How the US is emerging from its drugs death epidemic

Kayla first tried fentanyl as a troubled 18-year-old growing up in North Carolina.

“I felt literally amazing. The voices in my head just went silent. I was instantly addicted,” she recalls.

The little blue pills that Kayla became addicted to were likely manufactured in Mexico and then smuggled across the border into the United States – a deadly trade that President Donald Trump is trying to combat.

But drug cartels are not pharmacists. So Kayla never found out how much fentanyl was in the pill she took. Will the synthetic opioid be enough to kill her?

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

In 2023, there will be more than 110,000 drug-related deaths in the United States. It seemed impossible to stop the spread of fentanyl, which is 50 times more potent than heroin.

But then there was a stunning twist.

In 2024, the number of fatal overdoses in the United States fell by about 25%. This is almost 30,000 fewer deaths – dozens of lives are saved every day. Kyle's state, North Carolina, is at the forefront of this trend.

One explanation is a commitment to harm reduction. That means promoting policies that prioritize the health and well-being of drug users over criminalizing people—a recognition that in the age of fentanyl, drug use too often ends in overdose death.

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

Kayla no longer does street drugs. And she is a client of the innovative Law Enforcement Diversion (LEAD) program in Fayetteville. It is a partnership between city police and the North Carolina Harm Reduction Coalition. Together they work to divert substance users away from crime and onto the path to recovery.

“If someone steals from a grocery store, we look into their criminal history. And often what we see is that the crimes they commit seem to be funding their addiction,” says Lt. Jamaal Littlejohn.

This may make them candidates for the LEAD program, which means they can get support to fight their addiction and begin to think about secure housing and employment.

LEAD supporters say it's not about being soft on crime. Drug dealers still end up in jail in Fayetteville. “But if we can get people the services they need, it gives law enforcement more time to fight more serious crimes,” said 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 finance her fentanyl addiction. As part of the LEAD process, her criminal record was expunged. She recently graduated as a registered nurse and now works in a nursing home.

“This is the best thing ever. This is the longest time I've been clean,” she says.

Treatment was critical to Kayla's recovery. She has been on methadone for almost a year when she tells her story to the BBC. “It keeps me from going back,” she says.

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

In North Carolina, it has been a game changer, with more than 30,000 people participating in the program in 2024, with more to come in 2025.

At 9:00 a.m., at one Morse clinic in the state capital of Raleigh, two or three people are waiting in line for an appointment.

“The busiest time is from 5:30 to 7 a.m., which is before work,” says Dr. Eric Morse, an addiction psychiatrist who runs nine clinics offering medication-assisted treatment (MAT) in North Carolina. “Most of our people work: when they are sober, they come to work on time every day.”

The work at the clinic is well organized. Once patients are registered, they are called to a dispensing window to receive a prescription. They come and go in minutes.

They will be randomly tested for illegal drugs. Dr. Morse says about half of his patients still test positive for street-bought opioids, but he doesn't consider that a setback.

“Maybe you're using once a week, or you're used to three times a day… You're still playing Russian roulette with fentanyl, but you've pulled a whole bunch of bullets out of the chamber, so your survival rate increases significantly,” says Dr. Morse.

This is harm reduction. Thus, rather than being excluded from the treatment program, patients who test positive for drugs receive additional support and counseling. Dr. Morse says that 80-90% of people will eventually stop using street drugs altogether. And over time, many will also refuse to take medications.

Not everyone thinks this is the right approach.

Mark Pless is a Republican who sits in the North Carolina House of Representatives and used to work as a full-time paramedic. He notes that illegal drug use begins with choice.

And he doesn't believe in harm reduction. In particular, he opposes treating opioid use disorder with medications such as methadone or buprenorphine.

“You are replacing an addictive product with another addictive product,” he says. “If you have to take it to stay clean, it's still addictive. We need to figure out how to get people to where they can feel better—we can't keep them on drugs forever.”

He advocates for withdrawal treatment programs where drug users abruptly quit smoking.

But in North Carolina, there is resistance from health care workers.

“I believe there are multiple paths to recovery,” says Dr. Morse. “I don't disparage abstinence-based treatment unless you look at the medical evidence.”

Dr. Morse's recommendations Yale University study from 2023 analysis of the risk of death of opioid users participating in a treatment program compared with people not receiving treatment. The study found that a person receiving treatment for withdrawal was as likely or more likely to fatally overdose as a person who did not receive treatment and continued to use street opioids such as fentanyl.

In addition to treatment, another drug helps.

Naloxone is widely available and, used as a nasal spray, reverses the effects of an opioid overdose by helping a person breathe again. In North Carolina, it was administered more than 16,000 times in 2024. This potentially saves 16,000 lives – and that's just the cases where overdose reversals have been reported.

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

Many users of drugs such as cocaine, methamphetamine and heroin want to know that what they are taking will not kill them. Some people use test strips to test for fentanyl because they know it is involved in a large number of fatal overdoses.

But the strips do not identify all potentially harmful substances. Dr. Dasgupta runs the national drug testing laboratory. Consumers send him a small portion of their drug supplies through local nonprofits.

“Over the last three years, we've analyzed about 14,000 samples from 43 states,” he says.

Testing medications for potentially dangerous additives is an additional weapon in the harm reduction arsenal. Dr. Dasgupta believes another reason for the decline in overdose deaths in the United States is that young people are avoiding opioids such as fentanyl.

“We are seeing a demographic shift. Generation Z is dying from an overdose at a much lower rate than their parents' or grandparents' generation did at the same age,” he says.

Dr. Dasgupta isn't entirely surprised that 20-year-olds are avoiding opioids. A shocking four in 10 American adults know someone whose life was cut short due to an overdose.

It was this epidemic of deaths from prescription opioids that began in the 1990s that prompted North Carolina's former attorney general, now the state's governor, to speak out against powerful corporations profiting from many Americans' dark spiral into addiction.

Josh Stein has answered phone calls to his counterparts in other states and has taken a lead role in coordinating lawsuits against opioid manufacturers, distributors and retailers.

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

The result, after years of intense negotiations, was an opioid settlement worth around $60bn (£45bn). This is money that huge companies have agreed to pay to US states to be used to “reduce the opioid epidemic.” North Carolina's share is about $1.5 billion.

“These funds must be spent in four ways: on drug addiction prevention, on treatment, on recovery and on harm reduction. I think this will be transformative,” says Governor Stein.

Meanwhile, funding from the national government is uncertain. The Medicaid cuts included in President Trump's One Big Beautiful Bill could have a huge impact on this area.

At Morse's Raleigh clinics, 70% of patients depend on Medicaid. If they lose health insurance, will they stop treatment and become more vulnerable to death from an overdose? While North Carolina's drug death statistics look optimistic, thousands of people are still dying, and the state's Black, Indigenous and people of color populations are not experiencing the same rate of decline.

And there remain other states that have seen a stubbornly slower pace of decline in fatal overdoses, including Nevada and Arizona.

Nobody calms down. Least of all Kayla.

Being in the grip of fentanyl for three long years, she never overdosed on herself, but she had to save her friends. Kayla's parents didn't know what to do with her.

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

Kayla credits Charlton Roberson, her harm reduction mentor, with playing an important role in her recovery. Her goal now is to cut down on methadone and get off medications and drugs. She also wants to find a job in a hospital.

“I feel more alive than I ever did while taking fentanyl,” she says.

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