A Commonwealth Fund study on drug overdoses in the United States reported last month that more than 100,000 lives were lost in 2023—a more than 50% jump since 2019. By a substantial margin, the U.S. has the highest rate of overdose deaths in the world at 324 deaths per one million people. However, there are signs that harm reduction policies put in place by the Biden administration to address the crisis may be helping, with fatal overdoses dropping 14.5% between 2022 and 2023. The future of these policies is unclear under the new Trump administration.
Robert F. Kennedy Jr., nominee for Secretary of the Department of Health and Human Services, has said that he would prioritize combatting the drug epidemic. But at a Senate confirmation hearing this week, STAT News reports that while RFK Jr. endorsed methadone and buprenorphine—widely considered by experts to be gold standard treatments for opioid use disorder—he didn’t appear to view them as the best available options. Rather, he seemed to favor 12-step recovery programs, which have not been properly assessed for their impact on opioid users.
Early in President Trump’s first term in office, he declared the opioid epidemic a national emergency and signed an executive order establishing the President’s Commission on Opioids. The commission helped secure $4.6 billion in funding over two years from Congress to combat the crisis, including an increase in the number of patients receiving buprenorphine, a proven medical treatment for opioid addiction.
The Biden administration went further, however, by expanding harm reduction programs, including the use of opioid-treatment medications like buprenorphine, methadone and naloxone, an opioid antidote. It also supported certain syringe services initiatives, which are community-based prevention efforts that include substance use disorder treatments, but also access to and disposal of sterile syringes and injection equipment. Safe disposal of used needles and syringes can help prevent the spread of infectious diseases, such as hepatitis C and HIV. Just before leaving office, President Biden issued executive actions intended to continue expanding access to addiction treatment.
The question now is whether the new Trump administration will maintain funding for such programs. Additionally, it’s uncertain which approach the new administration will take to address the illicit drug crisis.
During Trump’s first term as president, despite some attention paid to harm reduction, his main focus was building a border wall which he insisted would stop the flow of illegal drugs from Mexico. This was a claim disputed at the time by many criminal justice experts. The epidemic continued to grow steadily under Trump’s watch, with the steepest increase in deaths occurring in 2020 when the borders were almost entirely closed owing to the COVID-19 pandemic.
While campaigning in 2024 for a second term, Trump reiterated the need for a supply-side approach to the crisis that would crack down on fentanyl smugglers and secure the U.S.-Mexico border. This policy emphasis on law and order also included eliminating the drug cartels operating in Mexico and Central America. As before, policymakers cast doubt on whether this would solve the problem. Approximately 90% of smugglers of fentanyl, cocaine, heroin and methamphetamine are U.S. citizens. And in 2021, U.S. citizens accounted for 86% percent of convicted fentanyl drug traffickers—ten times greater than convictions of illegal immigrants for the same offense.
At the same time, experts question the adequacy of the Biden administration’s policies to address the issue. Harm reduction programs and medications remain inadequate and underutilized. The Commonwealth study cited compared the situation in the U.S. with 16 other wealthy, industrialized nations. The data suggest that America’s peers are investing more heavily in a comprehensive array of prevention and treatment approaches.
While only 11% of Americans with opioid use disorder received opioid substitution therapy in 2020, that number merely rose to 25% by 2022. By comparison, it is 86% and 87% in Norway and France, respectively. Other countries examined by the Commonwealth Fund don’t have such high percentages as Norway and France, but perform better than the U.S.. There is easier and more affordable access to naloxone in peer nations, as well as better availability of fentanyl test strips and syringe service programs such as supervised injection sites. Overall, there is less stigmatization of illicit drug users.
Making matters worse, in the U.S., harm-reduction policies and practices are fragmented—meaning they differ considerably between states, and even among towns and cities within states. Moreover, emerging trends, such as polysubstance abuse and potent new drugs, complicate overdose prevention in the U.S.. For example, xylazine involvement in fentanyl deaths is on the rise. Xylazine is a type of tranquilizer used in animals and not approved for humans. It is particularly lethal in combination with fentanyl and has become a more common cause of overdose deaths in the U.S..
To address the problem of drug overdoses, the U.S. needs to pursue comprehensive approaches to prevention and treatment that include evidence-based interventions for substance use disorders. It’s unclear to what degree the Trump administration will adopt such harm reduction policies.