The Forces Finally Driving Down Deaths from Overdose

Editor's Note: This article appears in Governing's Summer 2025 magazine. You can subscribe here.

Kari Herbert was working at a residential treatment program in California when she met a patient whose situation struck her as devastating, despite her long experience confronting the human costs of the opioid epidemic. “She was young, she was beautiful, she was strung out,” Herbert says. “And she was pregnant.”

Two lives were at risk. If the patient did manage to give birth, her baby would battle withdrawal symptoms making it hard to eat, sleep or gain weight. The mom was ashamed but was open to help.

Luckily, Herbert had a fresh weapon to bring to this fight. Her program had begun using buprenorphine, a drug that can help opioid users overcome their cravings. The young woman responded so well that the baby didn’t require neonatal intensive care. (This was a first, Herbert says.) The mother was able to breastfeed. She escaped the trauma of losing custody. Following her recovery, she became a counselor, drawing on her experience to help other pregnant women face their drug problems.

Positive outcomes like that may seem all too rare. Fentanyl is the prime cause of an overdose death rate that has tripled over the last decade. In 2013, there were 3,105 deaths from fentanyl. In 2022, there were 73,838 fentanyl deaths — three-quarters of all the 108,000 drug fatalities for that year.

But in a turn of events that caught public health officials off guard, deaths dropped significantly in 2024. In February, the Centers for Disease Control and Prevention reported there had been about 87,000 overdose deaths from all types of drugs between October 2023 and September 2024, which represented a 24 percent drop from the previous year. An update in May brought the number still lower, showing a decrease of 27 percent. The news was even better regarding opioids specifically, with the overdose death toll down by 35 percent.
This good news is tempered by the fact that overdose remains the leading cause of death for Americans ages 18 to 44. Moreover, even as the national count went down, some states were seeing more deaths, including Utah, South Dakota, Alaska, Nevada and Montana. And opioid fatalities, while the most visible and terrible outcome from misuse, don’t convey the whole scale of the problem. The Food and Drug Administration (FDA) estimates that 6.1 million Americans 12 or older have opioid use disorder.

Still, after years of steep increases in deaths, the sudden turnaround is heartening. What accounts for it? The problem is too complex, and the decrease too new, for a single definitive answer. But there are many important factors.

Some experts point to the increased availability of naloxone, which can save lives in overdose emergencies. A change in use patterns is also part of the explanation because injecting fentanyl-laced drugs is more likely to be fatal than smoking them. The population of older users using needles has likely shrunk as the result of overdoses; those who are new to the drug are more likely to smoke. Enforcement also matters. Customs and Border Protection seized 80 percent more fentanyl in 2023 than in 2022.

People who use drugs are also increasingly aware that dealers lace other street drugs such as ecstasy, methamphetamine, cocaine and heroin with fentanyl. Forty-five states have changed drug paraphernalia laws to allow individuals to possess fentanyl test strips; some prevention programs make them available for free. These enable users to test drugs for fentanyl content and then make informed decisions about using them. The strips are also valuable tools for emergency responders who find and test drugs at the site of an overdose.

Major illicit suppliers have cut back on the amount of fentanyl in their products, says Linda Hurley, president of a Rhode Island treatment center. “I don’t mean to be crass,” she says, “but it seems to all of us that they decided that it was better not to kill all their market.”

Public health experts worry about the potential setbacks that could come with cuts to federal funding. Money for treatment increased during Donald Trump’s first presidency. Now, mass firings of federal health workers, as well as the wholesale reorganization of health agencies, have added uncertainty. The biggest concern among addiction professionals is cuts to Medicaid, the largest single funder of addiction treatment services. “The addiction treatment field is in panic right now,” says Terrence Walton, executive director of NAADAC, the Association for Addiction Professionals.
Still, at least $50 billion in settlements are coming to state and local governments from opioid lawsuits. States have been adapting their programs to concentrate help where it’s needed most. They’ve created successful interventions in the places where users are reachable, including hospital emergency departments, churches and prisons. In Alabama, the nonprofit Agency for Substance Abuse Prevention has developed curricula designed to help faith leaders respond more effectively when congregants come to them with drug problems. The state has thousands of religious institutions and faith leaders have deep connections with their congregations, helping parishioners on the tragic “back end” of addiction when it comes to funerals and comforting family members. Why not put them on the front end and give them tools that could prevent premature deaths?

That type of thinking — reaching out to users where they interact with institutions that can help — is informing a great deal of the current opioid response. “We’ve seen a lot of effort by state, federal and local officials in the past several years to expand buprenorphine access to a couple of populations historically at most risk of overdose — populations involved in the criminal legal system, particularly those leaving incarceration, and individuals presenting to the emergency room,” says Bradley Stein, a physician who directs an opioid policy center at the RAND Corporation.

The recent epidemic isn’t the nation’s first. Opium pills and injections of morphine, which is derived from opium, were given to Civil War soldiers to manage pain from gruesome injuries caused by conical lead bullets. Many became addicted and abuse spread to hundreds of thousands by 1890. A century later, in the 1990s, increases in opioid prescriptions led to a flood of drug fatalities. Another wave began in 2010, caused by heroin overdoses. Then, a few years later, easy-to-make fentanyl began to replace heroin as a street drug.

In 2018, the California Department of Health Care Services helped establish a program known as Bridge, which makes medication for addiction treatment available to emergency patients. Arianna Campbell, a physician assistant specializing in addiction medicine, was a driving force in developing the Bridge protocol. She started it with a program in the emergency department at Marshall Medical in Placerville, after she realized that cutting off prescriptions wasn’t enough. “We had brought a lot of people into the world of opioid dependence, then left them without adequate treatment,” she says.

Navigators at Marshall Medical such as Kari Herbert consult about 1,000 patients each year after they have been initially offered medication. Out of that number, more than 400 have accepted a referral to continuing care, with nearly 60 percent still in treatment six months after ER discharge, says project coordinator David Jay.
The program has expanded to include paramedics. About a third of the counties in California allow EMTs to initiate buprenorphine in the field, Campbell says. That’s needed because patients often decline transportation to the hospital, even after a serious incident. “If they don’t want to go to the emergency department, we can still get them the care they need and deserve and hopefully follow up in a clinic the next day,” Campbell says.

The Bridge team has helped 276 California hospitals implement its system of care. With foundation support, it’s taking its protocol national, working with hospitals or health-care systems in 18 states, as well as clinicians in all 50. “We want this to be seen as the standard of care in emergency medicine,” Campbell says.

As in emergency departments, the extreme consequences of drug use and the opportunities to prevent fatalities exist side by side in prisons. It’s estimated that 1 in 5 incarcerated people have been jailed for a drug offense. Among the state prison population overall, nearly half of state inmates have a substance abuse disorder, regardless of their initial crimes. The share rises to two-thirds among those in jail. Opioid overdose is the most common cause of death among incarcerated individuals following their release; their risk of fatal overdose is 10 times greater than the general population.

Rhode Island is the first state to offer a comprehensive treatment program to inmates. In 2015, Democratic Gov. Gina Raimondo convened a task force to develop a plan for reducing overdose death rates in her state, which had more than doubled between 2012 and 2014. “We started gathering data and found that of the people that died in 2014, almost 25 percent had recently been incarcerated,” says Linda Hurley, who served on the task force.

In 2016, the Rhode Island correctional system became the first to screen all inmates for opioid use disorder and to provide FDA-approved medications to help them manage withdrawal symptoms. In 2018, researchers from Brown University and the state Department of Corrections reported a 12 percent drop in state-wide overdose deaths and a 61 percent decrease in drug fatalities following release from incarceration.

Hurley’s program has a 93 percent success rate in keeping people in treatment after release, linking inmates to caregivers in the communities where they settle after prison. “Why in the world would we go to all the trouble to get somebody stable on a life-saving medication and then drop the ball and let them fend for themselves on release?” she asks.
Researchers estimate that almost a third of post-incarceration deaths could be prevented if medications were made available to all inmates. Prison systems in 33 states do offer medication to addicted inmates, according to the Prison Policy Initiative, but the protocol varies. Twenty-one states continue to provide medication to inmates who were being treated prior to admission. Another 14 states will initiate treatment only in the weeks prior to release. A National Institutes of Health survey of more than a thousand jails found that just over 40 percent offered medication for opioid use disorder.

Some states have passed laws requiring a review of administrative protocols to determine what might be done to expand access, says Samantha Harris, a health policy researcher at the Johns Hopkins Bloomberg School of Public Health. Some have implemented pilot programs. So far, momentum is being driven largely by blue states, Harris says. In some parts of the country, there can be stigma about providing addiction medication to any population. Incarcerated individuals can face even greater barriers to access.

Despite the sudden drop in the death toll, the people who run treatment programs are nervous about setbacks that funding cuts might cause. When it comes to their own money, including settlement dollars, states and localities could feel pressure to fill their broader budget holes rather than prioritizing treatment and prevention, says Abdullah Shihipar, a public health researcher at Brown University. “That’s already happening, and I worry that it will only be accelerated by this environment of cuts,” he says.