California’s Overdose Divide: the state’s most affected counties are not always its largest cities

A new Ocean Recovery analysis of CDC and California state data finds the overdose death rate varies significantly across California’s counties [1][4] — and that the fentanyl crisis, which has shown signs of decline in several parts of the state [5][6], is increasingly overlapping with a growing stimulant-related burden [2].

Press-ready report · Prepared for Ocean Recovery, Newport Beach, CA · Data extracted 16 June 2026

(Note: written in American English for US press use. Spokesperson quote is a placeholder for Ocean Recovery to attribute to a named clinician before publication.)

The story in one line

Where you live in California can dramatically change your risk of dying from a drug overdose, with substantial differences between counties across the state [1][4].

Key findings

• California’s drug overdose death rate ranged from 12 per 100,000 people in Imperial County to 90 per 100,000 in Del Norte County in 2023 — a 7.5-fold gap [1][4].
• Several of the highest-burden counties are in rural northern California, with San Francisco also appearing among the higher-rate urban counties [1][4].
• Statewide, approximately 11,378 Californians died of a drug overdose in 2023, at a rate of about 29 per 100,000 — among the highest levels recorded in recent years [2][3].
  
• Fentanyl drove a majority of those deaths. In Los Angeles County, fentanyl’s share of overdose deaths fell from 64% to 52% in a single year, alongside a 22% decline in overall overdose deaths in 2024 [5].
• While fentanyl-related deaths are stabilising or declining in some areas, stimulant-involved overdoses remain a major contributor in California. Naloxone is effective for opioid overdoses but not for stimulant overdoses [2][3].
• About 90% of Californians who needed substance use treatment in 2021 did not receive it — roughly 4.8 million people, based on national survey estimates [7].

1. The divide: a sevenfold gap, and it’s upside down

Drug overdose is often framed as an urban crisis — but California’s county data shows a more uneven geographic pattern.

In 2023, the latest year with available county-level data, reported overdose death rates ranged from 12 per 100,000 in Imperial County to 90 per 100,000 in Del Norte County — a 7.5-fold difference across California’s reported counties [1][3][4]. Data was available for 43 of the state’s 58 counties, with some counties suppressed for confidentiality [1][3].

Among reported counties, several of the highest rates appear in northern California counties, while San Francisco also ranks near the top at 76.4 per 100,000 [1][4].

California’s highest reported county overdose death rates, 2023 (selected counties):

Source: CDC National Center for Health Statistics, county-level drug overdose deaths, 2023 (crude rate per 100,000), via USAFacts. Lowest in the state: Imperial County, 12 per 100,000. Data was available for 43 of California’s 58 counties; the rest were suppressed for confidentiality [1].

Why the rural north? Some researchers point to geographic access to emergency care as a possible contributing factor, although the data here primarily shows a regional pattern rather than confirmed causation. Treatment is thinner on the ground too. State data shows the same rural skew in opioid deaths specifically: small northern counties sit at the top of the rate table, while large urban counties like Los Angeles rank far lower [4].

2. The shape is changing: fentanyl down, stimulants holding

The bigger story underneath the map is what’s killing people, and it’s shifting fast.

Fentanyl built the modern overdose crisis. By late 2022 it was involved in the large majority of California’s opioid deaths [3]. Now its toll is falling. National CDC provisional data show a decline in overdose deaths following the 2023 peak, though estimates vary depending on reporting windows and remain provisional [2]. In Los Angeles, fentanyl-related deaths fell sharply in a single year [5]. Wider naloxone access and changes in the drug supply are among the factors often cited in explaining recent declines, alongside broader shifts in opioid initiation patterns [2][3].

Methamphetamine is a different problem. Stimulant deaths have stayed high while opioid deaths fall, and polysubstance involvement is increasingly common in overdose cases [2][3]. That matters for a practical reason most coverage skips: naloxone reverses an opioid overdose, not a stimulant one [2][3]. The tool that’s bending the fentanyl curve has no effect on the meth half of the crisis, and there’s no equivalent rescue medication for stimulants [2][3].

So the headline decline is real, but partial. The deaths that remain are harder to prevent at the curb and harder to treat in the clinic, because stimulant use disorder has no approved medication the way opioid use disorder does [2][3]. The work moves from the ambulance to the treatment bed.

3. Orange County: the local picture

Orange County tracks the better half of the state trend. Fentanyl-related deaths fell to 407 in 2024, down from 613 the year before — a recent low in the multi-year trend, according to the OC Sheriff-Coroner and the county Health Care Agency [6].

That’s real progress, and worth saying plainly. It’s also not the whole picture. Orange County’s drug and alcohol mortality has seen longer-term changes over time, and when the county looks at every substance involved in an overdose death, alcohol and opioids appear most often [6]. Alcohol rarely makes the overdose headlines, yet across California deaths from excessive alcohol use increased during the early COVID-19 period [3]. The fentanyl number is improving. The underlying demand for treatment — for alcohol, for stimulants, for the people who use several drugs at once — is not going away.

4. The gap that decides the outcome

A falling death rate is good news that comes with a catch: it depends on people reaching care. California isn’t set up for that. About 90% of Californians who needed substance use treatment in 2021 didn’t get it, representing an estimated ~4.8 million people based on survey data [7], and the gap persists despite a large statewide treatment system.

That’s the link between the map and the trend. The counties dying fastest are often those with more limited access to treatment services. The drugs that are now hardest to survive are the ones with the least medication support. Closing the overdose gap is closely tied to treatment access and availability.

Suggested spokesperson quote

“The drop in fentanyl deaths is the first genuinely good news California has had in years, and it shows that treatment and harm reduction work. But a falling average hides a widening gap. The rural north is still losing people at several times higher rates than the safest counties, and the continued role of methamphetamine means we’re treating people where naloxone is not effective. The answer is the same in every county: get people into real treatment, sooner.”

— [Name, clinical title], Ocean Recovery (placeholder — Ocean Recovery to attribute to a named clinician before release)

Methodology

County and state overdose death figures are from the CDC’s National Center for Health Statistics, accessed via USAFacts, for 2023 — the most recent year with available county-level data — expressed as crude deaths per 100,000 residents [1]. Drug-category comparisons (fentanyl’s share of overdose deaths and methamphetamine as a leading contributor among stimulant-related deaths) are from CDC and CDPH for California, 2023 [2][3]; the precise California psychostimulant death rate should be confirmed on the CDPH Overdose Surveillance Dashboard before publication [3]. The 2024 county detail for Los Angeles is from the LA County Department of Public Health [5]. Recent provisional CDC estimates show a decline in overdose deaths following the 2023 peak [2]. Orange County figures are from the OC Sheriff-Coroner Division and the OC Health Care Agency [6]. Treatment-access figures are from SAMHSA via the 2021 National Survey on Drug Use and Health. All data extracted 16 June 2026 [7].

Some figures are based on provisional or survey-based estimates and may be revised as underlying datasets are updated [2][7].

Limitations

Three caveats, stated upfront because they make the analysis more useful, not less:

1. Small counties swing. Del Norte and other small counties with low population bases have small denominators, so a handful of deaths can move their rate sharply year to year. The 90-per-100,000 figure is real but more volatile than a large county’s rate [1].
2. County rates are crude, not age-adjusted. CDC doesn’t publish age-adjusted overdose rates at county level, so the county comparison uses crude rates. State-level drug-category rates are age-adjusted [1][2].
3. “Involved in” overlaps. Many overdose deaths involve more than one drug, so fentanyl and stimulant shares can both rise or fall without summing to 100% [2][3]. Polydrug deaths are counted in more than one category.

Press payload (for journalists)

• The claim: New Ocean Recovery analysis of CDC and California state data (2023 public datasets) [1][3].
• The hook: California’s overdose death rate varies by more than sevenfold across reported counties, and many of the highest-rate counties are rural, not urban [1][4].
• The featured stat: 12 per 100,000 (Imperial) vs 90 per 100,000 (Del Norte), within available county data [1][3].
• The shift: fentanyl deaths falling (declining share of fentanyl-involved deaths in Los Angeles County), methamphetamine remains a leading contributor among stimulant-related deaths — and naloxone can’t reverse a stimulant overdose [2][3][5].
• The table: ten highest-rate counties, ranked, above [1].
• The local angle: every California outlet can localize — “Where [your county] ranks,” where available in the dataset [1].
• The quote: spokesperson quote above .
• The caveat: small-population counties have volatile rates [1].

If you or someone you know needs help

Substance use and overdose are serious health issues. In the US, the SAMHSA National Helpline is free, confidential and available 24/7 at 1-800-662-4357, and the 988 Suicide & Crisis Lifeline can be reached by call or text at 988.

Sources

[1]. CDC NCHS, National Vital Statistics System, county-level drug overdose mortality data, 2023, accessed via CDC WONDER and USAFacts — https://wonder.cdc.gov/ and https://usafacts.org/answers/how-many-drug-overdose-deaths-happen-every-year-in-the-us/state/california/ 

[2]. CDC NCHS — provisional/national overdose data, 2023–2025; stimulant trends CDC National Center for Health Statistics, Provisional Drug Overdose Death Counts (Vital Statistics Rapid Release); Drug Overdose Deaths in the United States, 2003–2023 (Data Brief No. 522, December 2024); Changes in Drug Overdose Mortality by State: United States, 2022 to 2023 (Health E-Stats, February 2025) — https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm · https://www.cdc.gov/nchs/products/databriefs/db522.htm · https://www.cdc.gov/nchs/data/hestat/drug-overdose/drug-overdose-2022-2023.htm 

[3]. California Department of Public Health (CDPH) — fentanyl share of opioid deaths; under-25 trend; statewide rates Feng J et al., Opioid-Related Overdose Deaths in California, 2023, CDPH Substance and Addiction Prevention Branch, October 2025; and CDPH California Overdose Surveillance Dashboard — https://www.cdph.ca.gov/Programs/CCDPHP/sapb/CDPH%20Document%20Library/2023OpioidOverdoseDeaths.pdf · https://skylab.cdph.ca.gov/ODdash/ 

[4]. California DHCS — county opioid overdose death rates, 2023 California DHCS Opioid Response, Opioid Overdoses and Approved Naloxone by County — https://californiaopioidresponse.org/outcomes/naloxone-distribution-project-data/opioid-overdoses-and-approved-naloxone-by-county/ 

[5]. LA County Department of Public Health — 2024 overdose decline and fentanyl share shift LA County Department of Public Health, Public Health Reports Most Significant Decline in Drug-Related Overdose Deaths in LA County History (press release, June 2025); and Data Report – Fentanyl Overdoses in Los Angeles County (October 2025) — https://lacounty.gov/2025/06/25/public-health-reports-most-significant-decline-in-drug-related-overdose-deaths-in-la-county-history/ · http://lapublichealth.org/sapc/MDU/SpecialReport/Fentanyl-Overdoses-in-Los-Angeles-County.pdf 

[6]. OC Sheriff-Coroner Division / OC Health Care Agency — Orange County fentanyl deaths and overdose profile OC Sheriff-Coroner Division and OC Health Care Agency, Fentanyl-Related Deaths in Orange County See Five-Year Low, November 13, 2025 — https://ocsheriff.gov/news/fentanyl-related-deaths-orange-county-see-five-year-low · https://www.ochealthinfo.com/press/fentanyl-related-deaths-orange-county-see-five-year-low 

[7]. Substance Abuse and Mental Health Services Administration (SAMHSA), National Survey on Drug Use and Health (NSDUH): State Estimates of Substance Use Treatment Need and Receipt, California, 2021 — https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health