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The 2024 presidential election arrives at a moment of profound pessimism about the US addiction and overdose crisis. Overdose deaths, which were already surging before the COVID-19 pandemic, have reached new and alarming heights, claiming more than 100鈥�000 lives in the 12 months before September 2023.¹ The overdose crisis is substantially driven by the proliferation of illicitly manufactured fentanyl in the street drug supply, increasingly in combination with cocaine and methamphetamine.

In US politics, the overdose crisis has been both a unifying challenge and a source of major ideological division. A broad bipartisan consensus has emerged over the last decade supporting ongoing congressional appropriations, including the State Opioid Response grants. These appropriations have invested in the capacity of state and local government to respond with naloxone distribution and provision of medications for opioid use disorder. This bipartisan consensus has a basis in a simple reality鈥攖he overdose crisis affects all communities and elected officials have experienced loss in their own families. Notably, Donald Trump won a strong margin of victory in 2016 in counties that were hit the hardest by the overdose crisis.² Different than the crack epidemic of the 1980s鈥攚hich was heavily concentrated among Black, urban communities鈥攍awmakers of both parties have expressed more willingness to conceive of the opioid crisis as one that warrants a public health, rather than strictly a law enforcement, response. The public health framing reflects an optimistic vision that, with enough focus on prevention, treatment, and harm reduction, it is possible to save lives and restore communities that have been hit hard.

In 2024, this optimistic, bipartisan consensus supporting public health programs has not entirely eroded, but risks being overshadowed by other polarizing issues. Under the Biden administration, drug policy has become closely intertwined with a migration crisis at the southern border. In the Republican primary, all leading candidates criticized the Biden administration for a perceived lack of border security that has contributed to an influx of illicitly manufactured fentanyl from Mexico and other source countries. Current legislation in Congress declares fentanyl a 鈥渨eapon of mass destruction,鈥� increases criminal penalties for selling drugs that cause fatal overdose, and expands law enforcement operations across borders.³ Although resisting some of the more extreme measures, the Biden administration has expanded its diplomatic and law enforcement activity related to drug trafficking. Meanwhile, in public opinion polls, Republicans identify opioids as the number-one threat to public health in the US, whereas Democrats rate gun violence as a more serious threat.⁴

The divisive politics around fentanyl have also complicated attempts led by Democratic-leaning cities and states to decriminalize drugs. Following the example of Portugal, voters in Oregon approved a measure in 2020 that made personal possession of all drugs a civil penalty rather than a criminal offense. The Oregon law also expanded funding for drug treatment, crisis services, and harm-reduction programs. District attorneys in cities such as San Francisco, Baltimore, and Philadelphia have meanwhile reduced their prosecution of simple drug possession cases. However, these efforts have been met with considerable backlash, with imagery in the media showing downtown areas overtaken by public drug use, homelessness, and crime. In March 2024, the Oregon legislature passed a bill recriminalizing drug possession, which was signed into law by Governor Kotek. The new law will permit drug prosecution, but will still provide pathways that encourage jurisdictions to divert people from the criminal legal system.⁵

Overdose prevention sites (OPSs), where people can use previously obtained drugs under medical supervision, are another public health model that is being closely watched in 2024 and beyond. In New York City, OnPoint was established in 2022 as the first OPS to operate with the permission of local authorities. In its first year, OnPoint received 48鈥�533 visits and reversed 636 overdoses.⁶ OPSs have been approved in Rhode Island and is under discussion in other jurisdictions. However, the politics of OPSs remain contentious. For example, in California, legislation to expand OPSs was blocked by Governor Gavin Newsom in 2022.

The political viability of innovative harm-reduction models will be tested by the 2024 election, not only at the national level, but also through the outcome of state and local initiatives. OPSs in particular have been able to move forward due to the legal discretion of the US Department of Justice under the Biden administration. Under a future Trump administration, OPS operators risk federal prosecution under 鈥渃rack house鈥� statutes. Treatment and harm-reduction programs similarly face an uncertain future. Under both the Trump and Biden administrations, federal funds were expanded to support the operation of syringe services programs (though not the purchase of syringes and other drug use supplies) and both administrations took steps to loosen some federal regulations related to opioid use disorder treatment. However, advocates are pushing for bolder steps, including the deregulation of methadone beyond the highly regulated clinics where it is now dispensed and the elimination of a federal ban on purchasing syringes. These policy actions are more likely under a second Biden administration, which has thus far walked a careful line.

A fundamental reality that shapes the politics of drug policy going into the 2024 election is that voters and elected officials need to be convinced that the issue is 鈥渨innable鈥� and that public health tools are equal to the challenge. After an unrelenting wave of despair from overdose, it has become difficult to perceive the areas in which policy has been successful. One of the key reasons is that the potency and unpredictability of the illicit drug supply have been increasing more rapidly than the availability of the effective interventions to reduce overdose. Use of medications for opioid use disorder has increased in recent years, although it remains far from adequate, with only about one-fifth of all people with opioid use disorder receiving them.⁷ Broadened access to naloxone has saved thousands of lives, but likewise is unavailable to many people who need it the most.⁸ Expanded Medicaid under the Affordable Care Act has improved the affordability of addiction-related health care, yet Medicaid expansion has not reached states such as Texas and Florida.

At the same time, the public is losing patience with models that seem too lenient on people who use drugs. Oregon provides an important cautionary tale. Although the news media has tended to focus on the woes of public drug use and heightened crime in downtown Portland, the deep problem remains that Oregon (similar to many states) is struggling to provide basic social and health services for its residents. The fundamental challenges of service delivery are not politically popular talking points, but they are among the most daunting challenges to the field. These include efforts to engage and sustain care for people who are unhoused, expanded delivery of crisis response services, and addiction care in jails and prisons. The problem facing reform-minded policymakers is that achieving these gains takes time and often requires leaning into politically contentious issues.

Taken together, the opportunity space for progressive drug policy may seem especially narrow heading into the 2024 election. However, overdose deaths are not intrinsically a partisan issue and affect all Americans, and it still remains possible to harness optimism around public health approaches to the overdose crisis. Experience over the past decade has shown that it is possible to find bipartisan consensus on drug policy, especially related to drug treatment and naloxone distribution, even as big questions in overdose policy continue to be complicated by broader societal tensions around law enforcement, migration, and the social safety net. In an election year, these tensions will only increase, yet the hope is that pragmatic success from programs that save lives will ultimately increase the case for government-supported public health programs. At the same time, advocates and policymakers need to be vocal about highlighting successful models and making the case for resources to sustain programs that work. The public will demand these programs from elected officials when they perceive that they are a basic service that help their own families and improves their communities.

Corresponding Author: Brendan Saloner, PhD, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 344, Baltimore, MD 21205 (bsaloner@jhu.edu).

Published Online: April 22, 2024. doi:10.1001/jama.2024.4997

Conflict of Interest Disclosures: Dr Saloner reported receiving personal fees from Susman Godfrey outside the submitted work and acknowledges funding support from the Bloomberg American Health Initiative and the Greenwall Faculty Scholars program.