Drug deaths in America, which fell for the first time in 25 years in 2018, rose to record numbers in 2019 and are continuing to climb, a resurgence that is being complicated and perhaps worsened by the coronavirus pandemic.
Nearly 72,000 Americans died from drug overdoses last year, according to preliminary data released Wednesday by the Centers for Disease Control and Prevention — an increase of 5 percent from 2018. Deaths from drug overdoses remain higher than the peak yearly death totals ever recorded for car accidents, guns, or AIDS, and their acceleration in recent years has pushed down overall life expectancy in the United States.
It looks as if 2020 will be even worse. Drug deaths have risen an average of 13 percent so far this year over last year, according to mortality data from local and state governments collected by The New York Times, covering 40 percent of the U.S. population. If this trend continues for the rest of the year, it will be the sharpest increase in annual drug deaths since 2016, when a class of synthetic opioids known as fentanyls first made significant inroads in the country’s illicit drug supply.
The 2018 decline was largely explained by reductions in deaths from prescription opioid medications, the drugs that started the nation’s addiction epidemic back in the 1990s. But those declines appear to have been overrun by continued increases in deaths from illicit drugs, particularly methamphetamine, cocaine, and fentanyl.
President Trump made much of the slight decrease in overdose deaths in 2018, pointing to his administration’s efforts to expand addiction treatment and restrict the drug supply. Mr. Trump and Congress have provided several billion dollars in grants to states since 2017 for treatment, prevention, and recovery services, expanding access to buprenorphine treatment in particular. But at the same time, the administration has continued fighting in court to overturn the Affordable Care Act, a law that has allowed states to expand Medicaid and provide free addiction treatment to low-income adults.
Many local officials have also worked hard to reduce drug use, prevent overdose deaths and help get more drug users into recovery. Naloxone, an overdose-reversing medication, has been broadly distributed in recent years. Syringe exchange programs have been expanded, as well as coverage of addiction treatment through state Medicaid programs. States have also moved to limit prescriptions of opioid medications. But drug deaths have still reached a record high.
Brad Finegood, the strategic adviser on opioids and other drugs for the Seattle and King County Public Health Department, said his office had invested substantially in reducing overdose deaths from opioids, particularly by getting more opioid users access to medication-assisted therapies. He said he was saddened to see rising deaths from overdoses, particularly among people who are using both opioids and stimulants like methamphetamine. “Without some of the work that’s gone on, like medication-assisted therapy expansion, there’s fear that the problem would be that much worse,” he said.
On Wednesday, Brett Giroir, the administration’s assistant secretary for health, said in a statement, “We understand that there is an extraordinary amount of work to do, especially now as we are also dealing with the Covid-19 pandemic that could markedly affect our nation's mental health and risk of substance use.”
Several public health experts said conditions created by the pandemic could hurt the nation’s fragile progress in fighting the surge of drug deaths, but noted that the overdose rate was on its way back up well before the virus arrived. “Covid just makes it a bit worse,” said Dr. Dan Ciccarone, a professor of medicine at the University of California, San Francisco, who studies the opioid epidemic. “It's a small wave riding on top of a tsunami that continues to devastate.”
Fentanyl is Moving West
Fentanyl had been confined mostly to New England and other parts of the East, where it was generally found as an adulterant in powdered heroin. But in recent years, fentanyl and other potent synthetic opioids have been blamed for an increasing number of overdose deaths in California, Arizona, and other Western states.
Most of the heroin in the Western United States is in a form known as black tar: a sticky substance that is less easily combined with powdered adulterants like fentanyl. For the most part, this has kept fentanyl out of the heroin supply in the West. But, according to the Drug Enforcement Administration, increasing numbers of counterfeit pills containing fentanyl — often falsely marketed as oxycodone or other opioid painkillers — are appearing in these states, contributing to a surge in overdoses.
In addition, according to Alex Kral, an epidemiologist at RTI International, a nonprofit research firm, many opioid users are turning to fentanyl intentionally, using it to supplement or entirely replace heroin. Nationally, there are now fewer deaths involving heroin than either meth or cocaine, a striking change that has taken place over the last two years as heroin has all but disappeared from some regions.
Fentanyl deaths are also increasing in several states that had experienced reductions in overdose deaths overall in 2018. Much of the national decline in 2018 came in Ohio, Florida, and Pennsylvania, all states with fentanyl in the opioid supply. Deaths in Ohio and Florida rebounded in 2019.
Some cities continued to see a rise in fatal overdoses among Black and Hispanic residents last year. In St. Louis and adjacent St. Louis County, opioid-related deaths rose by 17 percent among Black men even as they dropped by 8 percent overall. And in Philadelphia, where overdose deaths among white people fell by 3 percent in 2019, they rose by 14 percent among Black people and by 24 percent among Hispanic residents.
Methamphetamine Deaths Are On The Rise
Meth use first spread in the United States in the 1990s and into the early 2000s, when it was often cooked in small home labs with pseudoephedrine, the main ingredient in many drugstore cold medicines. But today’s meth, largely imported from Mexico, is far more potent. It is increasingly mixed with fentanyl, sometimes without the user realizing it, or used to counteract fentanyl’s depressant effects. Some researchers say the combination may be particularly deadly, although they have yet to reach definitive conclusions.
Deaths involving meth, once concentrated in the Western states, have been moving eastward, even to regions like New England that meth once barely touched. And unlike with opioids, there is no way to reverse the effects of a meth overdose, just as there is no medication to treat meth use and the cravings it creates.
“Over the past year and a half, we’ve seen an increase in meth use, particularly among people who also inject opioids and are experiencing homelessness,” said Dr. Sarah Wakeman, an addiction medicine doctor at Massachusetts General Hospital in Boston.
The Pandemic is Complicating the Response
Because drug-related deaths take a particularly long time to confirm, the 2019 provisional data is the most recent available at the national level, and it won’t become final for several months. But more recent local evidence shows drug deaths continuing to rise. Provisional mortality data collected by The Times shows rising drug-related deaths across the country well into 2020.
In New Jersey, where drug-related deaths had leveled off, overdose deaths in the first half of 2020 were 17 percent higher than in 2019. In Colorado, they were up by 30 percent through March.
Counties across the country show similar spikes: up 35 percent in Los Angeles; 32 percent in Milwaukee; 20 percent in Harris County, Texas, home to Houston.
Much of this data predates the coronavirus pandemic and the resulting social disruptions. But researchers pointed to several reasons they believe the virus could be worsening the trend.
When state lockdowns first began in March, Dr. Anna Lembke, a clinician with Stanford’s Addiction Medicine Dual Diagnosis Clinic, noticed improvements for many of her patients. “Many patients described a kind of peacefulness without the constant hubbub of modern life and the constant triggers they’re exposed to,” she said.
As part of the public health emergency, the federal government did something unheard-of: It relaxed rules around prescribing methadone and buprenorphine, two common and effective treatments for opioid use disorder. Methadone clinics are now free to dispense up to four weeks’ worth of the medication at once rather than requiring daily visits, and doctors are no longer required to meet with a patient in person before prescribing buprenorphine. The loosening of rules requiring mental health visits to be held in-person has also expanded access to counseling, several researchers said.
The changes were celebrated by the public health community, according to Ricky Bluthenthal, a professor at the Keck School of Medicine at the University of Southern California: “Making these medications more widely available is huge. That’s a real thing.”
But as weeks turned to months and people remained isolated, he and others said, the lockdown began to do more harm than good for many who struggle with addiction.
“Social isolation has always been a huge component of drug overdose risk,” said Traci Green, an epidemiologist at Brown University who studies drug abuse and addiction. “So much of what we’ve been trying to do has been completely unraveled.”
The isolation of quarantine comes with practical dangers as well. Using drugs alone is much more dangerous than doing so with others, since there is no one around if a revival attempt is needed. And with in-person treatment vastly curtailed — including visits with doctors or nurses, frequent group counseling sessions, and stays at residential treatment centers — there is far less of the emotional support that can be vital to addiction treatment.
“Way too many residential programs just shut their doors and left patients with no safety net,” said Percy Menzies, the president of Assisted Recovery Centers of America, an outpatient treatment center for alcoholism and drug addiction based in St. Louis.
Another possible factor is that drug users have not been able to maintain their normal consumption habits during the pandemic, either because they have lost income and can no longer afford to buy drugs as often or because their local supply has been disrupted. Less use would lead to lower tolerance, putting people at much higher risk of overdosing when they do get access to drugs.
“If there’s no way to make money, your use goes down and your tolerance goes down,” said Dr. Josiah Rich, a professor of medicine and epidemiology at Brown. “But if the economy opens a bit and you get some resources, maybe a stimulus check, you might try to use the amount you used to. And you don’t have the tolerance to handle it.”
With the pandemic disrupting treatment centers, syringe exchanges, and other places that help people with drug addiction, there may also be less naloxone — the overdose-reversing medication that has brought back thousands from the brink of death — on the streets. And there is at least anecdotal evidence that with the nation’s borders closed because of the pandemic, the illicit drug supply has been disrupted and has become less predictable. Constant changes in potency make it harder for people to judge the strength of the drugs they’re using.
“The inconsistency of our drug supply right now is at an all-time high,” said Chad Sabora, the co-founder and executive director of the Missouri Network for Opiate Reform and Recovery.
Patrick Trainor, a spokesman for the Drug Enforcement Administration in Philadelphia, which has had one of the highest overdose death rates in the country in recent years, said there had been slight increases in the price of street drugs during the pandemic. Yet supply there has not dropped.
“It’s indicative the drug trafficking organizations had a plentiful supply to begin with, and there’s some thought they are artificially driving prices up,” he said. But as to whether overdoses are increasing because of the pandemic, Mr. Trainor said, “Nobody has hard data yet; they just don’t.”