Fentanyl Is in Everything

Around 2013, fentanyl started percolating in the United States street opioid supply, which was heroin-based at that time. Over the next few years it steadily pushed heroin out of the East Coast, and once the COVID-19 pandemic hit it rapidly did the same on the West Coast. As crackdowns have pushed the drug supply to evolve more quickly and chaotically, fentanyl has gradually begun showing up with non-opioid drugs.

Media and law enforcement, however, tend to describe it as an additive that predatory distributors mix into whatever they’re distributing—cocaine, meth, heroin, marijuana, vapes, pills that look like pharmaceuticals.

Fentanyl sometimes ends up in meth and cocaine supplies, probably not intentionally. This varies a lot by region and isn’t as common as most local news stories would have you believe, but is important to be aware of.

A pressed pill sold as Percocet or Oxycodone might not contain fentanyl, but you should assume that it does, if you don’t have the means to check. Same goes for anything sold as Xanax. A pressed pill sold as Adderall could conceivably contain fentanyl, but that would make it a pretty significant anomaly; what you should assume that it contains is meth.

We tend to fixate on whether something does or does not contain fentanyl, but that binary distinction isn’t what determines the risk. Someone opioid-naive who buys a fentanyl pressed pill that they believe to be real Percocet will still be okay if the amount of fentanyl in the pill is small enough. Conversely, someone who smokes what they know to be fentanyl pills off foil every day will be overdosing within minutes if they get one with more fentanyl than they were expecting.

Has fentanyl been found in marijuana? It has not. Periodically there are news stories or other vaguely credible-sounding claims to this effect, but none of them ever stand up to scrutiny. The one that got arguably the most traction was a 2021 statement from Connecticut health officials, announcing “the first lab confirmed case of marijuana with fentanyl in Connecticut and possibly the first confirmed case in the United States” and citing 39 incidents “where only marijuana use was reported but naloxone was required.” Later it turned out that this boiled down to a single case of minor, accidental cross-contamination among people who also used opioids.

You can immediately write off any claims of fentanyl being smoked with marijuana, or smoked with anything else using a combustion process rather than a vaping process. Fentanyl can’t be smoked with an open flame; it gets burned and rendered inactive.

A very small number of vapes appear to have tested positive for fentanyl. For one thing, this would probably happen with literally any physical object that school boards across the country started continuously testing for fentanyl. But the important takeaway is that the more credible claims involve vapes that had clearly been modified intentionally for personal use, not vapes that had been designed that way and marketed to children. You can still pick out any news story that describes a middle- or high-school student nearly dying from using a “fentanyl-laced vape”—even the stories circulated by elected representatives—and reliably find that it has either since been debunked or does not mention any actual laboratory confirmation of fentanyl, despite whatever the headline said. Usually the source for the claim is the student or their mom.

Higher-Potency Opioids Need Extra Doses of Naloxone

Naloxone works by binding to your mu receptors—the specific protein molecules that opioids also bind to—and kicking off whatever opioids might already be there. The clinical dose of naloxone, 0.4 mg/mL, is what’s usually sufficient to reach about 50 percent of your mu receptors, or enough to reverse an overdose. That’s why 0.4 mg/mL is the dose contained in a vial of generic intramuscular naloxone.

A Narcan nasal spray contains a 4-mg dose of naloxone. Intranasal administration can’t be directly compared to intramuscular, but it’s the less efficient of the two and so Narcan is designed to deliver more than the clinical dose. A 4-mg Narcan was more than enough for most heroin overdoses, is still more than enough for most fentanyl overdoses, and is also still more than enough for most overdoses involving fentanyl analogs, nitazenes, orphines and whatever novel synthetic opioids are found in the supply next. Naloxone’s effectiveness doesn’t change based on the opioid’s potency, since it acts on the mu receptors rather than on the opioids themselves.

When cops or well-meaning bystanders share stories about someone needing five doses of Narcan to wake up, and how this just shows how much more potent the supply is these days and how naloxone doesn’t cut it anymore, this almost always comes from the same mistaken assumptions about overdose reversal.

Naloxone takes two or three minutes to kick in, which is why it’s important to administer rescue breathing while you wait. But because the two minutes that you’re supposed to wait before administering a second dose can understandably feel like an eternity, especially to anyone not experienced in these situations, the temptation is often to pump in a second dose pretty quickly. Or a third dose, or fourth, or fifth, and so on until the person wakes up. When someone wakes up after a fifth Narcan, what you’re really seeing is the first dose kick in. All the extra naloxone did nothing to help, and for people with a physical tolerance to opioids it can precipitate withdrawal and put them at increased risk of overdosing again. At a proper dose, reversing an overdose with naloxone doesn’t require waking the person up at all.

In 2021, the 8-mg Kloxxado nasal sprays hit the market and marked the beginning of the naloxone arms race. In the five years since then, the Food and Drug Administration has approved a 5-mg intramuscular autoinjector—meaning it delivers about 12.5 more naloxone than the clinical dose—a 10-mg nasal spray that launched earlier in 2026. It’s also moved beyond naloxone to a different, longer-acting opioid antagonist, nalmefene. The first nalmefene nasal spray, Opvee, has already been followed by a nalmefene auto-injector. And government contracts investing in nalmefene as a preventative measure for fentanyl nuclear war. And biased research inventing meaningless metrics that are supposed to justify any of this as necessary.

Naltrexone Is Safe and Effective

Technically, the US has three approved medications for opioid use disorder (MOUD). In reality, we have two MOUD that are shown to be safe and effective, and we have naltrexone. Methadone and buprenorphine (Suboxone) decrease overdose risk. Naltrexone’s labeling is required to carry a warning that it increases fatal overdose risk.

Naltrexone is commonly known by brand name Vivitrol, the injectable formulation touted in county jails and other correctional settings. While methadone and buprenorphine are opioid agonists, naltrexone is an opioid antagonist—like naloxone and nalmefene. It purports to work by blocking the effect of opioids, so that even if a patient tries to use opioids they won’t feel anything.

What this effectively does is reduce tolerance, which is why the FDA labeling has to warn that deaths have been documented “at the end of a dosing interval, after missing a scheduled dose, or after discontinuing treatment.” The warning about risk of fatal overdose from “[a]ttempts to overcome blockade” is similar to the warning carried by the two approved nalmefene products, Opvee and Zurnai.

Unlike methadone and buprenorphine, naltrexone requires detoxing prior to initiating the medication—going into withdrawal for at least a week, maybe two. That alone makes it a non-starter for a substantial portion of people at risk. A recurring theme with research supporting naltrexone’s efficacy is that it doesn’t count the people who tried to start the medication and weren’t able to get through the detox process, preferring to factor in only the cases where people did manage to onboard. Or it uses the framing that once detox is out of the way, “naltrexone is about as effective as buprenorphine,” which still isn’t true.

People stabilize on methadone and buprenorphine because those MOUD help manage cravings and withdrawal symptoms. But studies tracking naltrexone outcomes never show anything long-term. Conclusions that it reduces cravings come from short-term data, and any evidence of its efficacy is based on negative urine drug screens after a few weeks or at most a few months. This research is never concerned with what happens after that. The idea of naltrexone remains popular because it fits an abstinence mentality, it’s punitive and it’s an easy out for corrections departments. Not because it’s helpful.

Syringe Litter

As popular as it is to demonize syringe service programs (SSP), the arguments against them don’t see too much innovation. There’s the complaint that SSP increase “crime,” which is not true. There’s the complaint that they increase drug use, which is not true. The most substantive complaint is that they increase “syringe litter.” This is also not true.

Neighborhoods that open SSP are overwhelmingly associated with a decrease in publicly discarded syringes, for a few different reasons. They’re often more convenient than sharps-disposal bins in parks, which require people to make a separate trip just to have fewer syringes than before. They provide portable sharps containers that are small enough for people to carry around, and larger ones people can keep at home. And they employ peer workers who do daily walkabouts picking up any syringes they see on sidewalks or other public areas.

At the heart of the syringe litter myth is the suggestion that children are at risk of contracting HIV from stepping on a needle while playing at the park. This is an easy one to debunk: It has never happened. There has never been a single documented case of anyone, child or adult, contracting HIV from a publicly discarded needle. It’s just another myth.

The human immunodeficiency virus is very fragile and relies on our immune cells to survive. Once outside the body, exposed to air, it dries up and dies almost immediately. This is why the only confirmed HIV needlestick transmissions have all involved health care workers in hospital settings, and even then they’re extremely rare. For the public, transmission risk is limited to situations involving blood, semen, vaginal or rectal fluids, or breastmilk delivered directly to a mucous membrane or into the bloodstream.

The hepatitis C virus can actually live for several weeks outside the human body, but globally there have been maybe three documented cases of hep C transmission from accidental needlesticks in community settings; none in the US nor involving children. Hep C can be easily and painlessly cured with oral medication, and doesn’t begin to damage the body for years or even decades.

As often as the media runs stories about syringe litter, you might notice that the accompanying photos often show a syringe with the front and back cap still on, sterile as the day it was born, thoughtfully arranged in the middle of a ditch. I was going to make a joke about how eventually they’ll show one of those individually packaged 27-gauge 1 cc syringes still in its individual package, but this has already happened.

Secondhand Overdose From Drugs in Prison Mail

After that viral video with the San Diego County Sheriff’s Department deputy in 2021, the online harm reduction community got the rare satisfaction of rallying around a talking point—you cannot overdose from touching fentanyl—and seeing the media actually take notice. A lot of news stories will now add some kind of disclaimer when referencing passive exposure, though this remains pretty hit or miss. You can’t overdose from skin contact. You can’t overdose from breathing in fentanyl molecules floating around in the air; fentanyl has a very low vapor pressure and barely releases any molecules into the air anyway. You can’t overdose from any other kind of passive exposure. The public is now moderately more aware that there is no such thing as secondhand fentanyl overdose. However, like everything else in harm reduction, this development has not made it into the prison system.

US prisons and jails have a completely different drug supply than the free world. There is fentanyl, but the mainstays are generally synthetic cannabinoids (K2; Spice) meth, Suboxone, tobacco and strips, a catch-all term for the ubiquitous strips of paper soaked with what could be anything, but is often synthetic cannabinoids or household solvents like insecticide. In recent years, many facilities have seen synthetic cannabinoids and/or strips replace meth or other contraband similarly to the way fentanyl replaced heroin in the outside drug supply.

Countless press releases and Facebook announcements have described how corrections officers required Narcan (multiple doses!) and were hospitalized following exposure to dangerous synthetic cannabinoids and other drugs concealed in incoming mail. This does not mean the officers were harmed. It does not mean the officers were ever in harm’s way. It does not even necessarily mean the officers were exposed to any drugs. It means that officers gave themselves Narcan and took themselves to the hospital. Synthetic cannabinoids are not opioids and are not affected by Narcan, but the whole situation is so far beyond logic that we don’t have time to stop for this.

The only one of these incidents that’s ever cited actual harm was in 2024 at USP Atwater, when mailroom supervisor Marc Fischer reported feeling ill and then died at a hospital about two hours later. Initially the cause of death was undetermined, pending toxicology, which gave media outlets across the country an opening to run headlines about “possible fentanyl exposure.” The Merced County Sheriff’s Office did not respond to Filter’s February 2025 coroner records request, which is fine because a week later documents filed in US District Court for the Eastern District of California revealed that the cause of death was a heart attack. Neither the AP nor the Los Angeles Times nor any other media outlet that ran a “possible fentanyl exposure” headline ever published anything further. The Bureau of Prisons, Correctional Peace Officers Foundation and various other agencies continue to honor Fischer’s memory by not acknowledging the autopsy, and praising his sacrifice in the line of duty while handling synthetic drug-soaked mail.

There is no evidence to suggest that secondhand exposure to synthetic opioids or cannabinoids poses any kind of risk. Many corrections officers know this, since they’re the ones bringing in most contraband drugs anyway. But they continue to bravely share their stories, and Occupational Safety and Health Administration investigations conclude that mailroom staff need head-to-toe personal protective equipment and HEPA-filtered biosafety cabinets, and federal corrections officers unions use those findings to call for the expansion of digitized mail-scanning.

And that’s what all of this is really about: understaffing and the nationwide push to privatize prison mail services, and cut incarcerated people off from receiving physical letters. Along with in-person visitation, and book donations, and any other “privilege” whose physical form can be replaced with a digital service conveniently offered by a handful of for-profit contractors. More than three out of four people incarcerated in US prisons no longer have access to physical mail.

At this moment, somewhere in the US another corrections department is drafting another press release breathlessly recounting how over the weekend one or more officers were hospitalized following exposure to deadly synthetic drugs, and pleading for Congress to recognize that no one should have to risk their life just to do their job of opening other people’s mail. Media and legislators will circulate it with no scrutiny whatsoever. To date, there are no confirmed reports of any corrections officers ever having been harmed by exposure to drugs in the mail.

Meth Overdose Crisis

Opioid overdose is potentially fatal because opioid molecules can bind to the brainstem receptors that regulate breathing; the mechanism of death is respiratory depression. Meth, like synthetic cannabinoids and various other stimulants like cocaine, doesn’t have any particular mechanism of death that accompanies overdose in the same way.

Stimulant overdose, or overamps as they’re sometimes called, don’t necessarily produce stereotypical symptoms like paranoia or hyperactivity. Often they make people fall asleep. Occasionally they might cause seizures. But then they resolve, and that’s that. The harms tend to come from exposure to law enforcement, rather than the physical ordeal itself.

Meth-involved overdose deaths in the US began rising more noticeably around 2019, peaking in late 2023 before starting to gradually drop back down; the same trajectory as fentanyl-involved deaths, but less drastic. It’s clear that more people are using meth compared to a decade ago, which means more people have meth in their system at the time that they die. But it’s not quite clear that meth is what’s causing them all to die, at least not on the scale being suggested by the media.

US death investigations are a mess. Depending on the state, they might be carried out by medical examiners, elected county coroners or local law enforcement. In Nebraska, for example, cause of death is determined by prosecutors. In most California counties, the coroner is also the sheriff. Forensic pathologists are still required to sign off on the death certificate, but there are only a few hundred of them in the whole country and many jurisdictions now use forensic pathologists who aren’t board-certified. In Canada and other wealthy countries full autopsies are considered standard for suspected overdose deaths, but in the US they’re rare. Where not mandated by state law, they’re pretty much reserved for cases where law enforcement could potentially use the evidence to prosecute someone, or the family could afford a private one.

In suspected overdose cases, the death investigation often consists of toxicology and an external examination—medical history plus a long look at the body and any evidence found at the scene. None of these can reveal a heart attack, or heat stroke, or pneumonia. But they can reveal meth, and even without fentanyl that’s all that’s needed to wrap the investigation, particularly for people who die without housing. No available medical history? Well, clearly their medical history is that they used meth.

“If they had a heart death, I think [any meth] is going to get attributed as a cause of death. Because that is the bias of the system,” a toxicologist who signs off on drug death reports told Filter in 2023. “It’s like: Here’s someone that was found in a tent, we can’t contact their next of kin, we did a [urine drug screen]. They’ve got meth in their system; keep it moving. We’re not going to do an autopsy.”

Some research has suggested that meth is linked to about two out of three US deaths among people without housing. Local-level studies have found similar patterns in places like California and Oregon.

Deaths attributed to just meth, with no fentanyl present, tend to be among people who were over 45 and had a history of cardiovascular disease. To which chronic meth use may have contributed, but it wouldn’t have been the only thing. When a non drug-user dies from a heart attack in a hospital, we say they died from a heart attack—not from a sedentary lifestyle or refined carbohydrates. When a meth user dies from a heart attack and they weren’t in a hospital, their cause of death was a heart attack. But we might say it was meth, if drugs were the only thing we checked for.

Novel Synthetic Opioids, Even Deadlier Than Fentanyl

No matter how much we sensationalize fentanyl and its potency, after hearing about it for so many years the public has somewhat acclimated to the idea. So fentanyl headlines lose their power, and the only way for media outlets to combat this is with something even more potent than fentanyl.

First it was fentanyl analogs, followed by nitazenes and most recently orphines. All have the potential to be more potent than fentanyl (as well as less potent, not that this is of interest to anyone). The problem with news outlets pouncing on each novel synthetic opioid (NSO) as it hits the supply isn’t so much that they misrepresent the potency; it’s that they misrepresent the prevalence. Each NSO is presented as a harbinger, like behind the first couple of reports is a dam about to break, unleashing the substance that will replace fentanyl the way fentanyl replaced heroin. That will usher in the next wave of the overdose crisis all on its own.

Outside of North America the emergence of NSO could have a very different significance, if fentanyl hasn’t already saturated the opioid supply the way it has here. But at the moment, there’s no real reason to think that any fentanyl analogs, nitazenes or orphines are poised to overtake fentanyl in the US supply. Some of them, like carfentanil or cychlorphine, have become more recognizable names, but we’re still talking about substances linked to a very small portion of overdose deaths, and that’s including the cases where they were detected at all not just the ones where they were detected alone or determined to be the cause of death.

Most of these substances arrive mixed in with fentanyl—though some are occasionally found on their own—and aren’t really distinguishable from fentanyl, from a user perspective. Health departments will take whatever one or two talking points exist , which are probably just the location where it was detected and how many times more potent than fentanyl it’s supposed to be, and stretch them over a public bulletin that doesn’t help the public do anything differently. There’s a NSO in the supply. It’s been detected six times, in these two states; you can’t test for it and it’s not distinguishable from fentanyl. You should still use naloxone and take the precautions you were taking for fentanyl. This kind of thing is for the benefit of website traffic and re-election campaigns, not the public.

Not all recent additions to the supply are interchangeable. Xylazine and medetomidine, both non-opioid veterinary tranquilizers, have come with distinct complications and forced harm reduction groups to evolve overdose response protocols around each of them specifically. NSO have certainly reshaped how we criminalize the supply, but they haven’t really reshaped the supply itself. Even carfentanil, which has been in the US about as long as fentanyl and remains the most potent opioid we know of, has ebbed and flowed at the edge of the supply and never grown into something with a market of its own. None of them have.

No matter how potent, a substance can’t really be more deadly than fentanyl if it isn’t causing more people to die.

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The authors of a study published in International Journal of Drug Policy show how this has disproportionately affected First Nations Peoples. They looked at safer opioid supply access among registered First Nations Peoples in Ontario between 2019 and 2023, and found that during that period the number of new program initiations increased nearly fivefold—from 15 individuals to 92. The rate was also higher than that of the general Ontario population.

Safer supply programs provide eligible patients with regulated, pharmaceutical alternatives to street-supply drugs, such as hydromorphone as an alternative to the unregulated fentanyl supply.

Coauthor Ashley Smoke was an early advocate for safer supply.

“We knew people were overdosing and dying when they did not have to,” Smoke told Filter. “What was needed was access to a safe and regulated supply of the substances people were already using, so they were not forced to rely on the poisoned street supply.”

Smoke, from Alderville First Nation, is a member of the Ontario Drug Policy Research Network Lived Experience Advisory Group. They are the cofounder of the Ontario Network of People Who Use Drugs, and wear many other hats in harm reduction and drug policy. In their first experience with safer supply they were referred to a program with a strong Indigenous culture, but struggled to access it because of the distance from where they lived.

Many Indigenous people in rural and remote areas experience the same problem. The study found that in 2023, only six of the 92 individuals who started safer supply lived in First Nations communities. The programs had been concentrated in urban areas. The authors also noted that providers within First Nations communities may be unlikely to prescribe safer supply, due to wariness about overprescribing.

The researchers cite ongoing trauma from the Indian Residential Schools and child welfare system.

During approximately the same time period used for the study, the overdose rate among First Nations Peoples in Ontario tripled. In 2022 the rate of fatal overdose was approximately nine times that of the general Ontario population.

The researchers cite ongoing trauma from the Indian Residential Schools and child welfare system. Between the 1830s and 1990s more than 150,000 Indigenous children across Canada were taken from their homes and sent to government-funded, primarily Christian boarding schools. In 2015 this was formally recognized as cultural genocide.

“Indigenous communities have been disproportionately affected by the toxic drug crisis for many years,” coauthor Katie Pine told Filter. “We continue to see the impacts on individuals, families and entire communities.”

Pine is an opioid strategic planning specialist for the Anishinabek Nation, based in North Bay. She said that while it was clear the crisis was continuing to disproportionately impact First Nations communities across Ontario, not enough is known about their on-the-ground experiences of accessing safer supply. The study showed that among First Nations Peoples there is “growing engagement with this harm reduction approach,” making the province’s current stance even more concerning.

“I don’t think any of the findings were particularly surprising to me,” Pine said. “I had worked with safer supply programs and had firsthand experience supporting people who were accessing those services.”

Pine hopes the paper reaches policymakers, and those in a position to fund these types of programs.

“Before safer supply, I had lost custody of my son,” Smoke said. “My relationship with my partner was broken. I had strained relationships with family members, and so much of my life was organized around trying not to be sick, trying to manage pain, trying to access substances, and trying to survive.” 

Safer supply changed all that. Once Smoke no longer had to rely on the unpredictable street supply, the “constant pressure, fear and instability” in their life decreased. They regained custody of their son. They were able to focus on repairing their relationships and building a career. Smoke and their partner now have their own home. Smoke credits safer supply for allowing them to make these changes.

“For Indigenous people, substance use cannot be separated from colonization, residential schools, the Sixties Scoop, child welfare, criminalization, racism, poverty, grief, trauma, displacement, and disconnection from culture, land, family and community,” Smoke said. “If safer supply only focuses on the prescription, it misses the full context of people’s lives.” 

Image via Washington State Healthcare Authority

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The data, announced July 15, cover the 12-month period between February 2025 and February 2026. So far jurisdictions have reported 67,531 overdose deaths for that time period. The predicted number of deaths, which is considered to be more representative since death records aren’t all reported at the same time and a small portion (0.24 percent) are still pending investigation, is 68,641. That puts the national overdose rate approximately where it was in 2019.

Overdose rose sharply at the onset of the COVID-19 pandemic, after already rising almost continuously since the CDC began tracking this data in 1999. But in 2023 the trajectory abruptly reversed, and for the past two-and-a-half years the provisional data have shown the national rate continuing to drop each month. In 2024 the rate of fatal overdose decreased by more than 26 percent. But in 2025 this decrease slowed to half-speed. In the most recent report, the national rate of decrease is 12.1 percent.

Behind the national average, there’s always been a wide range in how the crisis is experienced in different parts of the country. Nebraska and South Dakota were still reporting slight increases even when the national rate first began to plummet in late 2023. 

In New Mexico, where overdose has been rising the most sharply, the predicted number of deaths is 1,037, a 27.1-percent increase from the 816 deaths predicted during the 12 months leading up to February 2025. In Colorado the increase is 14.2 percent, with 1,852 predicted deaths up from 1,622 in the 12-month period a year earlier.

South Dakota (+12.5 percent) is predicting 90 overdose deaths, up from 80 during the same 12-month period a year earlier. Other states in which overdose has continued to rise are North Dakota (+7.1 percent) with 120 predicted deaths; and Minnesota (+1.7) with 1,008 predicted deaths;  Montana (+1.2 percent) with 175 predicted deaths. In Nebraska the rate of change was 0, with 149 predicted deaths.

Outside of the Western corridor, overdose has continued to drop.

In the previous monthly report that list had included Alaska and New Hampshire for the first time. The most recent data show overdose in both states starting to drop again, with Alaska (-6.2 percent) at 324 predicted deaths and New Hampshire (-0.8 percent) at 258 predicted deaths.

Though Arizona had previously experienced a surge comparable to New Mexico’s, the past several monthly reports have showed that surge slowing to half-speed, which is not the case in New Mexico and Colorado. The latest number of predicted deaths for Arizona is 2,914, up from 2,695. 

Between the provisional death count published in April and the most recent one in July, New Mexico’s rate of change increased from about 16 percent to over 27 percent. Colorado’s increased from 10.3 percent to 14.2 percent. But Arizona’s rate of increase fell, from 21 percent to 8.2 percent in the most recent report.

Outside of the Western corridor, overdose has continued to drop. The latest data show the jurisdictions with the steepest decreases are Rhode Island (-34.3 percent) with 203 predicted deaths; Oregon (-29 percent) with 1,044 predicted deaths; and Puerto Rico (-25.8) with 435 predicted deaths.

Overdose data are subject to a ton of inconsistencies, stemming from the various ways death investigations are conducted at the county level, and so these reports are most useful when viewed in terms of the overall scope and trajectory of the crisis rather than putting too much weight on fluctuations between smaller numbers. Alongside the latest monthly report, the CDC also published county-level overdose death data covering December 2024 through December 2025.

Fentanyl pill purity has dropped sharply in recent years. But this is not the same thing as supply reduction, and is not the result of fentanyl seizures at the border. There is still no evidence that fentanyl interdiction reduces overdose, not just because the federal government doesn’t actually evaluate what if anything its fentanyl seizures accomplish but because this strategy has never been shown to meaningfully reduce drug-related harms. It’s usually shown to increase them, in the long run.

Image (cropped) via Centers for Disease Control and Prevention

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On June 17 the Centers for Disease Control and Prevention released its latest monthly provisional overdose death count report, which covers the 12-month period ending in January 2026. During that time the US has so far recorded 67,895 overdose deaths, a number that’s predicted to rise to 69,147 once the remaining available data have been added. Because death records are updated and submitted unevenly, the predicted number is considered the more accurate one.

After overdose surged during the early COVID-19, the 12-month death count peaked at 112,996 between August 2022 and August 2023. Then the trajectory reversed, and the national overdose rate has decreased continuously month after month. Between 2023 and 2024, the data showed fatal overdose decreasing by nearly 27 percent. But in 2025 the decrease slowed to about half-speed. The latest CDC report shows it decreasing 13.2 percent, compared to the 12-month period ending in January 2025.

Nationally, the rate of overdose is back down to approximately where it was in September 2019. But over the course of the past few monthly reports, it’s become clear that overdose is going back up in the West even as it continues to go down—at half-speed, on average—almost everywhere else.

Though their rates have varied from month to month, the two states where overdose has been rising the most are Arizona and New Mexico. The latest report shows New Mexico with 1,010 deaths predicted, a 24.1-percent increase compared to the same 12-month period a year earlier. In Arizona, the predicted death count is 2,932, an increase of 11.5 percent.

In November 2024, fentanyl-involved deaths suddenly began to climb even faster than they’d been falling.

The other states where overdose deaths have increased compared to a year earlier are South Dakota, with 96 predicted deaths (+14.3 percent); Colorado, with 1,819 predicted deaths (+11.3 percent); Nebraska, with 155 predicted deaths (+6.9 percent); Montana, with 174 predicted deaths (+4.2 percent); Minnesota, with 1,017 predicted deaths (+3.9 percent); North Dakota, with 125 predicted deaths (+2.5 percent); Alaska, with 329 predicted deaths (+1.23 percent); and lastly New Hampshire, with 266 predicted deaths (+0.4 percent). This is the first 12-month period in which Alaska and New Hampshire have joined that list. 

For most of 2024, fentanyl-involved deaths in Arizona declined rapidly. But that November the data show a sudden, sharp turnaround as fentanyl-involved deaths began to climb even faster than they’d been falling. Methamphetamine-involved deaths, which for years had been increasing at a steady-ish pace, jumped up sharply and rose in tandem through May 2025.

Between November 2024 and January 2025, fentanyl-involved deaths took a similar trajectory in New Mexico, Colorado and Minnesota. Patterns in less-populous states aren’t as readily apparent, not just because of the smaller numbers but because these states tend to have more gaps in their reporting. Nebraska didn’t report any overdose deaths between April 2024 and May 2025, and North Dakota didn’t report any for about half the months from the same time period. Death investigations are such a skewed and unstandardized business from one jurisdiction to the next that this could mean a few different things, but probably does not mean that no one died of overdose in those states during those months.

Though overdose deaths in Arizona still increased compared to the previous 12-month period, in October 2025 they began to slowly drop back down. The latest data show deaths in Arizona continuing to go down through January 2026. New Mexico and the other western states with rising overdose deaths haven’t yet followed suit.

Image (cropped) via Centers for Disease Control and Prevention

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The CDC’s latest monthly provisional overdose death count was published May 13. It covers the 12-month period leading up to December 2025, with 69,973 deaths projected during that time. The actual number of reported deaths so far is 68,632, with 0.26 percent of the data still pending.

Nationwide, the projected rate represents a 13.9-percent decrease compared to the 12-month period leading up to December 2024.

After overdose deaths surged past 100,000 per year during the COVID-19 pandemic, between 2023 and 2024 the rate suddenly dropped by more than 26 percent. But even then, overdose was still going up slightly in Nevada and South Dakota. The national average has continued to decrease every month, but by now that decrease has slowed to about half-speed.

By April, when the CDC released data covering the crisis up through November 2025, the projected rate of fatal overdose—while still decreasing in most of the country—was shown to be going up substantially in Arizona (+21 percent), New Mexico (+16 percent), Colorado (+10.3 percent) and North Dakota (+8.4 percent). Montana, South Dakota and Utah were all projected to be within a single death of what was recorded for the previous 12-month period.

The latest data now show overdose also going back up in Minnesota, with projected deaths for the 12-month period leading up to December 2025 increasing by 3 percent compared to a year earlier. The data also show Nebraska with the same number of projected deaths as it had in the previous 12-month period.

By percentage, the crisis now appears to be accelerating the fastest in New Mexico, with the projected rate of overdose increasing 21.7 percent compared to a year earlier. Arizona shows the next-highest increase (+18.1 percent) followed by Colorado (+10.6) and North Dakota (+8.3). In Montana, South Dakota and Utah the situation appears essentially the same as it did in the April data release.

In terms of what all this actually means, the first thing to keep in mind is that percentages are not numbers.

In terms of what all this actually means, the first thing to keep in mind is that percentages are not numbers. The biggest factor that influences them is not necessarily the rate of change in overdose deaths, but the size of a state’s overall population. The 21.7-percent increase in New Mexico represents projected deaths increasing from 794 to 966. Arizona’s 18.1-percent increase, on the other hand, represents an increase from 2,531 projected deaths to 2,988. Many of the western states where overdose does not appear to be on the same trajectory as the rest of the country—Nebraska, North Dakota, South Dakota, Montana—are also among the states with the smallest population sizes, and have fewer overdose deaths to report than more populous states. So an increase of one or two deaths can look like a much bigger change when viewed as a percentage.

However, that doesn’t change the fact that there appears to be a disparity between the West and the rest of the country. All the other jurisdictions that are smallest by population size are in the Northeast, where overdose is still decreasing: Vermont (-27.3 percent); the District of Columbia (-13.8); Delaware (-6.8 percent); Rhode Island (-35.2 percent); Maine (-21.8 percent); and New Hampshire (-5 percent). 

Arizona, Colorado and Minnesota, meanwhile, have relatively large populations. 

This brings us to the data outlier: Wyoming.

The other major factor impacting this data is the nature of death investigations themselves. Cause of death is determined at the county level, through a variety of processes that may have little in common besides being chaotically underresourced. States that have medical examiner’s offices tend to produce more robust death data than those that rely on a patchwork of county coroners, who can be elected to the position without medical training. Some states use both, or alternative processes that are more obscure. Nebraska, for example, is the only state where all causes of death are determined by prosecutors. Multiple Nebraska counties have not reported a single overdose death for decades, which probably does not mean that nobody dies of overdose in those counties.

This brings us to the data outlier: Wyoming, the country’s smallest state by population size. The latest CDC data show Wyoming’s projected overdose rate decreasing 23.4 percent compared to the previous 12-month period. This represents a change from 107 deaths to 82 deaths, but even at these relatively low numbers Wyoming appears to be on a different trajectory than all the states that sit geographically above and below it. This might be the case, or it might be because drug deaths are being underreported. Or a mixture of the two.

Wyoming uses a system of elected coroners, some of whom have reportedly not been amenable to attempts to standardize their methods. According to a 2023 investigation by WyoFile, some also have financial stake in private funeral homes. They’re sometimes approached by families who don’t want a loved one to be remembered as someone who died of overdose, and would rather the death certificate say something else.

Image (cropped) via Centers for Disease Control and Prevention

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The letter updates a previous Dear Colleague letter SAMHSA issued in July 2025, in conjunction with President Donald Trump’s executive order targeting unhoused people who use drugs. In the 2025 letter, SAMHSA explicitly denounced harm reduction, claiming that most efforts associated with the term “only facilitate illegal drug use and its attendant harm.” The premise, however, was that opioid overdose prevention and blood-borne disease prevention are somehow separate from harm reduction. In that letter’s breakdown of which supplies and services were banned from HHS grant funding support, SAMHSA had specified that “[s]ubstance test kits, including fentanyl test strips and xylazine test strips,” were considered life-saving overdose prevention tools and therefore remained eligible. 

In 2025 the list of supplies and services that could not be supported with SAMHSA funding consisted of syringes; glass pipes; sterile water; saline; ascorbic acid; or “any other drug paraphernalia.” That list has now been expanded to include “substance test kits” and overdose hotlines, in addition to all the same items included in the 2025 version.

Fentanyl test strips, xylazine test strips and the more recent versions that detect medetomidine are all banned by name, along with “any other substance test kits … intended for use by people using drugs.” None of the funding restrictions apply to law enforcement, or anyone “using drug testing technologies in the regular course of discharging their professional duties.”

SAMHSA claimed that overdose hotlines, meanwhile, go against federal priorities as they “have a primary function of facilitating illicit drugs [sic] use by providing people using drugs a virtual or telephonic companion while they are using drugs.”

Overdose hotlines, which provide support for people using alone, were not mentioned in SAMHSA’s 2025 letter. A few weeks prior to that letter’s release, however, the agency had removed the 988 suicide hotline’s “Press 3” option for LGBTQ+ youth, claiming that this would keep the “focus on serving all help seekers.” Callers who pressed 3 could previously be connected to crisis counselors who’d been specifically trained to talk to queer and trans youth.

SAMHSA also made a third change. In its 2025 letter, the miscellaneous category of supplies and services that were eligible for funding support included food—”snacks, protein drinks, water”—as long as it didn’t exceed $10 per person and was “used in the course of service engagement.” This line item has been dropped from the updated April letter, though food service is not explicitly banned.

For a lot of people, MOUD alone actually is enough as far as treatment services go.

The agency also released a second Dear Colleague letter April 24, this one pertaining to medications for opioid use disorder (MOUD). Though its provisions are non-specific, it implies that future grant funding will be awarded to providers “advancing holistic care models” by prescribing MOUD alongside other interventions, not as a standalone treatment.

“SAMHSA funding should be used to provide comprehensive treatment and recovery support services rather than medication-only models for opioid use disorder,” the letter states. “Services should include medications, where clinically indicated, in conjunction with psychosocial and other treatment and recovery support services.”

The letter also emphasizes tapering and eventual discontinuation over long-term maintenance.

In justifying its stance, it explains that MOUD “alone cannot address the legal, housing, family functioning, and other challenges that people with substance use disorders commonly face.” To a certain extent this is true—nothing addresses the need for housing except for housing—but SAMHSA is obscuring the fact that for a lot of people, MOUD alone actually is enough as far as treatment services go.

This is because legal access to methadone or buprenorphine (but not naltrexone) inherently affects more than just someone’s cravings or withdrawal symptoms. It affects their exposure to law enforcement, their overdose risk, their availability to work a taxable job and the amount of money they can save. Psychosocial treatment and recovery programs don’t really affect any of those things.

Image via Wisconsin Department of Health Services

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“I have never lived in such a magical neighbourhood full of people who give a damn,” Archondous, a Vancouver Area Network of Drug Users (VANDU) board member, told Filter. “I can sit and talk to a stranger for 15 minutes and leave feeling better than I did before.”

Grassroots community-led initiatives, from VANDU to the Drug User Liberation Front (DULF), give Archondous hope. In a hostile political environment, as communities across BC held rallies and vigils for the 10th anniversary of the public health emergency, any source of hope is vital.

“I was someone who was a complete nihilist,” he said. “I’m still agnostic, but I feel that there is a love inherent in humans that is something holy.”

DTES activism has led to a number of progressive drug policies in British Columbia. But many were only implemented as half-measures.

On April 14, 2016, British Columbia declared the overdose crisis a public health emergency. Fatal overdose nearly doubled that year, to 997 deaths compared to 528 deaths in 2015. For the first time in decades, the average life expectancy at birth declined. Over the past 10 years, more than 18,000 people in BC have died of overdose.

“It was the establishment of unsanctioned sites by people like Ann Livingston in the Downtown Eastside … that really pushed [the province],” said Bernie Paulie, a researcher with the Canadian Institute for Substance Use Research and professor of nursing at the University of Victoria.

In 2016, Livingston and others organized an unsanctioned overdose prevention center (OPC) and invited then-minister of health Terry Lake to see it. Not long after, Lake announced that the province would authorize OPC for the first time. 

In 2023, when BC overdose deaths peaked at 2,590, the narrative turned against harm reduction and housing-first policies. Archondous remembers when he saw the political tide really change in Vancouver: the 2022 mayoral election of Ken Sim and the newly formed ABC Vancouver, a political party that campaigned with the support of the Vancouver Police Union and capitalized on fearmongering about homelessness.

Since then, Vancouver has lost multiple OPC, including the Thomas Donaghy Overdose Prevention Site, women’s drop-in center SisterSquare and the space DULF provided for its membership.

“We’ve seen, over the last three years especially, a quite dedicated misinformation campaign.”

DTES activism has led to a number of progressive drug policies established by the provincial government. But many were only implemented as half-measures, falling far short of what the community knew was needed. The results were then used to fuel a political backlash against harm reduction.

The province’s historic drug decriminalization pilot was limited to just a combined 2.5 grams of a handful of substances. The pilot was then rolled back amid complaints about public drug use, blaming decrim rather than skyrocketing housing prices.

Safer supply was restricted to a medical model, rather than a community-led one. At the program’s peak in 2023, pharmaceutical street-supply alternatives like hydromorphone were prescribed to just 5,189 people, few of whom were in rural areas. Meanwhile, an estimated 191,000 people were at risk of overdose—the majority of whom weren’t diagnosed with opioid use disorder, and weren’t eligible for a prescription.

The program was curbed following anecdotal claims about “diversion” and the prescriptions being accessed by minors. The government knew that prescribed hydromorphone’s role in the unregulated drug supply was negligible. But that didn’t matter.

“We’ve seen, over the last three years especially, a quite dedicated misinformation campaign—really misinterpreting what harm reduction services are and what they do,” DJ Larkin, executive director of the Canadian Drug Policy Coalition, told Filter. “We’ve also seen narratives really focused on abstinence-based treatment … everyone should have access to voluntary, not-for-profit, high-quality treatment when they want it. But it does not actually replace the need for policy reform.”

Since 2023, governments across Canada have defunded, scaled back or outright cancelled harm reduction policies—from OPC to safer supply to decriminalization to drug-checking.

“[It’s] one of the most important court cases of this decade.”

In October 2023 conservative politicians took aim at DULF, which had been providing community-led safe supply to the 47 members of its compassion club.

“[It’s] one of the most important court cases of this decade,” Larkin said of the constitutional challenge to the charges brought against DULF founders Jeremy Kalicum and Eris Nyx. “It has incredible potential to shift how we understand our laws are working and how they are not working to support the ability to provide life-saving services.”

Sanctioned safer supply programs have repeatedly been shown to have positive effects on participants. Reports by BC’s own coroners service and top public health official have since called for non-prescriber models. But both were dismissed out of hand by the minister of mental health and addictions.

“I think, as communities, we have to tell them that evidence matters,” Paulie said. “That evidence-based solutions matter.”

In 2024, the BC Centre for Disease Control estimated that harm reduction initiatives like safer supply, OPC and the province’s take-home naloxone program prevented around 82 percent of potential deaths.

Larkin said that drug policy has also been increasingly shaped by what’s happening across the United States border. With Canada’s publicly funded health care system often failing to cover treatment and other services related to substance use disorder, private-sector treatment is gaining ground. And fabricated claims of fentanyl entering the US through Canada led to billions of dollars invested in the Canada Border Services Agency, to combat what both US and Canadian governments know to be a false narrative. Larkin also cited rising transphobia and xenophobia as factors that are intersecting with and influencing drug policy across the continent.

“We’re hearing the same arguments, and all of it is blaming down towards people who have been failed by the system,” they said. “Rather than looking up at the government that caused the problem in the first place.”

Image via Dustin Godfrey

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Between November 2024 and November 2025, the United States has recorded 68,372 overdose deaths—a figure the CDC projects will rise to 70,231 as more data are submitted. On average, the death count across the country is 15.9 percent lower than it was in the 12-month period leading up to November 2024.

Between 2023 and 2024, the death rate fell by more than 26 percent. This was unprecedented—since the CDC began tracking overdose mortality in 1999, the only other time the death count wasn’t going up was a very slight decrease in 2018. In 2019, the rate began to climb more quickly, and then much more quickly once the COVID-19 pandemic arrived. In late 2023 it finally turned around, and for the past two-and-a-half years the national average has continued to drop each month.

Though the rate decreased fairly steadily, around March 2025 the pace became slower.

Over the course of 2024 the death count for each month was, on average, 2,221 lower than it had been the month before (using the predicted values, which are always slightly higher than the reported values but follow the same rate of change). The steepest decrease was 3,057 fewer predicted deaths in August than in July (for the number of actual deaths reported, the decrease was 3,091).

But over the course of 2025, on average the death count each month was only 1,007 lower than it had been the month before (data from November to December have not yet been published).

In New York, the rate fell more than 37 percent. In Arizona, it increased more than 21 percent.

National averages have never closely reflected what’s happening on the ground in different parts of the country. Even back when the CDC announced the historic drop from 2023 to 2024, South Dakota and Nevada had both seen slight increases.

The CDC’s most recent data show the national death rate 15.9 percent lower than it was compared to the previous 12-month period, but in New York the rate fell more than 37 percent. Vermont and Rhode Island are in a similar range. 

Deaths in Arizona, meanwhile, are predicted to increase by over 21 percent. This is by far the largest increase; the next-closest is New Mexico, with deaths predicted to increase by over 16 percent compared to where they were a year earlier.

In Colorado the predicted death rate is up 10.3 percent. In North Dakota, 8.4 percent. South Dakota, Montana and Utah are all predicted to be within a single death of what was recorded for the previous 12-month period.

Wyoming, geographically right in the middle of all the states going against the national trajectory, is still predicted to have deaths decrease by nearly 25.5 percent. But in many states, the percentages aren’t necessarily useful for understanding the scale or rate of change because the actual number of overdose deaths reported is very low—partly because of population size, but sometimes because of inconsistent data collection or simply underreported data. The 25.5-percent decrease in Wyoming represents the difference between 110 deaths and 82 deaths. In California, on the other hand, a 9.9 percent decrease represents 10,085 predicted deaths dropping to 9,158.

Image (cropped) via Centers for Disease Control and Prevention

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So far in April, HB4708 has passed the Restorative Justice & Public Safety Committee, received a second reading and changed chief sponsor to Assistant Majority Leader Rep. Will Guzzardi (D). It’s calendered for another committee hearing April 16. The pilot would begin January 1, 2027, in at least one IDOC facility.

As introduced, HB4708 would have required the pilot to provide a minimum of 4,000 doses and bridge participants to community treatment upon release, “including, but not limited to, a referral to a harm reduction provider.” It has since been amended to require that the pilot provide a full course of treatment to at least 3,000 people. It also stipulates that this would be covered by opioid settlement funds, and that the pilot should not commence until full funding has been secured so that every participant “may receive the full course of treatment clinically indicated.” There’s no longer any reference to harm reduction providers, but prior to a participant’s release IDOC would be required to make an appointment with an “appropriate provider or treatment site” and share the relevant medical information.

The bill would also now require an independent third-party evaluation, which would determine the pilot’s success by tracking a handful of metrics for each participant. These are primarily concerned with whether participants continue treatment in the community, but the evaluator would also record any post-release fatal or non-fatal overdose, any rearrest or other further interactions with the criminal-legal system, “institutional safety indicators” and of course cost-effectiveness. The latest amendment would require IDOC to publicize the pilot eligibility criteria and selection process, and a report would be submitted to lawmakers by January 1, 2029.

While it’s obviously important that participants don’t have their treatment cut off because funds ran out, or because IDOC failed to ensure continuity of care upon release, the effect of these provisions will be to deprioritize everyone who has more than a year or two left on their sentence. Not that they wouldn’t have been deprioritized already—MOUD is widely considered inappropriate for anyone whose release date is not imminent.

This is due to the misinformation about the harms of MOUD “diversion”; the lack of staffing resources and political will to contemplate treating the much larger share of the prison population; and the fact that while corrections departments across the country justify any and all policy changes by saying they’re necessary to combat the tidal wave of incoming contraband, they also cling to the narrative that there are simply no drugs in prison and so there’s no need to treat anyone unless they’re about to get out. Notably, the bill does not instruct the third-party evaluator to look into overdose rates among participants while they are still incarcerated.

Another Illinois bill introduced in 2025, SB2185, would require IDOC to screen everyone in custody for OUD and provide medication to anyone eligible, with funding from the Illinois Opioid Settlements Initiative. It’s currently in the Senate Appropriations-Public Safety and Infrastructure Committee, which is required to report on it by April 24. But this bill heavily emphasizes providing MOUD to people who were already enrolled in a treatment program at the time of their arrest, and makes clear that IDOC can defer or discontinue their MOUD if medical staff determine it’s no longer necessary. IDOC considers MOUD for prisoners who weren’t already taking it when they began their sentence, but only at its two women’s facilities.

The bill states that even if they weren’t already enrolled in treatment, an eligible “committed person shall be authorized to receive [MOUD] immediately and for as long as clinically indicated.” But again, IDOC gets to decide that. Even if all the other criteria are met, people with decades left on their sentence aren’t usually found clinically indicated in these situations.

The best-known long-acting buprenorphine product is Sublocade, a monthly injection manufactured by Indivior Pharmaceuticals.

HB4708 does not distinguish between long-acting injectable versions of naltrexone and buprenorphine. But the former, better known by brand name Vivitrol, is already widely used in reentry settings despite the fact that naltrexone is the only MOUD not shown to decrease overdose risk, and has been repeatedly associated with increasing overdose risk. 

The best-known long-acting buprenorphine product is Sublocade, a monthly injection manufactured by Indivior Pharmaceuticals. In 2025 Indivior expressed plans to focus its energies on Sublocade, which is exponentially more profitable than the company’s other ventures.

In late March, an Indivior-funded study published in the Journal of Current Medical Research and Opinion suggested that based on treating 100 patients per month, Sublocade would save over $22,000 and 747 staffing hours per month compared to oral buprenorphine, which in prisons must be dispensed every day. (Sublocade also managed to perform better than all other MOUD in the study, including beating a competitor brand’s other long-acting injectable buprenorphine product by $23 and one staffing hour per month.)

In an April 3 paper published in the Journal of Correctional Health Care, 87 percent of prison staff surveyed responded that long-acting injectable buprenorphine could help reduce “diversion” of prescribed Suboxone. Two of the seven authors are employed by Indivior.

Notwithstanding Indivior’s obvious incentive to produce science that shows its product to be just what corrections departments need, making Sublocade widely available in prisons would have substantial benefits. But a central problem plaguing this type of legislation is that it relies on the idea that MOUD provision requires steady, uninterrupted care—which it does—while only making it available to people at the last possible minute before release.

There is, however, at least one Illinois bill under consideration that acknowledges this. HB4583, introduced by Guzzardi in January and currently in the House Rules Committee, would require that everyone in IDOC be assessed for OUD and that medication be provided to anyone at risk, regardless of whether they’re nearing release.

“The Department of Corrections does not currently have extensive medication-assisted treatment programs readily available to meet the needs of all committed persons with opioid use disorder, despite estimates that more than half of the committed population meets the criteria for having a substance use disorder,” the bill states. “Individuals with opioid use disorder living in correctional settings are entitled to the same level of care as those in community-based settings.”

Image via Weber County, Utah

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Medetomidine began gaining notice in the East Coast drug supply in 2024. It can be thought of as the direct successor to xylazine, the unregulated veterinary tranquilizer that emerged a few years earlier but has recently diminished as various levels of government attempt to control the supply by way of harsher enforcement. Xylazine in combination with fentanyl was designated an “emerging health threat” by the Biden administration in 2023, and xylazine itself is currently on the cusp of being banned under Schedule III of the CSA. Predictably, targeting xylazine in this way has pushed the drug supply toward alternatives that are even less familiar.

“The public health community, as well as those who put themselves at risk of overdose due to illegal drug use, need to be aware of ever-evolving dangers,” stated Director of National Drug Control Policy Sara Carter in the White House announcement. “Medetomidine represents a real threat to communities, and this once again reaffirms that the only safe level of illegal drug use is zero.”

The CDC usually issues HAN every few weeks or so, but historically these have focused on disease outbreaks. There have been no HAN related to fentanyl or xylazine, for example. The only prior HAN to discuss overdose or banned drugs was a 2024 alert warning that overdose risk could increase as a result of patients losing access to prescription stimulant medications like Adderall.

The CDC stated that law enforcement drug seizures appeared to show medetomidine becoming increasingly prevalent. It was identified in 247 seized drug samples in 2023; then 2,616 samples in 2024; then 8,233 samples in 2025. Geographically, these samples have been concentrated in the Northeast, with very few samples identified in the West.

However, this still represented less than 1 percent of samples reported to the National Forensic Laboratory Information System in 2025. While the general consensus among public health experts is that medetomidine’s presence in the supply has been increasing, it should be noted that this kind of exponential uptick in detected samples always happens once a new substance attracts media attention and more laboratories start to check for it.

Outside of laboratory settings, there are also medetomidine test strips that work similarly to the better-known fentanyl test strips. Erin Tracy, lead chemist at the UNC Street Drug Analysis Lab, said that medetomidine test strips appear to be very sensitive—even compared to test strips for fentanyl or xylazine, which can detect those substances in very low quantities. This makes them potentially much more useful to people who use fentanyl than fentanyl test strips, which are often somewhat purposeless in this context.

Medetomidine is not associated with soft-tissue infections that often follow xylazine injection. But it has distinct side effects of its own.

As medetomidine and xylazine are similar, so are some of the effects associated with them—namely prolonged sedation, which can persist even after naloxone has restored independent breathing. Though all that’s necessary to reverse an opioid overdose is for the person to be breathing on their own again, the mistaken belief that they need to “wake up” can lead to administering more naloxone than was necessary.

Medetomidine is not associated with the soft-tissue infections that often follow xylazine injection. But it has distinct side effects of its own, most notably a withdrawal process that can be much more damaging than withdrawal from opioids alone. This is marked by rapid heartbeat and high blood pressure and can require intensive hospitalization.

The withdrawal symptoms can be mitigated with IV infusions of medications like dexmedetomidine, the more potent of medetomidine’s two isomers, which unlike medetomidine itself is FDA-approved as a sedative that can be used in hospital settings. 

“Withdrawal can be so severe that [experts] advise going to ER where staff have been oriented to manage medetomidine withdrawal,” Maya Doe-Simkins, co-director of naloxone-access group Remedy Alliance, told Filter. And “encouraging people who want to detox to do it at a hospital, versus regular detox.”

Though media and law enforcement have widely described non-opioids like medetomidine as “naloxone-resistant”—a misleading label that is always useless at best and harmful at worst—it’s not entirely clear whether it’s accurate in this case. There’s emerging evidence that xylazine responds to naloxone, and we haven’t established yet that medetomidine doesn’t act similarly. But the more relevant point is that since medetomidine is almost always found with fentanyl, naloxone can still help reverse overdose.

Doe-Simkins said that for people responding to overdose in regions where medetomidine has been identified, the standard best practices for naloxone administration still apply—ideally using intramuscular naloxone to start with a low dose and titrate up if needed, with the emphasis on rescue breathing rather than potentially giving someone more naloxone than necessary.

Image (cropped) via Centers for Disease Control and Prevention

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