Drug overdose deaths are still on the decline in Florida, but toxicologists, drug experts and those who advocate for people who use drugs say they don’t have a concrete answer for why.
According to data released by Florida's Medical Examiners Commission, in the first six months of 2023, overdose deaths decreased by 7% when compared to the same months the previous year. Opioid-related deaths dropped 11%, and deaths caused by fentanyl dropped 10%.
“There's so many hypotheticals one could have about why it's decreasing, and we really don't know why that is,” state toxicologist Dr. Bruce Goldberger said. “We still have a significant problem with overdoses in the state of Florida. But again, it's quite positive that it didn't increase.”
Florida Attorney General Ashley Moody has touted the decrease in deaths as a result of increased law enforcement, increased awareness about fentanyl and naloxone, the life-saving opioid overdose reversal drug.
“Florida has taken a very novel approach, an aggressive approach, and we’re seeing results,” Moody said at a press conference in the Tampa Bay area recently.
Florida lawmakers and Gov. Ron DeSantis have increased the criminalization of opioids in recent years, and the state leads the country in fentanyl seizures, Moody said.
Harm reduction advocates agree the increased stockpile of naloxone and awareness about the polluted drug supply could have helped curb deaths, but national trends in consumption and what’s being added to Florida’s supply could also account for the decrease in fatal overdoses in Florida.
In the first half of 2023, 7,412 people died from a drug overdose, with the vast majority of those deaths including the presence of more than one drug, according to the Drugs Defined in Deceased Persons report.
Fentanyl caused the most deaths – 2,541 – followed by cocaine (1,149) and methamphetamine (995).
The United States overall saw a 3 percent drop in overdose deaths in 2023, according to the U.S. Center for Disease Control.
“Every single death represents a mom, a child, an uncle, a brother, a cousin, a teacher, I could go on and on,” Moody said. “Everyone in Florida has felt the effect of an opioid death or a family member or a friend struggling with opioid addiction.”
Florida follows national drug trends
States across the country have seen a shift in how people are using drugs, which could account for the decrease in deaths, said Claire Zagorski, who researches drugs at the University of Texas at Austin.
“We're seeing less and less injection and more and more smoking, even of opioids,” Zagorski said.“It doesn't take away very much from people's experience, and it makes it a little bit easier to control it. It avoids needles, and it avoids blood borne infection spread.”
When injecting, the effects of the drug enter the bloodstream and get to the brain in a few seconds.A person smokes by inhaling vapors released from a drug heated by indirect heat, like from a lighter, in a glass pipe.
“When people smoke a drug, they're typically titrating themselves (or adjusting the dose) to a desired level,” Goldberger said. “When you inject a drug, there's no way to come back. Inject it, and if you overdose, well, if there’s Narcan nearby you can save someone.” Narcan is a brand name for naloxone.
Still, smoking isn’t entirely safe, Goldberger said. A study published earlier this year by UC San Francisco researchers proposes fentanyl resin brings new risks of overdose.
“Smoking fentanyl has potential health benefits over injecting and may be protective against overdose, but substantial uncertainty exists,” the study says.
Less opioids, more stimulants in Florida
The drug supply in Florida also has changed. Among the drugs found in those who overdosed, ketamine (sometimes called 'Special K'), xylazine ('tranq') and cathinones, also known as bath salts, were present in more people in 2023 than in 2022.
According to the Drugs Defined in Deceased Persons report, the occurrence of cathinones saw a 105 percent increase.Cathinones, which are cheaper, easier to make and comparable to methamphetamine, may be supplanting or adding to the meth market in the southeastern United States, Appalachia and the Rust Belt, Zagorski said.
“For the past few years, we're starting to see – slowly but surely – a little bit less opioid use and a little bit more stimulant use,” she said. “You can overdose from a stimulant. It's more commonly called overamping, but it's not usually fatal the way that opioids are.”
The effects are “very intoxicating” and “very impairing,” Goldberger said, and cathinones are prevalent in the southeast, especially in Florida.“It does have this tendency to cause aberrant behavior that can cause certain death,” he added.
Medical examiners also noted a 39% increase in ketamine, an animal tranquilizer, in dead users.Goldberger attributes the rise in ketamine use to the expanded accessibility in hospitals and medical settings.
The drug was commonly known as a horse tranquilizer and a '90s party drug. Now, ketamine is used for the treatment of depression and is dispensed in hospitals and clinics.
More from USA TODAY:What is ketamine? Here's how it works
The effects also change based on the dosage, Zagorski said.
“It's kind of interesting that it's having this uptick,” she added. “I'm not personally super sure at this point of what its impetus is for being there, if it's meant to kind of supplant or replace something else, or if it's just another addition to the larger roster of the available illicit drugs out there.”
Tranq in Florida
The increase of xylazine present in those who died from drug overdoses does have people worried.
Predominantly seen on the East Coast in places like Philadelphia, xylazine was created to be used in veterinary offices as a sedative. The drug is most commonly added to fentanyl and can cause hours-long blackouts and necrosis of the skin, which can lead to amputation. Its effects can't be reversed by naloxone.
In Florida in the first half of 2023, data shows a 19% increase compared to the same months the prior year. The Jacksonville area saw the most deaths, with xylazine present in 76 out of 278 deaths statewide. “We’re finally seeing it coast to coast,” Zagorski said.
The drug is used to stretch out the effects of opioids, and, combined with fentanyl, it increases the risk of respiratory depression, which can lead to death.
Xylazine test strips have not been decriminalized in Florida, but fentanyl test strips are not considered paraphernalia as of 2023. Nationally, 27 states allow for the possession of all drug checking material.
Goldberger said state medical examiners have not seen an increase in skin wounds or necrosis, xylazine-related signs of drug use.
In fact, Florida medical examiners, who meet every other month, have noted a drop in the presence of xylazine in drug overdose deaths in 2024.Whether it’s being replaced with something else, however, is unknown.
But there are signs: “Folks are already kind of reporting something new in the market that they don't know what it is,” said Tim Santamour, executive director of the Florida Harm Reduction Collective, an organization that advocates for people who use drugs.
“Something else is going on, not in Florida yet, but in other places around the country there are new things coming into the market, and we don't know what they are,” he added.
‘Folks want to be safe’
Since fentanyl test strips were decriminalized in 2023, Santamour said his harm reduction organization has passed out up to 25,000 test strips. “Folks want to be safe,” he said.
But the report doesn’t give him enough information to pinpoint whether it was the test strips that helped curb overdoses, or naloxone, or the shift from injecting to smoking, or law enforcement initiatives or change in the supply.
Santamour believes the data provided to the public, including those trying to save people from dying from accidental overdoses, is incomplete and released months after the information is useful.
"We could be a model in rapid response," he added.
The information in the Drugs Defined in Deceased Persons report doesn’t include data on every drug. Even though the report noted increases in ketamine and cathinones, the report did not include where those overdoses occurred.
The report also does not include sex, race or specific county. It divides the deaths into the state’s 25 medical examiner districts, which can include more than one county. The Jacksonville medical examiner's office, for example, includes not only Duval County but also Nassau and Clay counties.
“We don't know what communities,” Santamour said. “We know we're seeing increased overdoses among Black men over 30 to the 65-year-old range. What's going on there? How is that reflected in these numbers?
“We can take some joy in that, or some pleasure in that we've done something here, but in order to sustain it, we're going to have to understand exactly what it is that went on,” he added. “To do that, we're going to have to involve people who use drugs to ask them what's going on in their communities.”
For information on where to get naloxone, visit www.nextdistro.org/florida. Ana Goñi-Lessan, state watchdog reporter for the USA TODAY Network – Florida, can be reached atagonilessan@gannett.com.
