The Overdose Epidemic: A Persistent Public Health Crisis

By Leigh Wedenoja

The overdose epidemic continues to be one of the most intransigent public health crises that New York and the country as a whole have experienced. As detailed in the Rockefeller Institute’s overdose mortality dashboard, fatal overdoses in the US reached an apex in 2021, the most recent year available for official CDC mortality data. Provisional CDC data through May 2023 shows that we are on pace for deaths to exceed previous years yet again. Nationally, annual overdose deaths surpassed 60,000 for the first time in 2016, climbed to over 100,000 in 2021, and have remained above 100,000 since. According to the CDC, more than one million people have died from an overdose since 1999. Since 2021, the rate of increase in overdose deaths has slowed. The year-over-year percent increase in deaths from 2020 to 2021 was half the increase from 2019 to 2020. While still high, this lower rate of increase is a promising sign. One potential driver of this slowdown is the increased availability of the opioid overdose reversal medication naloxone and the many community efforts to provide naloxone training and supplies.

The Role of Fentanyl in Perpetuating the Overdose Epidemic

The main driver of this peak in overdose mortality is fentanyl and similar synthetic opioids. Fentanyl is a synthetic opioid used medically to treat extreme pain and originally entered the illicit market as a cheap adulterant mixed into heroin to strengthen the effect of the drug. Fentanyl has become sought after in its own right in recent years: it now is involved in 70 percent of all overdose deaths and is one of the leading causes of death for Americans under 50.

Due to its relative potency and lower price compared to prescription opioids like oxycodone and hydrocodone and natural illicit opioids like heroin, fentanyl has become ubiquitous in the illicit drug market. It is often used to produce counterfeit prescription pills and can even be found in illicit stimulants like cocaine and methamphetamine. Some stimulant adulteration is intentional and some is incidental through drug importation and sales pathways, meaning it was not purposefully added and the concentration of fentanyl could be unknown to both sellers and users.

Fentanyl is also more lethal when used in combination with other drugs, specifically other central nervous system depressants like benzodiazepines and barbiturates. Central nervous system depressants magnify the effect of opioids in slowing breathing and heart rate, which increases the likelihood of a fatal overdose. Recently, the veterinary tranquilizer, xylazine, sometimes referred to as “tranq,” has become common in illicit fentanyl. According to the DEA, in 2022 23 percent of fentanyl powder and 7 percent of fentanyl pills tested by the Drug Enforcement Administration lab contained xylazine and the DEA expected that rate to increase. In addition to increasing the lethality of fentanyl, xylazine can cause skin ulcers that appear as wounds that will not heal.

Community-Led Harm Reduction

While the overdose epidemic has been a persistent health crisis, there have been significant developments in both harm reduction intervention and treatment for people with substance-use disorder (SUD) who use opioids. Harm reduction and treatment are interrelated but distinct goals. The goal of harm reduction is to reduce the probability of overdose and death among people who use drugs, and the goal of SUD treatment is to help people abstain entirely from using those drugs. At present, the most effective tool available for harm reduction is widely considered to be naloxone. Naloxone is an FDA-approved medication that blocks opioid receptors and will immediately reverse an opioid overdose. Since March 2023, naloxone nasal spray has been available without a prescription under the brand name Narcan; generic naloxone is now also available by prescription and, more recently, since July 2023, through over-the-counter sales.

Over-the-counter naloxone is an important step forward for harm reduction because of the easy and increased availability of this tool. But the medication can only effectively save lives if people both have it and know how to use it when confronted with someone experiencing an opioid overdose. Even with over-the-counter approval, some pharmacies may not choose to carry naloxone, or the price tag may be too high for people who want it. Additionally, if potential naloxone administrators are not familiar with the symptoms of an opioid overdose or the proper timing and dosage of naloxone, administering it will not be as effective as it could be. These pitfalls have led to a number of community initiatives to get naloxone spray into the hands of people who can most effectively use it to save lives and to disseminate information and training on proper use of the overdose-reversal drug.

Due to their public-facing professions, restaurant and bar workers (among others) have increasingly found themselves confronted by the opioid overdose epidemic. In addition to their proximity to the public, the hospitality industry has historically had a higher-than-average rate of SUD. New York City has recognized the potential importance of hospitality workers in overdose harm reduction and introduced the NARCAN® BEHIND EVERY BAR campaign through the New York City Office of Nightlife and New York City Department of Health. The program distributes naloxone kits and hosts training for bar and restaurant workers on best practices for use.

New York City is only one of many cities in which public health groups have targeted the hospitality industry as a distribution point for naloxone. Recently, the Alliance for Positive Health, an organization that works to prevent the spread of HIV and provides overdose-related harm reduction services, hosted a naloxone training in Albany, New York, aimed at educating hospitality workers on the use of naloxone and distributing opioid reversal kits to bar and restaurant workers. The training was sponsored by community partners, including Albany County Legislator Matthew Peter, Albany Common Councilwoman Gabriella Romero, the State University of New York’s Rockefeller Institute of Government, and the University at Albany. The training was held on a Sunday afternoon in central Albany to cater to hospitality workers’ schedules with the goal of increasing access.

This in-person training complemented existing naloxone distribution programs in the city, including an Albany County initiative to place naloxone in public buildings and ongoing naloxone trainings at the University at Albany. Not only is access to naloxone itself crucial, but naloxone trainings provide community members with valuable additional information that helps them respond to an opioid overdose in the most effective and safe way.

The Alliance for Positive Health’s training included a variety of information on effective naloxone use, including:

  1. How to identify an opioid overdose and how to determine if a person is nonresponsive.
  2. How opioids affect the brain chemically and how naloxone works to reverse an opioid overdose.
  3. The fact that there are no negative “side effects” to naloxone administration—if a person is nonresponsive for a reason other than an opioid overdose, they will not be injured from naloxone administration.
  4. How to administer the nasal spray and when to administer additional doses.
  5. What information should be shared with EMTs or other emergency responders and medical professionals after naloxone is used.
  6. The Good Samaritan laws in New York that protect people who administer naloxone or call emergency services to ask for help with an overdose.
  7. Naloxone will only reverse an opioid overdose, not other types of overdoses, including those caused by stimulants like methamphetamine or cocaine.
  8. How long a person who receives naloxone needs to be monitored to make sure that they do not return to overdosing once the naloxone dose wears off.
  9. When and if to begin other lifesaving measures like CPR.
  10. Additional harm-reduction tools that are available, including fentanyl test strips, xylazine test strips, syringe exchanges, and other safer drug use strategies like test dosing and never using alone.

Training in naloxone use and opioid overdose recognition also allows participants to ask questions that are relevant to their personal circumstances and to clear up any misinformation they may have received. People who receive naloxone training are more knowledgeable and effective at reversing overdoses compared to those who receive naloxone alone. Training also helps reduce the stigma of carrying or administering naloxone. Gabrielle Draper, who facilitated the Alliance for Positive Health training, echoed that sentiment, stating that their “mission is really to remove the stigma that surrounds substance use and allow folks to come to us as they are.”

Naloxone training and distribution efforts are seldom centralized in municipalities and can involve overlapping government and community programs. In addition to the Alliance for Positive Health and the University at Albany, training in Albany has also been available through Albany County, New York State’s Substance Abuse and Mental Health Services Administration (SAMHSA), Recovery Community Centers, and many other community partners. SAMHSA also has an overdose prevention and naloxone manual available online. Each of these groups targets different populations, which helps assure that naloxone and training are available to all who need it.

Naloxone distribution and training are only two of many tools in public health policy and practice that are used to fight the overdose epidemic, but they remain some of the easiest to access and most effective. The options for naloxone distribution continue to improve: in July, the FDA approved an additional naloxone spray, RiVive, for over-the-counter sale where it joins brand name Narcan. These increased options will likely reduce the price of naloxone, which can be prohibitive for some people who seek to purchase it in a pharmacy. To address the cost issue, many community organizations, including the Alliance for Positive Health, distribute naloxone kits for free and many local governments, school districts, and universities also maintain free supplies for the overdose-reversal drug. Overdose deaths in the US remain high at more than 100,000 deaths annually, but the rate of increase has slowed, which is promising evidence that our public health strategies, including naloxone distribution and training, are beginning to have a positive effect on this crisis.


Leigh Wedenoja is senior policy analyst at the Rockefeller Institute of Government