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More than 100,000 people in the US died of drug overdoses in 2023

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An estimated 107,543 people died of drug overdoses in the US in 2023, a shocking figure that obscures a glimmer of hope - this is the first annual decline in drug overdose deaths since 2018.

The grim toll represents Americans' struggle with powerful synthetic drugs, in particular the synthetic opioid fentanyl, known to be up to 100 times stronger than morphine. More than 1 million people have died of a drug overdose since 2001, according to the Centers for Disease Control and Prevention.

The National Center for Health Statistics (NCHS), which tracks overdose deaths, attributed more than 74,000 deaths to fentanyl, followed by more than 36,000 deaths from methamphetamine. Often, overdose deaths involve more than one drug. Drug overdoses declined 3% in 2023.

"We are encouraged to see the preliminary data that shows a decrease in the overdose death rate for the first time in five years, especially following the period of rapid double-digit increases from 2019-2021," said the White House Drug Control Policy director, Dr Rahul Gupta.

The west was hit particularly hard by drug overdoses, according to the data from the NCHS. Alaska, Oregon and Washington all saw increases in drug overdose deaths of more than 27%. The increases may reflect how illicit drugs have moved across the US, after primarily emerging in states east of the Mississippi in the early 2010s. Other states saw notable declines: Nebraska, Kansas, Indiana and Maine all saw declines of 15% or more.

Recent reports by the Drug Enforcement Agency (DEA) and a study supported by the National Institutes of Health, both released this week, paint an increasingly complex picture of the US's illicit drug supply, with fentanyl-laced pills appearing to make up an increasing proportion of the illicit drug market.

"Pills are flooding the market," said Joseph J Palamar, associate professor in the department of population health at New York University, and the lead author of the NIH-supported study released this week in the International Journal of Drug Policy.

According to Palamar's study, law enforcement seized more than 115m fentanyl pills in 2023, compared with about 49,000 in 2017, a 2,300% increase, while new synthetic drugs such as xylazine have posed new threats.

Palamar also said he believes the arc of drug use has changed over time. In the early 2000s, a person might have developed substance use disorder by starting with a prescription opioid, such as Oxycontin, and moving to heroin. By the early 2010s, it was common for heroin to be laced with fentanyl.

Today, fentanyl may be preferred by some people and appears as an adulterant in many different types of illicit drugs. It is also pressed to look like prescription benzodiazepines or opioids, raising the possibilities that people believe they are taking prescription drugs, or may begin using with fentanyl.

"The most serious thing is you get these young people who think they're going to take a Xanax or a Adderall or an Oxycontin and then they find out there's fentanyl in it," said Palamar. "You have some kid who thinks he's getting an Adderall from Snapchat or whatever - that kid could overdose and die."

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The illicit drug supply is primarily controlled by Mexican cartels, according to the DEA's National Drug Threat Assessment. Cartels ship fentanyl, methamphetamine and synthetic drugs into the US through expansive networks, often with the backing of illicit Chinese chemical suppliers, pill presses and bankers.

The toll also reflects broader struggles within American society. An estimated 2.5 million people suffer with opioid use disorder, but only one in five are in treatment, even though the disease has increasingly come into public view because of a housing affordability crisis.

Experts attribute the low number of Americans in treatment to systemic barriers, including a focus on abstinence, insurance company policies and laws out of step with science and those of peer western nations.

At the same time, addiction and the overdose crisis have become a new front in the culture war. Republicans have criticized Joe Biden for failing to focus on interdiction of illicit fentanyl at the border, even as many Republican policies make treatment harder to access.

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