NEVADA OPIOID CRISIS DEATH TRENDS: AN EXCEPTION THAT PROVES THE LETHAL RULE
A seemingly anomalous continued surge in fatal ODs over a period of widespread decreases could have been predicted – by delay of any effective naloxone campaign and runaway dispensing of street currency for fentanyl
by Clark Miller
Published February 28, 2025
Updated March 6, 2025
The headline captures the trends perplexing experts, who are reduced to mystifying it.
According to a recently released CDC report, our state had the second-largest rate increase in the number of deaths due to drug overdose from June 2023 to June 2024, compared to the previous year.
The number of individuals succumbing to drugs rose from 1,271 to 1,603 — a 26% increase. That number in 2019? Just over 500 people.
Remarkably, though drug overdose is now the leading cause of death of people below the age of 50, most other U.S. states saw slowdowns in their overdose fatalities. In fact, the average was down 14% from June 2023 to June 2024.
What are local direct service providers and observers noticing?
Experts like Ariann Chelli, who works as the clinical director at Desert Hope Treatment Center, chalk this disparity in state and national statistics up to a combination of forces.
“[In Nevada] we have a really difficult time getting people from the ER, when they do experience an overdose, to treatment services,” she said. “Another issue that we have is when [patients] are discharged from the hospital and they are given a prescription for Narcan or Naloxone [both drugs used to reverse opiate overdose], they will not get it filled. Less than 20% [do].”
And ED doc David Hart, for this December 2024 report, adds that,
“When I trained over 10 years ago, it was not that uncommon to see somebody with an opioid overdose in the emergency department,” he said. “But now we’re dealing with it almost on a daily basis. … [At Sunrise Hospital] they see 25% of all of the opioid related visits for the whole state.”
So, suddenly, after 10 years, at the end of 2024, he’s seeing a surge to daily opioid overdoses.
We’ll want to remember and come back to that, it’s important.
And,
Altogether, this bleak landscape was what inspired Hart, Sunrise Hospital emergency medicine physician Suzanne Roozendaal, and local bar manager Mathew “Buck” Buckosh to pilot a program that gets Narcan into the hands of bartenders — who have the potential to intervene in overdoses.
And we’ll want to remember that as well – as an indication of the status and effectiveness of naloxone distribution campaigns in Nevada, compared to other states – that two busy medical professionals would feel compelled out of need to personally take on the provision of naloxone to local establishments.
The proven, gold standard medical cure for high-risk opioid use, buprenorphine (Suboxone) had been a part of Nevada’s strategy to address opioid overdoses at least as early as 2017 with a $5.6 million Substance Abuse and Mental Health Services Administration (SAMHSA) award.
Those programs were expanded beginning 2019 with a $1.68 million grant from the Centers for Medicare and Medicare Services, reported here.
Priorities for the state include helping providers offer medication-assisted treatment, or MAT; establishing an alternative reimbursement rate for those services; and analyzing and distributing best practices from neonatal abstinence syndrome programs. …
One of the goals of the planning grant, Woodard said, is to expand medication-assisted treatment programs in rural Nevada and enhance services in urban areas. The state has already worked toward a more holistic approach in the way it provides addiction recovery services by building out traditional medication-assisted treatment clinics into integrated opioid treatment and recovery centers, or IOTRCs, under a different federal grant program.
But most remarkably and potentially impactful, reported here, early in 2024, Nevada legislators, against advice and concerns of the psychiatric community, joined Idaho in allowing pharmacists to independently dispense buprenorphine to walk-in adults seeking it.
Legislators were apparently favorably swayed in their clinical appraisal of the proposal by testimony from Zach Rosko, a Nevada Pharmacy Alliance board member who also works in Idaho, that, “In a small community where there was not a single provider for Medicaid for opioid use disorder, an independent pharmacy was able to provide services and has now provided care for about 90 patients in their community”.
We’re beginning to see a picture,
and we need to add what we can about the effectiveness of naloxone distribution in Nevada.
In states that engaged in intensive, well-funded, targeted, local level direct distribution campaigns that resulted in the recent drops in opioid overdose fatalities, units distributed were in the hundreds of thousands per year, or more, and efforts included training and in some cases door-to-door outreach.
In my online searches for features of naloxone distribution in Nevada, I found evidence of efforts that were smaller in scope and with little evidence of direct outreach, instead distribution to community organizations and locations were individuals could access units by seeking them.
In a 30 minute Brookings Institution interview with University of Nevada Las Vegas “experts who are directly confronting the issue” there was no mention of naloxone campaigns in Nevada over the discussion of the crisis. They were Dr. Anne Weisman, director of wellbeing and integrative medicine and associate professor of medical education at the Kirk Kerkorian School of Medicine, and Dr. Sara Hunt, executive director of BeHERE Nevada, and associate professor at the Kirk Kerkorian School of Medicine.
In a local newscast interview addressing the crisis and surging opioid deaths at the southern Nevada “ground zero” Las Vegas area, the epidemiologist focused on opioid crisis response was asked about the severity of the crisis as well as harm reduction programs and responded with an explanation of fentanyl testing strips and with no mention of naloxone or distribution efforts for naloxone.
Those results point away from Nevada having developed the effective types of Narcan campaigns common in other states, where opioid OD deaths have declined, and are congruent with news reports highlighted earlier in this post.
Are congruent as well with the noted ER physician’s observation of an OD surge late last year, 2024, after legislative changes allowing pharmacies to simply dispense the substitute opioid buprenorphine (Suboxone) without a signed prescription from any licensed medical provider (LMP). “Bupe”, of course – as the common street currency for fentanyl and enabling fentanyl use in other ways – is established as fueling the persistently worsening crisis.
Effective distribution and layperson use has been particularly challenging in Nevada, a relatively large rural state making outreach more difficult and where in the few population centers unhoused persons in encampments are regularly displaced by police or flooding (described below). And as recently as December 2024, individuals discharged from ERs for opioid-involved overdose were not provided Narcan and training, instead a prescription and were on their own to obtain the naloxone, with fewer than 20% filling it.
Over the past year or so increasingly, illicit stimulant (primarily methamphetamine) users have been responded to for potentially lethal opioid overdoses because fentanyl is an unknown adulterant. Without intensive outreach and education, those users would have had little reason to carry Narcan. From the noted KNPR report –
“We used to have people who were doing stimulant drugs, and it was very rare to have an overdose happen,” said Chelli. “For somebody who did methamphetamines, there would be other consequences, but an overdose would be very rare. [But now] you see somebody who is using methamphetamines, and their overdose rate is also rising because fentanyl is essentially poisoning those substances.”
That they aren’t carrying Narcan is consistent with reports from direct service providers like Jessica Johnson, health education supervisor for the Southern Nevada Health District, reported as recently as October 2024.
One puzzle in Nevada and in other states is that increasingly, overdoses involve a combination of opioids, such as fentanyl, along with stimulants such as methamphetamine. Almost a third of overdoses in Nevada are caused by both being used together, according to a state report based on 2022 data. …
“We get people saying, ‘Oh I don’t need naloxone because I don’t use fentanyl,’ and our team is able to say, ‘Well, our surveillance data actually suggests there might be fentanyl in your methamphetamine’ or whatever it is.”
Subpopulations at risk
From 2019 to 2020 in Nevada overdose deaths more than doubled for individuals identified as Hispanic, largely “young males” and involving street fentanyl. A 2022 report identified continuing barriers to effective provision of naloxone to this population.
“This increase was concerning because it was the highest among any demographic group. We never really saw hospitalizations for drug overdose among Hispanic/Latinx persons increase, which is usually what tips us off to how mortality trends behave,” says Shawn Thomas, Opioid Epidemiologist.
Naloxone is a life-saving drug that can reverse the effects of overdose from opioids, such as illicitly manufactured fentanyls, but evidence of naloxone administration was low among decedents.
That means that effective provision of naloxone where it’s needed was suboptimal, echoed by additional statement –
“Part of OD2A’s role as been to provide the community with data about increases in drug overdoses. We have been trying to inform the community so that we can convene community leaders to expand harm reduction strategies among younger Hispanic/Latinx persons to increase naloxone access, to prevent future drug overdose deaths,” says Elyse Monroy, OD2A program manager.
[emphasis added]
In this Nevada Independent report, lack of outreach and education were also identified as barriers to effective naloxone distribution.
Additionally exacerbating consequences of underdeveloped naloxone campaigns in Nevada, the number of unhoused persons in metro areas has been rising over past years, as have deaths, and the “data so far indicate drug and alcohol abuse was the number one cause” per a January 2023 report.
Reported in June 2024, drug-related deaths among unhoused individuals had been steadily increasing in southern Nevada’s Clark County, home of Las Vegas, and elsewhere in the state.
As a barrier to understanding and addressing the problem and to having available comprehensive data related to high-risk substance use and OD deaths in these populations, there are per the report no national or state guidelines for data collection and organization. Direct observations include that “fentanyl is just running rampant” and that the circumstances of unhoused life make provision of direct services, including Narcan training and dispensing, challenging and ineffective,
In recent years, cities across Nevada, in conjunction with localities across the country, have ramped up enforcement of encampment removals and passed more laws that criminalize homelessness.
Fowle said some research has suggested that could lead to an increase in homelessness deaths.
“We know from talking to people who are experiencing homelessness how encampment sweeps and the criminalization of people experiencing homelessness through infractions and citations and general harassment by police affects somebody’s health,” Fowle said. “Not just the stress and trauma of moving constantly but losing medication they rely on, finding a new place to sleep every day, not being around a social support system that may help prevent an overdose.”
[emphasis added]
Research and reports are clear on that point – unhoused high-risk users forming relatively stable associations and in proximity to known social associates who have and are trained on Narcan use are the ones getting saved, their potentially lethal ODs reversed.
Nevada is certainly not unique in its homeless populations engaging in high-risk opioid and other drug use contributing to opioid overdose deaths and challenges in prevention. But Nevada may be unique in degree of challenges to effective distribution of and effective use of naloxone for reversals among unhoused peers.
In addition to the encampment sweeps aboveground, there are the underground encampments – the system of tunnels under Las Vegas where per this November 2024 report, “an estimated 1,500 homeless people live in an extensive labyrinth of tunnels”.
The described environment is unpredictable due to sweeps and flooding that can take lives, under more favorable conditions functioning like a gated community with restricted access –
Between the five-star hotels Caesars Palace and the Rio lies a wasteland divided by a railroad track. It is a place where homeless people, addicts and drug dealers gather. The contrast to the glitzy Las Vegas right next door could not be greater. As we approach, a man crawls out of a tent under the bridge and limps toward us. He thinks we are crystal meth dealers. When he realizes his mistake, he asks if we could at least help him find the drug somewhere.
On the other side of the empty, sandy area is an entrance to several tunnels. They are flood control tunnels. Since it only rains on a few days a year, they are usually dry. Their network covers hundreds of kilometers, and many are inhabited. About 1,500 people live in this dark world below the casino metropolis, the lights of which never go out.
…
Zack complains about the frequent police raids. «Whenever a crime happens somewhere, the police come here. Just because we have dusty pants.» Sometimes they then clear out all of the tunnels and dispose of everything, he says. «It’s like they just invade your apartment and destroy everything.» …
There are five tunnel entrances near the Rio hotel. Each of them is managed by a different person. No one may enter without their consent. The walls are soot-blackened from the fires on which the residents cook. «Meth – fucking madness» is written on one of the walls. …
His sleeping area is equipped with a car battery. He tells us that he cannot hear rushing water so deep in the tunnel in time to get out, so he has to rely on the guard at the entrance, who also warns the residents with a special whistle when the police arrive. This job is always held by newcomers. On the way out, a rat darts between our feet. George, Captain says, as if introducing us to a roommate. …
According to him, life in the tunnels is archaic, like in the novel «Lord of the Flies.» People see themselves as belonging to a kind of brotherhood or tribe and thus believe themselves to be deceptively safe, he tells us. In reality, however, one is always threatened by violence: «Life down there is as hard as it is in the Navy Seals.»
For Banghart, the move was a relief: «It was like having your own place.» He lived in the dark interior of the labyrinth, the police never came that far, he felt safe. At the Salvation Army, he got free meals, and he stole money for drugs – «even though I wasn’t particularly skilled.» Like most, he had a bicycle, «the tunnel dwellers’ car,» as he calls it. During the day he stayed in the tunnels where it was less hot, and went out only at night. …
What was the worst thing? «The feeling of being lost. I had no watch and no sense of time,» Banghart says. «Sometimes I would wake up somewhere and not know where I was. Everything was unpredictable and random. Suddenly a gang appeared and attacked me, no idea why or who they were.
It seems reasonable and accurate to conclude that population characteristics and living conditions of Nevada’s hot spots for opioid and other drug fatal overdoses are very challenging and not supportive – in addition to any institutional, public health, governmental, or organizational deficits and barriers – of effective access, outreach, training and provision of Narcan kits directly to those who need them, nor for the type of unhoused peer mutual support detection of and use of naloxone for layperson overdose reversals of the type increasingly contributing to reduced OD deaths common in less harsh and unpredictable community settings like those linked to below.
Lacking disconfirming evidence, we are compelled, obligated to draw the inescapable conclusions supported consistently by trends and evidence in other locales – that naloxone campaigns, if effective unlike in Nevada, are dropping opioid overdose deaths by serving as harm reduction against the harms predicted by expert gold standard treatment approaches for the opioid crisis.
In Nevada, those forces combined to provide expected outcomes.
Those other locales include:
