A sign calling attention to drug overdoses is posted to the door of a gas station on the White Earth Reservation in Ogema, Minn. (David Goldman/AP)
7 min

More Americans died of drug overdoses in 2021 than any previous year, a grim milestone in an epidemic that has now claimed 1 million lives in the 21st century, according to federal data released Wednesday.

More than 100,000 Americans died of drug overdoses in 2021, up 15 percent from the previous year, according to an estimate released by the National Center for Health Statistics. The tally of 107,622 reflects challenges exacerbated by the coronavirus pandemic: lost access to treatment, social isolation and a more potent drug supply.

‘Cries for help’: Drug overdoses are soaring during the coronavirus pandemic

More than 80,000 people died using opioids, including prescription pain pills and fentanyl, a deadly drug 100 times as powerful as morphine and increasingly present in other drugs. Deaths from methamphetamine and cocaine also rose.

Since the start of the 21st century, an overdose epidemic led by prescription pain pills and followed by waves of heroin, fentanyl and meth has killed more than 1 million people, or roughly the population of San Jose, according to the provisional data.

The opioid files

And there is no clear end in sight, according to experts.

“2022 will probably be as horrible as 2021 was, quite possibly worse,” said Keith Humphreys, an addiction and drug policy researcher at Stanford University.

Nora Volkow, director of the National Institute on Drug Abuse, said the country is emerging from the pandemic with a “significant increase” in depression, anxiety, loneliness and suicidal thinking, “and that’s not going to disappear.”

“I think the next few years will be challenging,” she said.

Officials warn that they are responding to more and more overdoses as the pandemic has persisted. Pennsylvania Attorney General Josh Shapiro’s office has seized 1.8 million doses of fentanyl in the first three months of 2022, more of the potent synthetic opioid than in all of 2021.

Overdose deaths nationwide jumped to previously unseen levels in the first half of the pandemic, rising 30 percent from 2019 to 2020. The pandemic strained finances, mental health, housing and more for many, all the while overshadowing the drug crisis. There is concern that a predicted spike in coronavirus cases this fall could again curtail access to treatment and medication.

Covid-19 has taken as many lives in two years as the opioid epidemic has over a two-decade span. The victims of the drug epidemic, however, are overwhelmingly young. Between 2015 and 2019, young Americans lost an estimated 1.2 million years of life from drug overdoses, according to a study published in JAMA Pediatrics in January.

They’d battled addiction together. Then lockdowns became a ‘recipe for death.’

Rural areas have been especially devastated by the overdose crisis during the pandemic, as residents struggle to reach remote, limited treatment options. Alaska experienced the biggest increase in overdose deaths in 2021, roughly 75 percent, according to the federal data. The National Center for Health Statistics is part of the Centers for Disease Control and Prevention.

In California, where more than an estimated 10,000 people died from overdoses in 2021, psychostimulants such as methamphetamine made up about half of the overdose deaths and led to 15 percent more deaths than the prior year, according to a Washington Post analysis of the data. Opioid overdoses, including fentanyl, jumped more than 27 percent in the state.

Between 2018 and 2020, drug users in San Francisco shifted from injecting tar heroin to smoking fentanyl after noticing improved health and reduced stigma, according to research co-authored by Alex Kral, an epidemiologist at RTI International who has studied California’s drug supply. Kral said that as drug use has evolved, data accounting for the changes has lagged, leaving researchers and health experts somewhat blind to the various drugs users more often use in tandem.

Experts have increasingly warned of a wave of meth. In 2021, nearly 33,000 people died from psychostimulants, less than half the deaths caused by opioids. The combination of an opiate with a stimulant — commonly called a “speedball” — has become increasingly popular, said Daniel Ciccarone, a professor at the University of California at San Francisco who studies drugs.

While the more potent drug supply will continue to drive deaths, Ciccarone predicted that the increasing rate of overdoses will flatten out or possibly decline within the next year due to a confluence of events: the pandemic easing, the government ramping up its response and drug companies paying billions to help abate the crisis. Still, the number of people using drugs is also on the rise, Ciccarone added.

“There’s something to be said about demand,” he said. “Why is America so hungry for drugs? Why does that seem to be increasing generation over generation? Does it have something to do with our economic inequalities and other disparities?”

The uneven nature of this modern plague may be due in part to how fentanyl has seeped into the drug supply. It first dominated the Midwest and New England but has spread across the country, Humphreys said, suggesting that it and other synthetic drugs could drive out less potent drugs in the next decade. Fentanyl, increasingly laced in counterfeit pills bought online and made in labs, is easier to produce than plant-based drugs, he said.

“There may not be much heroin around in 10 years because everything is fentanyl,” Humphreys said. “What do you do in a world where no one needs a farm anymore to make drugs?”

Humphreys, who has estimated that there could be another million overdose deaths in the next decade if policy does not change, said there is no silver bullet to addressing the multifaceted crisis. But one of the most sound ways to reduce overdoses, he said, is greater access to naloxone, the medication to reverse opioid overdoses.

“I think of naloxone like I do fire extinguishers,” he said. “Generally, they sit on a wall and they’re not needed. But when there’s a fire, there’s nothing like a fire extinguisher.”

A more powerful naloxone is on the way. The question is whether it’s needed.

In a first, the Biden administration presented the National Drug Control Strategy to Congress last month to lay out a road map for addressing untreated addiction and drug trafficking. The plan calls for an expansion of naloxone, drug test strips and syringe distribution programs.

While the plan takes the right steps toward mitigating the damage of the crisis, the harm is done, said Kasia Malinowska-Sempruch, director of global drug policy at Open Society Foundations. The upward trend of deaths will continue until the ideas trickle down to actual policy over the hardest-hit communities.

As part of his strategy to curb the flow of fentanyl into the country, President Biden asked Congress in his budget for a $300 million bump in funding for U.S. Customs and Border Protection and an increase of $300 million for the DEA.

Another wrinkle for the administration is ensuring the resources reach those who most need them, as the stigma of drugs has alienated some users.

While treatment has scaled up, it remains inaccessible to most of those it could help. Nearly 15 percent of people 12 or older needed substance-use treatment in 2020, while 1.4 percent received it, according to the Substance Abuse and Mental Health Services Administration.

In addition, Malinowska-Sempruch said, Biden’s plan stops short of recommending some solutions that could help meet drug users where they are, such as decriminalizing personal possession and creating supervised injection sites, where trained monitors watch users to step in and counter overdoses.

“It’s going to take a while before it can get better,” Malinowska-Sempruch said, “and that while is going to continue to cost lives.”

In the meantime, the Biden administration has pushed forward with “a new era of drug policy,” according to Rahul Gupta, director of the Office of National Drug Control Policy who pointed to actions to make overdoses preventable, such as distributing naloxone.

“It is unacceptable that we are losing a life to overdose every five minutes around-the-clock,” Gupta said.