Good news came out from the Centers for Disease Control and Prevention Wednesday: Preliminary data shows reported drug overdoses declined 4.2% in 2018, after rising precipitously for decades.
"It looks like this is the first turnaround since the opioid crisis began," says Bertha Madras who served on President Trump's opioid commission, and is a professor of psychobiology at Harvard Medical School.
She says it won't be entirely clear until the CDC finalizes the numbers but, "I think the tide could be turning."
But not everyone was celebrating. Some states actually saw double-digit increases.
"It's deflating," Rachel Winograd says. She's an associate research professor at the University of Missouri-St. Louis. "It's incredibly discouraging to see the increase in Missouri in 2018 that happened at the same time as we really ramped up so many efforts to save lives and improve lives in our state."
The provisional data shows Missouri deaths increased by 17% — one of 18 states that saw a year-over-year increase.
Over the last several years, Missouri has received $65 million in federal grants to address the opioid crisis, Winograd says, and she has helped the state decide where and how to spend that money. They've focused on expanding access to medication-assisted treatment, and "saturating our communities with naloxone — the opiate overdose antidote," she says.
"Any scholar who's been studying this epidemic will tell you that those are effective tools at saving lives. We've drastically increased access to those services and we know we've saved thousands of lives.
"The fact that the numbers didn't go down and that people were dying at an even higher rate — it was devastating," Winograd says.
The numbers out Wednesday are not final, notes Farida Ahmad, mortality surveillance lead of the National Center for Health Statistics at the CDC. She says they should be close to the final numbers, though. For provisional data, "our threshold is for 90% completeness," she says.
Michael Botticelli, the executive director of the Grayken Center for Addiction at Boston Medical Center and formerly President Obama's drug czar, says the geographic variation in drug deaths is troubling.
"I think it's important to pay attention to and really understand what is happening in each of these states, and why are some states seeing dramatic increases versus those seeing dramatic decreases?" he says.
The reasons for this geographic variation are numerous. For one, this data only reflects the difference from one year to the next, so states that had a bad year in 2017, can show an improvement in 2018, even if the overall picture is still grim.
Another variable is fentanyl, the highly potent synthetic opioid that's been responsible for a rising number of overdoses in recent years. Some states have a lot of fentanyl in their drug supply, and others do not.
"We saw increases all along the Mississippi river, and I would not be surprised if that was due to an increase in the proportion of fentanyl in their drug supply," Winograd says. Deaths from fentanyl continue to rise, according to Ahmad from the CDC.
Other variations in the drug supply could contribute to the differences from state to state, says Christopher Ruhm, a professor of public policy at the University of Virginia. He notes stimulants have a different geographic spread than fentanyl, and those deaths are also on the rise.
"Some of this may be due to the nature of the drug epidemic in different places, some of it may also be due to how much we are providing medication-assisted treatment, and engaging in other policies to try to address this problem," Ruhm says.
The social safety net also plays a role, says Winograd. In Missouri, "we just have fewer resources to help people in need," she says.
"We have a lack of housing, incarceration rates are increasing — these are all connected and making the most vulnerable people in our society at highest risk of overdose deaths."
Missouri was among five states that showed increased overdose numbers and had not expanded Medicaid, Winograd notes. Medicaid expansion means more people have coverage for addiction treatment, and research shows it's making a difference.
Ohio was a bright spot on the 2018 map, showing a 22% decrease in 2018, although in raw numbers, it still had 4,000 reported deaths.
"It is still a nightmare. And the danger in media over-portraying this is actually quite substantial," says Shawn Ryan, an addiction doctor in Ohio and past-president of the Ohio Society of Addiction Medicine. "If we look at just that decrease nationally — which is not that big — we're missing the point. In order to get back to baseline, we have a very long way to go."
In the CDC's preliminary national numbers, 67,744 people are reported to have died from drug overdoses in 2018. Even though that's several thousand less than died from drug overdoses in 2017, it's still many, many more people than died of AIDS in the worst years of the crisis.
The decline should not be a signal to slow down efforts — or funding — to combat the epidemic, Ryan says.
He cites the proposed CARE Act, a legislative effort led by Senator Elizabeth Warren, D-Mass., and Representative Elijah E. Cummings, D-Md., which would allocate $100 billion over 10 years for addiction and recovery services. The CARE Act is modeled on the Ryan White Act, put in place to combat the AIDS epidemic.
"That's actually much more in line with what's needed," says Ryan.
$100 billion would dwarf past federal funds for the epidemic. Grants from the State Targeted Response to the Opioid Crisis program, authorized by the 21st Century Cures Act, totaled $1 billion. In 2019, State Opioid Response federal grants are set to total $1.4 billion.
"If you look at the dollars spent to date, the fact that we've had the impact we've had is actually because of people being invested and working very hard for not that many dollars," says Ryan.
Boticelli agrees that the only way to ensure the national trend continues is to adequately fund it. "We can't look at a 5% reduction and say our work is done. I think it basically shows us that we have to redouble our efforts," he says. "How are we going to ensure that states have the resources that they need to continue to focus energy on this epidemic?"
In a statement Wednesday, Health and Human Services Secretary Alex Azar celebrated the decline and indicated that federal funding won't be going away. "By no means have we declared victory against the epidemic or addiction in general. This crisis developed over two decades and it will not be solved overnight," Azar wrote.
Rachel Winograd says for her, the increase in deaths in Missouri is an indication that there's much more to do.
"I am very proud of what Missouri has done. I don't think we should have done anything differently," she says. "And I do think that we've been even more aggressive than many of the states that saw decreases, in terms of our focus on evidence-based solutions.
"It's not that we did the wrong thing — it's that we didn't do enough of the right thing," she adds. "And we need more sustainable funding to do that."
Carmel Wroth contributed reporting to this story.