Aims To characterize decreases in overdose mortality in the United States between 2023 and 2024 by substance involvement, geography, race/ethnicity, demographic, and other key dimensions.

Design Population-based study of national death records.

Participants/cases All individuals who died from drug overdose between January 1999 and December 2024.

Measurements Annual or monthly (annualized) overdose deaths per 100,000 population. Year and month of occurrence of overdose death; substance involvement; census region and division; state; county; race/ethnicity, age, and sex.

Findings After over two decades of mostly exponential increases, monthly data show consistent decreases in overdose deaths between June 2023 and December 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulants); however, increasing trends through 2024 were still seen in deaths involving stimulants without fentanyl, and those involving xylazine. Death rates in the Northeast, South and Midwest fell to 19.5, 19.4 and 17.3 per 100,000, respectively, in December 2024, but remained elevated in the West, compared with other regions, at 27.2 per 100,000. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024 falling 29.3%, but remained elevated at 36.0 per 100,000, compared to the national average of 23.7 per 100,000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose mortality rate in 2024, at 50.8 per 100,000.

Conclusions Recent decreases in overdose deaths are encouraging and unprecedented. Racial gaps remained large but shrunk by a modest margin. The geography of the overdose crisis has shifted, with the West now the most affected region, which may have implications for the targeting of funding. The nature of the crisis is also shifting, as stimulants and xylazine continue to represent increasingly important public health challenges, and renewed attention to nonfatal aspects of addiction in the US is needed.

JP reported receiving personal fees from the Washington-Baltimore High Intensity Drug Trafficking Areas program, Elsevier, Wiley, Rutgers University, Arizona State University, the University of Southern California, Queensland University, the National Network of Public Health Institutes, Alta Mira Recovery programs, and Dartmouth University, and nonfinancial support from NIH/NIDA, the University of Florida, Rx Summit, the American College of Neuropsychopharmacology, and the Reagan-Udall Foundation for the FDA during the conduct of the study. DC reports personal fees from Emergent Biosciences outside the submitted work. All other authors declare no conflict of interest.

JRF received funding from the National Institute on Drug Abuse (1U01DA063078-01) and the National Institute of Mental Health (MH101072). JP received support from the National Institute on Drug Abuse of the National Institutes of Health (R01DA057289 and U01DA051126). DC was supported by National Institute on Drug Abuse (R01DA054190). CLS was supported by National Institute on Drug Abuse (R01DA057630; K01DA05771). AB was supported by National Institute on Drug Abuse (R33DA061260 and DP2DA049295). Funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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