Are U.S. Overdose Deaths Really Declining?

By Pat Anson

Preliminary data from the CDC suggest that U.S. overdose deaths have declined significantly, falling by 10% in the last year alone. If confirmed, the double-digit drop would mean there were 11,247 fewer drug deaths in the 12-month period ending in April 2024.

The decline, first reported by NPR, was hailed by addiction and public health experts as a hopeful sign that progress is finally being made in reducing the number of drug deaths, which have doubled in the past decade to over 100,000 a year.

“This is exciting," said Dr. Nora Volkow, director of the National Institute on Drug Abuse. "This looks real. This looks very, very real."

Good news, if it’s true. But caution is warranted about how “real” the decline is, because preliminary death data often changes as more information comes in.

Overdose data is fragmented in both quality and quantity, as it comes from 50 different sources. The data is collected by each state and then submitted to the CDC to decipher for its monthly Provisional Drug Overdose Death Count.

Some states still do not use toxicology tests to confirm whether a death is drug-related – leaving it up to medical examiners and coroners to decide which drugs, if any, may have played a role in someone dying. Some elected coroners, particularly in rural counties, have no medical training or expertise in drug death investigations. And in many cases, autopsies are not performed.

In addition to the wide variability in expertise and data collection, overdoses are typically not reported to the CDC until four months after the date of the death, sometimes longer. In its most recent provisional count, the CDC acknowledged that its overdose data may underestimate the actual number of deaths.

“Some states may have longer than usual delays in submitting drug overdose deaths. In particular, North Carolina is experiencing substantial delays in the resolution of pending records by the medical examiner’s office. Recent trends may underestimate the death count in affected states and this potential impact should be considered when comparing results for states to previous months,” the CDC said.

Percent Change in Drug Overdose Deaths (April 2023 to April 2024)

SOURCE: CDC

Reported vs Predicted

Because the provisional counts are often incomplete and the causes of many deaths are “pending investigation,” the CDC maintains two different data sets. One is the number of “reported” cases, and the other is the “predicted” number of deaths. The latter is where the 10% decline comes from.

The number of reported drug deaths is even lower than the predicted ones, suggesting there has been a 12.2% decline in overdoses nationwide. But that number is also misleading because it is based on incomplete data.

Take North Carolina, for example. For the most recent 12-month period ending in April, North Carolina reported 2,512 drug deaths, compared to 4,317 overdoses from the year before. That’s a whopping decrease of nearly 42 percent!

No one believes that number is real and will hold up over time. Not even Nora Volkow.

North Carolina is not an outlier. Reported drug deaths in Nebraska are down nearly 30 percent, but the data from there is considered “underreported due to incomplete data.” The same is true for Ohio, Pennsylvania and Michigan, where reported drug deaths are down about 20 percent. Big states like that can sway nationwide estimates.

Meanwhile, reported drug deaths are up in several western states: +42% in Alaska, +15% in Oregon, +13% in Nevada, +10% in Washington and +7% in Utah. It’s hard to square those numbers with any national trend.

“Utah’s trends haven’t aligned with national trends for some time. We plateaued while overdoses increased significantly at the national level, especially during the pandemic,” Megan Broekemeier, an overdose research coordinator for the Utah Department of Health and Human Services, told the Deseret News. “We haven’t seen statistically significant changes in the rate yet.”

‘The Dip in Overdoses Is Real’

To be fair, some of the overdose-related data is encouraging and suggest that drug deaths are in fact declining.

In a blog that tracks health data trends, Nabarun Dasgupta, PhD, a drug researcher and scientist at the University of North Carolina, reported a nationwide drop in ER visits and EMS calls (ambulance runs) involving overdoses. He estimates that non-fatal overdoses have fallen -15% to -20% nationwide

“A 15-20% decrease in non-fatal overdose and a 10% decrease in fatal overdose is a major impact. There is barely any public health intervention that has credibly achieved this magnitude of decrease,” wrote Dasgupta. “Our conclusion is that the dip in overdoses is real, and not a data artifact. It remains to be seen how long it will be sustained.”

Dasgupta attributes the decline to several possible factors, such as wider access to the overdose recovery drug naloxone and increased law enforcement seizures of illicit fentanyl.

He does not think the decline in opioid prescribing has anything to do with the drop in overdoses. Deaths linked to opioid pain medication have remained flat for nearly a decade, even as prescribing levels fell to 20-year lows.

“Let's put one hypothesis to rest: Reductions in opioid analgesic prescribing is not driving the changes in overdose rates. We've studied it, and that's not what is driving current fentanyl overdoses,” says Dasgupta.    

The CDC has a checkered history when it comes to tracking overdose deaths. When the agency released its controversial 2016 opioid guideline, it laid the blame for rising overdose deaths squarely on opioid analgesics.

“Overprescribing opioids – largely for chronic pain – is a key driver of America’s drug overdose epidemic,” said then-CDC director Dr. Thomas Frieden, a claim based on weak evidence and false assumptions.

Two years later, after millions of pain patients had their opioid doses reduced or cutoff, the CDC admitted that illicit fentanyl was driving the overdose crisis and that it mistakenly classified many fentanyl deaths as overdoses caused by prescription opioids.The death toll from prescription opioids in 2016 was nearly cut in half — from 32,445 down to 17,087 — when the deaths were reclassified as fentanyl-related.

The CDC says its data collection and analysis have improved in recent years, but they still come with a disclaimer that the monthly provisional counts “may not include all deaths that occurred” and are “subject to change.”

"I think we have to be careful when we get optimistic and see a slight drop in overdose deaths," said Dan Salter, Director of the North Carolina Office of National Drug Control Policy, told NPR. "The last thing we want to do is spike the ball."

Fatal Overdoses Show First Decline in 5 Years

By Pat Anson, PNN Editor

There’s good and bad news in the latest report on the overdose crisis in the United States.

Preliminary data released by the CDC show that there were an estimated 107,543 drug deaths in 2023, a 3.1% decline from 2022 and the first annual drop since 2018. The rate of confirmed overdoses fell even more -- by 5.1 percent – a number subject to change as lagging data and toxicology reports come in.

“We are encouraged to see the preliminary data that shows a decrease in the overdose death rate for the first time in five years, especially following the period of rapid double-digit increases from 2019-2021,” said White House Drug Control Policy director Dr. Rahul Gupta, in a statement.

That’s the good news.

The bad news is that drug deaths kept rising in several western states, with Alaska (+44%), Nevada (+29%), Oregon (+30%) and Washington (+28%) showing substantial increases.

In contrast, overdoses declined in the East and Midwest, with significant decreases in Nebraska (-25%), Indiana (-18%), Kansas (-16%) and Maine (-16%).

The report did not offer any explanation for the wide variation between states and regions.

Percent Change in Drug Overdose Deaths 2022-2023

SOURCE: nchs

The National Center for Health Statistics (NCHS) said over 74,000 deaths last year involved fentanyl – most of it illicit – and more than 36,000 deaths were attributed to methamphetamine.

Most overdose deaths involve multiple drugs, according to the NCHS, so “a single death might be included in more than one category” and be counted multiple times.

Although the numbers remain somewhat unreliable, this report and others suggest that fentanyl and other illicit drugs play a far greater role in the nation’s drug crisis than prescription opioids.

A study published this week in the International Journal of Drug Policy reported that law enforcement seized a record 115 million counterfeit pills containing fentanyl last year. That compares to only 4 million prescription opioid pills that were reported lost or stolen by the DEA in 2023.   

Fake Pills Containing Fentanyl Seized by Law Enforcement

International Journal of Drug Policy

“Availability of illicit fentanyl is continuing to skyrocket in the U.S., and the influx of fentanyl-containing pills is particularly alarming,” wrote lead author Joseph Palamar, PhD, an Associate Professor in the Department of Population Health at the NYU Grossman School of Medicine.

“Both the number and size of drug seizures containing fentanyl have increased in the US between 2017 and 2023, with the majority of seizures –– particularly in pill form –– occurring in the West.”

Prescription opioids are mentioned only a handful of times in the DEA’s recent National Drug Threat Assessment, mainly within the context of their theft and diversion falling to the lowest levels in 12 years. That report also warns that counterfeit pills are increasingly being found with xylazine, a potent animal tranquilizer, and nitazenes, a synthetic opioid that is 40 times stronger than fentanyl  

Fentanyl Linked to 94% of Overdose Deaths in Massachusetts

By Pat Anson, PNN Editor

There’s good and bad news in the latest report on overdose deaths in Massachusetts. State health officials say drug deaths were down slightly in the first nine months of 2022, compared to the same period last year. But deaths involving fentanyl – most likely illicit fentanyl -- rose to 94% of opioid-related overdoses, a record high.

Massachusetts was one of the first states in the U.S. to expand the use of toxicology tests to look for the presence of certain drugs involved in opioid overdoses, instead of just relying on death certificates and coroner reports. That makes its overdose data more accurate.

In the first nine months of 2022, there were 1,340 confirmed opioid-related overdose deaths in Massachusetts, and officials expect that to reach about 1,696 deaths by the end of the year. That’s 25 fewer deaths than in 2021, a decrease of 1.5 percent.

Nationally, drug overdose deaths also appear to be slowing. The CDC estimates there were 107,735 U.S. overdose deaths in the 12-month period ending in July 2022, down from over 110,000 deaths in the 12-month period that ended in March, 2022. Illicit fentanyl, a synthetic opioid about 50 to 100 times more potent than morphine, is involved in the vast majority of those deaths.

Deaths in Massachusetts involving a fentanyl have been rising for over a decade, from nearly 42% of opioid-related overdoses in 2014 to 94% this year. Over that same period, deaths involving prescription opioids such as oxycodone and hydrocodone have steadily declined from about 35% to 11% of overdoses in 2022.

More people are now dying in Massachusetts after ingesting fentanyl, cocaine, alcohol or benzodiazepines such as Xanax than from pain medication. Deaths linked to opioid medication fell by 30% in just one year, which coincides with a steep decline in prescriptions in Massachusetts over the past decade.   

Drugs Involved in Massachusetts Opioid-Related Overdose Deaths

Massachusetts Department of Public Health

“Every life lost to opioid overdose is its own tragedy,” Public Health Commissioner Margret Cooke said in a statement. “With this report, we are encouraged by the decrease, however modest, in opioid-related overdose deaths in Massachusetts so far this year. We will continue to build on our data-driven and equity-based public health approach as we address the impacts of the opioid epidemic and the COVID-19 pandemic, especially among vulnerable populations.”

Health officials say the illicit drug supply in Massachusetts is “heavily contaminated” with illicit fentanyl, which is frequently used in the manufacture of counterfeit medication sold on the street.

Pharmaceutical fentanyl is used as a surgical analgesic and in patches and lozenges to treat severe pain, but only small amounts are diverted for abuse. The DEA estimates that only 0.01% of prescription fentanyl is diverted for use by someone it was not intended for.

It's important to note that the presence of a drug found in a toxicology screen doesn’t mean it was the cause of someone’s death. Multiples substances are frequently involved in opioid overdoses, and the official cause of death is a clinical decision made by coroners and medical examiners.

Toxicology tests alone also don’t reveal if a prescribed drug was intended for the decedent, or if it was bought, stolen or borrowed by them. An earlier study of drug deaths in Massachusetts found that only 1.3% of overdose victims had a prescription for the opioid medication involved in their deaths.

The vast majority of patients prescribed opioids use them responsibly and don’t go doctor shopping. The Massachusetts Department of Public Health estimates that only 0.6% of patients who were prescribed an opioid this year had an “activity of concern,” such as getting prescriptions from multiple providers or having them filled at multiple pharmacies.

Computer Algorithms Improve Timeliness of Overdose Data

By Pat Anson, PNN Editor

An automated process using computer algorithms to analyze death certificates would speed up and improve data collection on drug overdose deaths, according to a new study by UCLA researchers.

The current system used to track U.S. overdose deaths relies on medical examiners and county coroners – including some with little medical training -- to determine the cause of death and drugs involved. Death certificates are then sent to local jurisdictions or the Centers for Disease Control and Prevention, which codes them according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10).

The coding process is manual and time consuming, resulting in delays of several months before the deaths are included in CDC overdose data. With drug deaths at record levels and more dangerous substances entering the illicit drug supply, researchers say that antiquated system delays an effective public health response.

"The overdose crisis in America is the number one cause of death in young adults, but we don't know the actual number of overdose deaths until months after the fact," said lead author David Goodman-Meza, MD, assistant professor of medicine in the division of infectious diseases at the David Geffen School of Medicine at UCLA.

"We also don't know the number of overdoses in our communities, as rapidly released data is only available at the state level, at best. We need systems that get this data out fast and at a local level so public health can respond. Machine learning and natural language processing can help bridge this gap."

Goodman-Meza and his colleagues used computer algorithms to analyze the text for keywords in nearly 35,500 death certificates from nine U.S. counties in 2020. The counties include major cities such as Chicago, Los Angeles, San Diego and Milwaukee.

The researchers say their automated system demonstrated “excellent diagnostic performance” in classifying the drugs involved in overdoses.

“We found that for most substances evaluated, the performance of these algorithms was perfect or near perfect. These models could be used to automate classification of unstructured free-text, thus avoiding the manual and time-consuming process of individually reading each entry and classifying them to a specific substance,” researchers reported in JAMA Network Open.

“Excellent performance was shown for multiple substances, including any opioid, heroin, fentanyl, methamphetamine, cocaine, and alcohol using models for general text. Yet for prescription opioids and benzodiazepines, there was a considerable performance gap.”

That “performance gap” is due in part to weaknesses in the drug classification system, which lumps many synthetic opioids under the same ICD-10 code, including fentanyl, fentanyl analogs, tramadol and buprenorphine – a semi-synthetic opioid used in the addiction treatment drug Suboxone.

In the past, CDC has classified all drug deaths using that code as “prescription opioid overdoses” even though the drugs may have been illicit --- which is the case for the vast majority of deaths involving fentanyl. This resulted in government estimates of prescription opioid overdoses being significantly inflated for many years.

Using the computer algorithms developed at UCLA, prescription opioids ranked far behind fentanyl, alcohol and other substances identified as the cause of death in 8,738 overdoses.

Drugs Involved in 2020 Overdose Deaths in 9 U.S. Counties

Source: JAMA Network Open

Until recently, there was a 6-month time lag in drug deaths being counted in the CDC’s monthly Provisional Drug Overdose Death Counts report. The timeliness of the reports were improved earlier this year to a 4-month delay, but Goodman-Meza says they could be improved even more.  

"If these algorithms are embedded within medical examiner's offices, the time could be reduced to as early as toxicology testing is completed, which could be about three weeks after the death," he said.

Overdose Deaths Double for Teenagers Amid Fentanyl Surge

By Pat Anson, PNN Editor

Drug deaths among U.S. teenagers have risen sharply in the last two years, according to a new study that found the number of fatal overdoses doubled for adolescents aged 14 to 18 years.

In 2019, there were 492 drug deaths among adolescents. In 2021, there were an estimated 1,146 fatal overdoses, a 133% increase.

The vast majority of adolescent drug deaths last year involved illicit fentanyl (77%), followed by benzodiazepines (13%), methamphetamines (10%) and cocaine (7%). Less than 6% of the overdoses among teens involved a prescription opioid.

The study findings, reported in the journal JAMA, reflect what is happening in the overall U.S. population, with drug overdoses rising to record levels. They also mark the reversal of a decade long trend of fewer overdose deaths among teens, which coincided with declining rates of illicit drug use.

Researchers say adolescents may be unaware or naive about the risks posed by fentanyl, a synthetic opioid up to 100 times more potent than morphine and 50 times stronger than heroin. In a prescription, fentanyl plays a valuable role in treating severe pain, but as a street drug it can be deadly

“Beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls,” lead author Joseph Friedman, MPH, University of California, Los Angeles, reported in the journal JAMA.

“In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency. Since 2015, fentanyls have been increasingly added to counterfeit pills resembling prescription opioids, benzodiazepines, and other drugs, which adolescents may not identify as dangerous and which may be playing a key role in these shifts.”

U.S. Adolescent Overdose Deaths

SOURCE: jama

Friedman and his colleagues found the highest overdose rates among Native American, Alaska Native and Latino adolescents, reflecting what they called a “wider pattern of increasing racial and ethnic inequalities” in drug deaths.

Fentanyl is even killing kids who have not reached their teenage years. In California, a boy was recently arrested and charged with murder in the death of 12-year-old Dalilah Guerrero. The 16-year-old suspect allegedly sold a counterfeit pill made with fentanyl to the girl, who overdosed after crushing and snorting the tablet at a party in San Jose.

The spike in adolescent drug deaths comes even as substance abuse by teens fell to record lows. An annual survey by the University of Michigan found significant declines in all types of drug use by adolescents in 2021, with the use of prescription opioids falling to the lowest level in nearly two decades.    

DEA Warns of Fentanyl Mass Overdoses

Public health experts and law enforcement agencies are growing increasingly alarmed by the rising number of fentanyl overdoses. Last week, the DEA warned of a nationwide spike in fentanyl-related mass overdose events, in which three or more overdoses occur in the same location.

In the past three months, at least seven mass overdoses were reported in Florida, Texas, Colorado, Nebraska, Missouri and Washington, DC, resulting in 29 deaths. Three people died in a hotel room in Cortez, Colorado after ingesting what that they thought were 30mg oxycodone pills, but were actually counterfeit pills containing fentanyl.

“Tragic events like these are being driven by fentanyl. Fentanyl is highly-addictive, found in all 50 states, and drug traffickers are increasingly mixing it with other types of drugs — in powder and pill form — in an effort to drive addiction and attract repeat buyers,” DEA Administrator Anne Milgram said in a letter to federal, state and local law enforcement agencies. 

“We recommend that the members of your offices assume that all drugs encountered during enforcement activities now contain fentanyl. Given fentanyl’s extreme toxicity and the increases we are seeing in the distribution of polydrug substances containing fentanyl, please take all the precautions you would take when handling fentanyl whenever you interdict any illicit substance.”

A recent study by the National Institute of Drug Abuse estimated that over 9.6 million counterfeit pills containing fentanyl were seized by U.S. law enforcement agencies last year.

Overdose Crisis Reaches Grim Milestone

By Roger Chriss, PNN Columnist

The CDC announced this week that the U.S. has seen over 100,000 drug overdose deaths in the 12-month period ending May, 2021. This record-high spike in overdoses is thought to be primarily a result of pandemic lockdowns and the continuing spread of illicit fentanyl.

National Institute on Drug Abuse director Nora Volkow, MD, told NPR that the overdoses “are driven both by fentanyl and also by methamphetamines" and predicted that the surge of fatalities would continue because of the spread of more dangerous street drugs.

Connecticut this week warned that fentanyl was found in marijuana and is the suspected cause of several near-fatal overdoses in the state. “This is the first lab-confirmed case of marijuana with fentanyl in Connecticut and possibly the first confirmed case in the United States,” said state public health Commissioner Manisha Juthani, MD.

When asked if there is anything giving hope about the future of the drug crisis, PROP co-founder Andrew Koldony, MD, told Axios, “Uh... not really.”

Public health is often depressing. It is also rarely simple. We are not going to arrest, restrict or treat our way out of the drug crisis. Although harm reduction and improved access to addiction services will help, they will not be sufficient to reverse current trends.

The U.S. does not even have good data on the street drug supply. RAND researcher Bryce Pardo, PhD, looking at better and more current data in Canada, sees designer street drugs becoming even more dangerous.

“There is a recent and alarming trend toward more harmful supply of drugs sold in illegal markets in Canada. Consumers in Ontario, Alberta, and British Columbia buying powder may be at greater risk for exposure to fentanyl mixed with novel benzodiazepines,” Pardo reported in JAMA Psychiatry. “There is a need to improve monitoring and surveillance of drug consumption in the US as markets continue to trend toward more harmful drug mixtures.”

The U.S. also doesn’t have good data on drug deaths. Even the term “overdose” is problematic now. Deaths that are “opioid involved” in toxicological terms are resulting from inadvertent exposure via tainted cocaine and methamphetamine. And although fentanyl and other opioids are still involved in the majority of deaths, there are now more psychostimulant-involved deaths than there were two decades ago.

The U.S. also lacks good data on the people who died, in particular their drug use history, general health status, and other factors thought to affect drug risks and outcomes. It is easy to speculate that the stress and isolation of the pandemic exacerbated existing risks, but it is important to note that suicides did not rise in 2020 when they might have been expected to.

There is no easy policy fix here. Restricting prescription opioids and legalizing cannabis didn’t work. Ideology will not help. Legalizing drugs is a meaningless slogan since neither “drugs” nor “legalization” is well-defined. The same with old narratives and origin stories about the crisis, which may help explain what happened but contribute little about what to do next.

Safe supply is an appealing but problematic notion. There is no obvious way to test illicit substances in human trials. Illicit labs are unlikely to hold back their products any more than illicit cannabis suppliers are going to obey the law. Street drug test kits might help, if only we knew enough about the drugs and their users.

Treatment is similarly challenging. As Kolodny told Axios, “If we really want to see deaths come down in the short run, someone who's opioid addicted has to be able to access treatment more easily than they can buy a bag of heroin or fentanyl.” Though this is an admirable goal, there is no practical way to do it.

And all of this assumes that street users are opioid-addicted. More and more are not, as the increasing levels of death and harm from psychostimulants shows. Further, an increasing number of deaths are “polydrug” deaths involving two or more substances, which makes addressing risks all the more complicated.

But despair is not the appropriate response. The U.S. was facing rapidly rising rates of tobacco-related illness and death for much of the 20th century. But a combination of public health measures has cut the mortality rate from smoking in half since 1990. These measures include stricter laws and regulations, increased costs, and in an unexpected irony, stigmatization of smoking.

Many of the proposed solutions to the drug crisis have been based more on intuition than data. At this point we simply do not know which public health measures are working or how to improve them. What little data we have is often imprecise and years old, and as the crisis accelerates, the importance of granular and timely data grows. Moreover, the measures to date have often been applied piecemeal for short periods, so their real efficacy remains to be determined.

The tragedy of drug deaths cannot be understated, and the potential for far more drug deaths cannot be underestimated. But if the U.S. can improve its understanding of drugs and its response to risks and harms, we needn’t see so many more deaths moving forward.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research. 

Overdose Crisis Began 40 Years Ago

By Pat Anson, PNN Editor

The overdose crisis in the United States began long before a spike in opioid prescribing and is likely to last for many more years, according to a new study published in Science magazine.

Researchers at the University of Pittsburgh Graduate School of Public Health looked at nearly 600,000 poisoning deaths in the U.S. from 1979 to 2016 and found a steadily rising number of overdoses caused by “subepidemics” of different drugs, including heroin, cocaine, illicit fentanyl, methamphetamine and prescription opioids. As each subepidemic rose and fell, the drug fueling it was replaced by another substance that can be abused.

“The epidemic of drug overdoses in the United States has been inexorably tracking along an exponential growth curve since at least 1979, well before the surge in opioid prescribing in the mid-1990s,” said senior author Donald Burke, MD, Pitt Public Health dean and UPMC-Jonas Salk Chair of Global Health. 

“Although there have been transient periods of minor acceleration or deceleration, the overall drug overdose mortality rate has regularly returned to the exponential growth curve. This historical pattern of predictable growth for at least 38 years strongly suggests that the epidemic will continue along this path for several more years.”

Burke and his colleagues say the type of drug and the demographics of those who die from overdoses has fluctuated over the years. When the use of one drug waned, another drug replaced it, attracting new populations from different geographic regions.

When plotted on a map, certain drugs dominate different areas. Almost every region in the country is a hot spot for overdose deaths from one or more drugs. Heroin and cocaine primarily impact urban populations, while prescription opioids and methamphetamine skew a bit more rural. Cocaine increased death rates for black men, while heroin raised the death rates for younger whites and older blacks.

To be successful, researchers say overdose prevention efforts must extend beyond control of individual drugs. The current subepidemic of drug deaths caused by illegal and legal opioids will likely to be replaced by something else.

“The recent historical variability with which some specific drugs have waxed and waned makes predictions about the future role of specific drugs far more uncertain. Indeed, it is possible that in the future, the drug overdose epidemic may be driven by a new or heretofore obscure psychoactive substance,” Burke warned. 

Click on the video below to see a chart of the different subepidemics and how they align to form an exponential growth curve:

Technological factors fueling the epidemic include enhanced communication methods (smartphones and the Internet), faster supply chains (FedEx and UPS) and underground drug manufacturing that increased the supply of drugs while lowering their cost. Socioeconomic factors such as unemployment, lost social connections and lack of healthcare may also be creating a climate of despair that leads to drug abuse. 

“Understanding the forces that are holding multiple subepidemics together into a smooth exponential trajectory may be important in revealing the root causes of the epidemic, and thisunderstanding may be crucial to implementation of prevention and intervention strategies,” Burke said. 

“Evidence-based public health responses have contained past epidemics. If we understand and address these root causes at the same time that we take on the opioid crisis, we should be able to curb the epidemic for good."