Perspectives
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The Toxicology Report
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We still don’t know what’s driving the trend, and numbers remain unacceptably high
by
Ryan Marino, MD, Contributing Writer, MedPage Today
October 4, 2024
Ryan Marino is a medical toxicologist, emergency physician, and addiction medicine specialist, and an associate professor in the Departments of Emergency Medicine and Psychiatry at Case Western Reserve University School of Medicine in Cleveland. Follow
The CDC released preliminary data showing U.S. drug overdose deaths dropped last year by more than 10%. This has been particularly newsworthy in the context of the ongoing “opioid epidemic” and heavy political campaigning around the dangers of fentanyl. Most noteworthy is that it marks the lowest annual death toll since 2020, and the first decrease since 2018. While it is preliminary data, it has already been extensively verified. In fact, this is a revision of earlier preliminary data, and now shows even fewer deaths than previously thought. The final number could go even lower.
This has been widely celebrated as good news by any metric. As it should be! If you are one of the many people who has personally been affected by this crisis, you can appreciate what it means knowing that thousands fewer people likely died last year than in preceding years, and there were thousands fewer moments of heartbreak and lives lost. This also ends the streak in record-breaking deaths every year, and could signify a reversal in the trend of overdoses, which have increased almost every year for more than the past three decades.
Now that deaths are finally falling, what lessons can we take from this and what can we do to continue — and even extend — this trend?
The Drivers Remain Unclear
Far from offering answers, I would argue that these questions actually raise concerns. The problem is that nobody has a good answer for why this decrease happened. And people have been trying to figure this out from the available data for months now. Multiple theories have been put forth to explain the decline — from a change back to pre-pandemic trends to those at highest risk simply having died off — but none of them offer a definitive explanation.
It’s also worth noting that no single policy change is able to explain this drop. Most of the policy changes we have seen in response to this issue could be described as “incremental,” and incremental policy changes have generally not been very effective at changing trends.
One of the other theories put forth is increased access to naloxone (Narcan), although there is limited evidence to support this; moreover, CDC’s data showing reduced nonfatal overdoses points away from more reversals as the cause here. Another theory is that xylazine, the non-opioid veterinary sedative that is increasingly being cut into fentanyl, might be reducing the amount of fentanyl people are using. Fentanyl is the primary cause of overdose deaths, so the idea is that xylazine can help “stretch” the effects of a fentanyl dose with a decreased risk of fatal respiratory depression. I’m willing to believe this is happening (although I have no evidence), but it would be almost impossible to explain such a significant decrease.
It is also worth noting that there are major disparities in mortality trends within this data. While the overall national rates trended downward, a number of states saw fairly dramatic increases in their overdose deaths. Multiple western states actually saw double-digit increases, like Alaska (+42%), Oregon (+22%), Nevada (+18%), and Washington (+14%).
At the same time, eastern and midwestern states — including states that have seen the highest total death tolls so far — saw major reductions, like Ohio (-19%), Pennsylvania (-19%), and West Virginia (-12%). There are additional disparities when other demographics, like race, are factored in. And youth opioid overdoses are actually continuing to rise.
Those numbers make sense in the context of fentanyl, which only overtook the drug supply out west in recent years but has been a ubiquitous presence in eastern and midwestern states for longer. My personal theory is that grassroots harm reduction work — primarily by people who use drugs themselves — is driving this trend, as they try to adapt to a changing drug landscape.
I can only speculate right now, but the large differences in rates even by town and city suggest local factors at work; furthermore, evidence suggests that people who use drugs are not only the early adopters and primary implementers when it comes to public health interventions in this space, but that they have repeatedly driven major successes in saving lives.
The Death Rate Remains Too High
While this downward trend is encouraging at face value, 100,000 preventable deaths per year is still an astronomically high and unacceptable number. This might be the lowest number in 3 years, but that belies the fact that it is still the third worst year on record. Moreover, this number is more than 10 times greater than the annual overdose death rate 20 years ago. While no amount of preventable deaths should ever be acceptable, we are very much still at major crisis levels. If we zoom out from the most recent years, this decline barely registers against the massive, sustained rise in overdose mortality.
Graph created by Marino using CDC data.
Fentanyl continues to drive the vast majority of overdose deaths, and a decline in fentanyl overdoses accounts for most of the drop in the death rate in the latest data. But the focus on fentanyl and opioids distracts from the fact that people are dying from other drugs too, and we have seen consistent increases in overdoses from drugs like cocaine and methamphetamine. Notably, things like naloxone do nothing to help with cocaine or methamphetamine overdose.
I can confirm that I’ve been seeing fewer fentanyl overdoses in the emergency department. But death and overdose are not the only harms from illicit drug use, and I continue to see high volumes of patients with other preventable problems like injuries, wounds, infections, and more. This data tends to lag significantly behind death reporting.
Fewer deaths is definitely good news. But death is not the only bad outcome. And we shouldn’t accept 100,000 preventable deaths per year — or any preventable deaths really. There is still more work to do, especially considering that many interventions, like addiction treatment, remain inaccessible to most Americans. Harm reduction works. Yet, harm reduction remains underutilized and subject to constant attack. And when the dust settles, I believe it’s almost certain that this improvement will be related to harm reduction efforts.
My advice at this moment is to be happy for positive change but not to get complacent and never settle for any preventable deaths.
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