Fentanyl and the U.S. Opioid Epidemic

Introduction

Fentanyl and other opioids have fueled the worst drug crisis in U.S. history. In recent years, fatal overdose numbers have become defined by illicit fentanyl, an extremely lethal synthetic opioid, with more than two-thirds of overdoses being from this class of drug. Illegal fentanyl supplies are largely produced in China and Mexico and then smuggled into the United States.

Analysts say the opioid epidemic started with the overprescription of legal pain medications in the 1990s, but it has intensified in recent years due to influxes of cheap heroin, fentanyl, and other synthetic opioids supplied by foreign drug cartels. The crisis has become a scourge on the economy, a threat to national security, and a major foreign policy challenge.

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. 

The opioid crisis has been characterized by three distinct waves. The 1990s saw growth in overdose deaths from opioid-based medications, such as Percocet and Oxycontin, as physicians increasingly prescribed them for chronic conditions despite concerns about their safety and effectiveness. This period was followed by the rise of illegal heroin that marked a brief second wave in the early 2010s. And most recently, synthetic opioids—fentanyl in particular—have been driving a dramatic spike in overdose deaths since around 2013. 

Fentanyl was legally manufactured and prescribed [PDF] as an intravenous anesthetic beginning in the 1960s. While it remains an important drug in health-care settings, its illegal manufacture and distribution has become an extraordinary threat to public health. In 2022, the head of the U.S. Drug Enforcement Administration (DEA), Anne Milgram, said that “fentanyl is the single deadliest drug threat our nation has ever encountered.”

New combinations of synthetic opioids continue to crop up as well, complicating the crisis. Xylazine, a powerful chemical used in horse tranquilizers, and other novel opioids are reported to have far higher potency than pure fentanyl.

What is the scale of the epidemic?

Overdoses involving synthetic opioids, primarily fentanyl, are the leading cause of U.S. deaths in people ages eighteen to forty-five. In 2022, deaths from all types of opioids surged to 81,806, more than ten times the number of U.S. military servicemembers killed in the post-9/11 wars in Iraq and Afghanistan. A study by researchers at the Mayo Clinic and Yale University found that deaths from fentanyl alone nearly tripled from 2016 to 2021. However, 2023 marked the first year in which fentanyl-related deaths began to decline, and they’ve continued to drop by at least 21 percent since then. 

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 led more people to take drugs alone, which brings a greater risk of overdosing, analysts say.

Along with the pandemic, the growing availability of illicit fentanyl, often disguised by drug cartels to appear as legal prescription opioids, has exacerbated the crisis. In 2024, the DEA seized more than fifty-five million fentanyl-laced, fake prescription pills, down from eighty million the previous year. The amount seized last year seizures was enough to equate to more than 367 million deadly doses. 

Fentanyl’s extreme potency also makes the drug more addictive and more deadly, further fueling the crisis. A lethal dose requires just two milligrams of the drug—an amount roughly equivalent to ten to fifteen grains of table salt.

What are the demographics of the opioid crisis?

Fentanyl’s deadly toll affects a broad swath of the American public. In 2023, Among U.S. drug overdose deaths in 2023, fentanyl was the top killer [PDF] for all regions of the country and all age, race, and ethnic groups. Still, it hit some harder than others—American Indian and Alaska Native people, Black people, younger adults, and men died from fentanyl-linked overdoses at higher rates.

Another concerning trend is the rise of fentanyl deaths in youths between ten and nineteen years old. Fatal fentanyl overdoses nearly doubled in teens between 2019 to 2021. Experts attribute some of this rise to the ease of purchasing counterfeit pills through social media. While this trend began to reverse in 2023, the rate remains high compared to pre-pandemic levels. 

Research has also shown that other demographic groups, including military veterans, people with disabilities, those who have lost a spouse, renters, and those without health insurance, have been disproportionately harmed by opioids. 

What are the economic consequences?

The opioid epidemic is taking a heavy toll on the U.S. economy, according to many reports. One of the most staggering and widely cited estimates, by 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) that year, 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. This massive sum includes the price of health care to treat overdoses, the costs of fighting fentanyl trafficking and pursuing criminal justice efforts, and lost productivity in the workforce, as well as the economic costs of human lives lost to overdose and the reduced value of life for overdose survivors.  

Where are the drugs coming from?

Most fentanyl in the United States is smuggled across the border with Mexico, U.S. officials say. Smugglers send it across in vehicles or with pedestrians, who can travel with small, easily concealable amounts of the drugs because of its high potency compared to other illicit narcotics. The median weight seized is just 1.2 kilograms (2.6 pounds), which contains more than fifty thousand lethal doses. By December 2023, at least 12,245 kilograms (27,000 pounds) had been intercepted at the southern U.S. border this year.

China was the dominant source of fentanyl coming into the United States, but the flow has significantly decreased since authorities banned production of all fentanyl variants in 2019. However, China is still the leading manufacturer of fentanyl ingredients, known as precursor chemicals. Most of the fentanyl smuggled into the United States from Mexico is made from chemicals from China. 

Mexican drug cartels are the leaders in fentanyl production. Two organizations, the Sinaloa Cartel, and the Jalisco New Generation Cartel, manage most of the production and distribution networks, often depending on American citizens to smuggle fentanyl across the border. Between 2019 and 2023, more than 86 percent [PDF] of fentanyl traffickers were U.S. citizens.  

In October 2023, the Sinaloa Cartel looked to publicly signal that it was moving away from fentanyl trafficking amid an intensifying crackdown on its operations by U.S. and Mexican authorities. As one of two major suppliers, this would be a significant shift, but it remains unclear how genuine or effective Sinaloa’s transition will be. 

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

For decades, the U.S. government has worked with several other countries, particularly Mexico, to restrict the flow of illegal narcotics entering the country. For instance, through the Mérida Initiative [PDF], the United States provided Mexico with some $3.5 billion in security and counternarcotics aid between the fiscal years 2008 and 2021, including for purchases of military aircraft and surveillance software. Under former President Andrés Manuel López Obrador, however, Mexico resisted cooperation with the United States on the issue, claiming that it does not produce fentanyl. This discord, combined with the sharp rise in fentanyl-related deaths in recent years, has raised alarm in Washington, with the Donald Trump administration invoking tariffs and increased border oversight on countries that contribute to the fentanyl flow. 

President Joe Biden also made the fentanyl crisis a domestic and foreign policy priority, and his administration curbed the death toll from overdoses, which climbed in the first half of his term and then fell by the second. In late 2021, he declared synthetic-opioid trafficking a national emergency and signed two executive orders allowing his administration to sanction individuals and entities associated with the production and dissemination of fentanyl. In late 2023, the U.S. government sanctioned twenty-five China-based firms and individuals it believed to be involved in producing fentanyl precursor chemicals. And Biden added China to the U.S. list of major illicit drug-producing and drug-transit countries, where it joins twenty-two others, including Colombia, India, and Mexico. 

Amid these efforts, the Biden administration kept up pressure on Mexico to intercept precursors received from China and to crack down on clandestine labs in its own country. And in November 2023, on the sidelines of the Asia-Pacific Economic Cooperation summit, President Biden reached separate agreements with Chinese President Xi Jinping and Mexican President López Obrador to increase bilateral cooperation on the preventing manufacturing and distribution of illicit fentanyl.  

At the same time, the Biden administration attempted to curb illicit opioid distribution domestically. In 2022, the DEA seized double the amount of fentanyl compared to the prior year, and it released a public alert about fake prescription drugs laced with fentanyl—six out of ten fake pills contain a lethal dose of the drug.

To ameliorate the drug’s harm, in March 2023, the Food and Drug Administration (FDA) approved the naloxone nasal spray Narcan as the first over-the-counter drug to reverse fentanyl overdoses. Experts say the public sale of Narcan, which became available in many chain pharmacies beginning in September that same year, marks a significant step forward in efforts to combat the epidemic, but it is not a panacea due to cost and accessibility challenges.

How is the Trump administration addressing the issue?

Trump has called fentanyl an “extraordinary threat.” His administration has claimed that fentanyl deaths range anywhere from three hundred thousand per year to “tens of millions”—figures that experts in law enforcement and public health say are inaccurate. While the numbers are still staggeringly high, data shows that the crisis was already easing by the time Trump took office. According to the Defense Department, proposals to label the drug’s trafficking as a weapon of mass destruction are gaining traction, and a congressional bill, called the HALT Fentanyl Act, seeks to land all fentanyl-related substances in schedule I of the Controlled Substances Act, or those considered to have a high potential for abuse. 

In March 2025, the U.S. National Intelligence Community, led by Tulsi Gabbard, listed fentanyl as a top threat to U.S. national security in its annual threat assessment. One month earlier, Trump had announced sweeping tariffs on Canada, China, and Mexico, citing the three countries’ roles in illegal drug flows. 

After Trump announced the tariffs, Mexico deployed another ten thousand troops to the shared U.S. border in an effort to combat drug trafficking. Mexican President Claudia Sheinbaum has also intensified law enforcement efforts and enhanced cooperation with the U.S. government; her administration has seized thousands of kilograms of fentanyl and arrested more than six thousand individuals linked to drug trafficking. While the United States’ northern border sees far fewer fentanyl seizures, Canada has allocated an additional $900 million for border security and appointed a fentanyl czar.

In its first term, the Trump administration pressed China to tighten regulations on fentanyl-related exports, which led to a reduction in the drug’s flow. However, as China contends with its own economic difficulties, efforts to stem the flow of illicit fentanyl today are less likely to succeed as Beijing is unlikely to cooperate with Washington on economic measures to curb fentanyl, experts say. 

They have pointed out that while countries have bolstered their anti-drug policies in response to U.S. tariffs, Trump’s economic measures will likely do more harm to the U.S. economy than close the floodgates on fentanyl. To better respond to the current crisis, experts have suggested carrying out more research and development and applying alternative approaches, including supervised consumption sites, improved disruption of illicit online transactions, stricter border inspections, and better overdose prevention and employee assistance programs.