Overdose deaths continued to rise in some communities across the US even as they declined nationally in 2024, according to an exclusive data analysis by the Guardian, which found wide geographical disparities in fatalities linked to the public health crisis.
The revelation comes just months after public health officials heralded a 27% drop in overdose deaths, a feat that the Centers for Disease Control and Prevention (CDC) attributed to factors including expanded access to the overdose-reversal drug naloxone and substance-use treatment, and shifts in the drug supply.
“This decline suggests more than 81 lives saved every day,” the CDC stated in a press release. On average, 220 US residents still died of overdose each day in 2024.
But when the CDC announced the decline in May of 2025, the downward trend in overdose fatalities had already begun to reverse in seven states, according to the Guardian’s findings.
Public health experts were unsure of what factors led to the decline and whether the reduction in deaths was the beginning of a long-term trend. “You can talk to five different experts, and you’ll get five different explanations for why the deaths are coming down. Nobody really knows,” said Andrew Kolodny, medical director for the opioid policy research collaborative at Brandeis University.
In order to better understand how – and why – the overdose epidemic is clearly diminishing in some parts of the country, but progress is waning in others, the Guardian analyzed key data points, including: CDC data on overdose fatalities and the distribution of medication for opioid overdose and addiction; US Census Bureau data on population, poverty, Medicaid and uninsured rates; and drug seizure data from the National Forensic Laboratory Information System. The analysis also reviewed data on patients in substance-use treatment provided by the urinalysis company Millennium Health, an accredited drug-testing specialty laboratory.
While overdoses declined nationally between August 2023 and December 2024, the most recent month when county-level data is available, they increased by as much as 120% during that time in some US counties. State-level data, which is available through April of this year, showed deaths beginning to rise again in January, reaching near peak levels in Arizona, and climbing more modestly in Delaware, Hawaii, Minnesota, New Mexico and Washington.
Overdoses are still the leading cause of death for Americans aged 18-44, according to the CDC, and would be listed as one of the 10 leading causes of death overall were they not lumped together in a single category with other accidental deaths and injuries.
Overdoses claimed over 80,000 US lives in 2024 – more than twice as many as motor vehicle accidents and nearly three times as many as Covid-19. Yet this was still seen as a major improvement.
Marc Fishman, an addiction psychiatrist at Johns Hopkins University who focuses on substance-use disorders in youths, is frustrated at the lack of national attention on addiction treatment.
“Who ever would have thought that we’d be applauding 80,000 deaths?” said Fishman. “If 80 goes to 70 goes to 60, that’d be something to celebrate. Let’s see if the trend continues.”
Drug supply
Of the factors the Guardian analyzed, changes to the amount of fentanyl, and in some cases methamphetamine, in the drug supply, as well as geography, were most strongly linked to changes in overdose deaths.
These two factors are likely related, according to recent research and the Guardian’s analysis. According to a September Lancet study: “Starting in 2013, fentanyl began replacing heroin in the eastern US and spread westward, driving profound increases in overdose deaths” that have not yet abated to the same degree as they have in the east. The increased prescription of opioids by doctors led many Americans to become addicted starting in the 90s, especially in eastern states such as West Virginia, where physical laborers took pills for their pain. Tightened restrictions on prescription opioids starting in the early 2010s led more people to turn to illegal opioids, such as heroin. Then fentanyl, which is cheaper and 70 times more potent, began to replace it.
Eight per cent of the population in western counties included in the analysis were living in areas where overdoses were still increasing by more than 10% since the peak of the crisis, according to the Guardian’s analysis, which also showed that peaks in overdose death rates lined up with peaks in fentanyl prevalence. The percentage of drug seizures containing fentanyl peaked in 28 states in 2023, the same year that overdoses began to decline nationally.
Naloxone
The overdose-reversal drug naloxone is widely praised as a game changer in the crisis, and is often cited first as a possible explanation for the decline in drug overdose deaths, including in CDC releases.
Opioid overdoses occur when the brain’s opioid receptors are overwhelmed and the body neglects to breathe. Naloxone reverses this process by blocking the opioid receptors in the brain, sending the recipient into immediate withdrawal as they awake.
Naloxone undoubtedly saves lives, and every public health expert who spoke with the Guardian unequivocally supports its continued promotion. But its necessity is also a grim sign of the severity of the US opioid crisis. Every time someone needed naloxone to reverse an overdose, that person was already on the edge of death – without a friend or bystander with naloxone on hand, their chances of survival would have been slim. People who use opioids encourage one another to “never use alone” and to have naloxone on them at all times.
“It is terrifying,” Fishman said. “I’ve been yelling about this for years. You can’t say I’m gonna reverse an acute overdose and then celebrate when you haven’t addressed the disorder.” Substance-use treatment can help prevent overdoses in the longer term, but it requires sustained investment in both addiction and mental health treatment. People who struggle with addiction are often self-medicating for other mental health conditions such as depression or PTSD.
It is difficult to tease out how much naloxone has contributed to a reduction in overdose death rates. Evidence is mixed, and the few studies that investigate the impact of naloxone on overdose rates were mostly conducted before overdoses began skyrocketing in the wake of Covid-19.
Flying blind
Back in 2015, the CDC issued recommendations to address the increasing amount of fentanyl in the drug supply. Some, such as an uptick in the distribution of naloxone, have happened. Many others, like consistent analysis of drugs found on the scene of overdoses, have not.
In statements about declining overdose deaths, the CDC touted its improved data collection and sharing. Experts say it is not enough.
“We should have much better data on this,” said Kolodny. “If you think about when Covid was raging, on a county level, on a zip code level, you could find out about Covid positivity rates on tests. You could find out deaths, hospitalization, and it was easily available for everybody. For opioids, we’re almost 30 years into the epidemic, and we still don’t have adequate surveillance.”
Kolodny said that CDC overdose death data is “the best we have” to track the crisis – “inadequate as it is. We’re looking at [data from] April. That’s crazy. It’s October.”
Eric Dawson, vice-president of clinical affairs at Millennium Health, said the company is already working with some health departments to try to “close the gap between what’s happening with fatal overdose today and what we’re being told today happened six, seven months ago”. A modeling study published in Jama this year found that Millennium Health’s urinalysis data for patients in substance-use treatment could be used to accurately predict overdose deaths.
The CDC only releases data on a past 12-month basis, so it is not possible to pinpoint spikes. Data about what type of drug caused a death, and the demographics of the fatalities, is available, but extremely limited – there is no way to tease out how many deaths were caused by multiple drugs, for example.
The CDC has not yet released data on how death rates among groups hardest hit by the crisis, such as Black and Indigenous men, changed in 2024, and may never do so under new Trump administration policies. When overdose fatalities began to decline in 2023, they were still accelerating among Indigenous, Black, Latino and multiracial populations, according to a June Jama study.
The CDC did not respond to the Guardian’s request for comment.
While the Drug Enforcement Administration (DEA) collects data on the drug supply, it does not share detailed data on information such as drug purity. Publicly available drug seizure data is only available on state and national levels and is currently more than 10 months old. When the DEA does occasionally share alerts and reports, they are often months or years behind new drug supply trends.
In its most recent drug threat assessment report, the DEA announced that the purity of fentanyl was decreasing. Kolodny noted that this decrease in purity is likely related to the lower prevalence of fentanyl in Millennium Health and drug seizure data. “Fentanyl became more expensive for the cartels to manufacture, and so less fentanyl is coming into the United States,” Kolodny said. But these trends do not apply evenly across the country. The DEA would not share regionally specific data on fentanyl purity with the Guardian, or respond to requests for comment.
Public health officials and researchers who spoke with the Guardian said the DEA doesn’t share this type of data with them either. “I don’t know why they don’t,” Jenny Hua, medical director of the Chicago department of public health, said. “I don’t know if it’s a cultural thing.”
“Of course, that data should be more readily available,” Kolodny said, adding that he understands why the DEA might be skeptical of researchers, whose goals don’t necessarily align with those of law enforcement.
While drug seizure data for 2025 is not yet available, 2025 Millennium Health data showed that in states where overdoses began to increase again this year, indicators of fentanyl use were also increasing.
Fentanyl positivity rates both in urinalysis and drug seizure data were most overwhelmingly tied to overdose death rates, but the picture becomes more nuanced when you zoom in on a local level.
In some states, including Ohio, Washington and Oregon, methamphetamine was also closely tied to overdose death rates, according to the Guardian’s analysis.
Data on the drug supply can help inform how to allocate overdose prevention dollars. Many interventions, including naloxone, are exclusively helpful for preventing opioid deaths. Methamphetamine is a stimulant, and stimulant-use disorder requires very different treatment than opioid-use disorder.
Katie Strozyk, who manages the opioid and overdose response program in Thurston county, Washington, said that surveys show many residents primarily use methamphetamine, but it can be difficult for them to find treatment because resources are directed toward opioids. Overdose fatalities increased by 6% between the peak of the crisis and December 2024 in Thurston county.
Overdose prevention is critical
Kolodny said that if overdose prevention was a priority, it would be possible to get more precise data at the local level much closer to real time. Some US counties are already demonstrating that this is possible. In Cook county, Illinois, for example, drug death toxicology reports can be available within less than a month.
Chicago has also ramped up its tracking of the drug supply and other overdose-related information, such as ambulance data, in order to pinpoint overdose spikes at a neighborhood level and understand why they are happening.
But in most of the country, this type of timely and hyper-local response is not happening. Strozyk of the Thurston county, Washington, opioid response program said officials they “may or may not ever know the underlying cause” of a local uptick in overdoses, so they focus on a proactive approach.
Hua said there are many factors beyond the control of health departments that influence death rates. It is easier to have a coordinated response in a big city, where people and resources are concentrated. Changes to the drug supply are also affecting different regions differently.
A spokesperson for the Georgia department of public health also said they lack local data.
Catoosa county, Georgia, saw an 120% increase in overdose deaths since the national peak, the highest among counties with data available in the Guardian’s analysis. Meanwhile, Dougherty county, Georgia, saw one of the largest decreases, by 74%. There is “no clear cause” for the disparity in the statewide data, the spokesperson said. “This is an example of why evolved surveillance and data-sharing strategies are critical to providing local partners with the information they need to focus their efforts on specific counties, populations and overdose risk factors.”
Kolodny says it is important to understand why deaths are increasing in certain states, noting that most of these states have high rates of methamphetamine use. “In methamphetamine states, you have a lot of people who are addicted to both drugs [methamphetamine and fentanyl],” Kolodny said, “Maybe there’s an increase in purity of methamphetamine that’s causing you more deaths. That’s hard to tease out.”
A spokesperson for the Medicaid office in Arizona, where overdoses reached near peak rates in 2025, said the rise “is driven largely by synthetic opioids, especially fentanyl, which is increasingly found in combination with stimulants such as methamphetamine. These drug combinations complicate overdose response and increase lethality.” The spokesperson said Arizona faces unique challenges, including “proximity to major trafficking routes”, and that the state was leveraging CDC funding to analyze drug paraphernalia and identify emerging drug threats, and was also working to link more people to substance use treatment.
The Guardian’s analysis of Millennium Health data found that the more you zoom in, the more specific trends emerge. In Cook county, there is a much stronger association between cocaine-positive urine samples and overdose deaths than in any state level data. Fentanyl is also associated with overdose deaths in Cook county. Hua’s team is already responding to cocaine’s popularity in the city.
“Whether it’s meth or cocaine, we treat these as stimulant-use disorders,” Hua said. As part of this focus, the health department has formed a partnership with Northwestern University to provide “contingency management” – a highly effective treatment strategy in which patients are rewarded for abstaining from drug use.
According to Kolodny, one of the reasons that the crisis became so alarming is because the focus is on deaths, rather than prevention.
A crisis of addiction
While death and drug supply surveillance in the US is lacking, there is even less good data on addiction, said Kolodny. “It’s very, very rudimentary, and it was completely useless until a couple of years ago. It’s called the National Survey on Drug Use and Health, so you can extrapolate from about 70,000 face-to-face interviews, but that’s not adequate.”
In Portugal, there is an agency devoted to tracking and intervening in addictive behaviors. The agency aggregates data from health agencies, law enforcement, population surveys and even drugs found in wastewater analysis to get a full picture. Portugal’s per capita overdose death rate is less than 1/30 of that in the US.
The US national survey is conducted by SAMHSA, an agency whose future under the Trump administration is uncertain. New rules that will require Medicaid recipients to work 80 hours a month could also compromise patients’ ability to access treatment – it can be very difficult to work while in intensive substance-use recovery. These rules will go into effect in 2027 under the One Big Beautiful Bill Act, signed into law in July.
Deaths should be considered a symptom of the crisis, not the main outcome, Kolodny explained. “At the height of the Aids crisis, tens of thousands of people were dying from PCP pneumonia,” he said, “If you had Aids, it knocked out your immune system, you got this type of pneumonia.”
But, Kolodny continued: “We didn’t approach the Aids crisis by calling it a PCP pneumonia epidemic. We realized it was HIV, an infectious disease that can be prevented through clean syringes and condoms, and it can be treated with antiretroviral therapy. But for the opioid crisis,” he said, we have it backwards. “This is a crisis of addiction: if you really understand that most of these deaths are occurring in people who are addicted, not people saying, ‘Hey, shooting up fentanyl would be a fun way to spend a Friday night.’ It’s people who are really struggling.”
Contributors
Visuals: Andrew Witherspoon
Data editing: Will Craft
Copy editing: Rusha Haljuci
Illustration: Angelica AlzonaThis article was produced as a project for the USC Annenberg Center for Health Journalism’s 2025 Impact Fund for Reporting on Health Equity and Health Systems
