How the US is emerging from its drugs death epidemic

Kayla first tried fentanyl at the age of 18, as a troubled child growing up in North Carolina, USA.

“I literally felt amazing. The voices in my head completely stopped. I was instantly hooked,” he recalls.

The little blue pills Kayla was addicted to were likely manufactured in Mexico and then smuggled across the border into the United States; It’s a deadly trade that President Donald Trump is trying to block.

But drug cartels are not pharmacists. So Kayla never knew how much fentanyl was in the pill she took. Was there enough synthetic opioids to kill him?

“It’s scary to think about it,” Kayla says, thinking about how she could overdose and die at any moment.

There will be more than 110,000 drug-related deaths in the United States in 2023. The advance of fentanyl, 50 times more potent than heroin, seemed unstoppable.

But then came a surprising twist.

By 2024, the number of fatal overdoses across the U.S. is down nearly 25%. This means almost 30,000 fewer deaths; Dozens of lives are saved every day. Kayla’s state, North Carolina, is at the forefront of this trend.

One explanation is a commitment to harm reduction. This means promoting policies that prioritize the health and well-being of drug users, rather than criminalizing people; Recognizing that taking drugs in the age of fentanyl often results in death from overdose.

In North Carolina, where Kayla still lives, and where overdose deaths are now down an impressive 35%, harm reduction strategies are well developed.

Kayla no longer uses street drugs. And he’s a client of an innovative law enforcement-assisted diversion (LEAD) program in Fayetteville. It’s a partnership between the town’s police and the North Carolina Harm Reduction Coalition. Together, they work to steer substance users away from crime and put them on the path to recovery.

“If someone is stealing from a grocery store, we look into their criminal history. And we often find that their crimes are funding the addiction they have,” says Lt. Jamaal Littlejohn.

This could make them candidates for the LEAD program, which could mean they can get support to combat their addiction and start thinking about safe housing and employment.

LEAD advocates say it’s not about being soft on crime. Drug dealers still go to jail in Fayetteville. “But if we can provide people with the services they need, we give law enforcement more time to deal with bigger crimes,” says Lt. Littlejohn, who watched his own sister struggle with substance use disorder.

Kayla blossomed. She’s a long way from the days when she used prostitution to fund her fentanyl habit. His criminal record was expunged as part of the LEAD process. She recently graduated as a certified nursing assistant and currently works in a home.

“This is like the best thing ever. This is the longest I’ve been clean,” he says.

There is a treatment that is critical to Kayla’s recovery. He had been on methadone for almost a year when he told his story to the BBC. “This is keeping me from going back,” he thinks.

Methadone and buprenorphine are medications used to treat opioid use disorder. They stop cravings and stop painful withdrawal. Nationwide, treatment has played a role in distorting overdose death statistics.

In North Carolina, this was groundbreaking: More than 30,000 people were enrolled in a program in 2024, with that number set to increase in 2025.

At 9 a.m. at one of the Morse Clinics in Raleigh, the state capital, two or three people are waiting their turn at the front desk.

Addiction psychiatrist Dr., who runs nine clinics offering medication-assisted treatment (MAT) in North Carolina. “The busiest times are from 5:30 a.m. to 7 p.m., before work,” says Eric Morse. “Most of our family works; when they’re sober, they come to work on time every day.”

The clinic runs a precisely tuned operation. After checking in, patients are called to the dosing window to pick up their prescription. They are in and out in minutes.

They will be subject to random drug testing for illegal drugs. Dr. Morse says about half of his patients still test positive for street-bought opioids, but he doesn’t see that as a failure.

“Maybe you use it once a week and you’re used to using it three times a day… You’re still playing Russian roulette with fentanyl, but you’ve taken a lot of bullets out of the chamber, so your survival rate increases significantly,” says Dr Morse.

This is harm reduction. Therefore, patients who test positive for drugs are given extra support and counseling rather than being removed from the treatment program. Dr Morse says 80-90 per cent of the public will eventually stop using street drugs altogether. And over time, most people will reduce their medication as well.

Not everyone thinks this is the right approach.

Mark Pless is a Republican who sits in the North Carolina state House of Representatives and used to work full-time as a paramedic. He points out that taking illegal drugs starts with a choice.

And he doesn’t believe in harm reduction. He specifically opposes treating opioid use disorder with medications such as methadone or buprenorphine.

“You’re replacing one addictive product with another addictive product,” he says. “If you have to take it to stay clean, it’s still addictive. We have to figure out how to get people to a place where they can do better; we can’t leave them on drugs forever.”

He supports drug abstinence treatment programs in cases where drug users turn “cold turkey.”

But there are objections from health experts in North Carolina.

“I believe there is more than one way to heal,” Dr. Morse says. “I don’t disparage abstinence-based treatment unless you look at the medical evidence.”

Dr Morse references A 2023 study by Yale University To analyze the risk of death of opioid users in a treatment program compared to people not receiving treatment. The study suggested that a person receiving withdrawal treatment is just as likely or more likely to experience a fatal overdose than a person who is not receiving treatment and continues to use street opioids such as fentanyl.

Treatment aside, another medication helps.

Naloxone is widely available and, when used as a nasal spray, helps a person breathe again by reversing the effects of an opioid overdose. It was administered more than 16,000 times in North Carolina in 2024. This means potentially 16,000 lives have been saved, and these are just the reversal of the reported overdose.

Dr., a scientist specializing in street drugs at the University of North Carolina. “This is as close to a miraculous drug as we can imagine,” says Nabarun Dasgupta.

Most users of narcotics such as cocaine, methamphetamine, and heroin want to know that what they are taking will not kill them. Some people use test strips to check for fentanyl because they know that fentanyl plays a role in many fatal overdoses.

However, the strips do not identify all potentially harmful substances. Dr Dasgupta runs a national drug testing laboratory. Users send him a small portion of their drug supply through local nonprofits.

“We analyzed close to 14,000 samples from 43 states over the last three years,” he says.

Testing drugs for potentially dangerous additives is an additional weapon in the harm reduction arsenal. Dr Dasgupta believes another reason for reducing overdose deaths in the US is because young people are avoiding opioids such as fentanyl.

“We’re seeing a demographic shift. Generation Z is dying from overdoses much less frequently than their parents or grandparents did at the same age,” he says.

Dr Dasgupta isn’t too surprised that people in their 20s are staying away from opioids. Surprisingly, four in 10 American adults know someone whose life ended due to an overdose.

This epidemic of deaths fueled by prescription opioids in the 1990s motivated North Carolina’s former attorney general (now the state’s governor) to take action against powerful corporations that benefit from the dark spiral that has led many Americans into addiction.

Josh Stein picked up the phone to colleagues in other states and took a leading role in coordinating legal action against opioid manufacturers, distributors and retailers.

“Tennessee had a Republican attorney general, I’m a Democrat in North Carolina… But we all care about our people and we’re all willing to fight for them,” Stein reflects.

After years of intense negotiations, the result is an Opioid Agreement worth around $60bn (£45bn). This is the money that major companies have agreed to pay to US states to be used to “reduce the opioid epidemic.” North Carolina’s share is around $1.5 billion.

“This needs to be spent in four ways: drug prevention, treatment, recovery or harm reduction. I think it’s transformative,” says Governor Stein.

Meanwhile, the national government’s finances are uncertain. Medicaid cuts under President Trump’s Big, Beautiful Bill Act could have a tremendous impact on this area.

At Morse Clinics in Raleigh, 70% of patients are dependent on Medicaid. If they lose their health insurance, will they discontinue treatment and become more vulnerable to death from an overdose? While North Carolina’s drug death statistics seem optimistic, thousands of people are still dying, and the state’s black, indigenous and nonwhite populations have not experienced the same rates of decline.

And there are other states, including Nevada and Arizona, that are seeing a stubbornly slower rate of decline in fatal overdoses.

Nobody is indifferent. At least Kayla.

While he was in the grip of fentanyl for three years, he never overdosed, but he had to save his friends. Kayla’s family didn’t know what to do with her.

“They kind of gave up on me, thought I was going to die,” he recalls.

Kayla credits harm reduction counselor Charlton Roberson with being instrumental in her recovery. His goal now is to get rid of drugs and drugs by tapering off methadone. He also wants to find a job at the hospital.

“When I use fentanyl, I feel more alive than ever,” she says.

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