How Much of the Drop in Fentanyl-Related Overdose Deaths Might Be Due to a Resurgence of Heroin?
A February 25 press release from the Centers for Disease Control and Prevention reported on provisional data showing that drug overdoses in the US dropped to 87,000 from October 2023 through September 2024. The previous year saw 114,000 overdose deaths. Fentanyl-related overdose deaths fell to 55,126 for that year, compared to 79,432 in the prior year. For perspective, overdose deaths totaled 70,630 in 2019, of which 35,030 were fentanyl-related.
This is encouraging news. However, as I have mentioned before, overdose deaths spiked during the COVID-19 pandemic, reaching the 100,000 mark in 2021. The isolation, anxiety, and despair that accompanied the pandemic and the public health response also contributed to an increase in adult substance use during this time, including alcohol consumption. Pandemic-related lockdowns made it more difficult for people to access harm reduction or drug treatment programs. Consequently, much of the welcome drop in overdose deaths may reflect a return to the trend line as the pandemic fades into history.
As I have also noted, another contributing factor may be that federal, state, and local governments have been gradually eliminating barriers that hinder harm reduction organizations from distributing naloxone, participating in syringe services programs, and providing fentanyl test strips.
However, another factor to consider is that heroin is reemerging in the black market drug supply. Heroin, which is roughly 50 times less potent than fentanyl, had been nearly entirely replaced in the black market during the pandemic. The border closures and supply chain disruptions drove drug trafficking organizations to switch from heroin to fentanyl, which was easier to produce and distribute under those conditions. When the public health emergency ended, these organizations opted to continue what was effective—producing fentanyl products in underground labs—rather than relying on growing, transporting, and processing opium into diacetylmorphine (heroin).
Researchers have known for some time that people who use drugs overwhelmingly prefer heroin to fentanyl. When drug traffickers began mixing fentanyl into heroin a little over a decade ago, many unaware heroin users became overdose victims. Over time, as fentanyl dominated the drug supply, users adapted to the situation.
However, Axios recently reported on a study showing heroin is making a comeback among drug users:
Between January and June of 2024, heroin was detected in about 10% of people using fentanyl in the western part of the US, according to drug testing data.
- Between July and November 2024, it increased to 23% in the region.
- In five states, there were statistically significant increases, including Arizona (389%), Colorado (264%), Oregon (160%), Alaska (102%), and Washington (80%), between the first and second half of 2024. The overall increase in the region during that time was 123%.
Anecdotally, during an interview I conducted last November, the director of a prominent harm reduction organization in Arizona informed me that they were observing an increase in heroin use in the state.
Heroin’s resurgence highlights the black market’s quick adaptability and the complete failure of drug prohibition enforcement. With pandemic-related obstacles to heroin production removed, drug trafficking organizations are responding to customers’ preference for heroin over fentanyl. Moreover, by increasing the heroin trade, they may better evade law enforcement, which is focusing on fentanyl trafficking.
Drug-tolerant fentanyl users who switch back to heroin or try heroin for the first time may be less likely to overdose on the less potent opioid.
If heroin’s resurgence is contributing to the drop in fentanyl-related overdose deaths, it serves as yet another reminder that prohibition does not eliminate drug use—it only reshapes the market, often in dangerous and unpredictable ways. Rather than chasing an endless cycle of enforcement and adaptation, policymakers should focus on harm reduction strategies that save lives and empower individuals to make safer choices.
Check out my new book, Your Body, Your Health Care, scheduled for release on April 8.