New provisional data from the Centers for Disease Control and Prevention (CDC) estimates that almost 108,000 people died of a drug overdose in 2021. That’s equivalent to the population of Green Bay, Wisconsin, dead. It is—once again—the largest number ever recorded in a single year, as overdose remains the leading cause of accidental death in the United States.
“Once again, we are devastated by these numbers,” Dr. Jules Netherland, managing director of the Drug Policy Alliance (DPA) Department of Research and Academic Engagement, said in a press release. “Over 107,000 of our friends, family and neighbors lost their lives to drug overdose last year. … The United States has spent over 50 years and well over a trillion dollars on criminalization—and this is where it has gotten us. It’s clearly not working. It’s time we start investing where it actually matters—in our communities, specifically Black, Latinx and Indigenous communities where we are now seeing the sharpest rise in overdose deaths.”
The data reflect that in 2021, as the COVID-19 pandemic continued, overdose deaths were 15 percent higher than in 2020. That’s a rapid climb in numbers that were already at record levels, even if the increase from 2019-2020—as the pandemic kicked in, bringing isolation and many other exacerbating factors—had been steeper still, at 30 percent.
“It’s extraordinarily alarming in that we continue to see a dramatic escalation in drug overdose deaths every calendar year,” Daliah Heller, vice president of drug use initiatives at Vital Strategies, told Filter. “Seeing this increase continue at steep levels is a reflection of the widespread presence of fentanyl in the drug market.”
Almost 81,000 of the deaths in 2021 involved opioids—up from 70,000 in 2020. Compared with 2020, about 13,400 more deaths involved “synthetic opioids,” including fentanyl and its analogues. And about 8,300 more deaths involving “psychostimulants,” a category that includes methamphetamine. About 4,600 more deaths involved cocaine.
Amid the overall increase, there were declines in some specific drug categories. About 200 fewer deaths than in 2020 involved “natural and semi-synthetic opioids,” which includes prescription painkillers such as oxycodone. Heavy government restrictions on legal opioid prescribing have continued to reduce the availability of these drugs—opioids with known purity and dosage—and, according to many analyses, pushed more people to riskier options. Additionally, 4,300 fewer deaths involved heroin; fewer people than before are able to obtain heroin, as fentanyl and other more potent synthetics widely replace it.
“It’s not that necessarily we’re seeing an increase in use, it’s that we’re seeing a contaminated drug supply that’s driving the deaths.”
Geographically, overdose deaths increased in every US state except Hawaii, where they decreased by just five (data are not available for Wyoming). But the rate of increase is quite uneven among different states. Alaska had the worst single-year rate of increase (75 percent), followed by Kansas (43 percent), South Dakota (35 percent), Vermont (34 percent) and Oregon (34 percent).
But when we adjust by population, West Virginia is most impacted, with 83 deaths per 100,000 residents—followed by Washington, DC (81), Tennessee (56), Louisiana (53) and Kentucky (53).
Other important demographic breakdowns aren’t available in the CDC’s provisional data. Neither do we know how many people died after consuming mixtures of drugs, and in what combinations. Drug-related deaths most often involve more than one substance, and drug batches in the illicit market typically include multiple substances, with potentially harmful adulterants ranging from fentanyl to xylazine. Whether used deliberately or unconsciously, combinations like fentanyl and heroin, or opioids and stimulants (“speedballing,” when done deliberately) are common. More precise data will be essential.
“We know that stimulant supplies are being contaminated with fentanyl to some degree,” Netherland of DPA told Filter.
“What’s interesting when you look across the board,” she added, “is it’s not that necessarily we’re seeing an increase in use, it’s that we’re seeing a contaminated drug supply that’s driving the deaths.” Netherland referenced a recent study in JAMA that showed teenage overdoses are surging, even as teen drug use is actually at a historic low.
Yet the Biden administration continues to invest heavily in the law enforcement and supply-side crackdowns that got us here.
Yet another devastating year of overdose deaths represents unnecessary further evidence of the consequences of US drug policy. Such deaths have been rising year-on-year for decades, with only occasional dips. Criminalizing drugs—which most people, we should remember, use without experiencing addiction or negative consequences—inhibits access to lifesaving resources and has resulted in a highly toxic illicit drug supply, incentivizing the marketing of more potent substances per the “Iron Law of Prohibition.”
Yet the Biden administration, despite its unprecedented inclusion of some harm reduction measures and funding in the 2022 National Drug Control Strategy, continues to invest heavily in the law enforcement and supply-side crackdowns that got us here. (Indeed, one of its immediate responses to the new data was to ask China to crack down harder on exports of precursor chemicals used to make fentanyl.) It’s a half-step forward and three steps back.
Asked what meaningful actions US governments can take right now, Netherland said, “One of the most immediate things is the expansion of overdose prevention centers. The only legally-sanctioned centers are operating in New York, which is wholly insufficient for the scale of the crisis we’re facing.”
Safe consumption sites (SCS), as they’re also known, provide a space for people to use state-banned drugs with peers, staff and the overdose-reversal drug naloxone on hand. New York City’s two facilities immediately began saving lives after they opened late last year. With almost 200 sanctioned SCS operating in 14 countries around the world, no overdose death has ever been recorded at any of them. The Biden administration continues to drag its feet on taking a public stance about SCS.
But far more than SCS will be needed to dismantle the whole edifice of prohibition and repression that’s killing so many.
Further vital steps to take immediately, according to Netherland, would include “expanding other harm reduction and public health measures [and] increasing access to treatment. And then ultimately, thinking about ways to create a safe supply would be a way to address this crisis.”
“We are grateful that the Biden Administration has embraced harm reduction as part of their National Drug Control Strategy,” she said in the press release, “but we need to see that commitment met with Congressional funding and a massive scaling up of these health services.”
Photograph of cocaine by Kastalia Medrano
The Influence Foundation, which operates Filter, previously received a restricted grant from DPA to support a Drug War Journalism Diversity Fellowship.