Just 14 years old when an uncle introduced him to OxyContin, Brandon Powell was sleeping in an alley in Baltimore’s Little Italy by age 30 and had turned to more powerful drugs. He supported a fentanyl habit by selling stolen diapers and Monster Energy drinks.

By then, the drugs had stopped giving him a high, or even any relief from debilitating withdrawal. The substances dealers were putting into their supply were so weak it felt “literally like shooting water,” he said.

This was in late 2023, as the United States was starting to see a major shift in its drug overdose crisis. The number of people dying had finally begun to fall, and the sharp decline has been especially dramatic in Baltimore.

For more than a half-decade, overdose deaths had claimed about 1,000 lives a year in the city, earning it the tragic distinction of being home to the worst overdose crisis in American history. But since 2023, the number of fatal overdoses has fallen by nearly half in the city and across the state, according to recently released data by the Maryland Department of Health. The sudden shift in what seemed an intractable problem has unearthed hope, as well as a host of questions.

Most of all: Why?

Research suggests the tide has turned, in large part, due to what Powell had observed on the streets — potent fentanyl, which has been a major driver of overdose deaths, seems to be fading from the drug supply.

The overdose crisis does not appear to be disappearing, but evolving, experts said.

Mixes of other chemicals — often less immediately lethal than fentanyl, but dangerous in other ways — have grown increasingly common. Drug dealers have been experimenting with risky additives to compensate for weak fentanyl, Powell said, which means more dangerous side effects for people who use drugs.

Authorities traced emerging threats like the powerful animal sedative medetomidine last year to multiple mass overdoses in Baltimore’s Penn North neighborhood that left dozens of people hospitalized. New data from law enforcement and a drug testing company also indicates that methamphetamine use — far harder to treat than opioid addiction — is on the rise.

Powell suffered from side effects a nurse said probably came from a veterinary tranquilizer called xylazine that has been added to fentanyl. He developed gaping wounds on his legs and hands, he said, which attracted maggots and revealed bone.

Once, Powell overdosed after using a free sample known as a “tester” given out by dealers to gauge the potency of a new batch of drugs. He immediately felt heavy and limp, and knew something was wrong.

Later, he learned his face had turned blue. A friend gave him four doses of naloxone, a medication that quickly reverses overdoses of opioids. When that didn’t seem to work, a bystander poured ice water on him.

That finally shocked him awake.

Emerging threats

Tracking the ever-changing drug supply is left up to scientists like Eric Dawson, vice president of clinical affairs of drug testing laboratory Millennium Health.

Dawson examines urine samples collected from doctors’ offices and treatment clinics across the country. His team then analyzes the data and writes reports that shed light on the state of the overdose crisis.

What he saw in Maryland’s samples, he said, was impressive — at least on one front.

The data showed a decrease of nearly 60% in samples testing positive for fentanyl over the past two years. In the samples that tested positive, the concentration of fentanyl fell, indicating the patients who had taken the drug were using less of it — whether knowingly or not.

“This very clearly tells me fatal overdoses should be falling in Maryland,” Dawson said.

But a troubling trend also emerged.

Illegal stimulant use without fentanyl is on the rise, Dawson said. While cocaine still dominates in Maryland, methamphetamine is gaining ground. Between 2023 and 2025, the percentage of patients testing positive for methamphetamine more than doubled, from about 2% to 5%, according to the laboratory’s data.

Law enforcement officials have also been seizing more methamphetamine. In Maryland and the surrounding region, authorities seized more than 400 kilograms last year, up more than 600% since 2020, according to the Washington/Baltimore High Intensity Drug Trafficking Area.

Doctors, researchers and community outreach groups say they have not seen widespread evidence of rising methamphetamine use in Baltimore. Rather, the drug is more common in rural Maryland and among certain groups, such as the LGBTQIA+ community.

Even so, Dawson warned that methamphetamine addiction can lead to psychosis, heart attacks and strokes.

“We move from a substance use crisis that’s marked by fatal overdose to something that’s much more chronic in nature,” he said.

Searching for answers

As overdose deaths declined, University of Maryland criminology professor Peter Reuter and Ph.D. student Kasey Vangelov turned to an unusual source for answers: Reddit.

Members of the online forum were posting about a fentanyl “drought” in late 2023, when fatalities began to drop. Reuter and Vangelov teamed up with other researchers and explored evidence of a major disruption to the fentanyl supply, publishing their findings in Science last month.

They theorized that the Chinese government intensified restrictions on the export of chemical compounds needed to manufacture fentanyl.

The drop in fentanyl purity coincided with “increased drug enforcement cooperation” between the U.S. and China following a November 2023 meeting between the countries’ two presidents, they wrote.

But factors other than foreign policy have also made a difference, said Jeff Beeson, the executive director of the Washington/Baltimore High Intensity Drug Trafficking Area. Beeson credited local and regional efforts to dismantle drug trafficking organizations, which he said create at least a temporary gap in the drug supply and lead to overdose reductions.

Research, however, shows that people may seek drugs from riskier sources when this happens, and overdoses may rise. Studies found that after drug seizures in San Francisco and Indianapolis, for example, there were more overdoses in the surrounding areas.

According to government officials, doctors and researchers, multiple factors influence overdose deaths, including:

• Greater access to life-saving medication and treatment: The number of people receiving naloxone has increased steadily over the years, with a historic high of 440,000 doses distributed statewide in 2025, according to state data.
• Staying safe: People who use drugs are taking safety measures such as snorting instead of injecting, and warning others about bad drug batches, research from the Johns Hopkins Bloomberg School of Public Health shows.
• Fewer reasons for people to turn to drugs: A spike in overdose deaths coincided with the COVID-19 pandemic and rising homicide rates, both of which are now abating, said Dr. Joshua Sharfstein, former Baltimore health commissioner.
• Those most at risk have already died: The grimmest theory of all is that many of those most likely to experience a fatal overdose have already died, leaving few behind.

Dr. Michael Fingerhood tries to reach people who are battling drug addiction and living on the margins.

In a makeshift clinic in an East Baltimore church, some come to Fingerhood’s appointments smelling of the fires they built to keep warm while homeless. Sometimes they sit far away, embarrassed by how long it’s been since they last showered. Fingerhood tries to get to know them without judgment.

“What brings you joy?” he often asks.

Over the years, several of his patients have relapsed and died of overdoses. He always wonders what he could have done differently. “It still hurts every time,” he said.

But last year, for the first time in recent memory, not one of his primary care patients died of an overdose.

It is a relief, but there’s much work ahead, said the longtime Johns Hopkins Medicine addiction medicine specialist who works with the Behavioral Health Leadership Institute, which provides easy-to-access drug treatment across the city.

“Any number of people dying from overdose should be cause for reflection on how we should do better to prevent it,” he said.

Finding opportunity

The numbers back up what Fingerhood is seeing.

A Banner analysis showed Baltimore City’s overdose death rate fell more than any other large county in the United States between 2023 and 2024, the most recent full year of data from the Centers for Disease Control and Prevention.

However, Baltimore continued to lead the country in deadly overdoses, its rate overtaking the next highest for a high-population area by a significant margin.

The fatal overdose rate for Black men over the age of 55 — who have been dying at disproportionately high rates in Baltimore for decades — fell the most, but still outpaced that of any other group in the city in 2024, according to the data.

Last year, Dr. Michelle Taylor moved from her hometown of Memphis to take over as Baltimore’s health commissioner. What attracted her, in part, was the unique opportunity to “address overdose response in a meaningful way,” she said.

Today, officials say Baltimore is in a better position to tackle this crisis than ever.

Since 2024, the city has won $580 million from a lawsuit against opioid manufacturers and distributors. Last year, the city began using the new money to fund community organizations that serve people who use drugs and to significantly expand the health department in hopes of capitalizing on recent progress.

To stay nimble in the face of a changing drug supply, the health department is implementing an emergency plan to respond to mass overdoses and hiring community health workers to work with seniors struggling with addiction, Taylor said.

Confronting new challenges

Despite the progress, experts warned, there are looming threats.

While President Donald Trump’s administration has said it intends to expand substance use treatment, cuts to Medicaid and other federal funds could devastate groups on the frontlines, including health care providers and harm reduction groups who try to keep people who use drugs safe.

And the drug supply could continue to be unstable and unpredictable.

On a recent Thursday afternoon, Powell drove to Penn North, where dealers sell drugs on crumbling stoops, in trash-filled alleyways and in open view of police cruisers.

But this time, Powell wasn’t in search of a high. He was looking for people to help.

In October 2023, he was given a second chance after being arrested for stealing. Instead of staying in jail, he was connected to a counselor and other resources through a program.

Now, more than two years sober, Powell revisits the sites he haunted in the depths of his addiction with piles of donated clothing and numbers for treatment programs. He sees men stumbling on swollen legs, as he once did.

For them he has a message: “They’ll put anything in dope.”

“Get out of there before it’s too late.”

Banner data journalist Allan James Vestal contributed to this story.