The good news: Data released by the U.S. Centers for Disease Control and Prevention (CDC) indicate that drug overdose deaths have dropped for the first time since 1990. Between the 12-month period ending December 2017 and the 12-month period ending December 2018, there was a 5.1% decline in overdose deaths. Now the bad news: Experts still see worrisome signs in the data.
“Over the last 39 years, we’ve had almost 700,000 overdose deaths. We have a pretty good historical record of what the trajectory looks like,” says Donald Burke, an epidemiologist at the University of Pittsburgh (Figure 1). “I would remain cautious. I think it’s far too early to be self-congratulatory.”
TRACKING OVERDOSE DEATHS
The number of drug overdoses in the U.S. has been tracking upward for nearly four decades. Between 1999 and 2017, the number of annual drug overdoses skyrocketed from nearly 17,000 to more than 72,000, according to government data. Two out of three drug overdose deaths involve an opioid, such as prescription opioids, heroin, and synthetic opioids like fentanyl. According to the CDC, overdose deaths from opioids have increased almost sixtimes since 1999, with an average of 130 Americans dying every day from an opioid overdose.
Brown University epidemiologist Brandon Marshall notes that in his state of Rhode Island, two years of declines in overdose rates seems to have given way to a plateau in numbers (Figure 2). “I think we saw the epidemic peak in 2017 and a lot of us were hopeful that it would be the beginning of a series of years of declines. Unfortunately, we’re just not there yet,” he says. “The most recent national data show that the number of overdose deaths is broadly stabilizing at a very high historical level. My fear is that we’re reaching a new normal, a crisis normal.”
Still a crisis
Health officials and epidemiologists say that despite fewer overdose deaths, there is still a lot of cause for concern. For instance, the CDC data show that deaths involving cocaine and psychostimulants like methamphetamine actually rose from 2017 to 2018. And Burke notes that even though there are fewer deaths than the year before, the number of deaths in 2018 is significantly above the expected historical trajectory. Plus, we’ve seen slumps in overdose deaths before—without major changes in the inexorable upward trend.
“It is possible that the small decline is real, but there have been pauses in the epidemic in prior years that were followed by continued worsening,” says Stanford University drug policy expert Keith Humphreys (Figure 3). This happened between 2011 and 2012, when drug overdose deaths appeared to level off around 41,500. Then came the introduction of highly potent synthetic opioids like fentanyl, and overdose deaths shot up.
While rates of heroin and prescription opioid overdose deaths have started to level out, overdose deaths involving synthetic opioids have continued to increase. Rates of overdose deaths involving fentanyl doubled each year from 2013 to 2016. “The life expectancy data come out shortly and I expect we will have a historic, year over year increase in death rate and decline in life expectancy,” says Daniel Ciccarone of the University of California, San Francisco. “That’s still being driven by fentanyl. We still have a crisis on our hands.”
Local efforts inspire optimism
With all that said, there is some room for hope. Prescription opioid- and heroin-related deaths are trending downward, pushing overall opioid and drug overdose deaths down even as fentanyl use continues to spread. Differences among states suggest that local initiatives are having a positive impact on overdose death rates. According to Marshall, the states with comprehensive, evidence-based plans are the ones seeing the declines.
Humphreys points to “great provision of treatment under the Affordable Care Act as well as expansion of access to the overdose rescue drug naloxone” as the most likely causes of the drop in overdose deaths. Indeed, in states like Vermont, Rhode Island, and Massachusetts, campaigns to prevent fatal overdoses with naloxone and expand access to addiction treatment have resulted in a decrease in overdose deaths.
In Rhode Island, Marshall lauds the success of a four pillar strategic plan focused on prevention, treatment, rescue, and recovery launched in 2015. “We’ve been successful at scaling up evidencebased treatment in Rhode Island in a big way,” he says. “For instance, on the rescue side, we’ve gone hard on distributing naloxone in communities and we know that’s making a difference. We distributed 16,700 naloxone kits in 2017. We’re a state of a million people, so that’s about one kit for every hundred people.”
Along with naloxone access and peer-recovery specialists for overdose victims, Rhode Island has a drug-treatment program available to all state prisoners — a group of people at high risk for relapse and overdose.
Room for improvement
While successes at the local level offer some cause for optimism, experts say there are too many people without access to life-saving prevention and treatment. “Clearly, the drop in overdose deaths is good news, but we are still losing over a thousand people a week, so this is no cause for celebration or complacency,” says Humphreys. “We still have substantial parts of the U.S., especially in rural areas, where treatment is in short supply. Also, many treatment programs do not offer FDA-approved medications that are effective in treating opioid addiction.”
Marshall says that in Rhode Island, the focus on harm reduction (e.g., syringe service programs, naloxone distribution) is making a difference, but such efforts need to be scaled up dramatically to reach everyone at risk for overdose. He also notes the need to support people in their recovery from addiction. “Another focus is on the social determinants of health, those factors we know are important to help people thrive and lead healthy lives, like employment, housing, and education,” says Marshall. “Even if we have a high-quality treatment system, we still need those supports in place for people to continue to be successful in their recovery.”
Ciccarone agrees that there is more work that needs to be done. “As a nation, we need to get our act together to create a healthier, more resilient society. We need to evaluate where we are and ask if we can do a better job,” he says. “That’s the challenge in front of us. If we as a society don’t act quickly, we could be stuck with a drug problem that is not solvable and living with high levels of mortality from whatever the drug of the year is. “We need a more comprehensive evaluation of the problem and a much more courageous treatment plan,” he adds.
For more information
- F. B. Ahmad et al., “Provisional drug overdose death counts,” National Center for Health Statistics, 2019. [Online]. Available: https://www.cdc.gov/nchs/nvss/ vsrr/drug-overdose-data.htm