US Has Highest Rate of Overdose Deaths in the World: Commonwealth Fund Report

The report found that harm-reduction policies and practices are fragmented in the United States.

Bottles of prescription painkiller OxyContin made by Purdue Pharma LP sit on a shelf at a local pharmacy in Provo, Utah, on April 25, 2017. George Frey/Reuters

The United States has the highest rate of overdose deaths in the world by a substantial margin, according to a Jan. 9 report by the nonprofit Commonwealth Fund.

It ranked last on a list of 31 countries and one U.S. territory, ordered by overdose death rates from lowest to highest, with 324 deaths per 1 million people in 2022. Puerto Rico was not included in the U.S. total. The U.S. territory had 246 deaths per 1 million that year, ranking just above the United States, in the report.

Scotland had the third-highest overdose mortality rate, with 219 deaths per 1 million in 2022, followed by Canada at 193 deaths, although both countries have seen declines in overdose death rates from 2021 to 2022.

The report noted that 100,000 Americans died by overdose in 2023, according to provisional CDC data.

According to the report, the U.S. approach to reducing overdose deaths is fragmented compared to other countries, citing the varying policies on access to medication and treatment programs across states.

“In the U.S., harm-reduction policies and practices are fragmented—meaning they differ state to state—making it challenging to prevent overdose deaths from a national angle,” it stated.

Some 109 countries have implemented harm-reduction policies as of 2023, but such policies remain limited in the United States, despite their critical role in reducing overdose deaths, the report stated.

The report highlighted that access to naloxone, an opioid-overdose antidote, varies across states in the United States, with some states allowing individuals to administer the medication themselves after getting a prescription, while others permit only medical personnel to administer naloxone. It noted that some individuals who need naloxone may be unable to afford it, indicating the need to ensure the medication’s availability.

The report noted that research suggests that synthetic opioids require higher doses of naloxone to reverse an overdose.

Emerging trends such as polysubstance use—where more than one drug is used—and the rise of new substances have also posed challenges to efforts to reduce overdose deaths in the United States.

The report stated that xylazine, which can be lethal when combined with fentanyl, has become a prevalent cause of overdose deaths in the United States, particularly in southern states.

“In a study of 20 states and Washington D.C., there was an almost fourfold increase in xylazine being found in deaths involving illegally made fentanyl between 2019 and 2022,” it stated.

Syringe services programs remain illegal in several states, despite their role in lowering the risk of overdose deaths, the report found.

The report’s author, Commonwealth Fund research associate Evan D. Gumas, said that such programs could help reduce disease transmission, improve cessation of drug use, reduce injection as the primary route of drug consumption, and improve access to drug treatment services.

“Despite early evidence showing that deaths may have dropped from 2022 to 2023, it is too early to treat these results as a positive development; we must continue to prioritize reducing the harms associated with drug use,” Gumas said. “The U.S. should look to the Portuguese model of emphasizing public health and health care—and other lessons from abroad—to reduce the associated harms of drug use and address the crisis happening all over the United States.”

Comparison of the lethal doses of heroin, carfentanil, and fentanyl. Drug Enforcement Agency

Drug overdose deaths in the United States declined by 3 percent in 2023, from 111,029 deaths in 2022 to 107,543 in 2023, marking the first annual decrease since 2018, according to the Centers for Disease Control and Prevention’s provisional data. However, as of 2023, the number had remained above 100,000 for three years in a row.

The CDC stated in a December 2024 report that 70 percent of U.S. overdose deaths in 2023 were caused by fentanyl, a synthetic opioid up to 100 times more potent than morphine. Just 2 milligrams of fentanyl can be lethal.

Overdoses from fentanyl have become a national crisis as traffickers smuggle the drug mainly over the U.S. southern border with Mexico, killing nearly 75,000 Americans in 2023 alone, according to the CDC.

Darlene McCormick Sanchez contributed to this report.