Is America’s opioid epidemic finally burning out?

Standing in the bitter cold outside the DeCoach Recovery Centre, a drug treatment clinic on the edge of an ocean of car parking in Hamilton, Ohio, Scott Weaver explains where his life went off track. First, he says, about ten years ago he was in a car wreck. “I started taking pills”, he explains, “but I wasn’t hooked on them at that time.”

Mr Weaver’s story reflects America’s opioid crisis. Having begun in earnest two decades ago with the overprescription of pain pills by pharmaceutical companies, it escalated through heroin and now to fentanyl, a synthetic opioid so potent that 0.2% of a gram can kill. Over a million Americans have died from overdoses since the turn of the century; 108,000 of those deaths were in 2022 alone.

And yet there is reason to think that the tide may be turning. Data published by the Centres for Disease Control and Prevention, a government agency, suggests that nationally, deaths peaked around August last year. In the 12 months to July this year, there were 90,000 deaths—still an appalling total, but a reduction of around a sixth (see chart). Could America be nearing the point where it is, as Mr Weaver might put it, “done” with opioids?

No one is exactly sure why deaths might have started falling. “We’re all speculating at this point,” says Daniel Ciccarone, a professor in addiction medicine at the University of California in San Francisco. Data on the number of people taking opioids is scarce, as is data on prices and purity.

Addiction treatment has been expanding for years. But the drop in deaths is too sudden and too widespread (almost all states have experienced it) to be primarily down to this. There has been no dramatic increase in prescriptions of anti-addiction drugs, either. More naloxone kits (an injection which can reverse an overdose, first approved under the brand name Narcan) are being distributed. That must be helping, but also cannot explain the drop.

One possibility is a supply shock. According to the Drug Enforcement Administration, which polices drug smuggling, the amount of fentanyl in pills they intercept has fallen. Some reports suggest the Sinaloa cartel, a huge Mexican organised-crime group, has stepped back from smuggling fentanyl because of American pressure. In July two high-ranking members, including the son of El Chapo, one of Sinaloa’s founders, were arrested after being tricked into travelling to America.

This cause-and-effect is difficult to prove. Professor Ciccarone says the suddenness of the improvement makes it plausible; others are less convinced. “Nobody has any basis for assigning a cause to that drop,” said Peter Reuter, a researcher in drug markets, at a conference on December 4th.

Another possibility is that the decline represents a return to pre-pandemic norms. When covid-19 hit, opioid overdoses soared. It is hard to say why, but feels intuitive: hospitals were full of covid patients, many treatment centres had shut, and more people were experiencing the sort of traumatic losses that can make them turn to opiates. If this is the primary reason, the current decline will level off, and seems unlikely to keep falling.

If this is instead a sustained drop, look to a third explanation. Though deaths have fallen in most of the country, the steepest improvements have been in places that were hit especially early, particularly in Appalachia and the Midwest. In Ohio, which covers both regions, the number of deaths dropped by a quarter in the year to July, the second biggest improvement of any state (North Carolina’s was even steeper).

The epidemic may simply be “burning out”, suggests Professor Ciccarone. The theory is that the most vulnerable have already died, those left behind understand the danger, and so new addicts do not replace them.

For a sense of why this is plausible, a visit to Butler County, Ohio—of which Hamilton is the seat—is instructive. The county (where J.D. Vance, the vice president-elect, grew up) is a sprawl of farmland and industrial towns north of Cincinnati. It was also early to the opiates boom (in the 1990s Mr Vance’s mother, who worked as a nurse, was among the first to get addicted to pain pills). Now, it is among the places improving fastest.

So far this year, there have been 88 fatal overdose deaths in the county, down from 130 last year,according to the coroner. In 2017, the county’s worst year on record, there were 236. “We never thought we would see this drop this fast,” says Jordan Meyer, an epidemiologist at the county’s health district, which distributes Narcan kits and fentanyl testing strips. That must have helped. But the biggest change in the county is how drug users are behaving.

“It’s fear,” says Dave Hawley, the clinical supervisor at River Rocks Recovery, a treatment centre in Middletown. With the rise of fentanyl, “it’s not about riding the edge any more.” In a place like Middletown, almost everybody will know somebody who has died of an overdose recently, he says. Much more so than heroin, or pilfered opiate pills, fentanyl is deadly. Even hardened addicts can easily overdose.

Users are increasingly aware of this, and even those shunning treatment are taking precautions. A few years ago the main way to take fentanyl was by injecting it. Now addicts are taking pills or smoking it, which can make it easier to control the dose. Xylazine, a veterinary sedative, is also increasingly mixed with fentanyl into a potent cocktail known as “tranq”. Tranq comes with awful costs—injecting it can lead to flesh-rotting infections—but curiously it may be helping some users to avoid taking too much.

According to Mr Hawley, many fentanyl addicts have switched to taking methamphetamine. This is used either as a straight substitute or to help ease withdrawal or overcome cravings. Meth is extremely unhealthy. But in the short term, it is cheap and lasts a long time, and the overdose risk is smaller; if you are in opioid withdrawal, it can give you the energy to go to work. Of the fentanyl overdoses still happening in Butler county, over half now also include methamphetamine. Awful as meth is, a lower death rate means more addicts might eventually get clean.

The idea that an epidemic can rise and then burn out, almost independently of the resources that flood into treatment or enforcement, is an uncomfortable one. But it has happened before: the European heroin epidemic of the 1980s and 1990s has not returned. And if this is what is happening with opioids now, the fall in deaths might, most promisingly, be sustained. Memories last longer than funding streams or police successes. At the treatment centre in Hamilton, Mr Weaver says he too thinks people have learned from the awful experience of the past few years. “It’s just more people who want to get their lives back together”, he says. For a while, drugs seemed to offer an escape from the monotony and trauma of daily life. But fentanyl was, perhaps, just too much.

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