Why Are Opioid Overdose Deaths Declining?

The epidemic in opioid deaths has been an ongoing and seemingly inexorable national tragedy. That hasn't changed. However, for the past two years there has been a remarkable reversal in the trajectory of this tragedy (JAMA Netw Open 2025:2;8:e2514997). As shown in Figure 1, opioid deaths peaked in June 2023. As widely documented in the press, there has been a continued month-by-month decrease in deaths from opioid overdose (asamonitor.pub/3Jm5xjK; asamonitor.pub/3UzppCs; asamonitor.pub/473bZWK). What's going on?Figure 1: CDC data on opioid deaths since 2015.We'll start by inspecting the data. We created Figure 1 on August 17, 2025, based on the most recent data from the CDC (asamonitor.pub/45JwXaY; asamonitor.pub/4oHKkkx). The Y axis is deaths over the preceding 12 months. The X axis shows the date of the 12-month sample. For example, the first date, January 2015, shows the number of deaths from February 2014 through January 2015. The red line shows all opioid deaths through the 12 months ending on March 31, 2025. The purple line primarily reflects fentanyl deaths, with a minor contribution from carfentanil (MMWR Morb Mortal Wkly Rep 2024;73:1099-1105; Drug Alcohol Depend 2025;274:112784). The black line shows deaths from prescription opioids, termed “natural and semisynthetic opioids” by the CDC. The brown line shows deaths from heroin. The obvious story in Figure 1 is the rapid uptake of fentanyl (and carfentanil). In 2015, fentanyl contributed to just 20% of the 29,000 opioid deaths. By January 2020, fentanyl contributed to nearly 75% of 51,000 opioid deaths. Deaths from prescription opioids and heroin were unchanged from 2015 through 2019. Then the pandemic hit (shaded area). Opioid deaths had already started to rise in mid-2019 and surged when the pandemic hit months later (JAMA Netw Open 2022;5:e2223631). Multiple studies have tied this surge in opioid deaths during the pandemic to socioeconomic and mental health challenges, government-mandated lockdowns, amplification of preexisting health risks, and even disruption in naloxone training among emergency responders (PLoS One 2024;19:e0310386; Lancet Psychiatry 2023;10:719-26; Econ Hum Biol 2025;58:101510; Harm Reduct J 2023;20:51; Drug Alcohol Depend Rep 2023;8:100173). By the end of 2021, fentanyl accounted for 88% of the 81,000 opioid deaths. Heroin use decreased during the pandemic, starting in mid-2020. This might be related to the 50% decrease in the price of illegally manufactured fentanyl from 2016 to 2021, when the median bulk price was just $2/1,000 micrograms (Addiction 2022;117:2745-2749). If a “hit” of fentanyl is 200 mcg, then the raw drug cost is just $0.40 per hit. Heroin use has continued to drop and now only accounts for 5% of opioid deaths. Deaths from prescription opioids began a small but continued decrease at the end of 2021. In 2015, prescription opioids accounted for 42% of opioid deaths. In March 2025, prescription opioids only accounted for 15% of opioid deaths. That is still 7,500 deaths – a significant public health problem! The pandemic officially ended in May 2023 (asamonitor.pub/4fFpTAy). Opioid deaths remained elevated through June 2023. Then, abruptly, opioid deaths started to drop. Figure 1 strongly suggests that the primary reason for the decrease was that the pandemic was over. Opioid death rates as of March 2025 are about the same as in January 2020. Fentanyl contributes to more of these deaths, and heroin and prescriptions contribute to fewer deaths. Figure 2 shows the death rates for methamphetamine and cocaine over the same time period. Stimulant-related deaths peaked in August 2023 and have decreased continuously since. This pattern is consistent with our hypothesis that the primary reason fatal drug overdoses have decreased is that the pandemic is over.Figure 2: Deaths related to methamphetamine and cocaine from 2015-25.Attributing much of the decrease to the end of the pandemic does not minimize the contributions of many interventions to reduce opioid deaths. In March 2023, the FDA approved over-the-counter sale of intranasal naloxone (BMJ 2023;380:749). Naloxone saves lives (ASA Monitor 2023;87:1-4). Bonnie Milas, MD, an anesthesiologist, spoke at a 2023 FDA advisory committee meeting urging the approval of intranasal naloxone after rescuing her two sons several times (asamonitor.pub/45Dcww5). Naloxone has a number of limitations. The typical price ($45) may represent a barrier to low-income households (JAMA 2024;331:250-1). Lay rescuers need training (Harm Reduct J 2022;19:117). It must be immediately available. Lastly, someone must be present to administer naloxone. According to CDC statistics, only 9% of fatal overdoses were witnessed (MMWR Morb Mortal Wkly Rep 2021;70:1740-6). As anesthesiologists, shouldn't we be first responders for our neighbors? What would happen if your neighbor, knowing you were an anesthesiologist, frantically knocked on your door at 2 a.m. because her teenage child had overdosed? Do you have naloxone in your house? Would you be able to save her child? Buprenorphine may also be contributing to the decline in opioid deaths. It has been known for nearly a half-century that buprenorphine has substantial efficacy in the treatment of opioid use disorder (Arch Gen Psychiatry 1978;35:501-16). Buprenorphine decreases all-cause mortality in patients with opioid use disorder by 60% (Mol Psychiatry 2019;24:1868-83). The lay press has excoriated the FDA, the DEA, the pharmaceutical industry, and physicians for the profound underutilization of buprenorphine (asamonitor.pub/41ev2cV; asamonitor.pub/41eAtbY). Of these, the most significant impediment has been the DEA. Fearing that approval would create legions of buprenorphine addicts, the DEA placed substantial restrictions on physicians prescribing buprenorphine. Prioritizing the hypothetical risk of buprenorphine addiction over the very real needs of patients misusing opioids, the DEA required physicians to either have a subspecialty license in addiction medicine or complete an eight-hour course on buprenorphine. The DEA also limited physicians to treating just 30 patients with buprenorphine. The restrictions on buprenorphine prescribing were lifted in January 2023 (asamonitor.pub/45DBr2R). Additionally, physicians can now prescribe buprenorphine using telemedicine, which is known to be an effective avenue for treating opioid use disorder (Heroin Addict Relat Clin Probl 2021;23:5-12). Fentanyl is so potent that thousands of doses can be inconspicuously smuggled. It is even worse for carfentanil, which is 20 times more potent than fentanyl. In 2019, one of this article's coauthors (SLS) compared the lethality of carfentanil to that of a thermonuclear bomb (Can J Anaesth 2019;66:351-5). In June 2016, the Royal Canadian Mounted Police (presumably without their horses) seized 1 kg of carfentanil from China (asamonitor.pub/4mGIAX0). This is enough opioid to kill half of the population of Canada, exceeding the capacity of any nuclear weapon. Because synthetic opioids are so potent, and are readily synthesized if precursors are available, police interdiction to stop the flow is a fool's errand (Can J Anaesth 2019;66:351-5). Most fentanyl is manufactured in Mexico using chemical precursors from China (asamonitor.pub/4fGTSrT). Fentanyl is not difficult to synthesize. Decades ago, I (SLS) lost one of my fellows to fentanyl synthesized in the top drawer of his desk from precursors (which are no longer available). The United States has worked with both China and Mexico to reduce the flow of fentanyl and its precursors into the U.S. (asamonitor.pub/4fHwPNu). The U.S. has also sanctioned suppliers of fentanyl and its precursors (asamonitor.pub/4mf8zVA). These diplomatic efforts appear to be reducing the flow of fentanyl into the U.S. (asamonitor.pub/3HFBRh0). The opioid epidemic was launched, in part, by the aggressive promotion of opioids to treat pain, the fifth vital sign. The medical profession responded (a decade later) to the rising death toll by revising the recommendations for opioid analgesia. From 2016 through 2019, prescriptions for opioid analgesics decreased by nearly 50% among Medicaid enrollees (asamonitor.pub/4oIcUSW). In 2022, the CDC issued additional guidelines for prescribing opioid analgesics (MMWR Recomm Rep 2022;71:1-95). The guidelines strongly endorse adequate pain management, but emphasize the need for discussions with patients about opioid use disorder, opioid overdose, and the risk of death. The data in Figures 1 and 2 appear to rule out two purported explanations about declining rates of opioid death. It has been suggested that the declining rate is partly due to a “cohort effect,” whereby vulnerable individuals have already died (JAMA Netw Open 2025 2;8:e2514997). Deaths from drug overdoses have not decreased below those observed prior to the pandemic, strongly suggesting that the supply of opioid users has not decreased. Another explanation is that the decrease is due to political alignment. There is no suggestion of this in the data. In 2017, Donald Trump assumed the presidency from Barack Obama. In 2021, Joe Biden assumed the presidency from Donald Trump. In 2025, Donald Trump again assumed the presidency. There are no step changes in the trajectory of deaths from drug overdoses during these transitions that suggest political alignment has any role. Indeed, both political parties are strongly aligned in determination to end the epidemic of opioid drug abuse. Why are opioid deaths declining? Physicians, pharmaceutical companies, government agencies, and the public have instituted consequential reforms over the past decade. These reforms have likely contributed to the decrease in prescription opioid abuse. These reforms have likely contributed to the overall decrease in death as well. However, opioid deaths today are the same as in 2019. Opioid deaths were a crisis in 2019. Opioid deaths remain a crisis today. This “In the Know” is a cautionary essay to not interpret the decrease in opioid deaths over the past 24 months as suggesting that we have figured out how to reduce deaths from self-administered opioids. All we can say today is that the end of the pandemic was temporally associated with a sustained decrease in death from self-administered opioids. Dibash K. Das holds a PhD in molecular, cellular, and developmental biology from CUNY Graduate Center and an advanced certificate in clinical and translational investigation from Weill Cornell Medicine.