Recent increases in adolescent mortality from overdose have outpaced increases in mortality in members of the general population.

Black and queer community-based harm reduction practices can help guide development and implementation of anti-overdose interventions.

Clinicians caring for patients with OUD should plan for possible disruptions of treatment caused by arrests and pretrial confinements.

Equity requires full access to evidence-based OUD care, housing stability, and education and employment opportunities.

American OUD care has generated deaths and discriminatory policies that need remediation.

Some US localities are trying interventions modeled on international approaches to decriminalization.

Becoming callous, bitter, or resentful are harms we can suffer when grieving losses, especially at epidemic scale.

Evidence of harm reduction interventions’ morbidity and mortality benefits is abundant and of high quality.

Structural determinants of health frameworks must be person centered and express antiracism to be effective.

Severe withdrawal, risk of patient-initiated discharge, and some inpatients’ uses of substances prompt questions considered in this commentary.