Indigenous people face persistent disparities in access to harm reduction services in the United States. In response, Native American health workers and their allies have worked tirelessly to bring resources like naloxone, medications for opioid use disorder and drug checking to tribal communities.
A new study published in the journal Drug and Alcohol Dependence, which analyzed medical examiner records in rural Minnesota, provides encouraging evidence that these efforts are paying off. From 2022 to 2024, the region’s fatal overdose rate declined by over 40 percent, with Indigenous communities experiencing an especially strong 47 percent decline. White and Black communities saw declines of 35 percent and 21 percent, respectively.
One severe racial disparity, which at one point saw overdose mortality more than 17 times higher among Indigenous residents than among the region’s white residents, has thus decreased. However, Indigenous mortality remained six times higher at the end of 2024.
The study analyzes 967 overdose death records from 36 Minnesota counties from 2022 through 2024, as reported by the Midwest Medical Examiner’s Office. While limited in geographic scope, it provides a much more up-to-date picture of the overdose crisis than national data.
“We are well into 2025 and still only have provision counts for 2023 nationally,” lead author Dr. Bradley Ray, of RTI International, told Filter. “Many jurisdictions don’t yet have the data to determine if there are reductions.”
In addition to examining overdose rates, Ray and his team also analyzed which substances were most often listed in postmortem toxicology reports. Despite growing national concern about xylazine, the reports contained little evidence of xylazine in the local drug supply. Among substances found to be present—which doesn’t, of course, demonstrate that a particular drug caused a death—fentanyl and methamphetamine dominated, with a few cases involving cocaine or prescription opioids, and nearly no reports of heroin.
“Based on the data we have examined, xylazine is not all that prevalent up here,” Ray explained. “It may be that rural America does not have xylazine at the levels that people in the urban areas are seeing.”
The study emphasizes that more research is needed to understand whether northern Minnesota’s decline in fatal overdose rates, persistent racial disparities and striking absence of xylazine are representative of rural and tribal communities more broadly. However, these local findings offer important clues as the federal data slowly trickle in.
“Time will tell as those data become more available,” Ray said. “We found a decrease in overdose deaths among American Indian and Alaskan Native people in 2024 that may be reflected in future national data or alternatively could be unique to this region.”
Sue Purchase, founder of Harm Reduction Sisters, which serves many of the communities included in the study, credits these improvements to recent legislative changes that protect harm reduction work.
In 2023, Minnesota was the first state to completely repeal its drug “paraphernalia” laws, removing many of the legal restrictions against syringe service programs and drug checking initiatives.
“[These laws] really paved the way for tribal nations to support harm reduction in a much more comprehensive way,” Purchase told Filter, adding that opioid settlement dollars also contributed to the feasibility of implementing these newly legalized programs.
However, she also cautioned that the medical examiner data likely underestimate the true disparity, due to how race is recorded.
“If you’re native and don’t have tribal ID on you, they count you as white,” Purchase explained.
Regardless of the accuracy of Ray’s figures, the disparity in overdose deaths between white and Indigenous populations remains alarmingly wide, both in Minnesota and throughout the country. To close the gap, Purchase emphasized doubling down on what is known to be effective.
“It’s all the things we always talk about,” she said. “Stigma kills. We have a general lack of housing. We have entrenched racist attitudes and closed minds.”
But this is easier said than done, as she acknowledged. And with federal policy changes negatively transforming the legal landscape for harm reduction—as well as housing, medical insurance and other resources critical to people who use drugs—Purchase worries that the current advances could quickly unravel.
“In many ways, we’ve been on a more positive trajectory,” she explained. “But due to, you know, the authoritarian crackdown, we’re going to lose any progress that we have made.”
With harm reductionists on the defensive nationwide, Purchase emphasized the importance of keeping Minnesota’s relatively progressive state laws intact.
“We really hope to protect those, keep those on the books and prevent further harm,” she said.
