overdose rate far exceeded that of any other large American city. In listings for counties, the major city is shown in parentheses. Note: Figures represent deaths caused by drug poisoning for counties of 400,000 or more. Source: Centers for Disease Control and Prevention By Molly Cook Escobar Medications that help patients control their cravings for opioids are effective. But the number of Medicaid patients getting them in Baltimore has dropped, even as the number of people fatally overdosing has shot up. Source: Maryland Department of Health By Molly Cook Escobar 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%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-deaths.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-deaths.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%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-deaths.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-deaths.html).

Baltimore has become the epicenter of the worst drug crisis ever seen in a major American city, an examination by The New York Times and The Baltimore Banner has found. The city’s death rate from 2018 to 2022 was nearly double that of any other large city — a fact not known by several top leaders, including the mayor and the deputy mayor, who used to lead the city’s Health Department. From 2018 to 2022, Baltimore’s fatal overdose rate far exceeded that of any other large American city. In listings for counties, the major city is shown in parentheses. Note: Figures represent deaths caused by drug poisoning for counties of 400,000 or more. Source: Centers for Disease Control and Prevention By Molly Cook Escobar The city once had an aggressive overdose prevention strategy, but as officials became preoccupied with other crises, many of their efforts stalled. Reporters for The Banner teamed up with The Times’s [Local Investigations Fellowship](https://www.nytco.com/careers/local-investigations-fellowship/), which gives local journalists a year to pursue an investigative story about their communities. They reviewed thousands of pages of government documents and interviewed more than 100 health officials, treatment providers and people who have been addicted to drugs to examine the city’s response. Here are five takeaways from our reporting. Baltimore has long been known as the United States’ heroin capital — a reputation cemented by the HBO series “The Wire” — and for decades it has had one of the highest fatal overdose rates of any large U.S. city. But the synthetic opioid fentanyl, up to 50 times more potent than heroin, has taken over the city’s drug supply, and the death rate has shot up. These days, nearly all illegal opioids available in the city contain fentanyl, and heroin is almost impossible to find. Baltimore’s fatal overdose rate has quadrupled since 2013. It dipped in 2022, but preliminary data for 2023, not shown below, indicates overdoses were on track to rise again. Source: Centers for Disease Control and Prevention By Molly Cook Escobar Medications that help patients control their cravings for opioids are effective. But the number of Medicaid patients getting them in Baltimore has dropped, even as the number of people fatally overdosing has shot up. Source: Maryland Department of Health By Molly Cook Escobar 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%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-takeaways.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-takeaways.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%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-takeaways.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F05%2F23%2Fus%2Fbaltimore-opioid-epidemic-od-takeaways.html).

The fatal overdose epidemic in the US, which began in the ’90s with increased overdoses of prescription opioids, finally looked like it was starting to take a turn in 2018. But then the Covid pandemic hit, and amid increased isolation during lockdowns, fatal drug overdoses in the US skyrocketed, crossing 100,000 fatalities in a single year for the first time in 2021. The main drivers of fatal overdoses over the last 10 years are synthetic opioids, like fentanyl. Fentanyl is a highly potent narcotic that often gets mixed into the American drug supply to make drugs — ranging from heroin to cocaine to Adderall — stronger and more addictive. The result is that huge numbers of people unknowingly consume a lethal dose of fentanyl laced into other drugs. America’s “war on drugs” and punitive approach to curbing drug use hasn’t solved this. So now American communities are turning to methods that emphasize “harm reduction” — creating environments for people with substance use disorder to find support, rather than punishment. A big part of that is the distribution of the drug naloxone, also known as Narcan. Naloxone is an opioid-antagonist, and can temporarily reverse an opioid overdose as it’s happening. It does this by blocking opioid receptors in the brain.Naloxone has been credited with saving tens of thousands of lives so far, according to the CDC, and is a tool for fighting the ongoing overdose epidemic that some medical experts are now urging all Americans to have on hand.Check out the video above to learn how naloxone could be a crucial element in reversing the fatal overdose epidemic in the US. _This video is presented by Brilliant. Head to_ [_https://brilliant.org/vox/_](https://brilliant.org/vox/) _for a 30-day free trial and 20% off your annual subscription. Brilliant doesn’t have a say in our editorial decisions, but they make videos like this possible._

Members of the Sackler family who own OxyContin maker Purdue Pharma have been cast as prime villains in the U.S. opioid epidemic. The Supreme Court on Thursday [rejected a deal](https://apnews.com/article/supreme-court-purdue-pharma-opioid-crisis-bankruptcy-9859e83721f74f726ec16b6e07101c7c) for the company to settle thousands of lawsuits over the toll of opioids through bankruptcy court. The deal was to be financed largely through the company being converted to a public benefits corporation, with profits being used to fight the opioid crisis, and the owners kicking in up to $6 billion for the same purpose. But in a 5-4 ruling, the court rejected the plan because it would have extended protection from civil lawsuits to company owners who didn't seek bankruptcy protection themselves — and not all the parties agreed to that. Here's a look at the family, the Stamford, Connecticut-based company the overdose crisis: Deaths from opioids started rising in the years after the powerful prescription painkiller debuted in 1996. The drug was marketed to doctors as having a low risk of addiction. Deaths linked to prescription opioids, including OxyContin, which came in high dosages and in its original formulation was easily crushed to make it even stronger, rose rapidly until 2011 — when more controls were put on prescriptions and there were more crackdowns on illegal sales — and have fluctuated since then. When those leveled off, deaths from heroin started to skyrocket. And as heroin fatalities dropped in the late 2010s, there were a growing number of [deaths linked to fentanyl](https://apnews.com/article/health-opioids-synthetic-government-and-politics-8f64b776b82d6e8bc2e324b732e4b6e2) and other potent, illicit, lab-produced opioids. The number of U.S. [overdose deaths from all drugs dropped](https://apnews.com/article/drug-overdose-deaths-us-cdc-12e961d78cc0458e84a07e0b3f7d1bbc) last year for just the second time in three decades, according to provisional data. Still, overdose deaths remain near a record high. The 2023 total is projected to be above 107,000, with about three-quarters of those involving opioids. About twice as many people in the U.S. are now dying each year from opioid overdoses as from car crashes. Three physician brothers — Arthur, Mortimer and Raymond Sackler — bought the drug company known as Purdue Frederick in 1952. Arthur, the oldest, was a pioneer of marketing drugs, including Valium, to doctors. His descendants sold their share of the company after his death in 1987, years before OxyContin hit the market. The other brothers and their heirs continued to hold seats on the company's board until the last of them resigned in 2019, ahead of efforts to settle the thousands of lawsuits the company was facing claiming the company was deceiving doctors and the public about the risks of OxyContin. They are still the owners, though they have not received profits in years. Documents made public as part of lawsuits showed that family members pushed for more sales of OxyContin, which ultimately made them billions. At the time of the drug's 1996 launch, Richard Sackler, a son of Raymond who was then a Purdue executive and later became president and board chair, told the company’s sales force at a meeting that there would be “a blizzard of prescriptions that will bury the competition.” Five years later, as it was apparent that the drug was being misused in some cases, he said in an email that Purdue would have to “hammer on the abusers in every way possible,” calling them “the culprits and the problem.” The Sacklers have been ranked as one of the country's wealthiest families and have largely [kept a low profile](https://apnews.com/article/museums-lawsuits-us-news-business-opioids-f69d14706030450da26dd6b0f5466eb8). One exception: They contributed millions to cultural and educational institutions and got their names on places including galleries in New York’s Metropolitan Museum of Art, the Louvre in Paris and a school at Tufts University. Many of those places have [removed the Sackler name](https://apnews.com/general-news-6af1746b10a444f0b1f0f4f335fd9668) over the last five years. At a hearing in 2021, Richard Sackler said that he, the family and the company [bore no responsibility](https://apnews.com/article/business-health-opioids-e6953c6edc71cbfc72aa5f2770311ad0) for the opioid crisis. In the same hearing, a cousin, [Mortimer D.A. Sackler](https://apnews.com/article/business-health-c4c6b013fc6b6e74c1440c22e79306b8), expressed some sympathy, saying, “We’re sorry if a medicine that we put out that was intended to relieve pain caused pain.” The next year Richard and two other family members appeared remotely for an [unusual court hearing](https://apnews.com/article/opioid-crisis-victims-purdue-pharma-settlement-8bd28d490d6b12b4cf93b4c1ff90cf41) in which a woman who lost a son to overdose called them “scum of the earth.” Beset by the lawsuits, Purdue and its owners took a series of major steps. By early 2019, the Sackler family members left the board. And by the end of the same year, the company filed for bankruptcy as part of a move to negotiate a settlement of all those suits. The [deal they eventually reached](https://apnews.com/article/purdue-pharma-opioid-settlement-9482fa0389f68de6844d13ea2ebefe5a) called for family members to contribute up to $6 billion over time — representing around half the family's collective fortune — to fight the crisis, with at least $750 million of that going to individual victims in payments ranging from about $3,500 to $48,000. The Sacklers would also give up ownership of Purdue, and the company would become known as Knoa Pharma, a business structured for its profits to battle the epidemic. In exchange, family members would be protected from civil lawsuits. In 2020 the company [pleaded guilty](https://apnews.com/article/purdue-pharma-opioid-crisis-guilty-plea-5704ad896e964222a011f053949e0cc0) to failing to maintain an effective program to prevent drugs from being diverted to the black market, providing misleading information to the DEA and paying doctors in a speakers program to encourage them to write more prescriptions. The plea was part of a deal with the federal government to settle criminal and civil cases that included $8.3 billion in penalties and forfeitures. But it was to pay only a small fraction — $225 million — so long as it executed the settlement through bankruptcy court. OxyContin is the best known prescription opioid, but Purdue is hardly alone in producing the drugs and facing lawsuits. Including Purdue's proposed settlement, there has been more than [$50 billion worth of opioid settlements](https://apnews.com/article/opioid-settlement-small-towns-local-governments-5daabce1ac8da004f94df0cc0b288e43) with state, local and Native American tribal governments. The money is intended to be used to combat the crisis. The companies involved have included drugmakers such as Johnson & Johnson and [Teva](https://apnews.com/article/health-lawsuits-epidemics-opioids-f98776b2dc83224d644246d40938b566); distributors including [McKesson, Amerisource Bergen and Cardinal Health](https://apnews.com/article/coronavirus-pandemic-business-health-opioids-camden-dec0982c4c40ad08b2b30b725471e000); and pharmacy chains including [Walgreen Co., CVS Health](https://apnews.com/article/health-business-lawsuits-rhode-island-epidemics-50f3aa9cbe82b775cd3d7520c286ef25) and [Walmart](https://apnews.com/article/walmart-opioid-lawsuit-settlement-e49116084650b884756427cdc19c7352). More recently there have been claims against pharmacy benefit managers such as Express Scripts and Optum Rx. Those companies have denied wrongdoing, and the cases have not yet gone to trial.

 After the Supreme Court struck down a controversial bankruptcy [plan](https://restructuring.ra.kroll.com/purduepharma/) from Purdue Pharma, the maker of OxyContin, those who sued the drug company were left uncertain about when promised funds would be available to combat addiction and other damage from the ongoing drug epidemic. The [ruling](https://www.supremecourt.gov/opinions/23pdf/23-124_8nk0.pdf) upended a carefully-crafted settlement worth roughly $8 billion, and involving the Sackler family, which owns Purdue, and all the individuals, states and local governments that had sued over harms from the opioid epidemic. In a 5-4 decision, the justices focused on the part of the Purdue bankruptcy plan that shielded members of the Sackler family from future opioid-related lawsuits. In the majority opinion, Justice Neil Gorsuch wrote: “In this case, the Sacklers have not filed for bankruptcy or placed all their assets on the table for distribution to creditors, yet they seek what essentially amounts to a discharge. No provision of the \[bankruptcy\] code authorizes that kind of relief.” Some relatives of overdose victims praised the decision. Ed Bisch’s son — also named Ed — overdosed on Oxycontin in 2001, at age 18. Bisch now leads [Relatives Against Purdue Pharma](https://www.facebook.com/RAPPedB/), and wants the Sacklers held personally accountable. “We did not want to give them exactly what they want,” Bisch said. “Today is a very good day for justice.” Purdue Pharma was facing thousands of lawsuits for falsely marketing OxyContin as non-addictive and fueling the opioid crisis. The company filed for bankruptcy in 2019. Before that, the Sackler family, which owns Purdue, had moved about $11 billion of profits into personal accounts. In his ruling, Gorsuch said members of the family had created a “milking program” designed to shelter opioid profits from their company’s bankruptcy. During the bankruptcy negotiations, the family offered to pay $6 billion in exchange for immunity from future lawsuits. A federal bankruptcy judge approved that deal in 2021, but Gorsuch ruled that it was an overreach. “The court is doing a reset here,” said [Melissa Jacoby](https://law.unc.edu/people/melissa-b-jacoby/), an expert on bankruptcy law at the University of North Carolina. “\[The Court is\] saying there is no authority to protect the Sacklers, who are not bankruptcy filers themselves, at least against claimants who have not agreed to settle with them.” ### Many on both sides are unhappy about new delays The total settlement would have amounted to roughly $8 billion directed towards states, local governments, personal injury victims, schools, and hospitals. In a statement, Purdue Pharma called the ruling “heart-crushing.” It also said Purdue would immediately reach out to the parties to work on a new agreement: “The decision does nothing to deter us from the twin goals of using settlement dollars for opioid abatement and turning the company into an engine for good.” The recent death toll from the ongoing opioid crisis exceeds 100,000 Americans every year. In the dissenting opinion, Justice Brett Kavanaugh wrote: "Today's decision is wrong on the law and devastating for more than 100,000 opioid victims and their families." Many relatives of overdose victims considered the bankruptcy deal the best they could hope for — a way to funnel money from the Sacklers to communities to fund addiction treatment programs, and to individuals harmed by Oxycontin. Now that money is on hold, potentially for years. ### Calls for swift return to negotiating table Advocates called for new negotiations as soon as possible. “I think everybody wants this done in an expeditious way. It’s important to get to the table and negotiate something that puts victims first very quickly,” said [Ryan Hampton](https://ryanhampton.org/), an author and activist on addiction issues who supported the bankruptcy settlement. Some suggested the Sacklers could use their personal funds to compensate victims, rather than waiting for a formal bankruptcy deal to be finalized for Purdue. “The Sackler family should begin the process today of compensating the thousands of individuals who lost loved ones to an overdose from their company’s product. There's no need to wait — and no time to waste,” said [Regina LaBelle](https://oneill.law.georgetown.edu/experts/regina-labelle/) in a statement. LaBelle is a former acting director of the Office of National Drug Control Policy and an addiction policy scholar at Georgetown University. In a statement sent to NPR, members of the Sackler family, who deny any wrongdoing, said they would work to renegotiate a settlement, but they also expressed some defiance, describing themselves as the victims of “profound misrepresentations about our families and the opioid crisis.” ### Money already flowing from other opioid-related lawsuits Most states [are already participating](https://nationalopioidsettlement.com/state-participation-status/) in other opioid-related settlements with opioid manufacturers Johnson & Johnson, Teva Pharmaceutical Industries, and Allergan; pharmaceutical distributors AmerisourceBergen, Cardinal Health, and McKesson; and retail pharmacies Walmart, Walgreens, and CVS. Many are also [settling with](https://nationalopioidsettlement.com/wp-content/uploads/2024/06/Kroger-statement.pdf) the national [supermarket chain Kroger](https://apnews.com/article/opioid-crisis-settlement-kroger-79356d42ded9c5099e1c2b88d3ffc061). It’s estimated that the total payout from multiple settlements could come to about $50 billion. Several of these deals [began paying out](https://nationalopioidsettlement.com/wp-content/uploads/2023/02/Participation-Process_v7-Key-Dates-Chart.pdf) in the second half of 2023, leading to bumps in states’ [opioid settlement pots](https://www.opioidsettlementtracker.com/globalsettlementtracker/#statuseshttps://www.opioidsettlementtracker.com/globalsettlementtracker/). There is no national database on how settlement dollars are being spent, but [efforts by journalists](https://kffhealthnews.org/opioid-settlements/) and advocates to track the money flows have revealed some of the more common ways the funds are being used. ### Wide leeway in how to spend opioid settlement funds One of the biggest is investing in treatment. Many jurisdictions are building residential rehab facilities or expanding existing ones. They’re covering the cost of addiction care for uninsured people and trying to increase the number of clinicians prescribing medications for opioid use disorder, which have been shown to [save lives](https://www.ncbi.nlm.nih.gov/books/NBK541390/). Another common expense is naloxone, a medication that reverses opioid overdoses. Wisconsin is spending [about $8 million](https://www.dhs.wisconsin.gov/opioids/settlement-funds.htm) on this effort. Kentucky has [dedicated $1 million](https://www.businesswire.com/news/home/20230427005905/en/Operation-UNITE-and-HarborPath-Awarded-1-Million-Grant-to-Fund-Naloxone-Plus-Program-in-Kentucky). And many local governments are [allocating smaller amounts](https://www.fayette-news.net/news/collaboration-to-combat-opioid-crisis-free-narcan-kits-distributed-in-fayette/article_11e5a56e-782d-11ee-a5b1-57a2f4f6c916.html). Some other choices have sparked controversies. Several governments [used settlement dollars](https://kffhealthnews.org/news/article/using-opioid-settlement-cash-for-police-gear-like-squad-cars-and-scanners-sparks-debate/) to purchase police patrol cars, technology to help officers hack into phones, and body scanners for jails. Supporters say these tools are critical to crack down on drug trafficking, but research suggests law enforcement efforts don’t prevent overdoses. _This article was produced in partnership with_ [KFF Health News](https://kffhealthnews.org/about-us/)_, 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/)_._

There’s no single reason for the slight drop in opioid overdose deaths across most of the U.S. last year. But finding new ways to make Narcan available in public, 24 hours a day, is helping.

For years, Baltimore’s leaders gave overdoses little public attention, even as the death rate swelled to unprecedented levels. But for a few weeks this summer, it seemed that the city would respond to its drug epidemic with new urgency. The City Council was about to hold four hearings — planned after [The New York Times and The Baltimore Banner reported](https://www.nytimes.com/2024/05/23/us/baltimore-opioid-epidemic-od-deaths.html) that the overdose rate here was far higher than in any other major American city. And Mayor Brandon Scott had just announced a $45 million legal settlement with a drug manufacturer, raising the possibility of well-funded new public health efforts to combat the epidemic, which had claimed nearly 6,000 lives here in the past six years. But hours before the first hearing, as demonstrators prepared to rally outside City Hall, the council president abruptly canceled the session, at the request of Mr. Scott’s administration. The administration said that holding any of the public meetings would jeopardize a lawsuit the city had filed accusing numerous opioid makers and distributors of causing the crisis by flooding Baltimore with pills. City leaders believe the case could result in a transformative amount of money for its overdose response — far more than the $45 million it collected in a settlement with a single company that shipped relatively few drugs to Baltimore. The decision to cancel the hearings was in keeping with the city’s reluctance in recent months to divulge nearly any details of its overdose prevention efforts, citing the lawsuit, which is scheduled for trial in September. Almost every council member was unwilling to comment on the hearings or on overdoses in the city, including several who had discussed overdoses earlier in the year. It is not uncommon for governments to limit public statements during litigation, and some lawyers and public health experts said it was understandable to avoid hearings on the eve of a trial. But others said the decision raised questions about Baltimore’s response plan — and how it was addressing shortcomings in the city and state’s efforts to curb the epidemic. Residents have been mostly left in the dark. 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%2F2024%2F08%2F08%2Fus%2Fbaltimore-overdose-deaths-lawsuit-silence.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F08%2F08%2Fus%2Fbaltimore-overdose-deaths-lawsuit-silence.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%2F2024%2F08%2F08%2Fus%2Fbaltimore-overdose-deaths-lawsuit-silence.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F08%2F08%2Fus%2Fbaltimore-overdose-deaths-lawsuit-silence.html).

Harvard University has decided that it will not remove the name of the Sackler family from two of its buildings, despite years of protests from families of opioid overdose victims and anti-opioid groups. In its recent denaming proposal update, a Harvard review committee rebuffed a 23-page proposal [filed](https://www.thecrimson.com/article/2022/10/4/hcopes-petition-remove-sackler-name/) in October 2022 by Harvard College Overdose Prevention and Education Students to dename the Arthur M Sackler Museum, part of the Harvard Art Museums, and the Arthur M Sackler Building, a campus building. The Sackler name is “deeply tied to the opioid epidemic,” according to the initial proposal which the Harvard Crimson reviewed. It went on to add: “To many of us – students, staff, and faculty – it is unacceptable and deeply offensive that we are represented by the Sackler name … It is embarrassing and unsettling to know that our school, unlike almost every other cultural and educational institution that at one point displayed the Sackler name, has decided to keep the name, despite the message of disrespect that it sends to our community and to the world.” The Sackler family owned and controlled Purdue Pharma, the former manufacturer of OxyContin. The prescription painkiller has played a central role in the US’s deadly opioid epidemic which has [seen](https://www.theguardian.com/society/2023/may/30/purdue-pharma-sackler-family-protected-from-opioid-lawsuits#:~:text=The%20company%20has%20tried%20to,overdose%20deaths%20over%20two%20decades.) more than 500,000 overdose deaths over the last twenty years. Explaining its decision to keep the Sackler name, the Harvard review committee [wrote](https://www.harvard.edu/denamingproposals/arthur-m-sackler-building-and-museum/): “Informed by research and review of relevant literature, the committee found that while Arthur M Sackler’s legacy is complex and debatable, the petition did not meet the standard for denaming under Harvard’s procedures for handling denaming requests.” Though he died nine years before the drug was introduced, Arthur Sackler’s name has become heavily synonymous with Purdue Pharma and the deadly opioid crisis. Still, the committee said it was “not persuaded by the proposal’s arguments that denaming is appropriate because Arthur Sackler’s name is tainted by association with other members of the Sackler family, or because Arthur Sackler shares responsibility for the opioid crisis due to his having developed aggressive pharmaceutical marketing techniques that others misused after his death”. The Harvard Corporation, the university’s highest governing body, accepted the committee’s recommendation, the Harvard Crimson [reported](https://www.thecrimson.com/article/2024/8/8/harvard-sackler-buildings-not-denamed/) this week. In response to the university’s decision, the anti-opioid group Prescription Addiction Intervention Now (Pain) said, according to the Associated Press: “Harvard’s continued embrace of the Sackler name is an insult to overdose victims and their families.” It added: “It’s time that Harvard stand by their students and live up to their mandate of being a repository of higher learning of history and an institution that embodies the best of human values.” Meanwhile, Mika Simoncelli, a Harvard graduate who organized a student protest over the name last year, told AP: “Even after a receiving a strong, thorough proposal for denaming, and facing multiple protests from students and community members about Sackler name, Harvard lacks the moral clarity to make a change that should have been made years ago.” Harvard’s decision stands in contrast to that of several institutions around the world including [Tufts University](https://www.theguardian.com/us-news/2019/dec/05/tufts-university-sackler-name-remove) in Massachusetts, the [Metropolitan Museum of Art](https://www.theguardian.com/us-news/2021/dec/09/new-york-met-art-museum-to-remove-sackler-family-name-from-galleries) and the [Guggenheim](https://www.forbes.com/sites/carlieporterfield/2022/05/09/the-guggenheim-and-londons-national-gallery-latest-to-remove-sackler-name-amid-opioid-controversy/) in New York, the Louvre in Paris [Museum](https://www.theguardian.com/society/2019/jul/17/louvre-removes-sackler-name-from-museum-wing-amid-protests) and [Tate Modern and Tate Britain](https://www.theguardian.com/artanddesign/2019/mar/24/sackler-money-tate-modern-art-nan-goldin-oxycontin) in London all of which have removed either Sackler-named programs or signage. Harvard did not immediately respond to the Guardian’s request for comment.

New [research](https://www.sciencedirect.com/science/article/pii/S2772724624000416?via%3Dihub) from the University of Southern California shows that cannabis might help some people stop or cut down on their opioid use. “We interviewed 30 people who were using opioids and cannabis and injecting drugs,” said Sid Ganesh, a PhD student at USC’s medical school and lead author of the study. The participants, who were receiving services from a methadone clinic and a syringe exchange in Los Angeles, said cannabis was a useful tool to help manage their opioid use, in part because it has become so much easier to access in recent years. Opioid use disorder patients often have to jump through hoops to access life saving treatments such as [suboxone](https://www.ncbi.nlm.nih.gov/books/NBK541389/) and [methadone](https://publichealth.jhu.edu/2023/barriers-to-methadone-access), and the [overdose-reversal drug naloxone](https://www.nbcnews.com/health/health-news/narcan-opioid-overdose-drug-otc-access-varies-us-stores-rcna135324). The study, published in Drug and Alcohol Dependence Reports, received federal funding through the National Institute of Drug Abuse, which has more [typically](https://pubmed.ncbi.nlm.nih.gov/39082097/) [supported](https://pubmed.ncbi.nlm.nih.gov/39037795/) [research](https://www.nature.com/articles/nature.2016.20410) that looks at cannabis’s harms rather than potential benefits. Notably, the study is unique because it uses qualitative data and focuses on the lived experience of people who use drugs. Ganesh says qualitative research provides insight into what actually works for study populations and why, especially when those populations are vulnerable and dealing with all kinds of issues that might not show up in a data point. Fifty-seven percent of participants in her study were unhoused or unstably housed, and 70% made less than $2,100 a month. “You need to understand what’s going on in people’s lives,” she said. Any information that can help untangle the complicated relationship between opioid addiction, overdose and cannabis use is urgently necessary. Opioid overdose deaths have been climbing in recent years, killing [more than 80,000 people in 2022](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates). [Several](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.1661) [studies](https://link.springer.com/article/10.1007/s11606-023-08195-3) [suggest](https://pubmed.ncbi.nlm.nih.gov/28189912/) that cannabis legalization [has helped people reduce their opioid consumption](https://norml.org/news/2024/08/01/survey-most-consumers-say-that-marijuana-reduces-their-need-for-prescription-painkillers/), but evidence is mixed on its impact on opioid overdose rates. [Some studies](https://www.sciencedirect.com/science/article/abs/pii/S0277953623000357) find states with legal cannabis have fewer opioid overdoses, [others report the opposite](https://www.sciencedirect.com/science/article/abs/pii/S016762962300005X). Still, others say there is [no difference either way](https://academic.oup.com/aje/advance-article-abstract/doi/10.1093/aje/kwae210/7716347). Ryan Marino, an addiction medicine specialist and professor at Case Western Reserve University’s school of medicine, says it’s tough to know what, if any, influence cannabis legalization has on these numbers. “Our drug supply is so toxic, overdoses have continued to increase regardless, because of the prevalence of fentanyl and constant changes in that,” Marino said. Ganesh and her colleagues found that cannabis could help study participants get through some of the most difficult stages of quitting or cutting down on opioids. They described using it to manage withdrawal symptoms, as well as cravings and anxiety during the period following withdrawal. ”When you’re smoking weed it gets you over the hump and that urge to get high for the first time,” said one participant. “That’s what’s so special about weed.” People who have recently quit or cut down on opioids are especially at risk for overdose because their tolerance is lower. Marino, who treats patients with opioid use disorder, says he’s seen some of his patients successfully use cannabis to get off opioids or at least use less, while others have tried it to no avail. He says the data isn’t yet there to suggest cannabis could help the majority of people struggling with opioid use disorder, but “if it helps one person to not use or not have an overdose, I mean, that’s worth more than any amount of evidence. Honestly, a life saved is a life saved.” [skip past newsletter promotion](https://www.theguardian.com/society/article/2024/aug/12/weed-help-cut-opioid-use#EmailSignup-skip-link-13) Sign up to Headlines US Get the most important US headlines and highlights emailed direct to you every morning **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion In order to really understand how effective cannabis could be as a treatment for opioid use disorder, researchers would need to conduct large-scale clinical trials examining the drug. Marino says that federal restrictions have made it extremely difficult to study cannabis this way, although that [could change in the near future](https://www.theguardian.com/society/article/2024/jul/06/cannabis-medication-dea-new-rules). One [small-scale trial from 2015](https://www.sciencedirect.com/science/article/abs/pii/S0376871615002495?via%3Dihub) did look at how cannabis might help patients stick with a detoxification treatment involving injections of naltrexone. This study found that dronabinol, a legal, synthetic form of THC, helped soothe withdrawal symptoms. The authors also tracked participants’ cannabis use after leaving residential treatment and found people who smoked their own cannabis during the outpatient phase were twice as likely to receive their second injection and complete the detox program. The participants in Ganesh’s study weren’t necessarily using cannabis because it’s the best drug available to help with opioid addiction, but because it was the drug they were able to get. One participant described using cannabis to cut down on fentanyl while waiting on a prescription for suboxone, which helps people quit opioids. Ganesh says that the most important takeaway from her research is that people who use opioids need better access to all kinds of harm reduction tools, including treatments like methadone and suboxone, clean syringes, naloxone and, yes, potentially cannabis. Marino has already seen changing attitudes toward cannabis affect his patients. In the past, he’s encountered patients who were kicked out of opioid treatment programs and even cut off from their suboxone when they’ve tested positive for cannabis, which he says can cause patients to use again, be arrested, and even die of overdose. Now, he sees a possible future where cannabis is no longer a barrier to treatment, but an acceptable tool for treatment.

 It was hard enough for Stephanie to get methadone treatment when she moved from Indiana to Florida last year. The nearest clinic, north of Tampa, was almost an hour away, and she needed help with transportation. But at least Stephanie didn't have to worry about affording it. Medicaid in Florida covers methadone, which reduces her opioid cravings and prevents withdrawal symptoms.  _This story was produced in partnership with_ [_KFF Health News_](https://khn.org/)_._ Stephanie had young children, and had trouble landing a job after the move. So even though Florida has strict eligibility rules for Medicaid, she qualified for coverage. For nearly a decade, methadone has helped Stephanie juggle jobs and take care of her kids. Stephanie, 39, asked to be identified by her first name only, because her two youngest kids don't know she's in treatment for opioid addiction. But methadone lets her “just have a normal — really normal — life,” she said. “You know, all the things that some people take for granted.” So it was devastating when Stephanie arrived last summer at her clinic in Inverness, Florida to pick up her weekly supply of doses, and learned she had been dropped from the state’s Medicaid rolls. Florida, like other states, was going through its data and checking the eligibility of each enrollee — part of a bureaucratic reset after the end of the pandemic.  Stephanie didn’t know why she was disqualified, but suddenly, her methadone prescription cost hundreds of dollars that she couldn’t afford. She panicked, afraid that a disruption in care would trigger debilitating withdrawal symptoms like vomiting, fever, cramps, joint pain and tremors. “That’s the first thing I thought,” she said. “I'm going to be so sick. How am I going to get up and take care of the kids?” As of Sept. 12, more than [25 million](https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/) Americans – including 1.9 million Floridians – had lost Medicaid coverage since the [expiration](https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html) of federal pandemic protections, which kept people continually enrolled until March 2023. They include patients in treatment for opioid addiction, such as Stephanie, for whom a loss of coverage can bring fatal risk. Research shows that when taken as prescribed, medications for opioid use disorder — such as methadone and a similar medicine, buprenorphine — can reduce dangerous drug use and cut overdose fatalities by more than half. Other [studies](https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19060612) find the risk of overdose and death increases when such treatment is interrupted. It is unclear how many people with opioid addiction have lost coverage in the massive Medicaid disenrollment, known as the “unwinding.” But researchers at nonprofit think tank KFF estimate that more than 1 million low-income Americans depend on the federal-state program for life-saving addiction care. At [Operation PAR](https://www.operationpar.org/) — an addiction treatment nonprofit where Stephanie and thousands of others along Florida’s Gulf Coast get care — the percentage of opioid treatment patients with Medicaid dropped from 44% to 26% since the unwinding began last year, the organization said in June. Operation PAR struggled trying to stretch the nonprofit’s limited grant dollars to cover the recent surge of uninsured patients, said Dawn Jackson, who directs Operation PAR’s newest clinic in Inverness, a small city about an hour north of Tampa. “There’s been sleepless nights,” Jackson said. “We’re saving lives — we’re not handing out Happy Meals here.” ### During an overdose epidemic, medications can save lives Methadone and buprenorphine are considered the [gold standard](https://www.psychiatry.org/patients-families/opioid-use-disorder#:~:text=Considered%20the%20%E2%80%9Cgold%2Dstandard%E2%80%9D,with%20an%20opioid%20use%20disorder.&text=Counseling%20and%20behavioral%20therapies%20may,they%20are%20effective%20by%20themselves.) of care for opioid addiction. The medications work by binding to the brain’s opioid receptors to block cravings and withdrawal symptoms without causing a high in a person with an opioid use disorder. The effect reduces illicit drug use and the accompanying risk of overdose. However, few Americans who need these medicines actually receive them — the latest [federal data](https://www.nih.gov/news-events/news-releases/only-1-5-us-adults-opioid-use-disorder-received-medications-treat-it-2021#:~:text=In%202021%2C%20an%20estimated%202.5,according%20to%20a%20new%20study%20.) show only about one in five in [2021](https://nida.nih.gov/news-events/news-releases/2023/08/only-1-in-5-us-adults-with-opioid-use-disorder-received-medications-to-treat-it-in-2021). Those low numbers stand in sharp contrast to the record-high number of overdose deaths — nearly [108,000](https://www.cdc.gov/nchs/products/databriefs/db491.htm#Key_finding) Americans in 2022. That number is driven [primarily](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) by opioids. Given the scale of the overdose epidemic, the impact of these medications is “nothing short of remarkable,” said [Zachary Sartor](https://americanhealth.jhu.edu/people/zachary-sartor), a family medicine doctor in Waco, Texas, who specializes in addiction treatment. “The evidence in the medical literature shows us that things like employment and quality of life overall increase with access to these medications, and that definitely bears out with what we see in the clinic,” Sartor said. “That benefit just seems to grow over time as people stay on medications.” Sartor, who works at a local safety-net clinic, prescribes buprenorphine. Most of his patients are either uninsured or have Medicaid coverage. Some of his patients are among the [2.5 million Texans](https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/) who’ve lost coverage during the state’s unwinding, he said, causing their out-of-pocket buprenorphine costs to abruptly rise — in some cases as much as fourfold. ### Disruptions in care can be life-threatening for those in recovery The loss of coverage also affects access to other types of health care, potentially forcing patients to make risky trade-offs. “It comes down to making a choice of accessing medications for \[opioid addiction\] versus accessing other medications for other medical conditions,” Sartor said. “You start to see the cycle of patients having to ration their care.” Many patients who initially lost insurance in the Medicaid unwinding have since had it reinstated. But even a brief disruption in care is serious for someone with an opioid use disorder, according to [Maia Szalavitz](https://maiasz.com/), a journalist and author who writes about addiction. “If you want to save people's lives and you have a life-saving medication available, you don't interrupt their access to health care,” Szalavitz said. “They end up in withdrawal and they end up dying.” When Stephanie lost her Medicaid coverage last year, Operation PAR was able to subsidize her out-of-pocket methadone costs, so she only paid $30 a week. That was low enough for her to stick with her treatment for the six months it took to contact the state and restore her Medicaid coverage. But the patchwork of federal and state grants that Operation PAR uses to cover uninsured patients like Stephanie doesn’t always meet demand, and waiting lists for subsidized methadone treatment are not uncommon, Jackson said. Even before the Medicaid unwinding, Florida had one of the highest uninsured rates in the country. Currently, 15.5% of working-age adults [in Florida are uninsured](https://www.census.gov/quickfacts/fact/table/FL,US/PST045223). Florida is also [one of 10](https://www.kff.org/affordable-care-act/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/) states that has not expanded Medicaid to allow more low-income adults to qualify. A temporary solution came earlier this year with an [infusion](https://www.myflfamilies.com/services/substance-abuse-and-mental-health/florida-opioid-settlement#:~:text=Opioid%20Settlement%20Funds,FY%2023%2D24%20Florida%20budget.) of opioid settlement money, which allowed Operation PAR to clear its waiting lists, according to Jon Essenburg, chief business officer. Although Florida [expects to receive](https://www.tampabay.com/news/florida-politics/2023/07/24/florida-is-getting-opioid-settlement-money-heres-how-itll-be-spent/) $3.2 billion in settlement funds over 18 years from opioid manufacturers and distributors, that’s not a long-term solution to persistent coverage gaps, Essenburg said, because all that money will be divided among numerous organizations and recipients. That’s why more stable reimbursement sources like Medicaid can help, he added. If more patients were covered by health insurance, it would help ease the burden on the clinic’s limited pool of assistance dollars. But it would also help people who are already struggling with financial stress. "Turning people away over money is the last thing we want to do,” said Dawn Jackson, director of the Inverness clinic. “But we also know that we can't treat everybody for free." Stephanie is grateful she never had to go without her medicine. “I don’t even want to think about what it would have been like if they wouldn’t have worked with me and helped me with the funding,” Stephanie said. “It would have been a very dark rabbit hole, I’m afraid.” _Kim Krisberg is a contributing writer for_ [_Public Health Watch_](https://publichealthwatch.org/) _and Stephanie Colombini is a health reporter for_ [_WUSF_](https://www.wusf.org/)_. This story is part of “_[_The Holdouts_](https://publichealthwatch.org/the-holdouts/)_,” a collaborative project led by Public Health Watch that focuses on the 10 states that have not expanded Medicaid, which the Affordable Care Act authorized in 2010._

Demand for a life-saving opioid overdose drug has doubled in one year as a “whole new cohort” of stimulant and hallucinogenic users, fearful of taking lethally laced narcotics, have rushed to get the medication. Prior to a recent spike [in overdose deaths](https://www.theguardian.com/society/2024/sep/13/nsw-heroin-overdose-cocaine-users-health-warning), regular users of illicit opioids were the predominant users of naloxone, which can rapidly reverse an overdose. However after an increasing number of incidents where [synthetic opioids were cut with other illicit drugs](https://www.theguardian.com/society/2024/apr/25/synthetic-opioids-warning-issued-in-nsw-after-nitazenes-cause-cluster-of-overdoses), killing some people, health authorities have urged all drug users to have naloxone on hand. That warning was directed at more than one million Australians who have taken cocaine in the last year and 400,000 who have used ecstasy. Officials are particularly concerned about the increasing presence of synthetic opioids called nitazenes – [often substantially more powerful than heroin](https://www.theguardian.com/australia-news/article/2024/jul/02/melbourne-cocaine-opioid-laced-protonitazene-nso-warning) – in drugs such as cocaine. The Albanese government rolled out the Take Home Naloxone program nationwide in July 2022 to allow free access without a prescription. In the financial year for 2022-2023, 110,976 units were supplied. That figure more than doubled in 2023-2024, reaching 243,248. Naloxone, which can be given as a nasal spray or injected, restores breathing after an overdose has slowed respiration. Luke Kelly, the president of the New South Wales branch of the Pharmaceutical Society of Australia, said until recently the two most common groups pharmacists supplied naloxone to were people with opioid dependence and those on some chronic pain medications. However, after health authorities urged all drug users to carry naloxone, Kelly said “this whole new cohort” created “a new area of need”. * **[Sign up for Guardian Australia’s breaking news email](https://www.theguardian.com/email-newsletters?CMP=copyembed)** On July 2 the Victorian health department issued a [drug alert about cocaine laced with a synthetic opioid](https://www.theguardian.com/australia-news/article/2024/jul/02/melbourne-cocaine-opioid-laced-protonitazene-nso-warning). It urged all drug users to carry naloxone. Seven days earlier, [four people were found dead in a Melbourne home](https://www.theguardian.com/australia-news/article/2024/jul/04/melbourne-four-found-dead-synthetic-opioid-broadmeadows). Tests established a synthetic opioid was present in all four victims. The department told Guardian Australia their data on naloxone, supplied through the state’s Take Home program, showed an increase across July and August compared to previous months. Earlier this month [NSW Health urged cocaine, methamphetamine and MDMA users to carry naloxone](https://www.theguardian.com/society/2024/sep/13/nsw-heroin-overdose-cocaine-users-health-warning). The warning came after two people died of a heroin overdose after using what they thought was cocaine at a house party in Sydney. Two others were hospitalised. A NSW [Health](https://www.theguardian.com/australia-news/health) spokesperson said in 2023-24, the Take Home naloxone program distributed more than 36,000 units, compared to 20,000 in 2021-22. Dr Mary Ellen Harrod, the CEO of the NSW Users and Aids Association (Nuaa), said stimulant users have been a big driver in demand for naloxone since the rise in reports of people unknowingly consuming opioids and often dying. [skip past newsletter promotion](https://www.theguardian.com/australia-news/2024/sep/22/naloxone-overdose-drug-demand-spike-opioids#EmailSignup-skip-link-17) Sign up to Breaking News Australia Get the most important news as it breaks **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion Nuaa, which provides naloxone through its [online shop](https://shop.nuaa.org.au/), said orders tripled after the NSW Health alert. “Whenever there’s an alert, we will see a huge spike in orders,” Harrod said. While knowledge of naloxone is greater among opioid users, as opioids are more frequently laced in stimulants, many others are becoming aware, she said. Kelly said pharmacists will not judge anyone requesting naloxone but warned of possible shortages if demand were to outstrip supply. The Therapeutic Goods Administration does not list a shortage of naloxone. “We believe that there still can be a lot of stigma attached to carrying naloxone but the fact is that anyone can witness an overdose,” she said. Polly\* said she ordered naloxone after the recent NSW Health alert. “I’m not a drug user. I don’t do drugs or hard drugs, but like anyone my age I know people who do. I have friends who do,” the 23-year-old said. “If it’s available and free, and can literally save someone’s life, I think everyone should carry it.” \* Name has been changed for privacy reasons _In Australia, the [National Alcohol and Other Drug Hotline](https://www.health.gov.au/contacts/national-alcohol-and-other-drug-hotline-contact) is at 1800 250 015; families and friends can seek help at [Family Drug Support Australia](https://www.fds.org.au/) at 1300 368 186. In the UK, [Action on Addiction](https://www.actiononaddiction.org.uk/) is available on 0300 330 0659. In the US, call or text [SAMHSA](https://www.samhsa.gov/)’s National Helpline at 988_

**Novo** Nordisk’s blockbuster drug Ozempic may offer yet another health benefit: helping to curb overdoses. The top 15 cities for startups People that are prescribed semaglutide — the active ingredient in Ozempic — as a treatment for type 2 diabetes may have a reduced risk of an opioid overdose, according to a [new study](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2824054) published Wednesday in JAMA Network Open. The study found that prescriptions for semaglutide were associated with lower overdose rates among patients with type 2 diabetes who also had a diagnosis of opioid use disorder (OUD). These findings contribute to a growing body of research that suggests that these popular medications might provide benefits beyond regulating blood sugar levels and weight loss. Researchers in this study analyzed electronic records of nearly 33,000 patients with OUD and who were prescribed diabetes medications between December 2017 and June 2023. About 3,000 of those patients were prescribed semaglutide. Researchers then tracked opioid overdose cases in patients for a year after they discontinued semaglutide or the other diabetes treatments. The study found 42 overdose cases among patients who received semaglutide, compared to 97 in those who received insulin, signaling a 58% lower risk of overdose for those on semaglutide. The study authors warned that due to study limitations, “Further research is warranted to investigate the underlying mechanisms and randomized clinical trials are necessary to corroborate the clinical effects on OUD.” In 2022, just [25% of U.S. adults](https://www.cdc.gov/mmwr/volumes/73/wr/mm7325a1.htm) who needed treatment for opioid use OUD received the recommended medications, according to the Centers for Disease Control and Prevention (CDC). Although more research is needed, semaglutide could some day be an alternative to current treatments of OUD. According to the National Center for Drug Abuse Statistics, opioids are involved in approximately [72% of overdose deaths in the U.S](https://drugabusestatistics.org/drug-overdose-deaths/). A [separate study from July](https://qz.com/ozempic-tobacco-treatment-study-1851609268?_gl=1*bbrzge*_ga*MTIwNzMxNDYwMS4xNzE2MTMzMDkz*_ga_V4QNJTT5L0*MTcyNzM2NzU2NC40MS4xLjE3MjczNjc4MTcuNDUuMC4w) found that Ozempic could also potentially help people struggling with tobacco addiction. Researchers found that smokers with type 2 diabetes that were prescribed Ozempic were up to 32% less likely to discuss tobacco use with a doctor a year after starting their treatment, compared to patients taking other diabetes drugs.

Experts have welcomed news of a reported drop in overdose deaths in the US and say they are cautiously optimistic about the downward trend, while warning that more work and extra resources will be needed to sustain progress. Overdose deaths in the US have dropped by about 10%, the largest decline in decades – falling to an estimated 101,168 deaths annually as of April 2024, according to an analysis of state-level data. Emergency room visits for overdose are down by 24% and 911 first-responder calls for overdoses are down by 16.7%. Some of the biggest changes are being seen in eastern states, while some states in the west are still struggling with higher rates. Overdoses rose precipitously in the first three years of the pandemic, reaching a peak of 111,029 deaths in 2022. Overdose deaths more than [quintupled](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#Fig1) in the past 25 years, with the majority caused by opioids – especially the powerful drug fentanyl. One in three Americans [know](https://jamanetwork.com/journals/jama-health-forum/fullarticle/2819328) someone who has died from drug overdose. There was a 3% drop in 2023, the first decrease in five years, the US Centers for Disease Control and Prevention (CDC) [said](https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2024/20240515.htm) in May. While the reasons for the decline are not immediately clear, researchers and those on the frontlines believe it is driven by changes in the drug supply as well as improved access to treatment and harm reduction programs. “Looking back over the last quarter-century, there’s been no intervention that has caused a decline in overdose deaths of this magnitude,” said Nabarun Dasgupta, a senior scientist at the University of North Carolina and one of the authors of the [analysis](https://opioiddatalab.ghost.io/are-overdoses-down-and-why/). “It’s unprecedented.” “The recent declines in estimated overdose deaths are unprecedented, robust, and appear to be reflecting real trends,” Dr Nora Volkow, director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, said in an emailed statement. “These data give us hope that we may finally be making significant progress in reducing the devastating loss of life from the overdose crisis.” But she also highlighted the continued – and increasingly unequal – death toll from the overdose crisis when it comes to who in society is affected the most. “It’s also important to acknowledge that progress has not been equal for all groups,” she said. “Unfortunately, for the most affected groups, namely Native Americans and Black American men, the death rates are not decreasing and are at the highest recorded levels.” Leo Beletsky, professor of law and health sciences at Northeastern University, remembers when 12,000 deaths in the US were considered “absolutely catastrophic” – compared with more than 100,000 now. He feels “cautious optimism” about the drop and urges policymakers to continue the momentum by scaling up prevention programs. “We’re seeing a reversal of a trend that’s been happening for a very long time – we’re still at historic highs,” Beletsky said. “We need to double down on what works and try to move away from things that do not work.” About 18 months ago, Eric Mockewich decided to get clean after years spent in and out of recovery. He entered treatment and now receives a monthly buprenorphine shot, which keeps him from entering withdrawal and helps him manage his opioid use disorder. Access to naloxone, the opioid-overdose reversal drug, “definitely helps”, Mockweich said, and so do housing, food, childcare and other social services alongside accessible, affordable treatment options. “Anything that keeps people alive long enough for them to make a decision to do something else is definitely good,” he said. In 2021, the Biden administration announced a [plan](https://www.hhs.gov/about/news/2024/02/01/biden-harris-administration-marks-two-years-advancements-hhs-overdose-prevention-strategy-new-actions-treat-addiction-save-lives-press-release.html) to prevent overdoses by expanding treatment and distributing naloxone, among other steps. > We need to double down on what works and try to move away from things that do not work Leo Beletsky After the price of naloxone [soared](https://www.theguardian.com/us-news/2021/oct/19/naloxone-price-soars-opioid-overdoses) for some harm-reduction groups, it became [much more affordable](https://www.harmreductionohio.org/price-of-naloxone-continues-to-fall/). Narcan, a nasal-spray naloxone, was approved for sale over the counter in 2023, making it more widely accessible. The administration also relaxed “very outdated” rules about medications like buprenorphine and methadone, Beletsky said. Only a third of people who need those medications can access them because of previous limitations, but access is slowly expanding, he said. “Distributing naloxone, providing people with substance use treatment, giving folks clear information about the drug supply – all of these efforts work,” Beletsky said. “We know that they are lifesaving.” Many of the resources offered during the pandemic, like Medicaid expansion and financial assistance, also helped, though those programs have now expired. Another major factor leading to the overdose drop may be changes in behavior. Xylazine, a tranquilizer, has become a more common adulterant in street drugs in recent years. Like fentanyl a few years ago, it appeared in the east and is moving west – the same pattern as the fall in overdoses. People who use drugs laced with xylazine often need to use less frequently than they do with fentanyl-laced drugs, because xylazine binds to receptors for longer. Using less often means “less rolls of the dice” that could result in overdose, Dasgupta said. But xylazine can cause extensive wounds when it’s injected. “It is pretty brutal,” Mockewich said. “When I went through treatment, there were people showing up – one girl had just lost her arm” due to amputation. Because of these risks, people who use xylazine may be more inclined to snort or smoke it, rather than injecting it – and those routes of administration may have lower risks of overdosing than injections. “The market is also maturing. People are kind of tired of fent,” Dasgupta said. The turn to xylazine could represent a desire for something else – especially among those using xylazine to keep from getting dopesick. “It’s something that maybe helps open a door a little bit for us, and now we need to rush in with all the resources that we have developed over the last decade,” Dasgupta said. “We should be dumping huge amounts of \[funding for\] medications for opioid disorder treatment and scaling that up orders of magnitude more to give people a better option.” That’s especially true for communities that aren’t seeing declines, including African Americans and Indigenous Americans in some states, he said. The options should include harm reduction services and substance use treatment, as well as “broader structural responses” like access to medical care, pain management and mental healthcare, Beletsky said. “All those things play into substance use and overdose.” Taking action also means stopping harmful actions and policies known to increase overdose risk, like incarceration, which increases the risk of overdose by 120% after people re-enter the community, Beletsky said. Drug criminalization only deepens stigma, making it harder to prevent overdoses, he said. “Law enforcement never stopped me,” Mockewich said. “Everything still goes on.” Dasgupta is worried about the [move](https://www.avma.org/blog/support-xylazine-legislation-builds-congress) to classify xylazine as a schedule III drug in the US. “If you were to suddenly cut off the supply of xylazine right now, I guarantee you would see a spike in overdose deaths,” he said. Drug interdiction at the border does not seem to have an effect on overdose rates, and can even worsen the crisis, experts agreed. Authorities are seizing significantly more meth and marijuana than fentanyl at the border. With lower availability of meth, drug dealers tend to cut it with fentanyl, leading to more overdoses. Authorities should instead focus on making the drug supply safer, Dasgupta said. Mockewich now works at a treatment facility, and he is planning to become a peer recovery specialist – a “bridge” career between leaving recovery and getting a full-fledged counseling degree for people who want to use their experiences to help other people get well, he said. “It allows people to get into the field and help put people in touch with services,” Mockewich said. “A lot of treatment has been based on abstinence and telling people how they have to live. In the peer networks, we’re just meeting people where they’re at.” Work like this is important because with more than 100,000 people dying and more people hospitalized each year, overdoses are “still a big problem”, he said. “The numbers are still way too high,” Dasgupta said. “You may have put the lid on the top, but we’re still at a rolling boil.”

 A hopeful and unexpected drop in U.S. drug overdose deaths appears to be gaining speed. [Fatal overdoses are down 12.7%](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm), according to data released this week from the Centers for Disease Control and Prevention. It marks another significant [improvement from last month](https://www.npr.org/2024/09/18/nx-s1-5107417/overdose-fatal-fentanyl-death-opioid), when surveys showed roughly a 10.6% drop in fatalities from street drugs. "This is the largest recorded reduction in overdose deaths, and the sixth consecutive month of reported decreases," White House officials [said in a statement](https://www.whitehouse.gov/ondcp/briefing-room/2024/10/16/white-house-drug-policy-director-statement-on-latest-drug-overdose-death-data/). Experts say the drop in street drug mortality marks a dramatic reversal from just a few years ago when fatal overdoses were spiraling upward at devastating speed, fueled largely by the spread of street fentanyl. If the trend holds, this year is expected to be the first since 2020 to see overdose deaths fall below the 100,000 mark. During a press conference on Thursday, public health officials from New York City and Seattle said their experience locally mirrors the national trend. Brad Finegood, who coordinates overdose and addiction programs in King County, Wash., which includes Seattle, pointed to a 22% decline in fatal overdoses in the first nine months of this year. "That for us represents an extremely significant decline," Finegood said. "Our nonfatal overdoses have also decreased significantly."  New York City saw more modest improvement: a decline of 1% in fatal overdoses from 2022 to 2023. “This represents the beginning, the green shoots of progress,” said city Health Commissioner Ashwin Vasan, who is leaving office on Friday. Vasan said New York's small decline in drug deaths reverses a four-year trend when fatal overdoses rose sharply. He also said fatal overdoses in the first three months of this year appear to have dropped rapidly. However, public health experts said some communities, especially Blacks and Native Americans, are not yet seeing significant declines in overdose deaths. “Older African American men are particularly vulnerable,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, a group made up of some of the nation’s largest urban public health departments. During Thursday's press conference, Juliano and other experts noted that poverty, homelessness and racial disparities in access to healthcare appear to be making it much harder for some groups to recover. Gupta, the White House drug czar, said the drop in drug deaths, while welcome, is only a beginning. "We have removed more barriers to treatment for substance use disorder than ever before and invested historic levels of funding to help crack down on illicit drug trafficking at the border," Gupta said. He pointed to the widespread availability of the opioid overdose reversal medication naloxone as another likely factor reducing deaths. "This new data shows there is hope, there is progress, and there is an urgent call to action ... to save even more lives," Gupta said in a statement. A debate has begun among drug policy experts and public health officials over why fatal overdoses are declining so rapidly. Scientists who study the street drug supply say there has been a notable [drop in the availability and purity of fentanyl](https://www.npr.org/2024/09/30/nx-s1-5124997/fentanyl-overdose-opioid-btmps-drug-cartel-xylazine-tranq-mexico-china) available on U.S. streets. Other researchers believe the shift reflects the devastatingly high number of drug deaths between 2020 and 2023, when tens of thousands of vulnerable people lost their lives to fentanyl, methamphetamines and other substances.

 Street drug deaths in the U.S. are dropping at the fastest rate ever seen, according to [a new report issued on Thursday](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) by the Centers for Disease Control and Prevention. Preliminary data shows roughly 97,000 fatal overdoses over a 12-month period. That's down roughly 14.5% from a year earlier. Public health officials say the drop translates into more than 16,000 lives saved and marks the lowest level of drug deaths in nearly four years. "The latest data show that our efforts are working," said Dr. Rahul Gupta, head of the White House Office of National Drug Control Policy. "Every life saved means one less grieving family and community." In September, addiction experts around the U.S. [began to report a sudden and apparently precipitous decline](https://www.npr.org/2024/09/18/nx-s1-5107417/overdose-fatal-fentanyl-death-opioid) in fatal overdoses. Prior to 2023, drug deaths had spiraled upward, climbing at times by more than 30% per year. Deaths [peaked at more than 111,000](https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2024/20240515.htm) in 2022, then declined slightly last year. Experts are now racing to understand why the trend shifted so rapidly. Some credit better addiction healthcare and the widespread use of the opioid overdose reversal drug naloxone. Researchers also point to less potent fentanyl being sold on the streets in some U.S. communities. High death rates in recent years may also mean fewer vulnerable people living with addiction. Whatever the cause, the latest CDC data — which covers the 12-month period ending in June of this year — suggests the reduction in fatal overdoses is holding steady and may actually be accelerating. Some experts, however, worry the decline in drug deaths will mean lessened focus on funding and health care programs for people using street drugs. "One of the fears is that, as overdoses decline, there will be complacency," said Dr. Brian Hurley, head of the American Society of Addiction Medicine. "One of our messages is making sure there's a sustained focus." Public health officials also point out that improvements in drug overdose deaths over the last year have largely benefited white communities. Some Black and Native American communities have actually seen drug overdose deaths rise. Speaking with NPR in September, [Gupta called for more funding](https://www.npr.org/2024/09/18/nx-s1-5107417/overdose-fatal-fentanyl-death-opioid) for addiction treatment and health care services in those communities. "There is no way we're going to beat this epidemic by not focusing on communities that are often marginalized, underserved, and communities of color," he said.

The [Biden administration](https://www.theguardian.com/us-news/biden-administration) saw unprecedented levels of [US opioid overdose fatalities](https://www.theguardian.com/us-news/opioids), but those deaths are now declining faster than they have in decades – progress a second [Trump administration](https://www.theguardian.com/us-news/trump-administration) could continue or threaten, experts say. The number of overdose deaths in the US declined for the first time in five years in 2023, and have [continued to decline](https://www.theguardian.com/us-news/2024/oct/04/overdose-deaths-decline) more rapidly this year, according to provisional [data](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm). Some of the decline may have resulted from Biden administration efforts to expand access to harm-reduction services, especially the overdose-reversal drug [naloxone](https://www.cdc.gov/overdose-prevention/data-research/facts-stats/naloxone-dispensing-rate-maps.html#:~:text=Key%20points,varied%20widely%20across%20the%20country.), which received over-the-counter approval for the first time [last year](https://www.npr.org/2023/02/18/1157556969/narcan-fda-over-the-counter). Public health experts worry that the second Trump administration will [gut access to healthcare](https://www.theguardian.com/us-news/2024/nov/12/trump-adminstration-health-policy), including addiction treatment. The president-elect’s legacy on opioids is complicated. When Trump first took office, he inherited a rapidly escalating overdose crisis. Opioid overdose deaths more than doubled during the Obama administration, [](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#Fig3)according to [data](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#Fig3) from the Centers for Disease Control and Prevention. The three most recent presidential administrations have all failed to quell escalating opioid overdose deaths, which nearly doubled again during the Trump and Biden administrations, dipping slightly in 2018 but overall jumping by 62% during Trump’s first term in 2020. Under Biden, deaths increased by 19% from 2020 to 2022, to 81,806, before declining by 2% last year. [A line chart showing the number of overdose deaths declining in the past 5 years](https://interactive.guim.co.uk/datawrapper/embed/e7b9e/1/) At times, the Trump administration seemed to work against itself when it came to the crisis. For example, Trump [repeatedly](https://www.washingtonpost.com/news/powerpost/paloma/powerup/2019/03/13/powerup-trump-budget-guts-white-house-drug-control-office-again/5c87fc8c1b326b2d177d6063/) attempted [to gut](https://www.npr.org/2017/05/05/527076657/leaked-document-indicates-big-proposed-cuts-to-drug-czars-office) funding for the Office of National Drug Control Policy, although Congress blocked his efforts. Similarly, Trump was [frequently](https://www.brookings.edu/articles/six-ways-trump-has-sabotaged-the-affordable-care-act/) in disputes with Congress over attempts to repeal elements of the Affordable Care Act and its expansions to Medicaid, which funds treatment for [40% of adults](https://www.rwjf.org/en/insights/our-research/2019/02/medicaid-s-role-in-fighting-the-opioid-epidemic.html) with opioid use disorder. Still, experts contacted by the Guardian within and outside the first [Trump administration](https://www.theguardian.com/us-news/trump-administration) credit the president-elect for putting unprecedented focus on the crisis. [Trump signed an executive order](https://trumpwhitehouse.archives.gov/ondcp/the-administrations-approach/presidents-commission-opioids/) in 2017 forming the Presidential Commission on Combating Drug Addiction and the Opioid Crisis. Bertha Madras, a professor in Harvard’s psychiatry department who served on the commission, said it wasn’t until Trump “established the commission that a significant integrated national response materialized”. Adm Brett Giroir, who served as an assistant secretary in Trump’s Department of [Health](https://www.theguardian.com/society/health) and Human Services, says that he was given the authority to head up an unofficial “opioids cabinet … which met every week at the White House under Kellyanne Conway to make sure every department was working on this crisis”. Others praise Trump for supporting harm-reduction efforts, despite past [opposition](https://journalofethics.ama-assn.org/article/needle-exchange-programs-status-us-politics/2016-03) from his party. “President Trump publicly supported syringe services programs, a first for a Republican president,” said Jerome Adams, who served as surgeon general under Trump. Indeed, the Trump administration in some ways paved the way for the Biden administration’s response to the crisis. Access to naloxone [expanded](https://trumpwhitehouse.archives.gov/briefings-statements/president-donald-j-trump-dedicated-administration-fighting-back-opioid-crisis/) significantly under Trump, and even more under Biden. But despite these efforts, the number of US overdose deaths climbed for the majority of Trump’s first term. Giroir and Madras both attribute the huge overdose spike in 2020 to the Covid-19 pandemic, which overwhelmed the healthcare system and increased [depression](https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide#:~:text=In%20the%20first%20year%20of,Health%20Organization%20(WHO)%20today.) and [suicide](https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04158-w). Andrew Kolodny, medical director for the Opioid Policy Research Collaborative at Brandeis University, says the administration should have done more. “The first time around, President Trump did an excellent job of calling attention to the opioid crisis and designating it as a [public health emergency](https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html),” he conceded, but he also said the then president failed to take sufficient action or establish a long-term plan. While the Trump administration allocated [unprecedented](https://bipartisanpolicy.org/report/combating-the-opioid-crisis-2020/) amounts of funding to combat the crisis, Kolodny said the impact was limited, because states were usually given funds in the form of one- or two-year grants. “That’s not really adequate for building out a treatment system that doesn’t exist yet,” Kolodny said. “If you were to hire a whole bunch of staff, what would you do if you don’t get that appropriation the next year? Do you lay everybody off?” [skip past newsletter promotion](https://www.theguardian.com/us-news/2024/nov/16/overdose-deaths-trump-administration#EmailSignup-skip-link-16) Sign up to The Stakes — Presidential Transition We will guide you through the aftermath of the US election and the transition to a Trump presidency **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion Experts disagree on whether the administration spent too much of that funding on law and border enforcement, rather than treatment. Giroir supported harm-reduction and treatment expansion during his time under Trump, and is proud of his efforts to remove red tape and increase access to the [opioid-cessation drug buprenorphine](https://jamanetwork.com/journals/jama-health-forum/fullarticle/2775876). Still, he says, “enforcement has to dominate the discussion”, because treatment is less effective than preventing addiction in the first place. Other experts say that criminalization only exacerbates the crisis. “Under Trump’s previous administration, they federally criminalized all fentanyl-related substances in 2018 – and overdose deaths increased from 67,367 that year to 70,630 and 93,331 in 2019 and 2020 respectively,” said Kassandra Frederique, executive director of the Drug Policy Alliance. Kolodny didn’t necessarily agree that criminalization drove the overdose increases, but he did say “the balance should be different” when it comes to prioritizing treatment over law enforcement. He said the best way to immediately reduce the overdose death count would be to make treatment “basically free” and overall easier to access than fentanyl. “\[People with opioid use disorder\] are not out there using fentanyl because it’s so much fun. If they don’t use, they’re gonna be very, very sick … People can really feel like they’re gonna die,” he said. It’s hard to predict how Trump will tackle the overdose crisis the second time around. He avoided the topic during his recent presidential campaign, and instead focused on inaccurate talking points about immigrants [trafficking drugs across the border](https://www.theguardian.com/us-news/2024/nov/03/opioid-crisis-overdoses-election-harris-trump). He also [falsely claimed](https://www.cnn.com/2024/10/31/politics/aca-trump-repeal-affordable-care-act/index.html) he had never wanted to repeal the Affordable Care Act. But a Republican-controlled Congress could cut ACA subsidies and Medicaid. Frederique worries that Trump will continue prioritizing drug arrests during his second term, but said during his first term “he also dedicated billions of dollars toward research, education, prevention and treatment. We are committed to supporting the Trump administration’s previous efforts to advocate for health approaches such as increasing access to treatment and naloxone.” * * * #### Page 2 Experts have welcomed news of a reported drop in overdose deaths in the US and say they are cautiously optimistic about the downward trend, while warning that more work and extra resources will be needed to sustain progress. Overdose deaths in the US have dropped by about 10%, the largest decline in decades – falling to an estimated 101,168 deaths annually as of April 2024, according to an analysis of state-level data. Emergency room visits for overdose are down by 24% and 911 first-responder calls for overdoses are down by 16.7%. Some of the biggest changes are being seen in eastern states, while some states in the west are still struggling with higher rates. Overdoses rose precipitously in the first three years of the pandemic, reaching a peak of 111,029 deaths in 2022. Overdose deaths more than [quintupled](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#Fig1) in the past 25 years, with the majority caused by opioids – especially the powerful drug fentanyl. One in three Americans [know](https://jamanetwork.com/journals/jama-health-forum/fullarticle/2819328) someone who has died from drug overdose. There was a 3% drop in 2023, the first decrease in five years, the US Centers for Disease Control and Prevention (CDC) [said](https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2024/20240515.htm) in May. While the reasons for the decline are not immediately clear, researchers and those on the frontlines believe it is driven by changes in the drug supply as well as improved access to treatment and harm reduction programs. “Looking back over the last quarter-century, there’s been no intervention that has caused a decline in overdose deaths of this magnitude,” said Nabarun Dasgupta, a senior scientist at the University of North Carolina and one of the authors of the [analysis](https://opioiddatalab.ghost.io/are-overdoses-down-and-why/). “It’s unprecedented.” “The recent declines in estimated overdose deaths are unprecedented, robust, and appear to be reflecting real trends,” Dr Nora Volkow, director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, said in an emailed statement. “These data give us hope that we may finally be making significant progress in reducing the devastating loss of life from the overdose crisis.” But she also highlighted the continued – and increasingly unequal – death toll from the overdose crisis when it comes to who in society is affected the most. “It’s also important to acknowledge that progress has not been equal for all groups,” she said. “Unfortunately, for the most affected groups, namely Native Americans and Black American men, the death rates are not decreasing and are at the highest recorded levels.” Leo Beletsky, professor of law and health sciences at Northeastern University, remembers when 12,000 deaths in the US were considered “absolutely catastrophic” – compared with more than 100,000 now. He feels “cautious optimism” about the drop and urges policymakers to continue the momentum by scaling up prevention programs. “We’re seeing a reversal of a trend that’s been happening for a very long time – we’re still at historic highs,” Beletsky said. “We need to double down on what works and try to move away from things that do not work.” About 18 months ago, Eric Mockewich decided to get clean after years spent in and out of recovery, and he entered treatment for his opioid use disorder. Access to naloxone, the opioid-overdose reversal drug, “definitely helps”, Mockweich said, and so do housing, food, childcare and other social services alongside accessible, affordable treatment options. “Anything that keeps people alive long enough for them to make a decision to do something else is definitely good,” he said. In 2021, the Biden administration announced a [plan](https://www.hhs.gov/about/news/2024/02/01/biden-harris-administration-marks-two-years-advancements-hhs-overdose-prevention-strategy-new-actions-treat-addiction-save-lives-press-release.html) to prevent overdoses by expanding treatment and distributing naloxone, among other steps. > We need to double down on what works and try to move away from things that do not work Leo Beletsky After the price of naloxone [soared](https://www.theguardian.com/us-news/2021/oct/19/naloxone-price-soars-opioid-overdoses) for some harm-reduction groups, it became [much more affordable](https://www.harmreductionohio.org/price-of-naloxone-continues-to-fall/). Narcan, a nasal-spray naloxone, was approved for sale over the counter in 2023, making it more widely accessible. The administration also relaxed “very outdated” rules about medications like buprenorphine and methadone, Beletsky said. Only a third of people who need those medications can access them because of previous limitations, but access is slowly expanding, he said. “Distributing naloxone, providing people with substance use treatment, giving folks clear information about the drug supply – all of these efforts work,” Beletsky said. “We know that they are lifesaving.” Many of the resources offered during the pandemic, like Medicaid expansion and financial assistance, also helped, though those programs have now expired. Another major factor leading to the overdose drop may be changes in behavior. Xylazine, a tranquilizer, has become a more common adulterant in street drugs in recent years. Like fentanyl a few years ago, it appeared in the east and is moving west – the same pattern as the fall in overdoses. People who use drugs laced with xylazine often need to use less frequently than they do with fentanyl-laced drugs, because xylazine binds to receptors for longer. Using less often means “less rolls of the dice” that could result in overdose, Dasgupta said. But xylazine can cause extensive wounds when it’s injected. “It is pretty brutal,” Mockewich said. “When I went through treatment, there were people showing up – one girl had just lost her arm” due to amputation. Because of these risks, people who use xylazine may be more inclined to snort or smoke it, rather than injecting it – and those routes of administration may have lower risks of overdosing than injections. “The market is also maturing. People are kind of tired of fent,” Dasgupta said. The turn to xylazine could represent a desire for something else – especially among those using xylazine to keep from getting dopesick. “It’s something that maybe helps open a door a little bit for us, and now we need to rush in with all the resources that we have developed over the last decade,” Dasgupta said. “We should be dumping huge amounts of \[funding for\] medications for opioid disorder treatment and scaling that up orders of magnitude more to give people a better option.” That’s especially true for communities that aren’t seeing declines, including African Americans and Indigenous Americans in some states, he said. The options should include harm reduction services and substance use treatment, as well as “broader structural responses” like access to medical care, pain management and mental healthcare, Beletsky said. “All those things play into substance use and overdose.” Taking action also means stopping harmful actions and policies known to increase overdose risk, like incarceration, which increases the risk of overdose by 120% after people re-enter the community, Beletsky said. Drug criminalization only deepens stigma, making it harder to prevent overdoses, he said. “Law enforcement never stopped me,” Mockewich said. “Everything still goes on.” Dasgupta is worried about the [move](https://www.avma.org/blog/support-xylazine-legislation-builds-congress) to classify xylazine as a schedule III drug in the US. “If you were to suddenly cut off the supply of xylazine right now, I guarantee you would see a spike in overdose deaths,” he said. Drug interdiction at the border does not seem to have an effect on overdose rates, and can even worsen the crisis, experts agreed. Authorities are seizing significantly more meth and marijuana than fentanyl at the border. With lower availability of meth, drug dealers tend to cut it with fentanyl, leading to more overdoses. Authorities should instead focus on making the drug supply safer, Dasgupta said. Mockewich now works at a treatment facility, and he is planning to become a peer recovery specialist – a “bridge” career between leaving recovery and getting a full-fledged counseling degree for people who want to use their experiences to help other people get well, he said. “It allows people to get into the field and help put people in touch with services,” Mockewich said. “A lot of treatment has been based on abstinence and telling people how they have to live. In the peer networks, we’re just meeting people where they’re at.” Work like this is important because with more than 100,000 people dying and more people hospitalized each year, overdoses are “still a big problem”, he said. “The numbers are still way too high,” Dasgupta said. “You may have put the lid on the top, but we’re still at a rolling boil.” This article was amended on 14 October 2024 to correct an error in the description of Eric Mockewich’s treatment.

Anti-opioid campaigners in the US have welcomed Donald Trump’s threat to hit Mexico, China and Canada with increased trade tariffs if they do not curb the smuggling of the powerful drug driving the US opioid epidemic. Families and doctors grappling with a crisis that has claimed about 900,000 lives say the move may signal that a second [Trump administration](https://www.theguardian.com/us-news/trump-administration) will finally get serious about tackling the flow of fentanyl into the US. But they also warn that much more needs to be done to reduce demand for opioids and to rein in the power of the pharmaceutical industry which created the epidemic. Trump [said](https://www.theguardian.com/us-news/2024/nov/25/trump-mexico-canada-tariffs-border) last week that he will issue an executive order on his return to the US presidency next month imposing a 25% tariff on goods from Mexico and Canada until their governments clamp down on the smuggling of fentanyl and other drugs into the US, and on people crossing the northern and southern borders illegally. The president-elect also said he will impose a 10% additional tariff on imports from China as the leading manufacturer of the precursor chemicals used by drug cartels to manufacture fentanyl, a highly potent synthetic opioid that is now the single largest cause of drug overdose deaths in the US. Ed Bisch, who lost his 18-year-old son Eddie to a prescription opioid overdose in 2001, said that tariffs are a sign that Trump “means business”. “I’m optimistic that the threat of substantial tariffs will lead to major cooperation in reducing the fentanyl poisoning of America,” he said. Bisch and other campaigners also say that some of Trump’s cabinet choices may signal a greater engagement with the crisis by the next administration, particularly as [Robert F Kennedy Jr](https://www.theguardian.com/us-news/robert-f-kennedy-jr), who is nominated as health secretary, was a heroin user and the vice-president-elect, JD Vance, wrote a bestselling book, Hillbilly Elegy, about growing up in a household and region hit by drug addiction. Trump campaigned in 2016 and again this year on commitments to tackle the opioid epidemic which has devastated regions of America in ways that are often unseen in other parts. The crisis dragged entire communities deeper into poverty, drove up crime and greater dependency on welfare, and tore families apart. Millions of children have been raised by their grandparents because the intervening generation was imprisoned, dead or in no condition to parent. In West Virginia, the state worst hit by the epidemic, [nearly half](https://westvirginiawatch.com/2023/10/20/nearly-half-of-wv-grandparents-raise-their-grandkids-spurring-financial-and-mental-health-needs/#:~:text=In%20one%20county,%20well%20over,to%20the%20state%27s%20drug%20epidemic.) of all grandparents are raising their grandchildren. The opioid crisis has also played an important part in undermining public confidence in government institutions and medical practice in parts of the US because the epidemic grew out of [the pharmaceutical industry pushing](https://www.theguardian.com/news/2018/nov/08/the-making-of-an-opioid-epidemic) the wide prescribing of narcotic pain killers from which drug makers made billions of dollars with the complicity of the Food and Drug Administration (FDA). The epidemic then evolved as illegal supplies of heroin and then fentanyl drove up the death toll. But critics say Trump failed to follow through on his campaign promises in 2016 and his next administration will be a test of how really committed is he is on the issue in the face of what is likely to be major pushback from the drug industry. > In Trump’s first term, he was the one who declared an opioid public health emergency, which is still in effect Robert Kent As president in 2017, Trump declared the opioid crisis a [public health emergency](https://www.npr.org/2017/10/26/560083795/president-trump-may-declare-opioid-epidemic-national-emergency). “No part of our society, not young or old, rich or poor, urban or rural has been spared this plague,” he said at the time. But two years later, the Government Accountability Office (GAO) [criticised](https://www.gao.gov/assets/d20124.pdf) the Trump administration for a lack of coordination of efforts and failing to fulfill a legal requirement to issue a national drug control strategy. Robert Kent, who served as general counsel for the White House office of national drug control policy under Joe Biden, credits Trump with declaring the epidemic an emergency and establishing an opioid commission that issued guidelines on how to combat the crisis. “In Trump’s first term, he was the one who declared an opioid public health emergency, which is still in effect. The problem was there were no concrete actions taken specifically as a result. He didn’t put significant new resources into it,” he said. Kent said that the Biden administration put a greater emphasis on “harm reduction” such as the provision of overdose antidotes and test strips allowing drug users to detect fentanyl. But he fears those may be in danger from Republicans who see such measures as enabling drug use. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and one of the first doctors to raise the alarm about the dangers of mass prescribing prescription painkillers, said harm reduction was necessary but did not get to the root causes of the epidemic. “It’s not hard for Trump to do better than Biden did on opioids. There were some good things that came out of the Biden administration. It was nice to see the federal government move more in a direction of harm reduction. But beyond that there wasn’t really that much done so by Biden,” he said. “When Biden ran for office, he put out a platform on how he would address the opioid crisis if he was president, and it was an excellent platform. But he never really implemented the plan.” Kolodny said that if Trump wants to have a significant impact in reducing opioid addiction he needs to create cheaper and easier access to treatment. “The vast majority of people with opioid use disorder actually want help for it. The reason they keep using fentanyl is that it’s much easier to get fentanyl and cheaper to get fentanyl than it is to get yourself onto buprenorphine or methadone treatment or find a doctor or programme that will very quickly enroll you in treatment when you ask for it,” he said. Researchers are still trying to decipher a drop in overdose deaths in the US last year. They believe better treatment and prevention are playing a part. The Drug Enforcement Administration [said](https://www.dea.gov/press-releases/2024/11/15/deas-third-annual-national-family-summit-fentanyl-highlights-progress) earlier this month that the amount of fentanyl found laced into other drugs had dropped and that they were therefore less potent and dangerous. The DEA head, Anne Milgram, [attributed](https://www.dea.gov/press-releases/2024/11/15/deas-third-annual-national-family-summit-fentanyl-highlights-progress) that to the Biden administration’s targeting of Mexican cartels and their supply chains. But Kent is cautious. “There’s a lot of people running around because we’ve seen a slight reduction in overdose deaths feeling like that’s mission accomplished when we’re only losing 93,000 people versus 111,000 a year. I would never define that as success in my world. Even within those numbers, underserved communities are being higher impacted at this point. In Black and brown communities the numbers are going up while the other numbers are going down. So there’s work to be done,” he said. Kent said he agrees with the need for an increased focus on the border. “We need to increase the number of staff at the border, just for a whole bunch of reasons, including illicit drugs coming across. There needs to be an investment in screening technology. And there needs to be a continued effort with China, trying to convince China to work with its chemical companies to stop selling the chemical precursors to the Mexican cartels so they can create the fentanyl,” he said. Bisch and others whose lives have been hit by the opioid epidemic are also keen to see broader reform of a system that enabled the drug companies to push mass prescription of opioids on the public in ways not permitted in other countries. Bisch supports Trump’s [nomination](https://truthsocial.com/@realDonaldTrump/posts/113523536267976149) for attorney general, Pam Bondi, who as Florida’s attorney general cracked down on doctors and “pill mills” churning out opioid prescriptions to anyone who would pay. In 2010, Florida dispensed more opioid prescriptions than every other US state combined as people travelled from across the country to buy the painkillers in bulk. Bisch wants to see Bondi use federal laws to prosecute the drug company executives who made false claims about the safety of prescription opioids in order to get them approved. He also backs Trump’s nomination of Kennedy, who has accused the FDA of putting the financial interests of the pharmaceutical industry ahead of people’s health by effectively encouraging the prescribing of too many drugs and the selection of Marty Makary to head the FDA. Makary has said doctors in the US prescribe too many medications compared with the rest of the world. “The best way to lower drug costs in the US is to stop taking drugs we don’t need,” he told the US Senate in September. In nominating Makary, Trump [said](https://truthsocial.com/@realDonaldTrump/posts/113529561942926805) the “FDA has lost the trust of Americans and lost sight of its primary goal as a regulator”. He said Makary and Kennedy would work together to “properly evaluate harmful chemicals poisoning our nation’s food supply and drugs”. Bondi is expected to have a relatively easy path to approval by the US Senate. But Kennedy and Makary may face a more difficult time. Kennedy, in particular, will face scrutiny over his rejection of vaccines. But Kolodny said they will also be up against the pharmaceutical industry. “I’ll actually be shocked if Kennedy gets confirmed and if Makary gets confirmed for FDA commissioner because big pharma doesn’t want them, and big pharma has a lot of muscle on Capitol Hill,” he said.

People with substance use disorder across the country are not getting a formal say in how most of the approximately $50 billion in [opioid lawsuit settlement money](https://apnews.com/article/coronavirus-pandemic-business-health-opioids-camden-dec0982c4c40ad08b2b30b725471e000) is being used to stem the crisis, a new analysis found. Some advocates say that is one factor in why portions of the money are going to efforts they don't consider to be proven ways to save lives from overdose, including equipment to scan jail inmates for contraband, drug-sniffing police dogs and systems to neutralize unneeded prescription medications. In Jackson County, West Virginia, officials voted earlier this year to use more than $500,000 in settlement funds for a first-responder training center and a shooting range. They also allocated $35,000 to a quick response team that works with overdose survivors. Josh George, who has been in recovery for three years after 23 years of drug use, primarily heroin, now runs a recovery group with his wife and other family members. Some of the money could have gone to the county's only recovery house, he said. “All these people were doing it on their own dime," George said, “trying to help these people.” Over the past eight years, drugmakers, wholesalers, pharmacy chains and other companies have agreed to settlements to resolve thousands of lawsuits filed by state, local and Native American tribal governments claiming the companies’ practices contributed to the crisis. Opioids have been a major problem in the U.S. since the late 1990s, with the [deadliest stretch earlier this decade](https://apnews.com/article/drug-overdose-deaths-us-cdc-12e961d78cc0458e84a07e0b3f7d1bbc) reaching more than 80,000 annually. The major causes have shifted from prescription pills to heroin to [fentanyl and other lab-produced substances](https://apnews.com/article/health-opioids-synthetic-government-and-politics-8f64b776b82d6e8bc2e324b732e4b6e2) often added to other illicit drugs. Funds from the multi-billion dollar nationwide settlements began rolling out in 2022 and will continue until at least 2038. The agreements require most of the money be used to [fight the crisis](https://apnews.com/article/opioids-settlement-money-recovery-addiction-d186d72250f35056892bc9d70b5ab2c3) but offer great flexibility in how to do it. Christine Minhee of Opioid Settlement Tracker and Vital Strategies, a public health organization, planned to release a state-by-state guide on Monday outlining how government funding decisions are being made. The guide aims to help advocates know where to raise their voices. Using that information and other data, Minhee, who has tallied just under $50 billion in settlements excluding one with OxyContin maker Purdue Pharma that the [Supreme Court rejected](https://apnews.com/article/supreme-court-purdue-pharma-opioid-crisis-bankruptcy-9859e83721f74f726ec16b6e07101c7c), found advisory groups help determine spending of about half of it. But they have decision-making authority over less than one-fifth of it. Less than $1 in $7 is overseen by boards that reserve at least one seat for someone who is using or has used drugs, though some places where it's not required may have such members anyway. Brandon Marshall, a professor of epidemiology at the Brown University School of Public Health and a former member of the Rhode Island Opioid Settlement Advisory Committee, said he has observed that processes involving experts and people with drug use experience have made quick allocations to groups working on harm reduction and other areas because they know the groups. “It’s not just a way to ensure that the funds are used effectively,” he said. “Those kinds of systems are also ensuring the funds are getting out the door faster.” [Public health advocates](https://opioidprinciples.jhsph.edu/the-principles/) say the money should be used in ways proven to save lives, prevent drug use and focus on racial equity and that the decisions should be transparent. But many communities are following regular government spending practices rather than [assessing local needs](https://apnews.com/article/opioid-settlement-small-towns-local-governments-5daabce1ac8da004f94df0cc0b288e43) or consulting with experts or people impacted by the epidemic. Renville County, Minnesota, used $100,000 in settlement money to pay about two-thirds of the cost of a body scanner for the county jail to detect drugs on incoming inmates, even if they have swallowed bags of them. “You can’t possibly tell me that whoever made those decisions thinks that’s the best use of the funding,” said Alicia House, executive director of the Steve Rummler Hope Network, which provides overdose prevention and education across Minnesota. Renville County Sheriff Scott Hable said in an interview that keeping drugs out of the jail — without subjecting people entering to strip searches — fits with the facility’s emphasis on treatment for inmates with substance use disorder. The scanner has been used nearly 1,400 times since last year, identifying contraband in six cases. Twice, it found packets of drugs inmates swallowed before entering, he said. The county’s governing body made the spending decision. Sara Benson, the county’s public health director, said the government is assembling an advisory group for future settlement use and wants to include people with lived experience. In West Virginia, Jackson County Commission President Dick Waybright said the training center will help law enforcement, EMS and 911 employees respond to the opioid crisis. “It wouldn't just be throwing money to a program that wasn’t going to last,” he said in an interview. Besides, he said, no one else besides the quick response team requested funds from the first opioid settlement payment. George's mother, Kelly DeWees, said there are many needs in an area hit hard by addiction, including transportation for people in recovery, prevention education and counseling for children of those with substance use disorder. Breath of Life, the group her son and daughter-in-law run, could use help launching a recovery home. The group is requesting the $15,000 that currently remains in the county’s fund and Waybright said he expects it to be awarded to them soon. For others, the spending decisions are even more personal. Tonia Ahern, a community coordinator for the National Center for Advocacy and Recovery, lost her son to an overdose when he was 29. She co-founded a group planning to produce a handbook of suggestions for New Jersey communities on how to use the funding. “If you haven’t ever experienced it, you have no idea what they need,” Ahern said.

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._