In a September blog post, I discussed the encouraging news from the National Center for Health Statistics (NCHS) that drug overdose fatalities decreased from approximately 112,000 to approximately 97,000 during the 12 months ending on April 30, 2024. I speculated that policymakers are increasingly willing to permit harm-reduction organizations to expand syringe services programs, distribute the opioid overdose antidote naloxone, distribute fentanyl test strips, and educate people who use drugs about ways to consume more safely. Last week, the NCHS reported that the trend continued through June 30. Overdose deaths dropped from 113,000 to 97,000 during the 12 months ending on June 30, 2024.

I recently spoke with Abby Rosen, the interim executive director of Sonoran Prevention Works(SPW), one of the oldest and largest harm reduction organizations in Arizona. Abby agreed with my hypothesis. She shared the experiences that the organization’s staff have been reporting. While these reports are anecdotal, staff reports from various and diverse communities across the state have been consistent.

In an email to me, Rosen wrote:

Staff across the state are observing a significant uptick in reported overdose reversals over the past few months. Participants are sharing these instances when they interact with staff at outreach site, SPW trainings, or when they come in to volunteer. Harm reduction tools, like intramuscular naloxone, are making a meaningful impact. These tools are being distributed to people who use drugs, so that they can continue to save others’ lives in their community.

Rosen added, however, that fatal overdoses are not going down equally among demographics and are still disproportionately high in Black and Indigenous communities in the state.

Another factor that might be contributing to the drop in overdose fatalities is the increasing number of people smoking fentanyl rather than injecting it. As drug dealers are increasingly selling fentanyl in pill as opposed to powder form, users find it easier to crush and smoke the drug than to dissolve the powder and inject it. 

In a 2022 Cato online event, Rosen’s predecessor as executive director informed us that SPW was increasingly distributing clean and safer smoking equipment relative to sterile syringes. Public health advocates have encouraged people who use drugs to switch to non-injection routes, which reduce the likelihood of skin, soft tissue, and blood-borne infection. Smoking fentanyl might reduce the likelihood of overdose, as it allows users to more easily titrate the dose to achieve the desired effect, which is harder to do when injecting.

To that point, Rosen wrote that SPW staff have noticed black market fluctuations in fentanyl strength and form that have impacted overdose rates:

The supply, strength, and form of fentanyl continue to fluctuate, and we’re even hearing reports of participants using heroin again—something that hasn’t been available in recent years. When there’s a gap in fentanyl supply, other opioids are filling the void. These changes in drug form (e.g., from pressed pills to powder) significantly increase the risk of accidental overdose, as users may not be prepared for the altered potency of the drug and/​or may be using a route of administration that is unfamiliar to them. For example, pressed pills are usually smoked, while powder is pretty easy to smoke OR inject, and injecting is always riskier. Therefore, education around harm reduction—such as the advice to “go slow” and “never use alone”—must remain a priority. It’s also critical that naloxone is accessible to every person who uses drugs, as well as to those in their communities. (emphasis added)

Rosen agrees that distributing fentanyl test strips (FTS)—still considered illegal drug paraphernalia in Idaho, Indiana, Iowa, North Dakota, and Texas—is saving lives. But staff have had to educate people on how to properly use them.

Many individuals want to know exactly what’s in their drugs so they can take the necessary precautions. While FTS are an effective harm reduction tool, they require proper training and education to ensure they’re used correctly. There’s a significant amount of misinformation circulating about FTS, and SPW is working to combat this by providing accurate training and guidance. Our goal is to equip individuals with the knowledge to prevent accidental overdose through proper use of these tools.

Finally, one cannot understate the benefits of naloxone distribution, which was made more accessible when the Food and Drug Administration reclassified naloxone nasal spray as over-the-counter in March 2023. Unfortunately, injectable naloxone—much cheaper for harm-reduction organizations to purchase—still is prescription-only, requiring a “standing order” from a state-licensed prescriber willing to issue one. (Full disclosure: I have issued the standing order for injectable naloxone for SPW.) Again, quoting Rosen:

SPW distributes around 7,000 naloxone kits per month, each kit containing two intramuscular syringes and two doses of naloxone, along with instructions in both English and Spanish. Since January 2017, we’ve distributed over 1 million doses of naloxone. This distribution has been a critical part of saving lives…

The “Iron Law of Prohibition” states that stricter enforcement of drug laws leads to the proliferation of more potent and dangerous drugs. As I mentioned in September, it is still too early to determine whether the recent trend of decreasing overdose fatalities will continue. After a brief pause in 2018, overdose deaths began rising again in 2019. However, it is already clear that harm-reduction strategies make illicit drug use safer, while tougher prohibition enforcement makes it more lethal.