Why Overdose Deaths Are Falling—and It Isn’t Because of the Drug War

Washington will likely claim credit for falling overdose deaths. The evidence points elsewhere.

---

Jeffrey A. Singer

The Centers for Disease Control and Prevention (CDC) recently reported that overdose deaths during the 12-month period ending in December 2025 declined by 13.9 percent compared to the previous year, reaching a total of 69,973, the overwhelming majority of which were due to fentanyl. While a drop in overdose deaths is welcome news, it is important to keep in mind that the total number of overdose deaths for the year ending in December 2019 was 70,630. Researchers at the University of Pittsburgh found that the pre-pandemic trend line had grown exponentially since the late 1970s before the COVID pandemic disrupted that trend with spikes in overdose deaths, substance use, and suicide rates. The new numbers may signal a return to that trend.

Younger Americans Are Using Fewer Drugs

Another factor that may be contributing to the decline in overdose deaths is that younger Americans appear to be using many psychoactive substances less than previous generations. Federally funded surveys, such as the Monitoring the Future survey, have documented substantial long-term declines in adolescent cigarette smoking, alcohol use, and many illicit drugs, while CDC Youth Risk Behavior Survey data show major reductions in teen alcohol use and cigarette smoking over the past two decades. Even youth vaping rates have fallen from their 2019 peak, according to the FDA/CDC National Youth Tobacco Survey.

Researchers increasingly describe Gen Z as engaging in less risk-taking behavior overall than earlier cohorts, including less drinking, smoking, and drug use. While this trend alone probably does not fully explain the recent decline in overdose deaths, particularly since most fatal overdoses occur among adults in their 30s to 50s, it may reduce the number of younger people who progress into the highest-risk patterns of substance use associated with overdose mortality.

As pandemic-era supply chain and transportation disruptions eased, illicit drug markets also have become more diversified. During the pandemic, fentanyl largely displaced heroin in many regions of the country. More recently, some researchers and harm-reduction workers have reported signs that heroin availability has modestly rebounded in certain markets. Because heroin is less potent and generally longer-acting than fentanyl, some opioid users who developed tolerance to fentanyl may prefer heroin when it is available, potentially reducing exposure to the highly concentrated fentanyl products that drove record overdose deaths during the pandemic.

Smoking Instead of Injecting

Another possible contributor has received far less media attention: more drug users appear to be smoking drugs rather than injecting them.

There is a growing body of evidence suggesting that part of the recent decline in US overdose deaths may reflect a shift in routes of drug administration away from injection and toward smoking, particularly with fentanyl. Researchers and harm-reduction experts caution against overstating the effect, because smoking fentanyl can still be highly dangerous and potentially fatal. Yet several studies suggest smoking may carry a lower overdose risk than injection.

A CDC study found that by 2022, smoking had overtaken injection as the most commonly documented route of drug use in overdose deaths, while injection-related overdose deaths declined. A 2024 study published in the International Journal of Drug Policy reported that people who inject fentanyl face a higher risk of nonfatal overdose than people who primarily smoke it. Researchers studying users in San Francisco likewise found that many who transitioned from injecting heroin to smoking fentanyl described smoking as producing a more gradual effect rather than the rapid “bolus” effect associated with injection, potentially lowering overdose risk. Their findings were published in the journal Drug and Alcohol Dependence. A recent STAT News report noted that many experts view this transition from injecting to smoking as “a promising development that could help extend the decline in deaths.” Harm-reduction organizations similarly acknowledge that while smoking fentanyl remains dangerous, injecting “carries the highest risk for overdose.”

Evidence also suggests this shift toward smoking has become increasingly common nationwide. A 2024 study examining treatment admissions nationwide found that injection of heroin and synthetic opioids has declined while smoking has steadily increased, with Arizona among the states showing especially high smoking rates. That study appeared in the International Journal of Drug Policy. The director of an Arizona harm reduction organization described similar trends during my 2024 interview.

Europe’s Harm Reduction Advantage

Smoking heroin and other opioids has long been more common in the UK and much of Europe than in the US, where injection has become far more entrenched. The European Union Drugs Agency reports that injection has steadily declined across Europe for years, while smoking and inhalation have become increasingly common routes of administration. Some researchers believe this difference may partially explain why overdose death rates in many European countries historically have remained lower than in the US. The European Union Drugs Agency notes that facilities serving people who inhale drugs report fewer emergency incidents than those serving people who inject.

But the route of administration is only part of the story. European countries have also embraced harm-reduction strategies far more aggressively than the US for decades, including syringe services programs, heroin maintenance programs, supervised consumption sites (also called “overdose prevention centers”), and widespread methadone treatment. Those policies likely play a much larger role in explaining the longstanding overdose mortality gap between the US and many European countries.

In recent years, federal and state public health institutions have begun to embrace harm-reduction strategies as well. Many states have reformed their drug paraphernalia laws to permit the sale and distribution of fentanyl test strips. Some have authorized overdose prevention centers despite their federal prohibition. The Food and Drug Administration (FDA) has allowed pharmacies to sell the nasal-spray version of the overdose antidote naloxone over the counter, and harm reduction organizations have widely distributed it in both nasal-spray and injectable forms to a drug-using population that is far more aware of the presence and potency of powerful synthetic drugs than it was when fentanyl first began infiltrating the illicit drug supply roughly 15 years ago. While it is difficult to quantify their precise impact, these harm-reduction measures almost certainly contribute to the recent decline in overdose deaths.

What Isn’t Driving the Decline

None of the most plausible explanations for the decline in overdose deaths involves intensifying the drug war. If anything, the evidence points toward lower-risk patterns of drug use, harm reduction, naloxone access, and behavioral adaptation in response to an increasingly dangerous illicit market. One factor that clearly has not contributed to the decline in overdose deaths is the extrajudicial killing of people operating small speedboats off the coast of South America by US warplanes, begun last September, based on suspicions of cocaine trafficking.

Washington will almost certainly try to claim credit for the decline in overdose deaths. But nothing in the evidence suggests that bombing suspected traffickers, intensifying interdiction, or escalating prohibition deserves the credit. If bombing traffickers and escalating interdiction were meaningfully reducing supply, illicit drug prices should be rising. Instead, black markets continue to deliver cheaper, more potent, and more easily transported substances. After more than 50 years of failure, the drug war remains far better at generating black markets than saving lives.