By admin 
Last year, the U.S. Centers for Disease Control and Prevention (CDC) reported a 3% decrease in drug overdose deaths. biggest decline in 5 years. Officials called the numbers “encouraging” but stopped short of saying the decline was a sign of a larger trend.
But as drug overdose deaths have continued to decline through the first five months of 2024, public health officials may have reason to believe the 2023 drop is more than just an anomaly.
Predicted preliminary overdose deaths fell 12.7% between May 2023 and May 2024, from a record high of 111,029 in 2022 to 98,820.
“It’s reasonable to be optimistic,” Lief Fenno, MD, PhD, president of the American Psychiatric Association’s Council on Addiction Psychiatry, told me. Medscape Medical News. “It should be a small thrill for everyone working at all levels to make a dent in this truly terrible overdose crisis we have been in for the past five years.”
Despite the decline, nearly 100,000 people dying annually is an “insanely high” number of losses, says Nabarun Dasgupta, PhD, MPH, a senior scientist at the University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina. Medscape Medical News.
“It feels like we have the lid on the pan, but we are still at the boil,” said Dasgupta, who works at the Opioid Data Lab, an academic partnership.
And the latest numbers represent just a patchwork of progress: Some states saw a drop in opioid overdose deaths of as much as 30% over that 12-month period, while others saw increases of up to 36%.
Furthermore, researchers still do not understand the reasons behind the increase in overdoses or the recent decline.
“There are clearly forces at play here that go beyond what we traditionally think of in terms of public health and public health interventions, and we don’t understand it, and we’re not the ones controlling the direction of the overdoses,” Dasgupta said.
Why this decline?
In all likelihood, there are a host of factors influencing the decline, says Fenno, who is also an assistant professor of neuroscience and psychiatry at Dell Medical School, The University of Texas at Austin.
“There hasn’t been any large-scale change that could explain the sudden turnaround,” he said.
One reason for the decline may be that “the susceptible population is no longer growing,” Daniel Ciccarone, MD, MPH, professor of family and community medicine at the University of California, San Francisco, told me. Medscape Medical News.
Since 2015, deaths have largely been due to the presence of fentanyl in the drug supply. Fentanyl’s lethality has not decreased, but the number of new users is declining. Ciccarone suspects this is because new, younger users have been warned about the drug. According to him, fewer users equals fewer deaths.
The decline could also be due to a synergy of increased naloxone availability and an increased number of physicians prescribing buprenorphine in the wake of the lifting of restrictions in late 2022. “However, there is no data to support that phasing out the buprenorphine waiver has already made a dent,” he said.
Government seizures of fentanyl likely haven’t made a difference, Ciccarone said. The drug remains cheap and easy to find, suggesting supply has not been affected, he said.
Based on recent data on fentanyl use, Dasgupta does not see a decrease in the number of new users. “There are still a lot of 20-year-olds who are using fentanyl for the first time,” Dasgupta says.
He has seen a shift in drug supply in the East, where fentanyl is mainly taken to prevent withdrawal symptoms. People are taking less fentanyl and adding other medications — like the animal tranquilizer xylazine in particular — to get fentanyl’s calming effect, Dasgupta said.
Xylazine is cheaper and overdoses of xylazine plus fentanyl are less severe than those with fentanyl alone, he said, and users could add cocaine or methamphetamine to counteract the sedation. All this leads to less use of fentanyl, which may lead to fewer overdoses.
Impact of Naloxone?
The widespread distribution of naloxone may explain a decline in overdoses in some geographic areas, Dasgupta said. In mid-2023, the U.S. Substance Abuse and Mental Health Services Administration made grants available to states to increase access to naloxone in communities.
For example, this may have helped reduce overdoses in St. Louis, Dasgupta said. The CDC reported a more than 20% decline in overdose deaths in Missouri for the year ending May 2024. Based on its own data, the University of Missouri-St. Louis reported that deaths statewide are on track for a 30% decline in the first half of 2024.
The university reported that its data showed an 11% decline statewide and a 14% decline in the St. Louis metropolitan area in 2023. St. Louis is the epicenter of deaths in Missouri, the report said, and experts at the university said the increased distribution of naloxone likely had made a difference.
Overdose deaths in Texas fell by about 2% through May 2024, according to the CDC. Fenno said Texas is doing some things right, such as naloxone dispensers and a medical technician-driven program that provides buprenorphine on-site within 24 hours of an overdose to interested parties.
Needle exchange programs and fentanyl test strips are illegal in Texas. Still, “there is more of a conversation at the state level about implementing public health strategies to reduce access to or harm caused by illicit opioids,” Fenno said.
Fentanyl isn’t leaving for Texas just yet. During his opioid treatment program, most of his patients reported that the first opioid they used was fentanyl. “People are starting to use fentanyl,” and younger users are not shying away from it, Fenno says.
‘Green shoots of progress’
States that have endured the worst of the opioid epidemic have seen a decline in deaths. For example, West Virginia saw a 15% drop in the CDC’s latest report, while Ohio saw a 22% drop, numbers Ciccarone calls “impressive.”
Overdose deaths fell 1% in New York City in 2023, after doubling deaths from 2019 to 2022, says Ashwin Vasan, MD, who just resigned as commissioner of the New York City Department of Health and Mental Hygiene. In an October news conference sponsored by the Big Cities Health Coalition, Vasan said the decline “represents the beginning, the green shoots of progress.”
Vasan mentioned city initiatives such as supervised consumption sites (run by contractors and so-called overdose prevention centers), syringe services, naloxone distribution and programs that connect people to medication-assisted treatment. He said the $154 million the city received from the settlement with opioid manufacturers is “starting to make a difference.”
Western states have not fared so well. Deaths rose 36% in Alaska, 22% in Oregon, 18% in Nevada, 7% in Utah and 11% in Washington state.
This is partly due to the east-west spread of the fentanyl epidemic, Dasgupta and Ciccarone said.
However, Brad Finegood, who oversees overdose prevention efforts as a strategic advisor in Seattle and King County, Washington, said real-time data points to a 22% drop in deaths in the first nine months of 2024.
“We’re seeing a huge increase in people using opioids containing naloxone,” Finegood said on the Big Cities Health Coalition call. About 85% of people who use drugs reported carrying naloxone, he said.
The county has increased access to methadone, buprenorphine and naltrexone, with an estimated 12,000 Medicaid recipients currently taking one of these medications, he added. A new 24/7 hotline that launched in January is helping people access buprenorphine. The service has served approximately 400 customers to date.
King County also has several mobile methadone vans in addition to fixed methadone clinics, and providers offer long-acting injectable medications for opioid use disorder.
African Americans, Native Americans are still at risk
There are still disparities in overdose deaths in King County, especially among older individuals of color, Alaskan Natives and Native Americans, Finegood said.
In New York, older black men are dying disproportionately, Vasan said. These individuals have faced “the cumulative effects of long-term physical and health neglect, social and economic needs and long-term marginalization,” and “the consequences of racism,” along with “fragility in the face of a shifting drug supply.” Vasan said, noting that fentanyl is 40 times stronger than heroin.
“People are still dying,” Dasgupta said, adding that “the numbers are rising among African Americans and Native Americans.”
But, he added, “we are at a major inflection point where a tremendous amount of new funding will come into play in opioid settlements. There is a lot we can do.”
Ciccarone reported that he is the volunteer medical director of Remedy Alliance/For the People, a major wholesale distributor of naloxone and other medications. Dasgupta reported that he is an uncompensated board member of Remedy Alliance/For the People and a contractor for the U.S. Food and Drug Administration in the field of opioid overdose measurement. Fenno and Vasan reported no revelations.
Alicia Ault is a freelance journalist based in St. Petersburg, Florida, whose work has appeared in publications such as JAMA and Smithsonian.com. You can find her at X: @aliciaault.