The U.S. Opioid Epidemic
Backgrounder

The U.S. Opioid Epidemic

Opioid addiction in the United States has become a prolonged epidemic, endangering not only public health but also economic output and national security.
A man uses heroin under a bridge where he lives in Philadelphia, Pennsylvania.
A man uses heroin under a bridge where he lives in Philadelphia, Pennsylvania. Spencer Platt/Getty Images
Summary
  • 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 has exacerbated the crisis, with reported spikes in overdose deaths across the country.

Introduction

The United States is grappling with one of its worst-ever drug crises. More than 1,500 people per week die from opioid-related overdoses, a toll that has spiked across the country amid the COVID-19 pandemic. Meanwhile, millions more Americans suffer from opioid addiction.

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Analysts say the problem started with the overprescription of legal pain medications, but note that it has intensified in recent years with an influx of cheap heroin and synthetic opioids, particularly fentanyl, supplied by foreign-based drug cartels. The crisis has reached such a scale that it has become a drag on the economy and a threat to national security: opioid misuse is costing the country tens of billions of dollars annually, not only in health-care expenses but also in the form of a weakened workforce.

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In recent years, the U.S. government has ramped up efforts to cut both foreign and domestic supplies of opioids by limiting the number of prescriptions as well as by providing counternarcotics assistance abroad. Meanwhile, federal and state officials have attempted to reduce demand by focusing less on punishing drug users and more on treating them. Other countries where opioid use has spiked, such as Australia and Canada, are experimenting with different policies.

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, and morphine, are commonly prescribed to treat pain, while methadone is primarily used in addiction treatment centers to reduce patients’ dependence on opioids. 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.

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Heroin for decades was the most commonly used illegal opioid, as the supply of the drug in the United States soared and its average retail-level price dropped by the mid-2010s to roughly one-third [PDF] of what it was in the early 1980s. However, by the end of the decade, heroin use and overdose deaths involving the drug appeared to be declining, according to the Centers for Disease Control and Prevention (CDC).

We didn’t develop an opioid epidemic until there was a huge surplus of opioids, which started with pharmaceutical drugs.
Bridget G. Brennan, New York Special Narcotics Prosecutor

In recent years, people have increasingly turned to synthetic opioids such as fentanyl. The U.S. Drug Enforcement Agency (DEA), the leading U.S. agency involved in counternarcotics, says fentanyl is “primarily responsible for fueling the ongoing opioid crisis.” Some law enforcement officials have labeled the drug “manufactured death” because it is cheaper and up to fifty times more potent than heroin. Fentanyl-related deaths are largely caused by the drug’s illegal use, though it can also be prescribed as a painkiller. The CDC notes that heroin and fentanyl are most often used in combination with other drugs, such as cocaine, or with alcohol, which increases the risk of overdose.

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What is the scale of the epidemic?

Overdose deaths involving opioids have increased more than sixfold since 1999. In 2019—the most recent year for which full data is available—opioid overdoses killed nearly fifty thousand people, or more than seven times the number of U.S. military service members killed in the post-9/11 wars in Iraq and Afghanistan. According to provisional CDC data, the number of opioid-related overdose deaths shot up in 2020 to around seventy thousand and again in 2021 to eighty thousand. Since 2015, the opioid mortality rate has contributed to a historic decline in life expectancy in the United States (though there was a short reprieve in 2018–19).

Many health experts attribute the high death toll to what they say was years of overprescribing by physicians. Doctors began prescribing more opioids amid a growing concern that pain was going undertreated, and also because pharmaceutical companies began marketing the drugs more aggressively while claiming they posed little risk. Health-care providers reported feeling pressure to prescribe opioid medications rather than alternatives, such as physical therapy or acupuncture, because patients request them and other treatments are often more costly or less accessible.

Opioid-related deaths increased in lockstep with the volume of opioids prescribed. A spike in the use of illegal opioids in the United States has followed the rise in prescriptions, as many users turn to heroin and other illegal drugs once they can no longer obtain enough of their prescribed drug to keep pace with what may be a developing addiction. “We didn’t develop an opioid epidemic until there was a huge surplus of opioids, which started with pharmaceutical drugs distributed legally,” New York Special Narcotics Prosecutor Bridget G. Brennan told CFR.

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

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. Economists Anne Case and Angus Deaton have argued that the rise in what they call “deaths of despair”—which include drug overdoses, particularly among white Americans without college degrees—is primarily the result of wages stagnating over the last four decades and a decline in available jobs.

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.

What are the socioeconomic consequences?

The opioid epidemic is having devastating consequences on other aspects of public health, causing high rates of hepatitis C, HIV, and other diseases, mainly due to shared syringes. Meanwhile, mothers can pass an opioid dependency on to their children if they use opioids while pregnant. Incidences of neonatal abstinence syndrome, or withdrawal symptoms experienced by newborns exposed to drugs while in the womb, jumped by more than 80 percent between 2010 and 2017. The opioid crisis likely also contributed to an uptick in the number of children in foster care.

Opioids have also taken a toll on the economy: The CDC calculates that opioid misuse costs the country some $78 billion per year, a tally that includes costs from health care, lost productivity, treatment programs, and legal expenses. In 2017 alone, the cost of opioid misuse and fatal overdoses was estimated to be around $1 trillion. Testifying before the U.S. Senate in 2017, Treasury Secretary Janet Yellen, then chair of the Federal Reserve, linked the opioid epidemic to declining labor-force participation among “prime-age workers.” Late Princeton University economist Alan Krueger wrote that it could account for 20 percent of the decline in participation among men and 25 percent among women from 1999 to 2015.

Where are the heroin and fentanyl coming from?

The opioid crisis has also become a national security concern. 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, which the DEA calls the “greatest drug trafficking threat to the United States” [PDF], typically smuggle narcotics across the U.S. southwest border in commercial and passenger vehicles and 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. Although most of the world’s heroin comes from Afghanistan, only a small portion of the U.S. supply is produced there.

Most fentanyl in the United States is smuggled across the southern border, U.S. officials say. Although fentanyl coming directly from China—previously the dominant source—has significantly decreased since 2019, experts note that many drug shipments from China are merely being rerouted through Mexico. Mexican cartels will “almost certainly have the greatest direct impact” on the U.S. fentanyl market in the coming years, the DEA cautions.

What is the United States doing to restrict foreign narcotics?

Since 2007, the United States has provided Mexico with more than $3 billion in security and counternarcotics aid, including for police and judicial reforms, in a program known as the Merida Initiative. U.S. officials say the initiative led to the capture of some top cartel leaders, including Joaquin “El Chapo” Guzman, but Mexican President Andres Manuel Lopez Obrador has sharply criticized the agreement, and in 2021, the two countries announced a new bilateral framework for health and security cooperation. Through a similar partnership with Colombia, the United States provided almost $10 billion beginning in 2000; that program effectively drew to a close following the end to the civil conflict there in 2016.

The DEA has also coordinated efforts with China, the primary source of fentanyl in the United States in the mid-2010s. Amid sustained U.S. diplomatic pressure, Beijing made several moves to crack down on fentanyl production, culminating in a 2019 ban on the production, sale, and export of all fentanyl-related substances. Experts note, however, that Beijing’s cooperation has lessened as bilateral relations have strained.

Recent U.S. administrations have also increased the number of border patrol agents to approximately twenty thousand. Heroin seizures and trafficking arrests more than doubled [PDF] between 2007 and 2017, many near the southwestern border. At the direction of President Donald Trump, the government erected some eighty miles of new barriers along the border. Some analysts argued that building up the border wall would do little to curb drug flows, as many illicit drugs are thought to be smuggled through ports of entry. In 2021, President Joe Biden issued two executive orders aimed at disrupting transnational criminal organizations, including by imposing sanctions on those involved in drug trafficking.

What are some efforts to restrict domestic supply?

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. Current CDC guidelines advise physicians not to prescribe opioids as a first-line therapy. Meanwhile, the DEA has required pharmaceutical companies to reduce their production of certain opioids, including oxycodone, fentanyl, and morphine, by at least 25 percent. Amid the COVID-19 pandemic, however, the agency allowed production boosts for substances including codeine, fentanyl, and morphine.

The Justice Department has ramped up efforts to prosecute those involved in overprescribing and trafficking. In 2018, it partnered with nearly all state attorneys general to share opioid prescription information in order to investigate drug crimes and soon after brought charges against more than 150 doctors, nurses, pharmacists, and others for their alleged roles in distributing opioids. Two years later, the department filed a civil suit against Walmart for allegedly failing to stop hundreds of thousands of improper prescriptions.

Additionally, many U.S. states have passed legislation limiting opioid prescriptions. States including Mississippi, New Jersey, Ohio, and Oklahoma, as well as thousands of cities, are suing pharmaceutical companies, alleging they overstated the benefits of prescription opioids and concealed the risks. In a landmark case brought by Oklahoma, Johnson & Johnson was ordered to pay the state $572 million in 2019 for its role in the epidemic. In another lawsuit, Purdue Pharma, the maker of OxyContin, agreed to dissolve itself and pay billions of dollars to state and municipal governments in exchange for immunity from thousands of other lawsuits against the company.

What is the United States doing to reduce demand?

Previous federal antidrug campaigns relied on incarceration to deter drug use and trafficking. This approach has been widely criticized for failing to keep people from cycling in and out of prison and for disproportionately targeting Black Americans. In recent years, federal and state officials have shifted toward prevention and treatment. Some city and local governments have launched what are known as harm-reduction programs, which focus on limiting virus transmission and overdoses through the promotion of safer drug use. Critics of such programs argue that decriminalization would lead to higher rates of drug use.

President Barack Obama reduced prison sentences for hundreds of nonviolent drug offenders during his tenure. However, he failed to secure legislation that would have eliminated mandatory minimum sentences for federal drug crimes. His administration also established hundreds of new drug courts, which proponents say are an effective alternative to incarceration. Drug courts, the first of which was launched in 1989, under the George H.W. Bush administration, provide nonviolent offenders an alternative to the criminal justice system that involves monitoring and rehabilitation services rather than prison time. In 2016, Obama signed legislation authorizing more than $1 billion in funding, largely in the form of state grants, to expand opioid treatment and prevention programs.

In recent years, federal and state officials have shifted toward prevention and treatment.

In 2017, President Trump declared the epidemic a public health emergency, freeing up some federal grant funds for states to direct toward the crisis and loosening restrictions on access to treatment. Meanwhile, a presidential commission recommended other policies [PDF] to combat the opioid problem. A year later, Trump signed into law the Support for Patients and Communities Act, bipartisan legislation aimed at further expanding access to addiction treatment and increasing research on alternative pain medications, among other things. However, some observers say it does not provide enough sustained funding to curb the crisis.

A year after taking office, President Biden released his first National Drug Control Strategy [PDF], which prioritizes expanding access to treatment and harm-reduction interventions, including the use of naloxone and drug test strips, and curbing 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.

Many experts working on the issue believe the government should direct more resources toward educating the public about risks. “I don’t think we’ve done enough in terms of informing people about the dangers—about the nexus between opioid medication and heroin and illicit drugs,” said Brennan. “If we did the kind of information campaign that was so successful with tobacco, I think we could see terrific results.”

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. Proponents of decriminalization point to the Netherlands for evidence that these policies work, though critics claim they have not curbed organized crime.

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, boosting funding for addiction treatment and increasing access to the drug naloxone, which can counteract opioid overdoses in emergencies. 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.

Australia. Heroin use in Australia declined following an abrupt shortage of the drug in 2000, but an increase in the use of prescription opioids saw opioid-related deaths more than double after 2006. The country launched a nationwide electronic system to monitor opioid prescriptions, but states and territories are individually responsible for implementing it, and the rollout has been slow. In 2018, the government enacted a ban on over-the-counter painkillers containing codeine, but the following year it recorded around 1,100 opioid-related deaths countrywide, on par with prior years.

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.

Recommended Resources

In Empire of Pain, writer Patrick Radden Keefe chronicles the Sackler dynasty’s role in the opioid crisis through Purdue Pharma’s marketing of OxyContin.

In this Brookings Institution report [PDF], Vanda Felbab-Brown writes that China remains the principal source of fentanyl in the United States, even if the drug isn’t coming directly from there.

On The Dose podcast by the Commonwealth Fund, experts discuss how the COVID-19 pandemic has exacerbated the opioid crisis.

For Scientific American, Maia Szalavitz lays out how U.S. policymakers’ efforts to reduce the medical supply of opioids backfired.

In this 2017 piece for the New Yorker, Margaret Talbot looks at opioid use in West Virginia, the state with the most deaths from overdoses at the time.

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Antonio Barreras Lozano and Nathalie Bussemaker contributed to this Backgrounder.

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