For months, public health experts have been monitoring a trend equal parts promising and perplexing: a steep decline in deaths associated with fentanyl, the opioid that for years has driven America’s overdose crisis.

The decrease has been dramatic in Buncombe County, which by many metrics has been ravaged even more severely by fentanyl than North Carolina’s other most populous counties. Fentanyl-positive deaths — those in which the drug appeared in a toxicology report, regardless of whether it was the primary cause of death — declined by more than 40 percent between 2023 and 2024, according to the North Carolina Office of the Chief Medical Examiner. The state has estimated a similar plunge in deaths from all illicit opioid overdoses in Buncombe.

Some of the data remain in flux; overdose deaths take months of investigation to confirm. But the most reliable indicators — fentanyl-positive deaths, suspected overdoses, and statistics on emergency department visits — tell the same story.

“All signs do point toward a decrease,” said Mary Beth Cox, a substance use epidemiologist for the North Carolina Division of Public Health.

2024 data is provisional and subject to change. Chart: Jack Evans | Asheville Watchdog. Source: North Carolina Department of Health and Human ServicesCreated with Datawrapper

Epidemiologists and behavioral scientists have pointed to some large-scale trends, from drug-market forces to societal shifts, that could be contributors. And efforts to combat the opioid crisis have often been hyperlocal, from grassroots harm-reduction collectives and independent clinics to North Carolina’s decision to delegate much of the spending of opioid-settlement funds to the counties. The resources available to people who use drugs, and the approaches taken by local law enforcement authorities and health departments, can vary wildly from one community to the next.

In Buncombe, experts point to a longstanding culture of recovery, and to the uncommon degree to which local government institutions have embraced harm-reduction programs that have been proven to be far more effective than punitive approaches. They also noted ways in which broader trends seem to be playing out locally.

But many are taking a cautious approach to the gains suggested by the data. Buncombe still has some of the worst opioid-overdose indicators in the state, and death rates are still far higher, here and elsewhere, than they were when the federal government declared an overdose crisis in 2017.

“It’s not like everything’s great,” said Shuchin Shukla, a physician with a focus on addiction services who’s been consulting with Buncombe County on its drug efforts since 2023. “We’re still in this terrible crisis.”

A devastating toll

Fentanyl has taken a horrific toll on Buncombe County. Since 2015, more than 900 people have died with the drug in their systems, according to an Asheville Watchdog review of medical examiner reports. It’s likely that a large majority of them died from overdose.

The devastation cut along and across demographic lines: A majority of those who died were between 25 and 44 years old, but some were teenagers, others septuagenarians. Many worked the manual labor and service industry jobs that undergird Asheville’s tourism-driven economy — construction, landscaping, restaurants. Also among them were students in high school, college, graduate and law school; a radio broadcaster; a geotechnical engineer; a dance instructor; a doula; a jeweler; a developer of subdivisions; a Border Patrol agent.

State reports show how fentanyl, which supercharged the opioid crisis that began with prescription medications before moving to heroin, rocked the county. From 2011 through 2016, a total of 32 people in Buncombe died of illicit-opioid overdoses, according to the North Carolina Department of Health and Human Services (NCDHHS). In 2017 alone, as fentanyl began taking over the drug supply, 72 died. The county’s overdose rates have since ranked among the highest in the state.

Like many places across the country, Buncombe saw a climb in fentanyl-death indicators through the late 2010s, then a surge in the wake of the COVID-19 pandemic. And then it seemingly hit a cliff. Eighty-two fentanyl-positive deaths were recorded in Buncombe last year, the fewest in a year since 2018. Emergency-department visits for suspected overdose fell by a third between 2023 and 2024. If the trend holds, this year could mark the fewest ED visits for overdose since the state started publishing that data in 2016.

Theories for main causes of decline abound

Some theories have to do with the drug itself — the way it moves, the way it’s sold, how it shows up in the supply. 

For politicians and government officials, popular explanations include increased law enforcement and border security efforts. In November, with more data emerging showing year-over-year drops in drug deaths, then-Drug Enforcement Administration head Anne Milgram credited the agency’s targeting of the Sinaloa and Jalisco cartels. President Donald Trump’s administration has oriented its restrictive border policies in part around stemming the flow of fentanyl.

But data complicates those explanations, said Adams Sibley, a behavioral scientist and postdoctoral fellow at the University of North Carolina’s Opioid Data Lab. Declines in overdose began in some states as early as 2021, well before key DEA actions against the cartels. And on the whole, he said, street prices for fentanyl seem to be holding steady or dropping — not spiking, as they would if the supply were greatly diminished.

A better explanation might have to do with what hasn’t changed. As the opioid crisis worsened, the shift from pain medications to heroin to fentanyl, each drug more potent than the last, dramatically increased the overdose risk. But fentanyl has saturated the market for years now, and although powerful analogs such as the synthetic opioid carfentanil have appeared in the drug supply, none has knocked fentanyl off its perch.

“People who use opioids for longer periods of time, years or decades, there hasn’t been a recent market spike where suddenly people are unexpectedly taking an opioid that’s beyond their tolerance,” Sibley said. “You can almost think of it like the market’s stabilizing.”

Andy Halberg, an Asheville physician who works in medication-assisted treatment, or MAT — which involves using drugs such as buprenorphine or methadone to address opioid use disorder — said he was surprised to learn of the dramatic decline in mortality. But he did surmise that the adaptation to fentanyl’s strength among drug users in Buncombe could be a key factor.

“People aren’t using heroin and oxycontin, not because they don’t want it,” he said, but because they can’t get it. “Those that didn’t die now are tolerant to fentanyl, and the usage isn’t really increasing.”

That theory is tied to an overall shrinkage in the population of people who use opioids, Sibley said. Drug use among adolescents is down across the board, from cigarettes to fentanyl. More people are entering treatment, or simply halting use as they get older. And, of course, an enormous number of people who use drugs have died over the past decade.

State reports show that deaths involving fentanyl toxicity alone are relatively uncommon; the drug usually appears alongside others, particularly stimulants such as methamphetamine and cocaine. Halberg said he rarely treats people who use opioids and nothing else. Most locals who use meth, he said, have come to realize that their supply is tainted with fentanyl — it’s making them dopesick, dependent on opioids to stave off withdrawal, and they’re having to decide whether to enter treatment or use both drugs intentionally.

“I speak to a lot of people in the jail that come in and they’re like, ‘Johnna, I just use meth,’” said Johnna Bock, who works as a peer-support navigator for Sunrise Community for Recovery and Wellness, a nonprofit recovery organization, and coordinates the Buncombe County Detention Facility’s MAT program. “And I believe them when they say that, that’s what they think they’re doing. But they will almost clear out the (drug-screening) panel.”

Though no new opioid has usurped fentanyl, one drug has emerged as a common adulterant. Xylazine is a powerful animal tranquilizer perhaps best known for the horrific wounds it causes on those who use it. Counterintuitively, its presence may also be contributing to the survival of people who use drugs. It’s being increasingly used to cut fentanyl, which has the effect of reducing potency, Shukla said.

“It’s not so much that xylazine’s a good thing,” Shukla said. “It’s just that fentanyl’s so bad that putting anything in there, pretty much, is safer than more fentanyl.”

Some observers have also speculated that xylazine causes fentanyl to last longer at lower potencies — that it gives fentanyl “legs.” But experts said it’s unlikely that most drug users are intentionally going for this effect. Instead, they’re hearing that most people dislike the effects of xylazine. Sibley said those who have encountered it report being knocked unconscious, waking up hours later disoriented, sometimes already in withdrawal.

In the face of a drug that’s at the least unpleasant, and at the worst causes horrible lesions and puts its users in dangerous situations, more people may be looking toward treatment and away from fentanyl altogether. Everyone who spoke to The Watchdog about xylazine described it as creating a climate of fear.

“It’s been 10 or 15 years since the halcyon days of heroin. Nobody’s getting a product they like anymore,” Sibley said. “People aren’t only dissatisfied, but they’re scared.”

Behavioral changes at play, experts say

Along with drug-market trends and demographic shifts are an array of factors that Sibley and his colleagues broadly describe as behavioral changes — among people who use drugs, but also among other community members and institutions.

Some of these are happening on a large scale. The Centers for Disease Control and Prevention, for example, has been tracking for several years a widespread shift away from injection toward smoking as a preferred method of drug use. Though smoking still presents some overdose risk, it’s lower than injection. That shift is apparent on the ground in Buncombe, local experts said. Bock said the harm-reduction program that the county health department runs in partnership with Sunrise now gives out more safe-smoking materials than it does clean syringes.

Also in play is the widespread adoption of naloxone, the overdose-reversal drug often sold under the brand name Narcan. After years of grassroots efforts and buy-in by state governments, Sibley said, many communities are reaching naloxone saturation, meaning the drug is on-hand anytime someone overdoses.

But there are still stark differences from community to community when it comes to harm-reduction and treatment options, and it’s here, experts said, that Buncombe County is an outlier in a positive sense. 

Asheville has a rich reputation as a recovery community, Halberg said, a feature that draws many people who use drugs. It has a high density of opioid treatment centers, such as Halberg’s Mayrx clinic, and of community harm reduction organizations, such as Sunrise, where Bock works.

It also has an unusually high level of harm-reduction investment from its public health and safety institutions. In 2022, paramedics in Buncombe began administering buprenorphine in the field; some 400 to 500 people have started on MAT this way, Shukla said. The county health department offers naloxone distribution and syringe exchange programs, which allow it to more easily connect clients to other county services, such as testing for HIV and hepatitis, or help getting signed up for Medicaid or food stamps.

“I think there’s real correlations between these services, not just in symbolic and cultural ways, but actual lives saved,” Shukla said.

In 2018, Quentin Miller was elected Buncombe County sheriff. A central argument of his campaign had been that the county couldn’t arrest its way out of the drug crisis. The county later reported that, of all people who died of overdoses in Buncombe between 2016 and 2019, more than half had spent time in the Buncombe County Detention Facility. Of those who had, nearly two-thirds had spent less than a day in jail during their last booking, and about the same number died within a year of release. 

In 2019, the jail expanded its drug-treatment program, which allows people to start MAT while in jail or continue their existing treatment, measures that remain rare in jails nationwide. In the program’s first two years, even as overdoses climbed countywide, they fell by 20 percent in Buncombe among people who had been in jail in the previous five years. Between last October and this March, more than 500 people participated in the program, and nearly half left jail with MAT medication.

“I’ve come to this conclusion: You can’t get high safely anymore,” said Bock, who is in recovery and takes Suboxone, the medication used in the jail’s MAT program. “I think people have started to understand that. … There are many pathways to recovery, and I think we are now stepping from the purely abstinence-based, 12-step programs into a better area of harm reduction.”

Experts wary of impact of Helene, reductions in funding

For all the resources available to people who use drugs in Asheville, Shukla said, it’s also a hard place to live. High housing costs and low-wage jobs create financial strain even in the best of times; both categories have gotten worse since Tropical Storm Helene, which destroyed homes and unsettled the job market. An NCDHHS report released earlier this year found that overdose was the leading cause of death among the homeless population.

It will take time for researchers to understand how Helene has affected drug use, but Sibley said he wouldn’t be surprised to find increases in overdoses over time.

“Fentanyl and other opioids are called drugs of despair for a reason,” Sibley said. “They’re often used to cope with life’s stressors, and there’s very few stressors that reach the level of having your home destroyed or your livelihood destroyed by a natural disaster.”

Experts are also closely watching for how changes in federal funding and policy under the Trump administration affect the resources available for people who use drugs and people who study them. Sibley noted that much research on drug interventions is supported by federal agencies and could suffer from the administration’s austerity measures. 

Local health departments across the country are also slashing harm reduction programs as they lose funding, Sibley said. And Health and Human Services Secretary Robert F. Kennedy Jr.’s plans to downsize the Substance Abuse and Mental Health Services Administration have triggered widespread concerns about the future of public health efforts meant to combat the overdose crisis.

If Congress slashes Medicaid, it could mark a dismaying setback in the war against overdose, experts said. State data show that Medicaid recipients are among the populations most likely to be hospitalized for overdose. Many of the most vulnerable people being helped by MAT programs are on Medicaid, Halberg said, and Bock said nearly everyone she works with through the jail program benefited from Medicaid expansion.

“Hope is a tough sell lately,” Shukla said. “With all the federal cuts, I think everyone’s a little wary.”

It’s clear that many of these interventions work, Shukla said, which makes their fragility so frustrating.

“It’s totally about political will,” he said. “It’s not a moonshot.”

Asheville Watchdog investigative reporter Sally Kestin contributed to this report.

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Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Jack Evans is an investigative reporter who previously worked at the Tampa Bay Times. You can reach him via email at jevans@avlwatchdog.org. The Watchdog’s local reporting during this crisis is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.

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