It’s one of the biggest public health setbacks in decades: Opioid overdose deaths are declining faster than at any time in the epidemic’s modern history. After rising persistently for more than 30 years, deaths peaked at 81,806 in 2022 and declined by nearly half, to 44,564, in 2025. This decline helped propel life expectancy in the United States to a record high in 2024.
Many want to take credit for this miraculous healing. Vice President JD Vance says this happened because the administration closed the border. Experts and public health agencies point to the saturation of communities with the overdose drug naloxone and increased access to treatment.
Yet none of these stories match the timing or extent of the decline. The number of deaths began to decline in mid-2023, months before President Trump’s inauguration and the subsequent border crackdown. We just published an article in JAMA pointing out that naloxone expansion doesn’t fit that either. Naloxone is an essential, life-saving medication that reverses tens of thousands of overdoses each year; however, EMS administration and lay witness administration of EMS have declined since mid-2023. Improved access to treatment is not a better explanation. Evidence-based drug treatment has increased, but steadily and gradually, far from the order of magnitude needed to explain such a large and sudden decline in deaths.
No one knows why opioid overdose deaths have dropped so dramatically. But the sad truth is that forces outside of medical care and public health policy must play a major role.
So far, the most plausible factor in the recent decline in overdose deaths is a change in the supply of illicit drugs. A recent high-profile article in the journal Science presented data that fentanyl became more diluted and harder to find — online articles discussing “fentanyl droughts” — as deaths declined, a plausible mechanism for these recent overdose declines. But there are big gaps in our understanding.
A big gap is that we don’t know for sure what the supply shock was or what caused it. The Science article suggests that this is the result of trade negotiations and crackdowns on the production of fentanyl precursors in China. However, other plausible explanations exist. The Sinaloa Cartel announced a ban on fentanyl production around the same time, and there were reports of resulting violence and casualties. Others cite possible abrupt changes in drug-taking behaviors, such as stopping opioid use because the supply has become less desirable due to the addition of sedatives such as xylazine and medetomidine.
All of this is very important to inform current policy. If tens of thousands of American lives were saved by decisions made regarding fentanyl precursors in China, the implications would be enormous. This suggests that trade policy can play a leading role in protecting public health. On the other hand, if other hypotheses, such as cartel violence or increasing xylazine adulteration, are more correct causes for the decline in opioid-related deaths, it is not clear that such policies would be of much help. What is clear is that all of us interested in public health would benefit from getting to the bottom of this.
How is it that we know so little about the biggest public health change in a generation, even though it has been and continues to be studied so intensely? The answer is best explained by the old analogy of a drunk man looking for his keys under a lamppost, not because that’s where he lost them, but because that’s where the light was brightest. We largely limited our searches to areas with available data.
Researchers like us have spent years studying treatment and harm reduction, a field that is replete with data, including insurance claims. This research has been extremely important because it has helped reduce barriers to care and radically reform the delivery of health care and other services to address substance use. This remains essential. But it is a shame that no comparable investment has been devoted to studying the supply of illicit drugs and the policies that affect it, despite its obvious and profound importance for public health.
The reason is a lack of data. Our main national survey on illicit drugs, the National Survey on Drug Use and Health, fails to account for many people most at risk, including those who are homeless or incarcerated. It asks virtually no questions about illicit drug prices, the main economic indicator of supply changes, and does not even include a question about illicit fentanyl use until 2022, when deaths had already peaked. Data on the prevalence of rare behaviors like heroin use are also often not available to researchers below the national level, even though use and supply vary widely by region.
There are already versions of what a better investigation could look like. The Centers for Disease Control and Prevention tracks risk behaviors and HIV incidence among at-risk populations across the United States, and Australia has conducted surveys of illicit drug use, prices and purity for decades. A better survey aimed at understanding trends in overdose mortality would be designed to reach those most at risk and those not captured in current surveys, such as people housed in shelters and prisons. This would involve asking what drugs people use, how they use them and how much they paid for them. It would allow samples of illicit drugs to be tested to determine what they contain. This would tell us if and how supply is changing, and how this affects drug use and risk.
Government agencies such as the Drug Enforcement Administration have other data that could improve researchers’ understanding of the drug supply, but we only get a glimpse of it when they are forced to release it. As an example, data from the Consolidated Ordering and Reporting Automation System tracks opioid shipments from distributors to pharmacies and was disclosed by court order following litigation in 2019, approximately eight years after the peak in opioid prescribing. This has led to studies of interventions that could have saved thousands of lives if they had been identified by researchers and implemented or scaled up earlier.
There is no guarantee that the progress made in public health over the past three years will continue, and there are still far too many overdose deaths. If we can’t explain why deaths are decreasing today, we won’t know what’s causing them to increase if they increase again. And we won’t know what to do.
J. Travis Donahoe is an assistant professor of health policy and management at the University of Pittsburgh School of Public Health. David T. Zhu holds an M.D./Ph.D. candidate at Virginia Commonwealth University. Michael L. Barnett is the Sorensen Family Provost Professor of Health Services, Policy, and Practice at the Brown University School of Public Health and a primary care physician at Brigham and Women’s Hospital.
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