Provisional data show that drug overdoses in the United States claimed more than 100,000 lives for a third consecutive year in 2023 — a more than 50 percent jump since 2019. By a substantial margin, the U.S. has the highest rate of overdose deaths in the world, followed by Puerto Rico — a U.S. territory. And while Scotland and Canada, the second- and third-ranked countries, saw decreases from 2021 to 2022, rates in the U.S. have remained high. Our analysis, using the latest mortality data from 2022, compares the U.S. overdose rate — 324 deaths per 1 million people, or almost 108,000 deaths in 2022 — to dozens of countries from across the globe and finds that the U.S. unequivocally has the highest rate of overdose deaths in the world.
The U.S. can learn from other countries by tracking emerging trends and adopting comprehensive approaches to prevention and treatment that prioritize public health and harm reduction.
Emerging trends. Polysubstance use — that is, exposure to more than one drug, with or without the knowledge of the person using them — and the emergence of new substances pose significant challenges. Recently xylazine, a type of tranquilizer not approved for humans and particularly lethal in combination with fentanyl, has become more prevalent in overdose deaths in every region of the U.S., but largely in southern states. In a study of 20 states and Washington D.C., there was an almost fourfold increase in xylazine being found in deaths involving illegally made fentanyl between 2019 and 2022. Polysubstance use has become the norm in Europe, where heroin has been replaced with combinations of opioids as the primary cause of drug-related deaths.
Counterfeit pills are frequently cited in overdose deaths. Often unknown to the person taking it, these pills may contain more than one substance or drug. The percentage of deaths involving counterfeit pills more than doubled between 2019 and 2021. These trends emphasize the importance of improving drug-screening methods and early-detection systems to detect contaminated drug supplies to alert the population and mitigate overdose risks.
Synthetic opioid deaths are rising around the world, though fentanyl is not the primary driver as in the U.S. Some European countries, particularly in the Baltic region, as well as the U.K. have reported concerning rises in nitazenes (a new synthetic opioid that has not been approved for medical use) in recent years, signaling a worrying shift. In Brazil, nitazenes make up the majority of synthetics detected in the drug supply. Such developments highlight the importance of international cooperation in monitoring drug trends and sharing strategies for early identification of drug-use trends; for example, through the United Nations Office on Drugs and Crime’s Early Warning Advisory system.
Treatment, prevention, and care. It is vital that we adopt comprehensive prevention strategies. In the U.S., access to medication-assisted treatment remains severely inadequate; prior research shows that only 11 percent of Americans with opioid use disorder (OUD) received opioid substitution therapy in 2020, compared with 87 percent and 86 percent in France and Norway, respectively. In Scotland, 51 percent of people with OUD received substitution therapy in 2020. The country recently announced an increase in funding to tackle the drug crisis, with funding going toward improving standards for methadone prescribing.
In the U.S., harm-reduction policies and practices are fragmented — meaning they differ state to state — making it challenging to prevent overdose deaths from a national angle. Harm reduction remains a critical means to reducing the number of fatalities due to drug overdose, as well as slowing the transmission of infectious diseases. As of 2023, 109 countries had national harm-reduction policies, but similar policies remain limited in the U.S.
Research has suggested that synthetic opioids require higher doses of naloxone to reverse overdose. Portugal has long had peer distribution of naloxone — meaning people who use drugs can distribute naloxone and other harm-reduction supplies directly to peers. Colombia and other countries have also recently introduced this practice. But in the U.S., there are restrictions on access to naloxone for overdose reversal or for fentanyl test strips for drug checking. Laws vary by state, with some allowing civilians to administer naloxone (once they obtain a prescription from a medical professional) and some only allowing administration by medical personnel. In addition, naloxone is not always free; this may present a barrier for people who need it most. In some states, fentanyl test strips are criminalized under drug paraphernalia laws.
It will be important to monitor the landscape of drug use and focus efforts on providing appropriate and timely care. For example, the U.S. has seen increases in smoking and other noninjection methods implicated in drug-related deaths, making it critical that harm-reduction efforts going forward highlight smoking and other drug-consumption routes, as well as ensuring support for syringe services programs. Syringe services programs are illegal in several states, despite evidence that shows they do not increase illegal drug use or crime, and at the same time, reduce the transmission of disease, improve cessation of drug use, reduce injection as the primary route of drug consumption, improve access to drug treatment services or resources, and lower the likelihood of death from overdose.
Effective health promotion. Across all its approaches and policies, the U.S. must prioritize messaging that does not introduce further harm by stigmatizing drug use and drug users. Despite early evidence showing that deaths may have dropped from 2022 to 2023, it is too early to treat these results as a positive development; we must continue to prioritize reducing the harms associated with drug use. Catering messaging and interventions thoughtfully to account for differences in populations is crucial to ensuring communications and interventions to prevent drug deaths are as effective as possible.
The U.S. should look to the Portuguese model of emphasizing public health and health care — and other lessons from abroad — to reduce the associated harms of drug use and address the crisis happening all over the United States.
