Non-Fatal Overdoses Fall More Slowly Than Fatal Ones, Analysis Finds

The decline in opioid overdose deaths that the United States has recorded since 2023 is real, but it is not a simple measure of how often overdoses happen. In an analysis published Oct. 14, the R Street Institute compared fatal and non-fatal overdose trends and found that non-fatal opioid overdoses are falling more slowly than deaths — a divergence the authors say suggests improved survivability, not just less drug use, is driving the death rate down.

The analysis draws on the Centers for Disease Control and Prevention's nonfatal overdose surveillance and on emergency medical services data compiled by the National Highway Traffic Safety Administration through the NEMSIS system. Non-fatal overdoses are also more common than fatal ones: R Street cites a 2024 study in the journal Injury Prevention estimating that in 2020 there were four non-fatal opioid overdoses for every fatal one.

Two ways to bring deaths down

The analysis frames the decline as the product of two different mechanisms that are easy to confuse. The first is stopping overdoses from happening at all — through treatment and through drug-checking supplies such as fentanyl test strips that help people who use drugs do so more safely. The second is making an overdose survivable, mainly through broad distribution of naloxone and public education about how to respond.

Sorting out how much each contributes is genuinely hard, the authors write. An overdose that never happened is not recorded anywhere, and non-fatal counts are themselves incomplete because people who overdose without EMS or hospital involvement never enter the surveillance data. That leaves a public health picture in which the most visible number — deaths — improves faster than the less visible one.

Surviving an overdose is not the same as escaping harm

An opioid overdose typically causes respiratory depression — breathing that becomes slow and shallow and can stop entirely. Oxygen deprivation is what drives the consequences: loss of consciousness, and brain injury that can begin within about four minutes without oxygen, according to the clinical literature R Street cites.

People who survive but sustain hypoxic brain injury can face lasting motor, mood, vision and cognitive problems, and the risk of long-term injury rises with each repeated overdose. Other physical effects include pneumonia, seizures and irregular heartbeat. R Street also points to research associating a non-fatal overdose with a higher risk of a later fatal overdose and with death by suicide.

The handoff that mostly does not happen

The part of the analysis with the most direct policy bearing is what happens after someone survives. A non-fatal overdose usually involves contact with the health system, which makes it an opportunity to offer harm reduction and treatment. It is mostly missed.

Citing a JAMA Network Open study, R Street reports that only 16.6 percent of people who experienced a non-fatal overdose received any treatment in the following 90 days. A separate study in JAMA Internal Medicine found that 6.2 percent of people who survived an opioid overdose filled a naloxone prescription and 4.1 percent received medications for opioid use disorder in the 12 months after their overdose. Both medications and a naloxone prescription are associated with lower odds of a subsequent fatal overdose.

The reasons run from the personal to the structural. A study of people who inject drugs in Baltimore found that a quarter sought treatment within 30 days of an overdose, and that among those who did not, 70 percent said they were not ready and 30 percent did not see their drug use as a problem. A Houston mobile outreach team that tried to offer treatment after non-fatal overdoses found two-thirds of the people it reached declined, mostly for the same reason. Even when treatment is welcome, capacity is a barrier: the country's medication-assisted treatment system is not large enough for the people seeking it, and waiting lists are frequently cited as the reason someone never enrolls.

What the evidence says works

Two approaches recur in the research R Street reviews. "Warm hand-offs," in which emergency clinicians make the first contact with a treatment program rather than handing over a phone number, are associated with higher enrollment than passive referral. Emergency responders in some jurisdictions can also initiate buprenorphine on the spot or prescribe it with a referral; an assessment of a California program that started buprenorphine in the emergency department found 85.8 percent of patients diagnosed with opioid use disorder elected to take it, and those who did were almost twice as likely to be engaged in treatment 30 days later.

For people who are not ready for treatment, the analysis argues there is still something to do: provide take-home naloxone after an overdose, explain harm reduction practices such as not using alone, and leave the information about treatment available for when it is wanted.

The overall conclusion is narrow but worth stating plainly. A falling death toll is genuinely good news, and it may say as much about who is being revived as about how many people are overdosing. The count of non-fatal overdoses, and the treatment gap that follows each one, is where the next phase of the epidemic is being recorded — and where the response is thinnest.

The SAMHSA national help line, 1-800-662-4357, provides free referrals for substance use and mental health treatment around the clock.