Which Cities and States in the USA Have the Highest Overdose Rates?

Baltimore City, Maryland, and San Francisco County, California, have the highest overdose death rates among large U.S. jurisdictions, both exceeding 40 deaths per 100,000 residents in the latest CDC data. At the state level, West Virginia, Alaska, and Washington, D.C. consistently report the highest age-adjusted overdose death rates. Synthetic opioids, primarily fentanyl, are involved in more than two of every three of these deaths.

This report breaks down the data by jurisdiction and drug type, explains the distinction between “highest rate” and “highest total,” and outlines the factors contributing to these numbers. Readers who are personally affected by substance use, or supporting someone who is, will find relevant resources at the end of this report.

Reviewed by the clinical team at MindSpace Recovery Center, a licensed outpatient addiction and mental health treatment facility in North Hollywood, CA (DHCS License #191591AP). MindSpace has treated patients across Los Angeles for over 20 years; clinical staff includes addiction psychiatrists, licensed therapists, and trauma-informed group facilitators.

How We Gathered This Data

This guide was developed for families seeking to understand the seriousness of a situation, often on behalf of someone they care about. All data presented here is drawn from the CDC’s National Center for Health Statistics and the Substance Abuse and Mental Health Services Administration, and has been reviewed by our clinical director prior to publication. Where findings reflect patterns observed directly in our own intake process, this is noted explicitly.

Most of the figures come from the CDC’s Provisional Drug Overdose Death Counts and Provisional County-Level Drug Overdose Death Counts, specifically, the most current federal source available. National and state figures cover the most recent 12-month reporting period; county and city figures are limited to jurisdictions with populations over 500,000 for statistical reliability.

A few notes:

• Provisional data. CDC figures are revised as investigations close so that recent months may be undercounted. We used the latest revision available.
• Rate over raw count. We prioritize deaths per 100,000, since rate reflects risk while total count reflects overall burden.
• Age-adjusted rates are included for state comparisons to correct for differences in population age structure.
• Drug-type figures come from the same dataset’s cause-of-death categories and can overlap, since many deaths involve multiple substances.

Where reporting windows caused notable variation (e.g., San Francisco County), we noted a range.

Highest Overdose Rates by City and County

Rate (not raw death count) is the appropriate measure of danger, as it accounts for population size. Cities are reported separately from their counties when they are independent of one another. This is why Baltimore City and San Francisco County appear as distinct entries.

Using the most recent 12 months of CDC data available for jurisdictions with populations over 500,000:

Jurisdiction	Overdose Deaths per 100,000
Baltimore City, MD	109.6
Washoe County, NV	71.1
Marion County, IN	70.1
Bronx County, NY	59.9
Pierce County, WA	57.7
Maricopa County, AZ	57
Washington, D.C.	56.4
Davidson County, TN	55.4
Bernalillo County, NM	50.2
San Francisco County, CA	41.5-71.1*

*San Francisco’s reported rate moves depending on the exact reporting window – CDC data gets revised as more deaths are confirmed. Even on the lower end, it’s landed among the top two or three highest-rate large jurisdictions in the country for years running, usually just behind Baltimore.

Baltimore and San Francisco share a common pattern where synthetic opioids are involved in roughly three of every four overdose deaths, and both have substantial populations experiencing homelessness with inconsistent access to treatment. This combination recurs consistently among the highest-rate cities. 

San Francisco’s overdose rate has remained elevated even as its total number of overdose deaths has declined – 2025 marked the lowest annual death total there in five years. These are two distinct measures, and the distinction is addressed below.

Highest Overdose Rates by State

This is the absolute rate of overdoses by state, if you look at total population and overdose deaths, from February 2025 to February 2026. 

Age-adjusted overdose deaths per 100,000 residents, for the 20 states and jurisdictions with the highest reported rates. Hover or click a state on the map, or a row in the list, to see the details together.

21.3 49 No data (not in top 20)

Top 20 ranked

per 100k residents

Figures reflect the dataset provided for this map (top 20 of 51 states/jurisdictions); the remaining states are shown in gray as no data. Population figures are for context only and are not used to calculate the rate.

The state-level figures below use age-adjusted rates, which account for differences in population age across states. This makes it a more appropriate measure for state-to-state comparison.

State / Jurisdiction	Age-Adjusted Rate (per 100,000)
West Virginia	80.9
District of Columbia	64.3
Tennessee	56.0
Louisiana	54.5
Delaware	55.3
New Mexico	50.3
Kentucky	53.2
Alaska	34.3

West Virginia has led the nation by a substantial margin for over a decade. The state was affected earliest and most severely by prescription opioids, then heroin, then fentanyl – the same three waves that defined the national crisis, concentrated most intensely within a single state.

Rate vs. Total Deaths – These Are Different Questions

This is where a lot of coverage is worth explaining:

• Rate (per 100,000 people) indicates how concentrated the danger is in a given location. This is the relevant figure when assessing risk in a specific place.
• Total deaths reflect the number of families losing someone in that state, in absolute terms. This figure is useful for funding decisions and public health planning.

California, Florida, Texas, New York, and Pennsylvania report the highest total overdose deaths nationally. California alone lost close to 21,700 people to overdose in a recent year. Yet none of these states rank near the top by rate – California’s rate falls below the national average once adjusted for population.

A state can therefore have a devastating total death count while remaining, statistically, a lower-risk location than a much smaller state with a higher rate. For assessing personal or family risk, rate is the figure that matters.

Highest Overdose Rates by Drug Type (Per State)

Heroin Overdose Rate by State

Rank	State Name	State	Population	Rate
1	New York City	YC	8,584,629	3.8
2	District of Columbia	DC	693,645	2.7
3	New Mexico	NM	2,125,498	1.8
4	Illinois	IL	12,719,141	1.7
5	Delaware	DE	1,059,952	1.2
6	Wisconsin	WI	5,972,787	1.1
7	Utah	UT	3,538,904	1
8	Massachusetts	MA	7,154,084	0.7
9	Connecticut	CT	3,688,496	0.7
10	New Jersey	NJ	9,548,215	0.7

Cocaine Overdose Rate by State

Deaths per 100,000 residents involving cocaine, for the 10 states and jurisdictions with the highest reported rates. Tap a spoke on the wheel, or a state chip below, to see its full detail.

Figures reflect the dataset provided for this chart (top 10 of 51 states/jurisdictions). Population figures are for context only and are not used to calculate the rate. If you or someone you know is struggling with substance use, the SAMHSA National Helpline (1-800-662-4357) offers free, confidential support 24/7.

Natural and Semi-Synthetic Opioid Overdose Rate by State

Rank	State Name	State	Population	Rate
1	Alaska	AK	737,270	4.5
2	Utah	UT	3,538,904	4.2
3	West Virginia	WV	1,766,147	4
4	Kentucky	KY	4,606,864	3.9
5	Wyoming	WY	588,753	3.9
6	Idaho	ID	2,029,733	3.7
7	Tennessee	TN	7,315,076	3.2
8	Connecticut	CT	3,688,496	3
9	Arizona	AZ	7,623,818	3
10	Delaware	DE	1,059,952	3

Synthetic Opioids (Fentanyl) Overdose Rate by State

Deaths per 100,000 residents involving synthetic opioids, for the 10 states and jurisdictions with the highest reported rates. Drag the line to set a threshold and see how many states meet or exceed it.

0 states have a rate of 0 or higher

035

Figures reflect the dataset provided for this chart (top 10 of 51 states/jurisdictions). Population figures are for context only and are not used to calculate the rate. If you or someone you know is struggling with substance use, the SAMHSA National Helpline (1-800-662-4357) offers free, confidential support 24/7.

Methadone Overdose Rate by State

Rank	State Name	State	Population	Rate
1	New Mexico	NM	2,125,498	4.2
2	Delaware	DE	1,059,952	4.2
3	Maine	ME	1,414,874	3.3
4	New York City	YC	8,584,629	3.2
5	Connecticut	CT	3,688,496	3
6	Maryland	MD	6,265,347	3
7	West Virginia	WV	1,766,147	2.7
8	Rhode Island	RI	1,114,521	2.7
9	Massachusetts	MA	7,154,084	2.2
10	District of Columbia	DC	693,645	2.2

Psychostimulants (Meth etc.) Overdose Rate by State

Rank	State Name	State	Population	Rate
1	New Mexico	NM	2,125,498	27.4
2	Alaska	AK	737,270	24.4
3	Arizona	AZ	7,623,818	22.2
4	Washington	WA	8,001,020	20.1
5	West Virginia	WV	1,766,147	19
6	Colorado	CO	6,012,561	15.1
7	Hawaii	HI	1,432,820	14.4
8	California	CA	39,355,309	12.9
9	Tennessee	TN	7,315,076	11.8
10	Kentucky	KY	4,606,864	11.7

Why These Places Keep Ranking High

A few things explain why the same cities and states show up at the top year after year.

1. Illicitly produced fentanyl contributes to more than 70 percent of overdoses nationally, and to an even greater share in the regions with the highest fatal overdose rates. It is inexpensive, highly potent, and frequently present in drugs where it is not expected, including counterfeit pills, cocaine, and methamphetamine.
2. A growing proportion of fatal overdoses involve two or more substances, particularly opioids combined with stimulants such as methamphetamine and cocaine.
3. Cities with limited treatment infrastructure, high rates of homelessness, or restricted access to harm-reduction resources (naloxone availability, drug-checking services, low-barrier treatment entry points) consistently show higher rates, regardless of the surrounding state’s overall wealth.
4. County-level overdose rates are also influenced by the thoroughness of local medical examiner investigations. Better-resourced systems tend to report higher numbers, as fewer deaths go misclassified.

Explore more of the reasons in our guide to overdose death causes.

Urban versus Rural Overdose Rate

Rural counties in most of the years in the 2000s have had the highest cases of overdose in the US, particularly those in Appalachia. There was a shift in 2016 when urban centers recorded higher cases of overdose than in the past ten years.

The rise in the use of fentanyl is the cause of this shift. In 2018, for example, about 90% of fentanyl-involved deaths took place in locations east of the Mississippi River. Fentanyl, however, had made it into the illegal drug distribution system in the whole country in 2022, including California, Arizona, and New Mexico.

Drug Overdose Demographics Around the US

Men experience overdoses at roughly twice the rate of women, and this ratio has held steady for over a decade.

Among all age groups, adults aged 35 to 44 have the highest overdose mortality rate – more than four times that of individuals aged 15 to 24.

Demographic patterns have shifted since earlier periods in the epidemic, when white and Native American populations recorded some of the highest overdose rates. Beginning around 2011, overdose deaths among Black Americans began to rise sharply; today, in most major cities, overdose rates within the Black population exceed those of other racial and ethnic groups. Contributing factors include inequitable prescription histories, limited access to care in the wake of that earlier wave, and the greater volatility and lethality of the illicit fentanyl supply. The Hispanic overdose death rate remains below the national average overall, though it is notably elevated in certain states, including New Mexico and Colorado.

Final Remark

This data is based on CDC and public health information up to 2026 and is purely informational. It does not replace medical advice. In case of imminent danger of overdose, call 911.

If you’re in LA, MindSpace is a licensed clinic offering mental health and addiction treatment in LA with a specialized focus on addressing both problems at the same time. Outpatient IOP and PHP services are available at our North Hollywood facility and accommodate your life, treating fentanyl, heroin, marijuana, methamphetamine, cocaine addictions, etc. There’s no need for a referral to get started, and insurance verification should take less than a day.

Sources

• Provisional Drug Overdose Death Counts. CDC. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 
• Provisional County-Level Drug Overdose Death Counts. CDC. https://www.cdc.gov/nchs/nvss/vsrr/prov-county-drug-overdose.htm 
• Steep increases in fentanyl-related mortality west of the Mississippi River: synthesizing recent evidence from county and state surveillance. medRxiv. https://doi.org/10.1101/2020.06.15.20131839