Jeffrey A. Singer
On May 14, the Centers for Disease Control and Prevention reported that overdose deaths dropped in 2024 to their pre-pandemic levels. There were 79,526 total overdose deaths during the 12 months ending December 31, 2024. That’s close to the 77,017 overdose deaths recorded in the year before the pandemic, ending April 30, 2020. The drop in fentanyl-related overdose deaths drove these statistics.
In 2018, researchers at the University of Pittsburgh demonstrated that the overdose death rate had been on an exponential growth trend since the late 1970s, with various drugs predominantly causing overdose deaths in different time periods. Overdose deaths spiked during the COVID-19 pandemic, reaching a high of 111,466 in the 12 months ending June 30, 2023.
The pandemic brought widespread isolation, anxiety, and despair, leading more adults to increase their substance use, including drinking more alcohol. Lockdowns made it harder for people to access harm-reduction services and drug treatment programs. At the same time, border closures and supply chain disruptions pushed drug trafficking organizations to shift from heroin to fentanyl, which was easier to manufacture and distribute under the circumstances. Together, these factors fueled a spike in overdose deaths during the pandemic. As the public health emergency ended and daily life returned to normal, some of the recent decline in overdose deaths may reflect a subsiding of that earlier surge and a return to the trend line.
As I have written here, state and local governments have been increasingly willing to apply harm-reduction strategies to address the overdose crisis. Historically, many policymakers have opposed these measures, asserting that they enable individuals to use drugs that the government prohibits. Harm reduction is nonjudgmental—just like when doctors prescribe medications to manage cholesterol, blood pressure, or prediabetes in patients who might avoid medication through lifestyle changes. We aim to reduce risk, not demand perfection.
In 2023, the Food and Drug Administration finally reclassified naloxone nasal spray as an over-the-counter drug. This change significantly improved access for people who use opioids, allowing them to obtain this effective overdose antidote more easily from pharmacies and harm-reduction organizations that distribute it widely.
All but five states—Idaho, Indiana, Iowa, North Dakota, and Texas—have amended their drug paraphernalia laws to allow individuals to obtain fentanyl test strips without the risk of incarceration, according to a report from the Legislative Analysis and Public Policy Association. This straightforward harm-reduction measure has assisted individuals purchasing drugs on the black market in testing them for the presence of fentanyl and adjusting their use accordingly.
Harm-reduction organizations report that illicit drug users have become much more aware of the risk of fentanyl overdose and have adjusted their usage accordingly. For example, they are more likely to test their drugs and avoid using them alone so that a bystander can reverse an overdose with naloxone. They also report that an increasing number of people are smoking fentanyl rather than injecting it. As drug dealers are increasingly selling fentanyl in pill form as opposed to powder form, users find it easier to crush and smoke the drug than to dissolve the powder and inject it. Smoking fentanyl might reduce the likelihood of overdose, as it allows users to more easily titrate the dose to achieve the desired effect, which is harder to do when injecting.
Finally, with the end of the pandemic, the illicit drug market has resupplied heroin, which many opioid users prefer over fentanyl. Researchers have known for some time that people who use drugs overwhelmingly prefer heroin to fentanyl. When drug traffickers began mixing fentanyl into heroin a little over a decade ago, many unsuspecting heroin users became overdose victims. Over time, as fentanyl dominated the drug supply, users adapted to the situation.
Earlier this year, a report from Millennium Health revealed a surge in heroin availability and use in 2024, particularly in Western states. This was confirmed during a conversation I had last year with the executive director of a major harm-reduction organization in Arizona. Heroin is 50 times less potent than fentanyl. Therefore, users switching back to heroin, especially if they’ve developed a tolerance to fentanyl, might reduce their risk of overdose.
Whether this decline signals a lasting shift or a brief return to the trend line, it underscores that smart public health strategies—and evolving drug markets—can influence outcomes. It’s a reminder that harm reduction, not criminalization, should guide our next steps.