How opioid deaths tripled in Philly over a decade − and what may be behind a recent downturn

After nearly a decade of almost year-over-year increases in overdose deaths, the tide may finally be turning in Philadelphia.

The Centers for Disease Control and Prevention announced in May 2024 an estimated 3% decrease in overdose deaths in the U.S. in 2023 compared with 2022. Shortly after, data from the Philadelphia Department of Public Health showed a similar trend: Fatal overdoses across the city decreased 7% in 2023, from 1,207 to 1,122. The city is expected to release its 2024 data in the spring of 2025.

While these declines are notable, the city’s 2023 fatal overdose numbers are three times higher than they were in 2013.

Still, if 2024 numbers confirm the downward trend, it allows a little hope into an otherwise bleak epidemic that is killing more Philadelphians than homicides, car accidents and diabetes combined.

Something may finally be working. But what?

If over a decade spent treating and researching substance use disorders has taught me anything, it’s that the overdose epidemic is what researchers and policymakers refer to as a wicked problem. Wicked problems are constantly changing, complex, interconnected knots of other problems with no clear solution.

But let’s look at what we do know about how overdose deaths in Philadelphia spiked in the first place – and why they may finally be decreasing.

Why overdose deaths spiked

The first wave of the overdose epidemic began in the late 1990s and is attributed to overprescription of opioid pain medicines. But the largest acceleration in deaths didn’t occur until after the government and health insurers implemented prescribing controls in the early 2010s. These controls led many people who were no longer able to get prescribed opioids to turn to illicit heroin.

In a phenomenon known as the “iron law of prohibition,” stricter drug law enforcement led drug-trafficking organizations to shift from heroin toward more powerful synthetic opioids that are easier to produce, conceal and distribute. Gram for gram, pure fentanyl is over 50 times stronger than pure heroin.

But street-obtained fentanyl has proven to be anything but pure.

Local drug-testing efforts found as much as a fiftyfold difference in potency between bags of fentanyl that appear identical.

This unpredictable potency is considered to be the chief contributor to the deadliness of street fentanyl. It’s like cracking a beer and not knowing whether drinking it will get you mildly buzzed or send you to the graveyard.

Research suggests drug busts, though touted as improving public safety, can lead to more inconsistency and unpredictability in the potency of illicit opioids. An analysis of 14 studies conducted in the U.S. demonstrated a marked increase in fatal overdoses following the supply disruptions that result from drug seizures.

There’s also some evidence that the heightened economic insecurity and despair caused by the COVID-19 pandemic may have intensified the fatal overdose epidemic.

Potential reasons for decline

Just as economic insecurity was associated with rising deaths, the subsequent economic recovery as the U.S. emerged from the pandemic may have contributed to the 2023 drop in overdose fatalities nationwide.

However, the unequal distribution of that recovery seems to track with worsening racial disparities in overdose rates in the late 2010s to early 2020s.

Another possible explanation for the reduction in overdose deaths is the increasing availability of buprenorphine.

Buprenorphine, an FDA-approved medication for opioid use disorder, reduces withdrawal and cravings for fentanyl. What’s more, it decreases overdose risk by more than 50%.

However, efforts to increase access to this medication have stagnated. National prescribing rates for buprenorphine were relatively stable from 2019 to 2023, and the CDC estimates that only a quarter of those who need treatment are getting it. Efforts to make buprenorphine available without a prescription have not yet gained traction.

Access to and education around naloxone, a lifesaving drug used to reverse opioid overdoses, has also increased, and the drug is increasingly being administered by bystanders. Over 1.3 million doses were distributed in Pennsylvania since 2017. National research suggests these distribution efforts, often spearheaded by local harm-reduction organizations, have led to quicker administration of naloxone. This saves lives while also decreasing reliance on emergency medical services.

Finally, the consequences of a seemingly minor characteristic of fentanyl’s pharmacology might also be reducing the overdose death rate in Philadelphia.

Fentanyl’s effects last only a third as long as heroin. This shorter duration led drug traffickers to add the animal tranquilizer xylazine – also called “tranq” – and the veterinary anesthetic medetomidine into Philadelphia’s street drug supply. In 2019, two-thirds of heroin or fentanyl sampled in Philadelphia had xylazine in it. By 2021 all of it did.

These additives lengthen the duration of the effect, mitigate withdrawal symptoms and possibly reduce the amount of fentanyl needed per dose. Some evidence from animal studies shows that xylazine reduces fentanyl intake by suppressing fentanyl withdrawal, thereby lengthening the time before a person uses again.

What’s more, the skin wounds and sedative effects that are associated with xylazine may be motivating some people to avoid using street fentanyl.

What’s next for Philadelphia

The opioid settlement, a multibillion-dollar payment from the pharmaceutical industry to resolve legal actions against them, has led to increased funding in Philadelphia for naloxone and medications such as buprenorphine to treat opioid use disorder.

However, in the past year the city eliminated funding for needle exchanges and implemented compulsory treatment strategies, which research suggests often do not reduce drug use or criminal recidividism.

Meanwhile, at the federal level, Republican members of Congress have proposed cuts to Medicaid, the health insurance program for low-income Americans.

Whether new data, when it’s released, will show overdose deaths in Philly have continued to decline or are back on the rise is anybody’s guess. But I do know that harm-reduction advocates, medical providers and communities of people who use drugs will continue to fight this epidemic as if their lives depend on it. For many, it does.