It’s Time to Tackle the Epidemic of US Drug-Related Deaths

This brief is part of “Election 2024: Policy Playbook,” a series by the Baker Institute and Rice University that offers nonpartisan, expert analysis and recommendations to equip policy leaders governing the United States and Texas in 2025.

The Big Picture

• Drug overdoses have become the primary cause of death among adults aged 18 to 45.
• Nearly 49 million Americans aged 12 or older had a substance use disorder (SUD), as of 2022.
• In 2023, more than 108,000 Americans died from a drug overdose.
• Elected officials must expand access to harm reduction, treatment, and recovery services while committing to broader reforms that address the root causes of drug misuse and addiction.

Summarizing the Debate

Drug overdose is now the leading cause of death for adults between the ages 18 and 45. Fentanyl — a synthetic opioid 100 times stronger than morphine frequently found in counterfeit pills and other illicit-market drugs — was involved in roughly 70% of fatal overdoses in 2023.

But fentanyl is not the only problem. Overdoses involving cocaine and methamphetamine have been increasing since 2010. Many individuals use multiple drugs, which can increase the risks for adverse events and complicate treatment. As the illicit drug supply continues to evolve, the prevalence of highly potent substances other than fentanyl is increasing.

The influx of fentanyl into the U.S. has been blamed on illegal immigration. However, restricting immigration will not reduce overdoses. 

• In fiscal year (FY) 2023, 86.4% of individuals sentenced for fentanyl trafficking were U.S. citizens.
• The international criminal network that profits from trafficking drugs is not responsive to U.S. immigration policy.
• In the unlikely event that law enforcement successfully reduces the supply of fentanyl, another drug may take its place, given the strong demand for drugs in the U.S.

Expert Analysis

Congress appropriated roughly $10.6 billion for opioid response efforts for FYs 2017–28. It also expanded treatment access and removed barriers to care, particularly for buprenorphine, a medication used for opioid use disorder. State and local governments have expanded access to treatment, made the overdose reversal drug naloxone more freely available, and piloted both mobile treatment units and overdose prevention centers.

Despite these efforts, rates of overdose and SUD are increasing. There are several reasons for this: 

• Most overdose response initiatives target people with SUDs. But occasional or recreational users also have an elevated risk for overdose because of the lethality of the unregulated drug supply. This large and diverse population is not easily reached through traditional addiction service avenues. Aside from drug checking programs in some pockets of the country, there are no concerted government efforts to improve the safety of the drug supply.
• Addiction is a complex illness, and recovery can be elusive even under ideal circumstances. Most Americans still encounter stigma and other barriers to care. Medications for opioid use disorder reduce the risk of overdose by up to 59%, yet only one in five individuals in need of these medications receive them. Medications for alcohol use disorder are similarly underutilized.
• The U.S. is not adequately addressing key risk factors for substance misuse. These include poverty and declining wages, housing insecurity, untreated physical and mental illnesses, and loneliness.

Policy Actions

U.S. lawmakers should expedite current efforts to increase access to care for people who use drugs. They should also commit to alleviating underlying risk factors for substance misuse.

The following is recommended to support this work:

1. Pass the Support for Patients and Communities Reauthorization Act. The 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act boosted funding and revised Medicaid policies to expand treatment for low-income, pregnant, and incarcerated individuals. The reauthorization bill — which has been stalled in the U.S. Senate since December 2023 — is needed to extend key provisions through FY 2028.
2. Relax methadone and buprenorphine restrictions. Methadone can only be dispensed at heavily regulated opioid treatment clinics and just 5% of zip code tabulation areas have a methadone clinic. Too few pharmacies dispense buprenorphine, especially in majority Black, Hispanic, and low-income neighborhoods. Expanding the types of locations that dispense these medications to include local and federally-qualified health centers ­­— as well as other community providers — would help eliminate access barriers and improve treatment retention, especially in rural communities.
3. Increase Medicaid reimbursement rates for SUD treatment. Access to Medicaid is associated with reductions in opioid-related mortality. However, not enough providers accept Medicaid because of low reimbursement rates. Increasing payments for SUD treatment would incentivize providers to treat Medicaid-insured patients.
4. Enhance enforcement of the 2008 Mental Health Parity and Addiction Equity Act. The denial and delay of mental health and substance use coverage by private insurers is a major reason why individuals do not receive needed treatment. But state and federal agencies need sufficient resources to enforce parity laws. The consequences for violators should also be severe enough to deter this behavior.
5. Decriminalize drug contamination testing services. Most individuals who use drugs do not know the true contents of what they consume. The lack of knowledge about  fentanyl’s presence in the U.S. illicit drug market fueled a more than 700% increase in opioid-related overdose deaths from 2015 to 2021. Information about a drug’s contents can reduce users’ exposure to unwanted adulterants. It can also improve overdose response efforts by providing public health and safety officials with real-time information about the drug supply. 
6. Use the Surgeon General’s National Strategy to Advance Social Connection as a starting point to address the nation’s epidemic of social isolation. Since isolation is a contributing factor in drug use, governments should prioritize social connection and invest in local infrastructure that fosters community togetherness.
7. Commit to reducing poverty. Expansion of the Child Tax Credit and Earned Income Tax Credit, child care subsidies, paid sick leave, and other policies that support workers can boost low-income Americans’ financial health, leading to lower levels of illegal drug use.

The Bottom Line

Tackling the epidemic of drug-related death, harm, and addiction requires immediate action from federal and local policymakers and agencies to increase access to lifesaving services. It also requires a genuine commitment to a society that offers Americans a real shot at a healthy and meaninful life.

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.