Substance use is a serious concern in Alabama, driven primarily by opioids. Fentanyl has transformed the crisis in recent years, and the state’s history of heavy opioid prescribing set the stage. Key figures:

• 31.5 drug overdose deaths per 100,000 people in 2022, more than double the 2014 rate, according to the Alabama Department of Mental Health.
• 6,307 overdose deaths from 2015 through 2021.
• 835 fentanyl-related deaths in 2022, up from just 121 in 2018.
• 61% of overdose deaths involved synthetic opioids such as fentanyl.
• 143.8 opioid prescriptions per 100 people at the 2012 peak, the highest rate in the nation and nearly double the U.S. rate of 81.3.
• Overdose deaths have recently declined, a reversal after years of steep increases.

The crisis has deep roots. Alabama once led the nation in opioid prescribing, and fentanyl later drove deaths sharply higher as it entered the illegal drug supply, from 193 in 2019 to 428 in 2020 and 830 in 2021. A recent decline offers a hopeful turn, though the crisis remains severe.

Alabama is one of ten states that has not expanded Medicaid, so many low-income adults fall into a coverage gap where they earn too much for traditional Medicaid but too little for marketplace subsidies. The Alabama Department of Mental Health coordinates the state’s public substance-use services. Of the 125 facilities listed below, 83 accept Medicaid.