More Than 40 States Recorded Declines in 2024 Fatal Drug Overdoses Since Deaths Peaked in 2022

More Than 40 States Recorded Declines in 2024 Fatal Drug Overdoses Since Deaths Peaked in 2022

Drop in Overdose Death Rates Was Driven Largely by Ebbing Fentanyl Deaths; Fewer States Saw Declines in Cocaine and Methamphetamine Deaths

Since their rapid ascent and tragic peak during the COVID-19 pandemic, U.S. drug overdose deaths have dropped precipitously.^[1] In 2024, just under 80,000 lives were lost to fatal overdoses. While still historically high, that represents a dramatic decline after more than 100,000 deaths a year in 2021, 2022, and 2023.^[2]

The decline in overall drug overdose deaths has been driven primarily by a reduction in fatal overdoses involving fentanyl and related synthetic opioids, a class of drugs that has emerged as the center of gravity in the U.S. opioid epidemic in recent years.^[3] Between 2022 and 2024, fatal overdoses involving fentanyl and related synthetic opioids declined from a high-water mark of nearly 74,000 to fewer than 48,000—a drop of 35%.

It is not entirely clear why drug overdose deaths have declined so quickly. One possibility is individual-level behavior changes, such as fewer people using drugs or more people using drugs in ways aimed at reducing risks, such as avoiding injection in favor of smoking as a mode of administration.^[4] Another possibility is that public health interventions, such as expanding access to evidence-based treatments for opioid use disorder (OUD) and widespread distribution of the opioid overdose-reversing medication naloxone, have begun to pay dividends.^[5]

Additionally, some recent research has suggested that the supply of illicitly manufactured and trafficked fentanyl has been constrained, perhaps a result of U.S. and international policymakers’ efforts to hamper supply chains for illicitly trafficked fentanyl.^[6]

However, we should also recognize that the U.S. drug crisis is not remotely over. In fact, there are various signs that continued success in reducing drug overdose deaths may become increasingly difficult to achieve, as drug markets evolve, demographic patterns shift, and drug traffickers adapt. For instance, as fentanyl emerged as a growing public health threat in recent years, other non-opioid drugs—especially cocaine and methamphetamine—became intertwined in drug trafficking and the overdose crisis, killing record numbers of people, as well.^[7] 

These developments appear to have contributed to new disparities in drug overdose deaths. For instance, the most recent data show that cocaine overdose deaths disproportionately kill Black people, and methamphetamine overdoses disproportionately kill American Indian or Alaska Native people. Additionally, cocaine and methamphetamine overdose deaths have continued to climb among elderly adults, even as overdose death rates have leveled off or declined for other ages.

Another issue is that there are indications that drug traffickers have been innovating in ways that could undermine recent progress. For instance, in some parts of the U.S., drug traffickers have been adding the non-opioid animal tranquilizer xylazine to fentanyl and other substances, which can cause a variety of new challenges, such as overdoses that cannot be reversed with naloxone.^[8],[9],[10]Additionally, public health and law enforcement officials have raised concerns about the emergence of new kinds of illicit synthetic opioids, including nitazenes and orphines, which can be much more potent than fentanyl.^[11],[12]

Important to acknowledge for this analysis is that the United States’ outdated vital statistics data infrastructure makes the identification of emerging drug threats to public health challenging to quantify—and challenging to mitigate—until they develop into full-blown crises.^[13]

Using mortality data from the U.S. National Vital Statistics System, obtained through the U.S. Centers for Disease Control and Prevention’s (CDC) WONDER database, this analysis examines recent state-level patterns in fatal drug overdoses, with a particular focus on how the crisis has evolved since fatal overdoses peaked in 2022. 

We have also written two additional blogs that accompany this analysis: one providing an overview of U.S.-level trends since 2011, when the CDC first declared a drug overdose “epidemic,” and another analyzing variation in overdose deaths by demographic group.

Variations and Trends in Drug Overdose Deaths by State in 2024 

All Drugs

At the state-level, an overwhelming majority of 41 states, plus the District of Columbia, experienced statistically significant declines in fatal overdose rates from all drugs between 2022 and 2024; only Alaska, Nevada, Oregon, and Washington saw statistically significant increases in their overdose death rates for all drugs, while Hawaii, Iowa, South Dakota, Utah, and Wyoming saw no statistically significant change. This reflects a U.S.- level decline in fatal overdose rates from all drugs, as well.

For much of the history of the opioid crisis, overdose death patterns have varied across states and regions. The Mississippi River can be used as a geographic boundary to illustrate differences in overdose death rates by drug type, roughly splitting states into two halves, with 26 states laying entirely or mostly east of the river and 24 states laying entirely or mostly west of the river. 

For fatal overdoses from all drugs, a majority of states with rates significantly higher than the U.S. rate were found east of the Mississippi River (Figure 1). 

In 2024, Nebraska had the lowest rate of fatal overdoses from all drugs, at 8.1 deaths per 100,000 people, while West Virginia had the highest rate, at 48.9 deaths per 100,000 people (Figure 2).

Figure 1. State vs. U.S. Overdose Death Rates from All Drugs, 2024

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Figure 2. Highest and Lowest State Overdose Death Rates from All Drugs, 2024

Five Highest Rates

Five Lowest Rates

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Fentanyl

For fentanyl and similar synthetic opioids, 42 states, plus the District of Columbia, experienced statistically significant declines in fatal overdose rates between 2022 and 2024; only Alaska, Nevada, Oregon, Utah, and Washington saw statistically significant increases in their overdose death rates for fentanyl, while Hawaii, Montana, and South Dakota saw no statistically significant change. 

States were roughly split between those that had rates significantly higher than the U.S. and those that had rates significantly lower than the U.S.; only three had rates not significantly different from the U.S. rate (Figure 3).

States with fentanyl overdose death rates significantly higher than the U.S. rate were largely concentrated in the eastern U.S.; most states east of the Mississippi River had rates significantly higher than the U.S. rate, while only six states west of the Mississippi River had rates higher than the U.S. rate (Figure 3). 

In 2024, Nebraska had the lowest rate of fatal overdoses from fentanyl, at 2.6 deaths per 100,000 people, while West Virginia had the highest rate, at 36.1 deaths per 100,000 people (Figure 4).

Figure 3. State vs. U.S. Fentanyl Overdose Death Rates, 2024

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Figure 4. Highest and Lowest State Fentanyl Overdose Death Rates, 2024

Five Highest Rates

Five Lowest Rates

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Prescription Opioids

For prescription opioids, 34 states experienced statistically significant declines in fatal overdose rates between 2022 and 2024; zero states saw a statistically significant increase in fatal overdoses from prescription opioids, while 14 states, plus the District of Columbia, saw no statistically significant change. 

State and regional patterns differed for prescription opioid overdose death rates. More than 20 states had prescription opioid overdose death rates that were not significantly different from the U.S. rate, partly a result of less state-level variation in rates compared to other drug types. Additionally, the states with rates that were significantly higher than the U.S. rate were split relatively evenly between states east and west of the Mississippi River (Figure 5). 

In 2024, Nebraska had the lowest rate of fatal overdoses from prescription opioids, at 0.7 deaths per 100,000 people, while Utah had the highest rate, at 4.7 deaths per 100,000 people (Figure 6).

Figure 5. State vs. U.S. Prescription Opioid Overdose Death Rates, 2024

Source: SHADAC analysis of National Vital Statistics System (NVSS) data.

Figure 6. Highest and Lowest State Prescription Opioid Overdose Death Rates, 2024

Five Highest Rates

Five Lowest Rates

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Cocaine

For cocaine, 24 states, plus the District of Columbia, experienced statistically significant declines in fatal overdose rates between 2022 and 2024. Three states (Nevada, Oregon and Washington) saw statistically significant increases, and 17 states saw no statistically significant change in their cocaine overdose death rates. Significance testing was not possible for six states (Idaho, Montana, Nebraska, North Dakota, South Dakota, and Wyoming) due to suppression of rates by the CDC for small numbers of cocaine overdose deaths in those states in 2022, 2024, or both. 

Cocaine overdose death rates demonstrated a clear regional pattern. All states with cocaine overdose death rates significantly higher than the U.S. rate were found east of the Mississippi River (Figure 7). 

In 2024, Nebraska and Montana had the lowest rate of fatal overdoses from cocaine, at 1.0 deaths per 100,000 people, while the District of Columbia had the highest rate, at 23.7 deaths per 100,000 people (Figure 8).

Figure 7. State vs. U.S. Cocaine Overdose Death Rates, 2024

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Figure 8. Highest and Lowest State Cocaine Overdose Death Rates, 2024

Five Highest Rates

Five Lowest Rates

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Methamphetamine

For methamphetamine and other psychostimulants, 31 states experienced statistically significant declines in fatal overdose rates between 2022 and 2024; only Alaska, Hawaii, Nevada, Oregon, and Washington saw statistically significant increases in their overdose death rates for methamphetamine, while 14 states saw no statistically significant change. Significance testing was not possible for the District of Columbia due to suppression of its 2022 rate by the CDC for small numbers of methamphetamine overdose deaths. 

Methamphetamine overdose deaths also demonstrated a regional pattern, with a majority of states with rates significantly higher than the U.S. found west of the Mississippi River, though there were also several states with rates higher than the U.S. rate found east of the Mississippi (Figure 9). 

In 2024, Connecticut and Maryland had the lowest rate of fatal overdoses from methamphetamine, at 1.9 deaths per 100,000 people, while West Virginia had the highest rate, at 28.0 deaths per 100,000 people (Figure 10).

Figure 9. State vs. U.S. Methamphetamine Overdose Death Rates, 2024

Source: SHADAC analysis of National Vital Statistics System (NVSS) data.

Figure 10. Highest and Lowest State Methamphetamine Overdose Death Rates, 2024

Five Highest Rates

Five Lowest Rates

Source: SHADAC analysis of National Vital Statistics System (NVSS) data. 

Conclusion and Discussion

The U.S. marked a milestone in 2024, with the largest decline in fatal drug overdoses in the past quarter-century, as well as the first time they have dropped for two consecutive years. These developments should be encouraging, as they demonstrate that progress is possible in the effort to turn the tide and save lives. 

However, we should be cautious not to declare victory just yet, as the 2024 drug overdose death toll of more than 79,000 lost lives remains historically high—it is, in fact, higher than any time before their spike during the COVID-19 pandemic. We still have far to go before the U.S. drives overdose deaths down to the levels seen before the opioid epidemic began in the late 1990s and early 2000s.

Patterns at the state level reinforce the cautiously sanguine findings seen at the national level: Fatal overdoses from all drugs declined or leveled off in nearly all states between their peak in 2022 and the latest data from 2024. That pattern appears to have been driven largely by declines in fatal overdoses caused by fentanyl and similar synthetic opioids, which also dropped or leveled off in all but a few states. The pattern of declining or plateauing overdose death rates was similar across the states for prescription opioid painkillers, cocaine, and methamphetamine and other psychostimulants—though none of these has dropped so precipitously as those involving fentanyl and similar synthetic opioids.

These latest data on drug overdose deaths provide evidence for optimism that the crisis need not be hopeless. But the data presented in this blog—combined with prior experience on the continually evolving nature of the opioid crisis, presented in precursor briefs—point to certain known threats that cannot be dismissed.^[14],[15]

One such threat is that the crisis may, yet again, pivot in ways that could allow for a resurgence in overdose deaths, such as when the illicit market for opioids shifted from heroin to fentanyl. Public health and law enforcement agencies throughout the U.S. have continued to identify new and emerging illicit drugs, including novel, powerful opioids that could supplant fentanyl, as well as non-opioids that are increasingly mixed by drug traffickers into the illicit drug supply.

A second threat is that the crisis has repeatedly spread to new subpopulations or geographies that had previously been less-severely impacted by growing drug overdose deaths. For instance, the sudden surge in fentanyl overdose deaths a decade ago was initially concentrated mostly in eastern U.S. (tracking the earlier similar rise in heroin deaths), but, in time, that crisis spread throughout the states.^[16]

Similarly, the illicitly trafficked stimulants cocaine and methamphetamine used to be somewhat geographically stratified, with methamphetamine being a greater challenge in western states and rural communities, and cocaine being a greater challenge in eastern states and urban communities.^[17] But in the age of fentanyl, these geographic boundaries have blurred.

Together, these threats and findings underpin a need for continued diligence in tracking changes in overdose crisis trends, as well as state-level variation. Though the declines in overdose deaths in 2024 are encouraging, prior experience reinforces that backsliding is possible. But continued tracking and early identification of emerging threats, along with state- and subgroup-level dynamics, can be used by policymakers, public health professionals, the health care system, and others to design and deploy tailored interventions.

While we do not know definitively what has caused the decline in overdose deaths, it is important to acknowledge the recent reversal in the trajectory of the opioid crisis. If for no other reason, noting that improvement reinforces the notion that progress is possible—that saving lives is both a laudable and achievable goal. 

The fact that we still do not know why overdose death rates have fallen is concerning, though. It reinforces the idea that the U.S. invest should in research and evaluation efforts to study what has been working to change the course of the crisis, as well as what has not been working, so that policymakers can focus scarce resources on initiatives most likely to pay off by saving and improving people’s lives. 

To dive deeper into the latest overdose deaths data, read the two blogs that accompany this analysis:

• Drug Overdose Deaths at the National Level in 2024
• Drug Overdose Deaths by Demographic Subgroup in 2024