Comment: It matters that we understand decline in overdoses

By Lisa Jarvis / Bloomberg Opinion

Last fall, when initial data from the Centers for Disease Control and Prevention showed a surprising drop in drug overdose deaths, the universal response was relief. We were finally getting something right in addressing the opioid epidemic, which accounted for most of the decrease and has killed hundreds of thousands of Americans.

That progress has been hard-won and should be celebrated. Addiction specialists are hopeful we can push the still-too-high numbers of opioid deaths even lower in 2025.

But we also shouldn’t miss the trees for the forest. So much more work is needed to understand what’s behind the decline and how to ensure everyone who needs help gets it. And the Trump administration, which made tackling the opioid crisis a priority during the president’s first term, should more carefully consider how some of its proposed policy and funding changes could upend all of this.

Let’s start with the general themes that appear to be responsible for the improvement on a national level. People working on the ground and studying interventions all agree that making naloxone (Narcan), which can reverse an overdose, widely available and increasing access to treatments like buprenorphine and suboxone have been critical to saving lives. There also seems to have been a change in the quality of the fentanyl on the streets that might be weakening its appeal to users. Some experts point to the depressing possibility that many of the most at-risk people succumbed to an overdose earlier in the epidemic.

With opioids, though, it’s essential to look beyond the macro trends. For example, state-level data makes clear that the crisis didn’t start to abate all at once last year (a situation that would have suggested the change was driven by a sudden change in policy or supply), but instead, declines in deaths were staggered, state-by-state, over three years, says Nabarun Dasgupta, an epidemiologist at the University of North Carolina Injury Prevention Research Center who studies drugs and infectious diseases.

Trends that point to where to invest future resources are buried within that state-level data. It reveals, for example, that graphs showing the epidemic is improving don’t reflect everyone’s experience. Scott Weiner, an emergency and addiction medicine specialist at Brigham and Women’s Hospital in Massachusetts, says that all of the decline in opioid deaths in his state came among white drug users; meanwhile, the rate of deaths among Black opioid users increased. That disparity has grown among Black, Hispanic and American Indian/Alaska Natives in many states, and resources should be focused on interventions that have been shown to work.

Philomena Kebec, a judge and attorney who belongs to the Bad River Band of Lake Superior Chippewa Indians, described what that looks like in tribal communities in Wisconsin, where opioid deaths began to abate in 2023. They’ve taken multiple tacks to get naloxone to everyone who might need it, including a mail-order program where orders are assessed and filled by someone with lived experience with addiction. There is also an emphasis on community engagement, which saves lives. “I think there’s a greater awareness of the need to watch out for people,” she says. Fewer people are using alone, so “when somebody goes down, there’s someone there who handles it.”

Meanwhile, Arizona has also seen a significant drop in opioid deaths over the past two years, but Dasgupta’s group noticed a consistent spike in deaths during July. That suggests the extreme heat is playing a role in overdose deaths, something public health officials could factor in as they map out prevention strategies.

Amid attempts to unpack the nuances of the progress, there is a cautiousness when talking about what comes next. Everyone believes the numbers should continue to decline so long as current efforts stay on track.

However, several potential developments could easily send the U.S. overdose rate soaring again. The Trump administration is seeking steep cuts to Medicaid, which could have a devastating effect on access to treatment for opioid use disorder. The current proposal calls for the committee overseeing Medicaid and Medicare to extract $880 billion from its budget over the next decade; cuts that would fall squarely on Medicaid.

Potential cost-saving strategies include instituting a work requirement, an approach that a recent analysis published in Health Affairs found could jeopardize insurance access for some 4.56 million people with substance use disorder. Another approach being floated would eliminate the matching federal funds that states receive under the Affordable Care Act’s Medicaid expansion. A recent Brookings Institute report found that more than half of those treated for opioid use disorder in 2021 fell under Medicaid expansion; and getting rid of those matching funds would cut anywhere from $5.4 billion to $14.1 billion in treatment funding.

Another potential risk to maintaining the progress might sound paradoxical. But if the Trump administration cracks down too harshly on synthetic opioids, it could open the door to other, even more dangerous drugs. “A sudden clamp down on illicit fentanyl and xylazine is going to lead to the emergence of more potent synthetic opioids, which are waiting in the wings,” Dasgupta says. He points to the situation in Europe, where the arrival of a powerful class of opioids called nitazenes has led to a rise in deaths in several countries. The problem isn’t just its potency but that we lack the kind of tools that have helped reduce deaths from fentanyl; like easy detection in blood and urine samples or test strips for users.

The first Trump administration is credited with initiating the work that has gotten us to this point. To keep that legacy intact, the current one should carefully consider the unintended consequences of its actions.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.