US overdose deaths decreased in 2023 – will Trump continue this trend?

The Biden administration saw unprecedented levels of US opioid overdose fatalities, but those deaths are now declining faster than they have in decades – progress a second Trump administration could continue or threaten, experts say.

The number of overdose deaths in the US declined for the first time in five years in 2023, and have continued to decline more rapidly this year, according to provisional data.

Some of the decline may have resulted from Biden administration efforts to expand access to harm-reduction services, especially the overdose-reversal drug naloxone, which received over-the-counter approval for the first time last year. Public health experts worry that the second Trump administration will gut access to healthcare, including addiction treatment.

The president-elect’s legacy on opioids is complicated. When Trump first took office, he inherited a rapidly escalating overdose crisis. Opioid overdose deaths more than doubled during the Obama administration, according to data from the Centers for Disease Control and Prevention. The three most recent presidential administrations have all failed to quell escalating opioid overdose deaths, which nearly doubled again during the Trump and Biden administrations, dipping slightly in 2018 but overall jumping by 62% during Trump’s first term in 2020. Under Biden, deaths increased by 19% from 2020 to 2022, to 81,806, before declining by 2% last year.

At times, the Trump administration seemed to work against itself when it came to the crisis. For example, Trump repeatedly attempted to gut funding for the Office of National Drug Control Policy, although Congress blocked his efforts. Similarly, Trump was frequently in disputes with Congress over attempts to repeal elements of the Affordable Care Act and its expansions to Medicaid, which funds treatment for 40% of adults with opioid use disorder.

Still, experts contacted by the Guardian within and outside the first Trump administration credit the president-elect for putting unprecedented focus on the crisis.

Trump signed an executive order in 2017 forming the Presidential Commission on Combating Drug Addiction and the Opioid Crisis. Bertha Madras, a professor in Harvard’s psychiatry department who served on the commission, said it wasn’t until Trump “established the commission that a significant integrated national response materialized”.

Adm Brett Giroir, who served as an assistant secretary in Trump’s Department of Health and Human Services, says that he was given the authority to head up an unofficial “opioids cabinet … which met every week at the White House under Kellyanne Conway to make sure every department was working on this crisis”.

Others praise Trump for supporting harm-reduction efforts, despite past opposition from his party.

“President Trump publicly supported syringe services programs, a first for a Republican president,” said Jerome Adams, who served as surgeon general under Trump. Indeed, the Trump administration in some ways paved the way for the Biden administration’s response to the crisis. Access to naloxone expanded significantly under Trump, and even more under Biden.

But despite these efforts, the number of US overdose deaths climbed for the majority of Trump’s first term. Giroir and Madras both attribute the huge overdose spike in 2020 to the Covid-19 pandemic, which overwhelmed the healthcare system and increased depression and suicide.

Andrew Kolodny, medical director for the Opioid Policy Research Collaborative at Brandeis University, says the administration should have done more.

“The first time around, President Trump did an excellent job of calling attention to the opioid crisis and designating it as a public health emergency,” he conceded, but he also said the then president failed to take sufficient action or establish a long-term plan.

While the Trump administration allocated unprecedented amounts of funding to combat the crisis, Kolodny said the impact was limited, because states were usually given funds in the form of one- or two-year grants.

“That’s not really adequate for building out a treatment system that doesn’t exist yet,” Kolodny said. “If you were to hire a whole bunch of staff, what would you do if you don’t get that appropriation the next year? Do you lay everybody off?”

Experts disagree on whether the administration spent too much of that funding on law and border enforcement, rather than treatment. Giroir supported harm-reduction and treatment expansion during his time under Trump, and is proud of his efforts to remove red tape and increase access to the opioid-cessation drug buprenorphine. Still, he says, “enforcement has to dominate the discussion”, because treatment is less effective than preventing addiction in the first place.

Other experts say that criminalization only exacerbates the crisis.

“Under Trump’s previous administration, they federally criminalized all fentanyl-related substances in 2018 – and overdose deaths increased from 67,367 that year to 70,630 and 93,331 in 2019 and 2020 respectively,” said Kassandra Frederique, executive director of the Drug Policy Alliance.

Kolodny didn’t necessarily agree that criminalization drove the overdose increases, but he did say “the balance should be different” when it comes to prioritizing treatment over law enforcement. He said the best way to immediately reduce the overdose death count would be to make treatment “basically free” and overall easier to access than fentanyl.

“[People with opioid use disorder] are not out there using fentanyl because it’s so much fun. If they don’t use, they’re gonna be very, very sick … People can really feel like they’re gonna die,” he said.

It’s hard to predict how Trump will tackle the overdose crisis the second time around. He avoided the topic during his recent presidential campaign, and instead focused on inaccurate talking points about immigrants trafficking drugs across the border. He also falsely claimed he had never wanted to repeal the Affordable Care Act. But a Republican-controlled Congress could cut ACA subsidies and Medicaid.

Frederique worries that Trump will continue prioritizing drug arrests during his second term, but said during his first term “he also dedicated billions of dollars toward research, education, prevention and treatment. We are committed to supporting the Trump administration’s previous efforts to advocate for health approaches such as increasing access to treatment and naloxone.”