What’s behind the decrease in overdose deaths?

The stats: In the 12 months ending April 2024, there were an estimated 101,168 overdose deaths, a 10% decrease from the prior 12 months.

Why it’s important: This is a huge reversal from recent years, when overdose deaths regularly increased by double-digit percentages.

BUT:

• The number of overdose deaths is still higher than it was before the pandemic, and over 100,000 overdose deaths is still a high toll.
• The decreases are not shared evenly among states or racial/ethnic groups. Overdoses are still increasing in some states, and Black and Native American/Alaska Native individuals have been seeing increases or smaller decreases than White individuals in many instances.
• The data is preliminary and lags by around six months.
• It is not clear what may be driving the decrease or if the decrease will be sustained or just a blip.

An analysis of state data on overdose deaths, emergency department visits and calls to emergency medical services confirms the national trend showing a decrease in overdose deaths.

Why is this happening?: There are many theories on what may be causing the decline, some more plausible than others.

1. Increasing drug treatment: We wish, but unlikely

Last year, the federal government eliminated the extra licensing requirement (X waiver) for prescribing buprenorphine. But there has been no change in the number of patients receiving buprenorphine, despite an increase in eligible prescribers.

In February, the Substance Abuse and Mental Health Services Administration (SAMHSA) made permanent the COVID-era flexibilities allowing greater access to methadone take-home doses. But methadone clinic practices are getting more restrictive (see article #2 below).

2. Increased naloxone distribution: Plausible but need more information

Major scale-ups of naloxone distribution plans were implemented in 2022 and 2023, and naloxone nasal sprays became available over-the-counter in 2023. But implementation has varied across states, and naloxone is still hard to find and expensive.

3. Law enforcement operations: Unlikely

There has been an increase in federal law enforcement efforts and drug seizures at the border in the past couple of years. But most seizures have been of methamphetamine and marijuana, and interdiction efforts can lead the drug supply to become more adulterated and dangerous, which may increase overdoses.

4. Drug trafficking organization changes: Too soon to say

The Sinaloa Cartel announced last year that they would stop shipping fentanyl to the U.S., and U.S. authorities captured two senior members of the cartel this year. But fentanyl has likely not stopped flowing, and other drug trafficking organizations may just replace any decrease in supply.

5. Reduced risk among people who use drugs: Plausible but complex

People who use drugs increasingly are developing tolerance to fentanyl. This could help explain why the decrease in overdose deaths has been slower in West Coast states, where fentanyl was introduced more recently and tolerance has not caught up to risk.

6. Marijuana legalization: Highly unlikely

While it could seem like marijuana legalization may offer some people who use opioids an alternative, studies have not shown an association at the population level. And the reduction in overdoses does not seem to follow the geographic pattern of marijuana legalization.

7. Xylazine: Potentially

Xylazine can have horrible effects (e.g., wounds), but it seems to make opioids last longer, leading people to need to use drugs fewer times in a day — i.e., less opportunities to overdose. When some of the fentanyl is replaced by xylazine in the drug supply, it may reduce overdose risk. Xylazine contamination may also be pushing some to use different routes of administration (smoking, snorting vs. injection) or to stop using drugs. This hypothesis aligns with the geographic trends of overdose declines.

8. Changes in routes of administration and pricing: Plausible

People who use drugs have been switching from injecting to smoking. This may reduce overdose risk because they are exposed to less fentanyl per drug use episode.

The cost of drugs has dropped in the past couple of years, and the availability of drugs has increased. This may lead to fewer instances of withdrawal, reducing the risk of lowered tolerance and overdose.

The main point: There is no silver bullet to ending the overdose crisis.

• There is no single obvious answer on what has caused the decrease or if it will last.
• While a decrease in overdose deaths is good news, a lot more progress is needed.
• Imagine how many more lives could be saved if treatment rates increased!

Source: U.S. overdose deaths plummet, saving thousands of lives (NPR)

State and OTP choices could limit impact of methadone rules overhaul

What’s new: Earlier this year, the Substance Abuse and Mental Health Services Administration (SAMHSA) made permanent COVID-era changes making it easier for methadone patients to take their medication at home.

• Under previous rules, many more patients had to visit an opioid treatment program (OTP) daily to receive the medication.
• Clinics must comply with the new rules by Oct. 2, unless they are in a state with more restrictive regulations.

Why it’s important: This first big update to methadone regulations in 20 years could expand access to treatment, but it could fall flat if state governments and methadone clinics fail to act.

The details:

• Some states (e.g., Colorado, New York, Massachusetts) are updating their rules to align with the new federal flexibilities.
• But others are not, including West Virginia and Tennessee, the states with the highest overdose death rates. A Tennessee proposal would increase random urine drug screening, make counseling mandatory for many patients and require clinics to hire pharmacists if they want to dispense take-home doses.
• Clinics have broad discretion to decide who qualifies for take-home doses. Money is likely to play a role, as payments to clinics are sometimes tied to in-person dosing.
• For example, in Arizona, clinics get $15 per in-person dose from Medicaid vs. $4 per take-home dose. The state is considering making those amounts equal or adopting bundled payment to reflect the overall cost of treatment. New York’s Medicaid program uses bundled payment, reducing the financial incentive for in-person dosing.
• Some clinic leaders may disagree with the philosophy behind the changes, some may balk at the legal liability, etc., potentially making the changes difficult for clinics even in states that adopt the rules.

The new federal rules also (in states that adopt them):

• Eliminate the requirement for patients to demonstrate a one-year history of opioid use disorder before starting treatment
• Allow counseling to be optional instead of mandatory
• Allow telehealth to assess patients
• Allow nurse practitioners and physician assistants to start people on methadone (rather than only physicians)

Source: US will let more people take methadone at home (Associated Press)

HHS updates on family caregiver strategy

What’s new: The Department of Health and Human Services (HHS) delivered a progress report on federal implementation of the 2022 National Strategy to Support Family Caregivers.

• The strategy includes commitments from 15 federal agencies to nearly 350 actions to carry out recommendations for ensuring that family caregivers have the support and resources they need.

The details: The strategy is much broader than family caregiving for those with addiction, but some agencies have taken action to support individuals caring for those impacted by mental health or substance use:

• ASPE (the HHS Office of the Assistant Secretary for Planning and Evaluation) completed a research project examining the needs of family caregivers of adults with behavioral health or substance use disorders, set to be released this year.
• SAMHSA (the Substance Abuse and Mental Health Services Administration) hosted a Family and Caregiver Technical Expert Panel, which recognized the stigma and challenges families face when taking care of family members with mental health/substance use disorder.
• SAMHSA provides Statewide Family Network grants to enhance the capacity of statewide mental health family-controlled organizations to engage with family members who are raising youth and young adults with serious emotional disturbance (SED) and/or co-occurring disorders.
• SAMHSA is developing a curriculum to provide peer support for caregivers during emergency situations.
• SAMHSA and ACF (Administration for Children and Families) hosted webinars about substance use and its effect on child welfare, substance use and caregivers, and providing care for a child with SED.
• ACF issued a rule allowing child welfare agencies to use separate licensing/approval standards for foster family homes of relatives/kin and requiring equal foster care payments for these homes.
• ACF Children’s Bureau has created online resources about kinship caregiving, has funded kinship navigator programs in all states and has a program to build evidence for kinship navigator programs. It holds webinars with states highlighting best practices and has funded development of a national training curriculum for foster and adoptive parents and kinship families.
• The Department of Education amplifies messages that can help keep family caregivers, grandparents and other relatives raising children informed about available services.

Source: HHS Releases Progress Report on Federal Implementation of the National Strategy to Support Family Caregivers (Department of Health and Human Services)