Overdose Deaths Are Falling, But Substance Use Treatment Gaps Remain

Drug-related overdose deaths in the United States have dropped from more than 110,000 in 2023 to approximately 75,000 in 2024. That is a meaningful step forward in the fight to improve substance use treatment and save lives. Behind that number, though, lies a far more complicated picture that health professionals and policymakers are still scrambling to address.

Illegally manufactured fentanyl drives the vast majority of opioid-related deaths, and nearly 60 per cent of those fatalities now involve more than one substance. Even as total overdose numbers edge downward, the drug supply has become more unpredictable and more lethal.

“We have very effective ways of being able to treat, identify, prevent and help people recover,” said Dr Yngvild Olsen, a national adviser at Manatt Health and former director for the Centre for Substance Abuse Treatment at SAMHSA, speaking at the AMA State Advocacy Summit in January 2026. “And help continue that recovery from a health lens, and not just a public safety criminal lens.”

The problem, increasingly, is not a lack of solutions. Access is what keeps failing.

What the Data on Substance Use Treatment Actually Shows

The American Medical Association’s 2025 report on substance use and treatment lays out a striking set of contradictions. Opioid prescriptions have fallen by more than 51 per cent since 2012, dropping from 260.5 million to 125.7 million in 2024. Total dosage strength, measured in morphine milligram equivalents, declined by 65 per cent over the same period.

Yet patients with legitimate pain still struggle to access non-opioid alternatives. Insurers frequently do not cover them, or erect barriers that make access impractical.

Buprenorphine, one of the most effective medications for opioid use disorder, saw a rare dispensing decline in 2024. Prescriptions fell from 15.7 million to 15.4 million after years of steady growth. Pharmacy reluctance, insurance restrictions and prior authorisation requirements all appear to be contributing factors, though the full picture remains unclear.

Methadone carries more than 50 years of evidence behind it. Despite that record, regulators still restrict it to specialist opioid treatment programmes. Many patients simply cannot reach those clinics, leaving a proven opioid use disorder treatment out of reach for large numbers of people.

Insurance Barriers Are Blocking Substance Use Treatment, Sometimes Fatally

Prior authorisation sits at the heart of one of the most damaging obstacles in substance use treatment. Insurers require approval before certain medications can be dispensed, and for patients with opioid use disorder, even a short delay can end in tragedy.

“Imagine a patient who has just seen their doctor, received a prescription for buprenorphine, and then is turned away at the pharmacy because approval hasn’t come through,” said Lauren Finke, senior policy director at The Kennedy Forum, speaking at the AMA summit. “That delay can push someone back to using dangerous, unpredictable street drugs, sometimes leading to overdoses that can be fatal.”

Financially, the logic of delay makes no sense either. Hospitalisation after an overdose costs far more than removing prior authorisation and allowing immediate access to proven opioid use disorder treatment. The AMA has pushed insurers to eliminate prior authorisation for substance use treatment medications entirely, citing Washington DC and Illinois as states where Medicaid has already done so.

The barriers, however, remain in place across much of the country.

A Crisis That Is Growing More Complex

The substance misuse landscape in the United States is shifting in ways that make treatment harder to deliver. Stimulants, particularly methamphetamine and cocaine, now appear in 59 per cent of all overdose deaths, often alongside opioids. No FDA-approved medications exist yet to treat stimulant use disorder, so clinicians must rely primarily on behavioural interventions such as contingency management.

Cannabis use disorder has quietly become a serious concern. In 2023, approximately 19.2 million Americans met the clinical criteria for the condition, representing around 30 per cent of all cannabis users. Emergency department visits for cannabinoid hyperemesis syndrome rose by more than 400 per cent since 2016. That figure tends to surprise people who assume legalisation reduces health harms.

Other substances are adding further layers of risk. Xylazine, a veterinary sedative found with increasing frequency in the illicit drug supply, does not respond to naloxone. Tianeptine, sometimes sold in petrol stations under various brand names, carries opioid-like properties and has been linked to serious harm and death. Nitrous oxide deaths climbed by nearly 600 per cent between 2010 and 2023.

States Are Pulling Back on Opioid Use Disorder Treatment at the Wrong Moment

At a moment when the crisis demands more coordinated investment, many states are cutting back rather than expanding.

Dr Olsen noted at the AMA summit that support for harm reduction programmes has declined noticeably at the state level. Reduced access to services designed to lower the immediate risks of drug use is already producing visible consequences: rising rates of hepatitis C and HIV in communities where prevention services have been defunded or closed.

Unspent settlement funds add to the concern. In Iowa, millions won through legal action against pharmaceutical companies sit idle. Nearly half of Ohio’s opioid settlement money has been described as untraceable. Michigan providers, meanwhile, called the rollout of a $1.5 billion settlement a “huge disaster.” The gap between available resources and effective deployment is one of the most solvable problems in this space, yet it keeps being ignored.

New Tools Are Helping to Expose Gaps in Substance Use Treatment Coverage

One development attracting cautious optimism is the Mental Health Parity Index, a data visualisation tool developed by The Kennedy Forum in collaboration with the AMA and Third Horizon. It enables physicians, patients and policymakers to examine how well commercial insurance plans perform on mental health and substance use treatment coverage compared to physical health services.

A pilot launch in Illinois exposed widespread areas where parity violations are likely. A national rollout is planned for 2026.

“We really took that transparency and coverage data and created this so that you can look and see things for yourself in your own jurisdiction,” said Finke. Insurance commissioners and state regulators have historically lacked documented complaints to build a strong case for change. This index gives them the evidence base they need.

Naloxone Is Saving Lives, But Gaps in Access Persist

Community-based naloxone distribution stands out as one of the clearer wins in overdose prevention. The opioid overdose reversal medication received FDA over-the-counter approval in 2023, and distribution has scaled considerably. In 2024, Remedy Alliance for the People delivered more than 2.1 million doses across 45 states and Puerto Rico.

Access still falls short in too many places. States recording the highest overdose rates frequently report the lowest availability of over-the-counter naloxone. Black Americans receive fewer naloxone prescriptions than other groups. Women are less likely than men to receive the medication from emergency medical services during an overdose. High retail cost continues to deter uptake even where naloxone is technically on the shelf.

Laws giving lay bystanders civil protections for administering naloxone have produced a 9 to 11 per cent reduction in opioid-related deaths. More states could adopt this approach immediately.

Fixing Substance Use Treatment: What Must Change

The AMA’s 2025 report and the discussions at the State Advocacy Summit point to a system with effective tools that keeps finding ways to limit their reach.

Physicians and patient advocates are pressing for several concrete changes. These include banning prior authorisation for substance use treatment medications such as buprenorphine above 24mg daily, expanding methadone access so patients can collect prescriptions from community pharmacies, enforcing mental health and substance use disorder parity laws to hold insurers accountable, and guaranteeing that people entering prisons or jails can continue opioid use disorder treatment and connect to community care on release.

“At the end of the day,” said Finke, “these laws are meant to protect patients. It is up to us to ensure that legislators and regulators hear their voice.”

The evidence points clearly in one direction. Whether the political will exists to follow it remains the defining question.

References: 2025 AMA Report on Substance Use and Treatment; AMA State Advocacy Summit, January 2026; SAMHSA 2024 National Survey on Drug Use and Health

Source: dbrecoveryresources