Drug overdose remains a leading cause of death in the United States, according to the Centers for Disease Control and Prevention (CDC). While 2023 marked the first annual decline in drug overdose deaths, the crisis persists and continues to evolve as new substances emerge.
Overdose deaths involving synthetic opioids, such as fentanyl, declined in 2023, while deaths linked to cocaine and psychostimulants (such as methamphetamine) increased, according to the CDC.
Trends also varied across states. Kansas, Maine and Nebraska saw declines of 15% or more in overdose deaths, whereas Alaska, Washington and Oregon experienced notable increases of at least 27% in 2023 as compared to 2022 according to the CDC.
As these patterns shift, states continue to consider strategies that address drug threats and reduce overdose mortality. This resource highlights key policy approaches and state-level examples aimed at preventing and reducing overdose deaths, including:
- Naloxone access
- Syringe service programs
- Drug checking equipment
- Opioid settlement funds
- Drug awareness campaigns and education
- Treatment Initiation in Emergency Departments
- Non-Opioid Pain Treatment Options
Naloxone
Naloxone is an opioid antagonist medication that reverses overdoses when administered promptly according to the CDC. According to the Network for Public Health Law, all 50 states have laws allowing individuals to access naloxone, though specific provisions—such as prescribing authority and legal protections—vary. Some states authorize naloxone distribution through standing orders or innovative methods like naloxone vending machines (The National Council for Mental Wellbeing). Others have enacted "Good Samaritan laws”, granting immunity to those who administer naloxone in an emergency (National Library of Medicine).
To further expand access to naloxone, some states require law enforcement officers and first responders to carry naloxone and provide them with training on its use. Others mandate its availability in schools, colleges, libraries and other public venues.
States acquire naloxone through opioid settlement funds and bulk purchasing programs. For example, Alaska recently launched an initiative to make naloxone accessible in schools and California supports tribal governments in obtaining naloxone through the Naloxone Distribution Project.
Syringe Service Programs
Syringe service programs provide access to sterile syringes, safe disposal of old syringes and connection to health care and treatment services for people who use drugs (CDC). These programs play a role in preventing overdoses by increasing access to naloxone and substance use disorder treatment. According to the Legislative Analysis and Public Policy Association, as of 2023, 38 states, Washington, D.C., and Puerto Rico authorize SSPs. There are at least 534 SSPs operating across the United States and its territories.
Some states, like Delaware, have legislation legalizing SSPs, while others, like Kentucky, rely on local policies to operate. The workforce plays a critical role in distributing sterile syringes, providing education and connecting individuals to care. California extended the authority of pharmacists and physicians to sell syringes without a prescription.
Drug Checking Equipment
Drug checking equipment, such as testing strips for fentanyl and xylazine, help individuals identify harmful adulterants in drugs, enabling them to make informed decisions and reduce the risk of overdose according to the CDC. In some states, possessing or distributing this equipment remains prohibited under drug paraphernalia laws. States may consider exempting drug checking equipment from these laws to expand access.
According to the Network for Public Health Law, 30 states allow the possession of all drug checking equipment, while others permit its use only for specific substances, such as fentanyl and xylazine. To further expand access, states may decriminalize drug checking equipment, authorize its distribution and allocate funding to support these efforts.
Recent legislative actions reflect this trend. Illinois allows county health departments to distribute fentanyl tests strips for free and allows pharmacies to sell them over the counter. Oklahoma exempted drug testing strips from its drug paraphernalia laws, thus decriminalizing fentanyl testing strips, xylazine testing strips, and any other testing strips.
Opioid Settlement Funds
Opioid settlement funds have been distributed to the states following lawsuits against opioid manufacturers (National Opioids Settlement). These funds are uniquely designated to address the public health crisis stemming from opioid addiction, with a strong emphasis on prevention, treatment and recovery efforts. States often distribute the funds to various programs to support a wide range of opioid-related initiatives. The settlements offer an opportunity to support prevention and treatment initiatives across multiple sectors.
According to the National Academy for State Health Policy, 39 states have been awarded funds following the settlements, with many required to allocate funds for overdose prevention according to the National Association of Counties. Under these settlements, states and local communities are required to use the majority of their settlement dollars for opioid remediation. Remediation refers to the provision of care, treatment and other programs and expenditures designed to address the misuse and abuse of opioid products, treat or mitigate opioid use or related disorders or mitigate other alleged effects of the opioid epidemic, according to the national settlement.
A non-exhaustive list of activities the settlement deems to be remediation is available in “Exhibit E” of the national settlement. States may, for instance, invest in harm reduction strategies, such as broadening access to naloxone kits, syringe service programs, and fentanyl testing resources. States can also channel funds toward expanding evidence-based treatment services, including increasing the availability of medication-assisted treatment facilities and training for addiction counselors and peer support specialists.
Additionally, Exhibit E supports initiatives for youth prevention and public education campaigns, enhanced data collection and monitoring systems to track opioid-related outcomes and community-based programs that promote recovery and address disparities in care.
Another challenge for states is to ensure the money is used to prevent opioid misuse and provide treatment for opioid users and not be diverted to unapproved uses under the settlement. Many advocates point to the rerouting of dollars associated with the tobacco settlements as a potential outcome if appropriate guardrails aren’t in place. In fiscal year 2020, states collected more than $27 billion from the tobacco settlement and taxes, and about 2.7% of the funds were used for tobacco use prevention programs. To address this, states are taking steps to require accountability. According to the National Academy of State Health Policy, 29 states have required reporting requirements in their memoranda of understanding. Some states, like Colorado and North Carolina, have developed public-facing dashboards to track settlement spending.
States have established settlement funds and advisory councils that oversee and direct resources towards prevention, treatment and recovery. For example, Idaho created a state-managed opioid settlement fund for prevention and recovery, while New Jersey established the Opioid Recovery and Remediation Fund that allocates funds for substance use prevention and treatment.
Drug Awareness Campaigns and Education
Since the onset of the overdose epidemic, several states have established and launched educational campaigns that aim to raise awareness about drug misuse, provide education and reduce stigma. Treatment is available for substance use disorders, but stigma can prevent people from seeking or receiving help. In recent years, at least nine states have launched campaigns focused on fentanyl awareness and at least nine states have enacted legislation to provide drug education in grades K-12. These efforts aim to equip communities with knowledge and resources needed to prevent overdoses and address impacts of substance use.
Washington implemented a statewide drug overdose prevention and education campaign to educate the public about the dangers of opioids. Texas designated a specific week of the year to provide education to students in public schools regarding fentanyl.
Treatment Initiation in Emergency Departments
Many non-fatal overdoses are treated in emergency departments, creating an opportunity to initiate treatment with medications like buprenorphine and methadone and prevent future overdoses according to the Substance Abuse and Mental Health Services Administration. A 2015 JAMA study found that patients who received an intervention in an emergency department were twice as likely to seek treatment for opioid use disorder compared to those who did not receive such intervention.
According to the Council of State Governments, at least five states have enacted legislation to connect patients in emergency departments to treatment and explore the role of peer support specialists’ role in engaging individuals in treatment.
Recent legislative efforts reflect a growing trend toward requiring or encouraging emergency departments to provide treatment information. Massachusetts funded a pilot program to test emergency department-initiated treatments like buprenorphine and naltrexone. Similarly, Kentucky mandated that emergency departments inform overdose patients of the availability of treatment services.
Non-Opioid Pain Treatment Options
Many individuals are first introduced to opioids through prescriptions for pain management. Providing access to non-opioid alternatives for pain management can help reduce the risk of opioid misuse and overdose. At least eight states have enacted legislation promoting alternative pain management strategies since 2010.
Some states have taken steps to remove barriers to non-opioid alternatives, such as physical therapy and other non-opioid medications, by ensuring coverage of and encouraging the use of abuse-deterrent drugs and alternative therapies. Louisiana requires Medicaid managed care organizations to cover non-opioid medications. Maine mandates health insurance coverage for diverse pain management services, prioritizing non-opioid alternatives.