Fentanyl and the U.S. Opioid Epidemic

• Since 2000, more than a million people in the United States have died of drug overdoses, the majority of which were due to opioids.
• Fentanyl and other synthetic opioids have been driving the crisis in recent years, with an increasing share of the supply coming from Mexico.
• The COVID-19 pandemic exacerbated the crisis, with reported spikes in overdose deaths across the country.

Introduction

Fentanyl and other opioids are fueling the worst drug crisis in the history of the United States. More than 1,500 people per week die from taking some type of opioid, according to the National Center for Health Statistics, making opioids by far the leading cause of fatal overdoses in the country.

In recent years, the crisis has become defined by fentanyl, a synthetic opioid that is some fifty times more potent than heroin.

Analysts say the opioid problem started with the overprescription of legal pain medications, but it has intensified in recent years due to influxes of cheap heroin and synthetic opioids, including fentanyl, supplied by foreign drug cartels. The crisis has reached such a scale that it has become a significant drag on the economy and a threat to national security.

Authorities in the United States and many other countries where opioid deaths have spiked, such as Australia and Canada, are experimenting with different policies to combat the crisis.

What drugs are contributing to the crisis?

Opioids, a class of drugs derived from the opium poppy plant, can be divided into two broad categories: legally manufactured medications and illicit narcotics.

Opioid medications, including oxycodone, hydrocodone, morphine, and fentanyl are often prescribed to treat severe pain, while methadone is primarily used in addiction treatment centers. Opioids gained popularity among doctors in the 1990s for treating patients who had undergone surgery or cancer treatment, but in the 2000s physicians increasingly prescribed them for chronic conditions, such as back or joint pain, despite concerns about their safety and effectiveness.

For decades, the most commonly used illegal opioid was heroin. However, by the end of the 2010s, heroin use and overdose deaths involving the drug appeared to be declining, according to the Centers for Disease Control and Prevention (CDC).

In recent years, synthetic opioids, and fentanyl in particular, have been driving a dramatic spike in overdose deaths. After its development in the 1960s, fentanyl was legally manufactured and prescribed as an intravenous anesthetic. And while it remains an important drug in health-care settings, its illegal manufacture and distribution has become a major threat to public health. In March 2023, Department of Homeland Security Secretary Alejandro Mayorkas called fentanyl overdoses “the single greatest challenge we face as a country.”

What is the scale of the epidemic?

Opioids, primarily fentanyl, are the leading cause of U.S. overdose deaths, which have roughly quadrupled over the last ten years for which data is fully available. In 2021, the death toll surged to 80,411, more than ten times the number of U.S. military service members killed in the post-9/11 wars in Iraq and Afghanistan.

The COVID-19 pandemic worsened the opioid epidemic. Disruptions to supply chains forced people to turn to drugs they were less familiar with, and social-distancing measures meant more people were taking drugs alone, analysts say.

Along with the pandemic, the growing availability of illicit fentanyl, often disguised by drug cartels to appear as another type of prescription opioid, such as OxyContin, has exacerbated the crisis. In 2022, the U.S. Drug Enforcement Administration (DEA) seized more than fifty million fentanyl-laced, fake prescription pills, more than double the amount seized the prior year. Over half of these fake pills contained potentially lethal amounts of fentanyl, the DEA says.

What are the demographics of the opioid crisis?

The vast majority of those who overdose on opioids are non-Hispanic white Americans, who made up close to 70 percent of the annual total in 2020. Black Americans and Hispanic Americans accounted for about 17 and 12 percent of cases, respectively.

U.S. military veterans, many of whom suffer from chronic pain as a result of their service, account for a disproportionately high number of opioid-related deaths. Veterans are twice as likely as the general population to die from an opioid overdose, according to a study commissioned by the National Institutes of Health.

Research has also shown that the opioid epidemic has hit some groups harder than others, including men, people with disabilities, those who have lost a spouse, renters, and those without health insurance. One analysis found that opioid overdoses have taken about a year off the life expectancy of U.S. males.

What are the economic consequences?

The opioid epidemic is wreaking havoc on the U.S. economy. In 2022, the U.S. Congress Joint Economic Committee (JEC) found that the opioid epidemic cost the United States nearly $1.5 trillion in 2020, or 7 percent of gross domestic product (GDP), an increase of about one-third since the cost was last measured in 2017. The JEC projected this increase would continue given the rise in fatal overdoses.

Another of the epidemic’s major economic tolls is on the workforce. Researchers estimated in late 2022 that opioids were responsible for about 20 percent of the approximately 6.3 million workers who were missing from the U.S. labor force, compared to prepandemic numbers.

Where are the heroin and fentanyl coming from?

Most of the heroin coming into the United States is cultivated on poppy farms in Mexico, with several major cartels controlling production and operating distribution hubs in major U.S. cities. Mexican cartels typically smuggle narcotics [PDF] across the southwestern U.S. border in commercial and passenger vehicles moving through ports of entry or via underground tunnels. Large quantities of heroin are also produced in South American countries, particularly Colombia, and trafficked to the United States by air and sea.

Most fentanyl in the United States is also smuggled across the southern border, U.S. officials say. Fentanyl coming directly from China—previously the dominant source—has significantly decreased since 2019, but China is still the main manufacturer of the ingredients needed to create fentanyl.

Drug cartels have been the leaders in fentanyl production. Larger organizations such as the Sinaloa Cartel and the Jalisco New Generation Cartel have their own distribution networks; some also depend on American citizens to smuggle fentanyl across the border. Between 2017 and 2021, 86 percent of fentanyl traffickers were American citizens.

What is the United States doing to combat the opioid crisis?

Over the years, the U.S. government has various strategies to restrict the flow of illegal opioids from abroad, including providing Mexico with $3.5 billion in security and counternarcotics aid through the Merida Initiative (2008–2021) and coordinating efforts with China to crack down on fentanyl production. The Merida Initiative, in particular, was widely applauded for the broad bilateral cooperation it set in motion, but the project suffered a series of political and diplomatic setbacks in its final years.

In 2021, the United States and Mexico announced the Bicentennial Framework for Security, Public Health, and Safe Communities, a new cooperative security relationship focused on finding public health solutions to drug abuse, reducing arms and human trafficking, and disrupting the organized crime groups responsible for synthetic opioid production.

Within its own borders, the United States is working to restrict the distribution of illicit opioids. Federal agencies, state governments, insurance providers, and physicians all influence the supply of opioid medications. Federal regulators have introduced new limits on opioid prescriptions, reducing the total nationwide in 2020 by nearly 45 percent from the peak in 2012, according to the CDC. In addition, there has been an increased focus on seizing fentanyl and raising public awareness about its dangers. In 2022, the DEA seized double the amount of fentanyl compared to the prior year. It also released an alert to the public about the lethality of fake prescription drugs laced with fentanyl—six out of ten fake pills contain a lethal dose of the opioid.

Along with restrictions on distribution, the United States is trying to decrease the demand for illegal opioids and ameliorate the harm they can do to those who use them. A year after taking office, President Biden released his first National Drug Control Strategy [PDF]. The plan prioritizes expanding access to treatment and harm-reduction interventions, including the use of naloxone, which is used to reverse overdoses, and drug test strips. It also aims to curb drug trafficking. Earlier, his administration eased restrictions on the use of buprenorphine, a drug treatment that lessens withdrawal symptoms and thereby reduces the risk of relapses and overdoses. State lawmakers have also taken steps to address fentanyl problems in their jurisdictions by pushing for harsher punishments for possession of the drug. Some of these moves have been met with criticism from those who point to similar policies enacted during the crack cocaine epidemic in the 1980s, which they say backfired.

How have other countries dealt with opioid addiction?

Netherlands. The Netherlands permits the sale and use of small amounts of cannabis to steer users away from so-called hard drugs [PDF], such as cocaine and heroin, and has implemented harm-reduction policies. In the 1990s the country began offering heroin at no cost, and the rate of high-risk or “problem” use was halved from 2002 to some fourteen thousand cases in 2012, according to the European Monitoring Centre for Drugs and Drug Addiction, which estimates that the total has since leveled off. However, the usage of illicit painkillers such as fentanyl has increased in the Netherlands, and the Dutch Ministry of Health has released statements that categorize this rise as a public health priority. The Ministry of Health has taken several steps to be more conservative in the prescription of opioids and looked into alternative pain treatments.

Canada. Amid its own opioid crisis, Canada has authorized the opening of supervised consumption sites and partnered with China to curb fentanyl flows into the country. British Columbia and Alberta, two of Canada’s most populous provinces, declared a public health emergency and crisis, respectively, allowing them to boost funding for addiction treatment and increase access to naloxone. Additionally, in 2018, the health ministry called on drug manufacturers and distributors to halt most marketing and advertising for opioids.

Opioid-related deaths in the country declined modestly in 2019, but—like in the United States—the total jumped amid the pandemic in 2020, to more than six thousand. Most recently, in early 2023, the Canadian province of British Columbia decriminalized the the possession of small amounts of cocaine, heroin, fentanyl, and other hard drugs; people found with up to 2.5 grams of any of these will be provided with information on addiction programs instead of facing legal action.

Portugal. After facing an intense epidemic in the 1990s that led Lisbon to be known as the “heroin capital of Europe,” the country adopted a harm-reduction drug policy that decriminalized the possession of narcotics for personal use and focused on treatment instead of incarceration. By 2018, Portugal had the lowest rate of drug-related deaths in Europe, with the number of heroin users dropping from about one hundred thousand people in 2001 to one-quarter that amount. Its recovery programs have been highly praised and adopted by other countries around the world. However, authorities in Portugal say that fentanyl flows have yet to arrive in the country in a significant way, so it’s too early to tell if the same or revised anti-heroin strategies would work as well as they did.

– Claire Klobucista and Alejandra Martinez, CFR

Recommended Resources