Lisa Lee remembers when fentanyl first hit Reno. Lee, a founding member of the Northern Nevada Harm Reduction Alliance, was distributing the overdose antidote naloxone out of the back of her silver SUV to the street encampments near downtown, which she visits regularly. Just a day or two after she’d provided 30 kits of naloxone, someone called desperate for more, which was unusual. She then realized just how unprepared anyone was for an opioid drug roughly 50 times stronger than anything else on the streets — and the spike in overdoses about to hit the Mountain West.
It was during the pandemic, in early 2021. Overdose rates were already worryingly high: Sometimes she’d hear of a few a week, sometimes a few a day. But suddenly there were 10 in a single encampment — and people were reporting that it sometimes took more than one dose of naloxone to restart the victim’s breathing.
Lee, who is in recovery from heroin addiction herself, described the scene as “sheer panic.” A man she knew ran up to her, just minutes after being revived. “He’s hugging me and he’s like, ‘I’m back. I almost died today,’” she says. As fentanyl continued to flood the state, she says she’s lost count of the number of friends she’s lost to it.
In 2018, a Nevada law went into effect limiting the prescriptions of opioids. Lee saw the ripple effects firsthand: She was the program director for a methadone program at the time — the same program where she had once been a patient.
Pain patients who didn’t use illegal drugs — not just people with addiction — began calling for help. “They’d had a safe supply. Now they’re getting pills from their grandkids’ friends that are, of course, not covered by insurance,” she says. Many lost their cars or housing.
Since neither pain management nor addiction treatment was provided for people who were dropped by their doctors or faced rising prices for pills as the supply shrank, many began turning to street heroin. As these new markets grew in places where the drug was formerly rare, suppliers began supplementing it with fentanyl, which can be lethal at a dose equivalent to just 10 or 15 grains of table salt. The drug began wreaking havoc across America.
Recently, however, for the first time since the late 1990s, what seemed like an unstoppable rise in drug overdose fatalities has begun to slow. Between 2023 and 2024, overdose deaths in the U.S. dropped by nearly 24 percent, according to the Centers for Disease Control and Prevention. Headlines declared overdose deaths falling at the fastest rate ever seen, calling the decrease “historic.” Even now, CDC data analysis suggests the downward trend is continuing for the country.
But zoom in, and the picture looks a little different.
Unfortunately, fatalities are not falling everywhere — in some states and certain populations, they are still climbing. This is most marked in the West, which is the only region in the U.S. reporting increased fatalities. Montana, Utah, Nevada and Alaska all saw a rise, with Nevada’s and Alaska’s death rates reportedly climbing into double digits. The recent decrease in overdose deaths also varies sharply by race. Recognizing why these disparities persist can shed light on what matters most in turning the tide.
“It’s still really important to recognize that this is an extraordinary amount of death,” says Karla Wagner, professor of public health at the University of Nevada in Reno, emphasizing that even states seeing declines should not pull back from their efforts. “We’re still looking at 90,000 dead friends and family members a year across the country.”
Overdose deaths are falling at the fastest rate ever seen in the U.S.But zoom in, and the picture looks a little different.
One of the most overlooked aspects of the fentanyl crisis is its geography. Drug trafficking has historically been distinctively regional, with different networks supplying different places with varying products. On the East Coast, heroin was historically supplied as a white or beige powder — whereas in California and nearby Western states, it was typically dark and sticky “black tar.”
Perhaps because it is easier to mix fentanyl with powdered heroin — or simply because of cartel supply networks — fentanyl spread first in the East. The drug rapidly gained a foothold because making and importing it costs a fraction of what it does to supply heroin, in part because its extreme potency makes it lighter and easier to smuggle.
Even as late as 2018, some 88 percent of deaths caused by fentanyl and similar synthetic opioids — which are now by far the most common type of overdose fatalities — occurred east of the Mississippi. “It just seems like with novel substances, it goes from east to west,” says Brandon Delise, senior epidemiologist for the Southern Nevada Health District. “That may be because the established networks for trafficking and consumption have just historically favored the East Coast as a starting point.”
The decline in deaths is now following roughly the same pattern. West Virginia, for example, which has led the nation in overdose deaths per capita for most of the crisis, saw these fatalities decline by nearly 40 percent between 2023 and 2024.
“The places that — literally to the month, almost — started with rising fentanyl overdoses, were also the first places to show, if you look at monthly data, declines,” says Dan Ciccarone, professor of family and community medicine at the University of California, San Francisco. “A first approximation of what’s going on is that the West got fentanyl later, and we’re still learning to cope with it.”
States with policies that ranged from progressive to conservative saw overdoses skyrocket when fentanyl arrived, simply because it was so much stronger than anything else. In 2021, for example, Oregon was in the process of implementing a ballot initiative to decriminalize the possession — but not the sale — of all drugs, while expanding access to treatment for those struggling with addiction. Fentanyl hit the state around the same time, leading to increases in visible public drug use and overdose. Although nearby states that did not decriminalize saw the same negative trends, politicians in Oregon blamed the new policy, recriminalizing possession in 2024.
But states with tough drug policies — like Texas and Idaho — had essentially the same rise in overdose associated with fentanyl that Oregon and California did. And, around three or four years later, those same states are now seeing overdoses fall.
So, what is responsible for this decline? One distressing part of the answer is likely that fentanyl has already killed most of the local residents at the highest risk, shrinking the vulnerable population and therefore the new death numbers. At the same time — and far more hearteningly — fewer young people are using opioids.
National statistics from surveys on youth drug use support this idea. For example, in 2002, over 9 percent of high school seniors reported having misused a prescription opioid in the past year; in 2024, that proportion was 0.6 percent. In terms of street opioids like heroin, 1 percent of 12th graders reported past-year use in 2002; in 2024, just 0.2 percent did, an 80 percent decline.
“The most obvious thing is that drug cycles come to an end,” says Ciccarone. Crack cocaine, for example, showed a similar rise and fall when young people who saw the drug devastating their older siblings and parents began to steer clear of it.
But experts say that this is not the whole story. Decisions made by people who use drugs, the suppliers and policymakers also seem to matter.
One factor may be changes in the drug supply itself. The Drug Enforcement Administration has noted a recent decline in the potency of fentanyl. It argues that this shows that their crackdown has started to work. It is also plausible that traffickers have changed their formulas, recognizing that killing so many customers is not good for business.
Policy changes to increase access to overdose antidotes like naloxone and treatment could also be making a difference. Harm reduction groups — which invented the strategy of distributing naloxone directly to people at risk — reported providing around 702,000 doses in 2019. In its first year, 2022, Remedy Alliance/For the People, a nonprofit pharmaceutical company that makes cheap naloxone, had distributed over 1.6 million units.
Between 2019 and 2023, the number of naloxone prescriptions filled at pharmacies rose over 25 percent — and the drug became available over the counter in 2023, which should further improve accessibility.
At the same time, the percentage of people with opioid addiction who received gold-standard treatment — which involves long-term use of either methadone or buprenorphine — more than doubled in recent years. Since these are the only treatments that cut the death rate by 50 percent or more, improving access to these medications can have a significant impact. Unfortunately, as late as 2022, 75 percent of those who needed such treatment did not receive it. And access to these more effective treatments is even more limited for those at the highest risk of overdose.
Fentanyl spread from the East to the West. The decline in deaths is now following roughly the same pattern.
The encouraging declines in national overdose mortality statistics hide variations by both geography and race. Black and Native American communities are still seeing sharp increases in overdose deaths, while deaths in white populations are falling. These differences may offer insight into which policies are helping, and which are harming.
For one, Black people have long faced far higher arrest and incarceration rates compared to white people, despite equal levels of drug use and sales. If, as many believe, criminal justice crackdowns aid access to treatment, Black people should have higher treatment rates and lower overdose deaths. But the disparities run in the opposite direction, with less treatment received and greater overdose risk. Native people experience similar results, with more incarceration and less treatment completion.
“I think there needs to be more research to figure that out,” says Chelsi Cheatom, chief operating officer for the PACT Coalition for Safe & Drug-Free Communities in Las Vegas, noting that she has seen the racial disparities in overdose deaths in her work in the state.
Research conducted in large urban areas finds that Black people are less likely to receive overdose reversal training and have less access to naloxone. Cheatom advocates for messaging and distribution to change this.
Another issue in large Western states is helping people who live far from big cities. Many parts of Montana, Utah, Nevada and Alaska are so unpopulated that they don’t even qualify as “rural” for those who study these issues. These areas have six or fewer people per square mile and are known as “frontier” regions. Lisa Lee is aiming to reach these more isolated groups who live in these regions, particularly Black and Native communities. “We’re really trying to branch out into places that aren’t served and build trust,” she says.
This often involves connecting with people who are respected in these areas and helping them help each other, as well as providing accurate health information and supplies like naloxone, clean needles, test strips that can detect the presence of fentanyl in the drug supply and other tools that can protect residents.
Though some argue that providing such help “enables” continued addiction, the research clearly suggests these programs make it more likely that people will access treatment and recovery.
“The only way that someone can recover, the only way that someone can ever stop using drugs, is if they’re alive,” says Cheatom. To help drive overdose deaths down in every state in the U.S., she says, support for a continuum of care, including harm reduction, prevention and treatment for everyone, is needed.
Lisa Lee notes that the latest provisional figures from the state medical examiner suggest that Nevada may be beginning to see a drop in fentanyl deaths, and a recent analysis by the Opioid Data Lab at the University of North Carolina at Chapel Hill supports this view. They may be on the cusp of saving more people than they are losing. She says she finds hope in her kids, and the young people whom she mentors in her harm reduction work, watching them catch on and recognize the power of love and kindness. Most people who overdose don’t want to die, she says. “People just want relief.”
This story appears in the April 2025 issue of Deseret Magazine. Learn more about how to subscribe.