COLUMBUS, Ohio – For the first time in a decade, the number of deaths from fentanyl and similar synthetic opioids is declining. Individuals in the struggling Hilltop neighborhood attribute this positive change to the widespread availability of naloxone, a drug that reverses overdoses.

James “Sleaze” Morgan reports that naloxone has revived him from overdoses as many as 20 times over the past few years.

This lifesaving nasal spray is readily available in more than 10 local Hilltop “trap” houses where people gather to use fentanyl. Local authorities distribute naloxone for free, ensuring that supplies are plentiful at the location where Sleaze smokes fentanyl and acts as security in exchange for drugs.

On a recent occasion, a user heated fentanyl powder, inhaled the fumes through a straw, and quickly lost consciousness. Sleaze reacted by grabbing several naloxone canisters. After administering three doses in the man’s nostrils, he revived him.

“It’s become second nature for me,” says Sleaze, whose nickname is inked above his left eyebrow. “I used three canisters, and he woke up.”

Research indicates that the easy access to naloxone is a significant reason for the notable decrease in synthetic opioid overdose deaths in the past year. Between July 2024 and the previous year, overdose deaths fell by 22% nationwide and by 34% in Ohio, as reported by the U.S. Centers for Disease Control and Prevention. In total, around 17,500 people lost their lives less than the prior year.

This decline aligns with the U.S. Food and Drug Administration’s decision in March 2023 to make naloxone available without a prescription. Various brands can be purchased at pharmacies and online, with prices ranging from $30 to $45 per kit. Current programs in Ohio and other states distribute this medication at no cost. The Columbus Police Department highlights naloxone as a key reason for the drop in 911 overdose calls.

Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy, states that a federal initiative aimed at distributing naloxone and other addiction treatments throughout communities is contributing to the ongoing decline in overdose deaths. He also notes that legal actions against fentanyl suppliers and chemical manufacturers have significantly disrupted the drug supply chain, leading to less potent fentanyl on the streets.

However, the number of deaths remains alarmingly high. According to Reuters, illicit fentanyl – produced from Chinese-sourced chemical compounds smuggled into the United States and Mexico – remains affordable and abundant, costing just $10 per dose in Columbus.

Journalists researching the intricate global supply chain of this drug traveled to Ohio. The state was one of the first hit hard by fentanyl-related deaths – though no specific reasons have been established – and is also among the first to see a decline in fatalities. Yet, the experiences of Sleaze and other users in Columbus illustrate the ongoing challenge of overcoming fentanyl’s dominance in America, even with a significant antidote available.

READ MORE from Fentanyl express: Behind America’s opioid crisis

• Part 1: With $3,600 and Wi-Fi, we bought everything needed to make fentanyl
• Part 2: How fentanyl traffickers are exploiting a U.S. trade law to kill Americans
• Part 3: Trump camp says China is ‘attacking’ U.S. with fentanyl. They aim to fight back
• Part 4: The shadowy ‘brokers’ helping Mexico’s cartels smuggle fentanyl chemicals from China

This year, it is estimated that between 50,000 and 60,000 Americans will die from synthetic opioid overdoses, primarily due to fentanyl and similar drugs. This represents about a sixfold increase since 2015, the year before the fentanyl crisis began. Since that time, the U.S. is nearing 450,000 deaths from synthetic opioids.

Scott Sanders, executive director of the Hope Resource Center, a support organization for Sleaze and others in Columbus’s Hilltop region, distributes around 1,000 naloxone kits each month, ensuring users have access to critical life-saving medication.

Two canisters of nasal spray are proving life-saving, but according to Sanders, the number of people struggling with substance abuse on Hilltop’s streets is on the rise.

This year, visits to Hope’s drop-in center have surged by approximately one-third, reaching around 18,300 in the 12 months leading to November 2024, compared to about 13,400 in the previous year.

“This deeply worries me,” Sanders states. “While officials celebrate the decline in fatalities and think everything is under control, we are busier than ever.”

Aside from naloxone, researchers point to two other factors that may be contributing to the decrease in overdose deaths. One is that illegal drug dealers are increasingly mixing “tranq”—a type of veterinary tranquilizer—into the fentanyl they sell. The reason for this practice is unclear, but tranq is generally less lethal than fentanyl and creates a longer-lasting high, which might help delay withdrawal symptoms and reduce cravings for another dose. Consequently, if users take fentanyl less frequently, they have fewer opportunities to overdose. Some researchers are beginning to think that tranq might be as significant in reducing fatalities as naloxone itself.

Other experts are investigating whether the reduction in new “susceptible” users might also explain the trend. The overwhelming number of overdose deaths over the last few years, totaling approximately 280,000 since 2021, could have significantly reduced the number of potential fentanyl users, inevitably leading to fewer overdoses.

During a November visit from Reuters to Ohio, naloxone appeared to be the focal point of many conversations. Users in the area commonly refer to this overdose-reversal medication as Narcan, named after the first brand to offer it in a nasal spray form.

Sleaze is one of ten individuals from Ohio who shared with Reuters that they have been revived multiple times using naloxone. While their personal accounts couldn’t be verified, Sanders from the Hope center noted he is aware of several people who have needed revival more than once.

Those who have been saved by naloxone, including Sleaze, also disclose the grim aftermath of its use. It triggers severe withdrawal symptoms from fentanyl, a substance that is 50 times more potent than heroin, resulting in an intense craving for another dose almost immediately.

Supporting naloxone

Ohio has been at the forefront of the fentanyl crisis since the drug emerged on the streets of nearby Dayton in 2017. In the first ten months of this year, state and local authorities distributed nearly 320,000 two-dose naloxone kits. This figure represents an increase of 20,000 kits from the total for 2023 and 110,000 more than the previous year’s total. According to CDC data, synthetic overdose deaths in Ohio fell by roughly one-third to 2,676 in the 12 months ending in July, marking the lowest number since 2016.

In Columbus, Sanders encourages patrons at the Hope center to take as many naloxone kits as they desire. On a cold, rainy day in mid-November, Ryan Hall popped into Sanders’ office to say hello. Hall, who claims he has 13 children with “six different mothers,” was there to celebrate his 41st birthday. He has experienced numerous relapses and gone in and out of addiction treatment in recent years, having been revived by naloxone multiple times, as noted by Sanders.

Hall insists he is sober, but Sanders remains skeptical. Having overcome his own crack addiction in 2017, Sanders offers his support, suggesting Hall call him when he feels ready to enter treatment again. (On December 9, Sanders took Hall to a rehab facility.) A significant part of Sanders’ role involves facilitating access to treatment and sober living accommodations for those in need.

Moments later, a 40-year-old named Sleaze walks into Sanders’ office and takes a seat.

“I love getting high,” he admits.

However, he’s not a fan of being revived with Narcan. An overdose from fentanyl leads to death through respiratory failure. Naloxone works by displacing fentanyl from the brain’s opioid receptors and preventing new fentanyl molecules from attaching.

The effect is almost instantaneous: the person begins to breathe again and regains consciousness. Yet, for those battling opioid addiction, the reality is harsh: the cravings return. Police report that individuals revived from overdoses often react violently, thrashing their limbs, while others experience uncontrollable vomiting.

Sleaze expresses that after receiving naloxone, he feels extreme discomfort and usually darts away in fear. He mentions having been Narcan-ed just a few weeks earlier.

His first encounter with naloxone occurred in 2022, which also marked the first time he tried fentanyl. He had just been released from prison after serving a seven-year sentence for stealing televisions from Walmart. He admits to continuing his opioid use even while incarcerated, a habit he picked up in his early adulthood.

Yet, he had always avoided fentanyl: he lost too many friends to its deadly grip. Struggling with homelessness, he was living in his girlfriend’s car while his mother was sentenced to prison for cocaine distribution.

“My entire world just came crashing down,” he confesses. That fateful day, someone handed Sleaze a small bag that previously held fentanyl powder. He injected the remaining residue and lost consciousness instantly. “I didn’t even have time to pull the needle from my arm.”

His girlfriend revived him using naloxone spray. The withdrawal symptoms soon followed with overwhelming intensity, a sensation he had never endured before.

“I was in so much pain,” he reflects.

His former girlfriend and mother were unavailable for comment at the time. His mother is serving a minimum sentence of nine years at the Dayton Correctional Institution for drug offenses.

Just five minutes after his exchange with Reuters, Sleaze steps outside.

In a narrow passage near the Hope center, a man known as Sleaze keeps watch behind him. After being released from prison this past summer, he removed his ankle monitor and stopped checking in with his probation officer. He adjusts his knit cap low on his forehead and uses a dose of powder.

About fifty yards away, a cyclist on a red bike observes him. Sleaze gives him a quick glance, noting that the man is not a police officer.

Two weeks later, Columbus police would apprehend Sleaze for violating his felony probation.

Is fentanyl changing?

According to Scott Oulton, the head of forensic sciences at the U.S. Drug Enforcement Administration, tests conducted on seized fentanyl powder and pills since late summer 2023 indicate a steady decrease in purity levels.

In the past two fiscal years, the DEA has analyzed around 9,200 samples nationwide. The average purity of fentanyl powder fell from 19.5% in 2023 to 15.2% in 2024, while the average fentanyl concentration in each tablet dropped from 2.3 milligrams to 2 milligrams. Oulton notes that this reduction in purity aligns closely with a decrease in synthetic opioid-related deaths.

However, some scientists familiar with the DEA’s findings express doubts that the results represent what is accessible on the streets. Their independent tests reveal that the drugs available to users still contain high levels of fentanyl.

Alex J. Krotulski, who oversees the toxicology and chemistry lab at the Center for Forensic Science Research & Education in Horsham, Pennsylvania, conducts analysis for police and other clients. He states that the purity of fentanyl and similar substances he has been measuring has remained around 10% for the past three years. Nabarun Dasgupta, a senior scientist at the University of North Carolina’s Injury Prevention Research Center, reports similar findings, revealing no decline in fentanyl strength.

Yet, Krotulski and Dasgupta observe another noteworthy development.

They have noted a rise in a significant type of adulterant found mixed in with fentanyl: veterinary tranquilizers, often referred to as “tranq,” which are utilized to sedate dogs, horses, and other animals. This category includes the widely known tranq xylazine and a newer long-lasting tranquilizer called medetomidine, which can be used on both animals and people. Krotulski indicates that, during the third quarter of this year, medetomidine became more prevalent than xylazine in samples from Philadelphia.

Health officials were alarmed at the emergence of xylazine in fentanyl supplies beginning in 2021 in cities like Philadelphia. Users reported severe necrotic wounds that damages skin and underlying tissue, a side effect of the veterinary drug, which can lead to severe complications including amputation if left untreated.

Recently, some health researchers see a potential benefit in the presence of these dangerous tranquilizers. They suggest that these substances may help reduce the occurrences of opioid overdoses.

Fentanyl is highly addictive, leading users to seek more doses throughout the day compared to heroin or other opioids. The high is transient, often lasting just one or two hours for experienced users, which causes cravings for another hit. Tranq drugs like xylazine and medetomidine provide longer-lasting effects and can delay the onset of opioid withdrawal, meaning users may require fewer hits and thus take fewer risks with their lives.

Additionally, xylazine and medetomidine do not lead to respiratory failure — the common cause of death from fentanyl overdoses — and are significantly less addictive than opioids. Including these tranquilizers in street fentanyl may help lessen withdrawal symptoms as the opioid effect diminishes. Some experts now believe that these substances could contribute to the recent decline in overdose fatalities.

New York City, much like Ohio and Philadelphia, has been severely affected by fentanyl. In June, medetomidine was detected in the local drug market for the first time.

Sam Rivera, who leads OnPoint NYC, a facility that supports individuals struggling with substance use and vulnerability, notes that opioid users have traditionally devised methods to stave off withdrawal symptoms. One common strategy, referred to as “speedballing,” involves mixing a stimulant, such as methamphetamine or cocaine, with opioids to prolong the high and delay the urge for more drugs.

For instance, a user known as Sleaze reports that he prefers to inject meth, followed by cocaine, after using fentanyl.

Dasgupta from the University of North Carolina states that while the exact relationship between xylazine and overdose reduction is unclear, longer intervals between drug use could potentially lower the risk of fatal overdoses.

However, not everyone agrees that tranquilizers like xylazine are influencing the decrease in overdose deaths.

Dr. Bonnie Milas, an intensive care anesthesiologist at the University of Pennsylvania, administers a drug similar to medetomidine alongside fentanyl for surgery on heart and lung patients. She suggests that those street combinations are unlikely to save lives, as illicit drugs often have uncontrolled dosages. In fact, these combinations could be more perilous than fentanyl alone.

She highlights a warning issued by the Philadelphia health department on December 10 regarding the fentanyl and medetomidine mixture, indicating it can lead some users to experience severe withdrawal symptoms that necessitate emergency treatment.

“I’m familiar with this from my clinical experience,” Milas explains. “On a personal level, I understand the reality of witnessing an overdose.”

Milas tragically lost her two sons to fentanyl overdoses. In two instances, she managed to save her younger son from overdosing by administering naloxone, but she was not present for the final incident.

Following these losses, she has become a strong advocate for making naloxone readily available and ensuring it is included in every household’s first-aid supplies, asserting it is the most effective method to keep individuals alive until they are prepared for rehabilitation.

The ‘susceptibles’

Charles Fain Lehman, a specialist in policing and public health at the Manhattan Institute, offers a different perspective on the decline in overdose fatalities, attributing it to the “depletion of susceptibles.”

Lehman references surveys indicating that young Americans are

High school seniors are increasingly steering clear of hard drugs, with their narcotics use now just a quarter of what it was in the 2000s. According to Lehman, the significant rise in synthetic opioid overdose deaths recently suggests that the number of individuals at risk has significantly diminished.

Lehman points out that only a limited number of people use narcotics, indicating that there is “a fixed population of people who are at risk for overdose death.” He notes that it’s grim but true: “If you die young, you can’t die later.” As many susceptible individuals have passed away in recent years, he believes the number of overdose deaths in the U.S. is starting to decrease.

The Hilltop area of Columbus is still heavily affected by fentanyl and has many individuals at risk. Women who are struggling with addiction often resort to selling sex at most corners along Sullivant Avenue, which is the neighborhood’s main thoroughfare. Additionally, homeless individuals and drug users can be found in wooded patches near railroad tracks, in derelict homes, and doorways.

Many people who visit the Hope Center attribute their addiction to family members who abused drugs, according to Sanders. Their stories frequently follow a similar pattern: starting with prescription painkillers, moving on to heroin, and ultimately ending with fentanyl.

Angel Mccallister enters the office clad in a black sweatshirt and torn black stockings. Her auburn hair cascades over her shoulder. She has not yet smoked fentanyl that day, leading to her feeling anxious and sick. Although it’s lunchtime, food isn’t her priority.

Now 32, Angel has struggled with addiction for two decades. Her mother was a user of prescription medications like oxycodone, and by the time Angel turned 12, she found herself addicted to illicit pills and powdered heroin. One day while babysitting for a couple she knew, Angel found herself in withdrawal and sought a fix. The wife agreed to help and injected her with heroin.

This moment marked her first experience with intravenous opioids, which she found far superior to snorting them. Everything changed for her.

“It was like my boyfriend, you know? It was always close, always available when I needed it,” she reflects.

Eleven years ago, Angel became a mother. After fentanyl started appearing in her community a few years later, she switched from heroin to injecting fentanyl. Nowadays, she smokes the drug.

Her son now lives with Angel’s grandmother, while Angel’s mother continues to battle addiction. An aunt has died due to a fentanyl overdose. Attempts to reach Angel’s mother and grandmother were unsuccessful.

To support her addiction, Angel often engages in sex work several times a week. She confides that she has been assaulted more times than she can count.

Overwhelmed with emotion, she turns away and conceals her face with her hair, tears streaming down her cheeks. Sanders gently places a hand on Angel’s shoulder in comfort.

Taking a deep breath, she clears her hair from her face. Having been revived with Narcan countless times, she estimates that she once survived a suicide attempt through overdose.

How to save a life

Naloxone is a nasal spray medication available over the counter that can quickly reverse the effects of overdoses caused by fentanyl, heroin, and other opioids.

Medical professionals recommend that everyone, especially those with opioid prescriptions at home or those living with a substance user, keep naloxone in their first aid kits or bags. An opioid crisis can affect anyone, including small children who may accidentally ingest drugs.

Naloxone is marketed under brand names like Narcan and RiVive and can be purchased online or at major pharmacies for $30 to $45 per kit. Each kit typically contains two nasal spray applicators, and sometimes more than one dose is necessary.

Numerous health departments and community organizations distribute these kits without any questions asked. A simple web search for “free naloxone” yields hundreds of resources.

Milas, an intensive care anesthesiologist at the University of Pennsylvania, administers fentanyl alongside other medications to treat critical patients. She has personally lost two sons to accidental fentanyl overdoses. Milas advocates for the American Society of Anesthesiologists’ REVIVEme.com program, which provides a tutorial video and guidance on naloxone usage during an overdose situation.

Milas frequently shares her experiences with support groups for people who have lost loved ones to fentanyl. “I assure them not to feel guilty or responsible,” she shares. “They did their best, but in the end, the outcome was beyond their control. Know that you did everything you could, and find comfort in that.”

READ MORE from Fentanyl express: Behind America’s opioid crisis

• Part 1: With $3,600 and Wi-Fi, we acquired everything needed to manufacture fentanyl
• Part 2: Examining how fentanyl traffickers exploit a U.S. trade law to harm Americans
• Part 3: The Trump campaign claims China is ‘attacking’ the U.S. with fentanyl and aims to counteract this
• Part 4: The shadowy ‘middlemen’ aiding Mexican cartels in smuggling fentanyl precursors from China