Overdose Deaths Are Falling Everywhere in America Except Arizona — and Its Own Settlement Money Is Stuck in Court

In April, Margarita Macías found her son in a Phoenix park, not breathing. Marck had been using fentanyl, and this time the powder did what powder does — it hit harder and faster than the counterfeit pills he’d used before, with no way to know the dose until it was already in him. She’d been telling him for months, in the way mothers say things they need their kids to actually hear: “If you want help, I can help you, son.” This time she had naloxone. He survived, and weeks later he was in a residential recovery program, talking about learning to weld.

Arizona is the exception nobody in the country’s good-news cycle is talking about.

Arizona’s overdose deaths rose 18.1% over the same 12 months the rest of the country’s fell 13.8%, and the state is sitting on more than a billion settlement dollars earmarked to fix exactly this — tied up in a fight over whether the governor and legislature can spend it on prisons instead.

Two things are true in Arizona at once. People are surviving overdoses who would have died five years ago, because naloxone is easier to get than it’s ever been. And the state’s overall death count keeps climbing anyway, because the drug supply, the climate, and the money meant to fix both have moved the wrong way at the same time.

Nationally, that survival story is playing out more often than it has in a decade. The CDC’s latest annual count, released May 13, put 2025’s overdose deaths at 69,973 — down 13.8% from 81,313 the year before, the third straight year of decline. A Commonwealth Fund report published September 3 called the drop-off “unprecedented” — Brown University epidemiologist Brandon Marshall told STAT it’s rare to see mortality “come down so dramatically, so quickly.” CDC’s rolling dashboard, last refreshed September 9, keeps confirming it.

The Rest of the Country Turned a Corner. Arizona Ran Into a Wall.

Run the numbers side by side and the divergence isn’t subtle. For the same 12 months CDC used for its national 13.8% decline, Arizona’s provisional count rose from 2,531 deaths to 2,988, an 18.1% increase — the worst of any state except New Mexico, up 21.7%, and Colorado, up 10.6%. Nearly every other state fell, some by more than a quarter.

By summer, the gap had become the headline instead of a footnote. Arizona’s death rate hit an all-time high of 43.5 per 100,000 people — roughly double the national rate, and the state overtook West Virginia’s rate for the first time since the prescription-pill epidemic of the late 1990s and 2000s. A peer-reviewed analysis by researchers Manuel Cano and David Zhu, published in April in the International Journal of Drug Policy, documented the mechanism: Arizona’s rolling 12-month death count began climbing again in late 2024 and early 2025, exactly when the national curve was still falling — a real rebound, not noise, though it’s a single state-level study and the provisional counts it relies on get revised as records finalize.

The most recent partial-year data backs that up. Comparing January–August 2025 to the same months in 2024, Arizona’s count rose from 1,689 to 2,034 deaths — up 20%, with the sharpest increases where a market shock hits hardest: deaths among 18-to-24-year-olds rose 35%, deaths among Hispanic Arizonans rose 43%. There’s a sliver of better news — Filter’s July analysis found Arizona’s rate of increase had slowed to 8.2% for the 12 months ending in February, down from 18% two months earlier, even as New Mexico’s kept accelerating to 27%. Arizona isn’t in free fall. It’s just the one state that hasn’t started climbing out of the hole everyone else is climbing out of.

Powder, Heat, and a Housing Crisis: Why the Same Fentanyl Wave Hit Arizona Differently

None of this happened for one reason, and anyone who tells you it did is selling something. What changed first, according to the people treating it, is the physical form of the drug. Arizona’s illicit fentanyl market — once dominated by counterfeit pressed pills stamped to look like oxycodone — shifted to powder roughly two years ago, and powder is a worse bet: a pill at least has a rough, consistent dose. “With the powder, you would overdose instantly if you weren’t careful,” Francisco Cabrera, a Tucson man who has used fentanyl for more than a decade, told the New York Times. ASU drug-market researcher Raminta Daniulaityte put it more bluntly: “People adapt to market changes. But initially when things change, it can have devastating consequences.” Even DEA regional leadership couldn’t explain it — associate chief Brian Clark said cartel suppliers hadn’t meaningfully changed, so the shift looks like market adaptation, not strategy.

What changed first, according to the people treating it, is the physical form of the drug.

Layer heat on top of an unpredictable supply and you get Arizona’s second, harder-to-fix problem — and it isn’t metaphorical. Pima County Health Department program manager Mark Person told a Tucson TV station the pattern is now an annual clock you can set: “Every single year for the last five years at least, as soon as June, July, and August hit, the number of our overdose deaths go up by about, you know, 7 to 8%”. In Maricopa County, drug deaths rose 60% on days over 110°F and nearly doubled at 104°F and above, and 80–90% of the people dying from fentanyl are also using methamphetamine — a combination the county’s chief medical examiner, Dr. Jeffrey Johnston, said produces no clean line between the two causes: “There really isn’t a bright line.” Meth constricts blood vessels and raises body temperature at the exact moment the Sonoran Desert is doing the same thing.

A third factor sits under both: where people are when it happens. Phoenix cleared its largest homeless encampment, “the Zone,” in 2022, scattering roughly 10,000 people nightly across parks and riverbeds, away from the dealer and the person who’d notice if they didn’t wake up. Arlene Mahoney, executive director of the Southwest Recovery Alliance, calls this the real driver: “It’s about destabilization. People are losing the places and people they rely on.” Dr. Matt Evans, medical director of addiction medicine at the Phoenix nonprofit Circle the City, ties displacement directly to relapse risk: “People are suffering from displacement, so they’re having to go from one place to another” — an unfamiliar supply, dosed by a stranger instead of someone they trust. Sonoran Prevention Works CEO Scott Greenwood summed up surviving all three factors at once more bluntly: Phoenix in summer “is like a blast furnace.”

Twenty-five years ago, the geography of American overdose deaths pointed the other direction. Purdue Pharma’s sales reps built OxyContin’s launch around the coalfields of West Virginia and eastern Kentucky in the late 1990s, and by the 2000s Appalachia carried the country’s highest death rate for a generation — the region that gave the epidemic its shorthand, “hillbilly heroin.” That epidemic migrated as the supply did: from diverted pills, to heroin after the 2010 OxyContin reformulation cut off easy pill access, to fentanyl, which needed no poppy fields and no prescription pad at all. Arizona surpassing West Virginia’s old peak isn’t a new story — it’s the same drug supply finding its next weak point: brutal heat, a large displaced population, a border two hours from where the fentanyl gets pressed.

Arizona Is Sitting on Over a Billion Dollars for Exactly This — and Spent 2026 Fighting About Whether to Use It

Here’s the part that should make you angrier than the weather or the drug supply, because it’s the one thing state officials actually control. Arizona is owed more than $1.1 billion in opioid settlement funds over 18 years from the national litigation against manufacturers, distributors, and pharmacies — money that, unlike the tobacco settlements of the 1990s, comes with legal strings requiring it be spent on opioid abatement, not general government operations. In 2024, the legislature and Governor Katie Hobbs diverted $115 million of it into the general fund to help close a budget deficit, routing it to the Department of Corrections, Rehabilitation and Reentry instead of treatment providers. Attorney General Kris Mayes sued, arguing the diversion was flatly illegal under the settlement terms; a judge initially froze the transfer, then let the state proceed anyway.

Then, this May, an Arizona Auditor General report handed Mayes exactly the evidence she’d been asking for: the prison system spent $50.9 million of that settlement money in 2024 “but lacks records supporting they were spent for approved purposes.” Auditor General Lindsay Perry’s office warned the gap raises real risk Arizona could be found out of compliance with the settlement — and could ultimately forfeit some of the more than $1 billion still owed to it in future years. Mayes said the audit “proves what she charged two years ago” and began weighing a new lawsuit — while Hobbs and the legislature were reportedly planning to sweep another $40 million, pushing the total diverted toward $150 million. As of this writing, no new suit has been filed and no court has ordered the money returned; whether Arizona has to make the fund whole is still open, not resolved — the kind of implementation gap that swallows treatment dollars while it drags on.

It’s worth naming what that $150 million wasn’t doing while lawyers argued. The Arizona Public Health Association’s June report, authored by Allan Williams, credited the national decline substantially to exactly what Arizona’s diverted money should have expanded: wider naloxone and fentanyl-test-strip access, faster treatment intake, and settlement dollars flowing into programs with measurable outcomes elsewhere in the country. Not every Arizona county sat on its hands — Maricopa County committed $4.3 million this year to 17 local organizations and put $1.5 million into medication treatment inside county jails, enrolling more than 400 people. But county effort can’t offset a state fight over whether the largest pool of dedicated money is even available to spend.

But county effort can’t offset a state fight over whether the largest pool of dedicated money is even available to spend.

What Actually Moves the Number Is Not a Mystery, and It’s Not Complicated

This should be the most reassuring part of this article, and it’s usually buried at the bottom instead of stated plainly: nobody is confused about what reduces overdose deaths. Naloxone — the medication, sold under the brand name Narcan among others, that reverses an opioid overdose in real time — is the single biggest lever anyone has pulled, and Arizona made it legal to get without a prescription a decade ago. Methadone and buprenorphine, the medications that treat opioid use disorder directly rather than just reversing one overdose, cut overdose death risk by roughly 60% and 40% respectively, according to Dr. Evans — and Arizona’s settlement money is legally required to expand access to exactly those. None of that is theoretical. It’s the same toolkit researchers credit with the 13.8% national drop, deployed unevenly.

If you’re using, or expect to keep using for a while, this isn’t an abstraction — it’s the difference between whether you’re here in October. Powdered fentanyl has no visible tell for its dose, so testing before you use isn’t overcautious, it’s just accurate information. Fentanyl test strips have been legal statewide since 2021, and both they and naloxone are free, mailed to any Arizona address with no ID and no judgment, through Sonoran Prevention Works. Arizona’s Good Samaritan law means neither you nor whoever calls 911 for you can be charged for possession in the moment that matters — none of which requires the legislature and the attorney general to finish fighting first.

What the Numbers Actually Argue For

Dr. Evans doesn’t frame this as a mystery either — he frames it as a choice. “You cannot double down on the same policies that have caused the situation,” he said, pushing back on enforcement-first approaches to a market problem. He’s right, and the evidence sits in a Maricopa County courtroom, in the form of a billion-dollar fund the state keeps arguing over instead of spending. The rest of the country isn’t beating this epidemic with a secret — it’s beating it with naloxone in more bags, methadone in more clinics, and settlement money that actually reached them. Arizona has the same fund. It just hasn’t decided, two years into the fight, that treatment gets to win the argument over prisons.

Marck Martinez is welding now, or trying to be, because his mother had naloxone in April and the paramedics got there in time. Multiply that by the thousands of Arizonans whose mothers didn’t have it, or weren’t there, or whose supply that week was stronger than the batch before — and the gap between a national success story and a state still setting death records stops being about weather or geography. It’s about which of those outcomes the state actually paid for.