The U.S. Drug Epidemic: A Leading Cause of Death

November 8, 2023

Scientists looking at test results in a lab.

The current U.S. drug epidemic is a fentanyl-fueled public health crisis. A synthetic opiate originally developed to provide pain relief to patients undergoing chemotherapy, fentanyl is 50 to 100 times more potent than morphine. In fact, “fentanyl is the single deadliest drug threat our nation has ever encountered,” said Anne Milgram, spokesperson for the U.S. Drug Enforcement Administration (DEA).

Death tolls corroborate her claim. The Centers for Disease Control and Prevention (CDC) reports that more than 107,000 Americans died of drug overdoses in 2021 — roughly one overdose every five minutes. Of these, deaths from fentanyl and other synthetic opioids (non-methadone) increased by 23% in 2021 to an estimated 71,000 deaths in people ages 18 and older, according to the CDC.

Some communities have been particularly devastated, with Alaska experiencing a 75% increase in drug overdose mortalities in 2021.

With lethal fentanyl use on the rise, as well as a dangerous trend of people using opiates and methamphetamines together, public health professionals are doing everything in their power to study and stop the U.S. drug epidemic.

How can public health leaders address this ongoing opioid crisis while promoting health access, health equity and social justice — protecting and supporting vulnerable groups rather than further marginalizing, criminalizing and punishing them?

Is Fentanyl a Leading Cause of Death for 18- to 45-Year-Olds?

Although the exact numbers of fentanyl deaths by age category are difficult to accurately assess, data collected by the CDC illuminates the risk of fentanyl to 18- to 45-year-olds.

In 2021, “accidents” or unintentional injuries — including drug overdoses — were the leading cause of death in the 18- to 45-year-old age group, according to PolitiFact. Given that an estimated 90% of all (non-methadone) synthetic opioid-related unintentional injuries involve fentanyl, drug overdoses involving fentanyl may well be one of the leading causes of death for people in this age group in 2021. This estimate could put fentanyl-related deaths of 18- to 45-year-olds ahead of deaths in this same age group due to:

Suicide
Firearms
Cancer
Cardiovascular disease
Complications due to coronavirus (COVID-19)

Of course, comorbidities make the exact number of fentanyl deaths almost impossible to ascertain with 100% certainty. Not all jurisdictions have sufficient funds to drug test every person who dies. And some people die with multiple drugs in their system, which can be coded and counted as a “multidrug intoxication” rather than a fentanyl death specifically.

Why Are There So Many Fentanyl Deaths Today?

Overdose deaths climbed during the COVID-19 pandemic, leading to what the Substance Abuse and Mental Health Services Administration (SAMHSA) described as “the most significant substance use and overdose epidemic [the U.S.] has ever faced.”

Many interrelated factors seem to contribute to the nationwide drug epidemic:

Clinically inappropriate prescribing of medications with misuse potential has contributed to the drug epidemic, according to the overdose prevention strategy proposed by the Department of Health and Human Services (HHS).
Snowball effects. People who have had at least one overdose are more likely to overdose in the future, according to the CDC, which can cause a snowball effect that easily overwhelms community health organizations.
High-risk factors for low-income, underinsured, and incarcerated people. People who lack access to health insurance, live in poverty or have been incarcerated are at a higher risk for fatal opioid overdose, according to the 2020 “Mortality Disparities in American Communities” (MDAC) study. Economic pressures including low wages and housing insecurity thus put more people at risk for fatal drug use.
Stigma and lack of education around treatment. Stigma and lack of education about drug use and lifesaving emergency medications such as naloxone continue to prevent people from getting the support they need to seek rehabilitation.
Limited pharmacy access. In some places, a personal prescription is required to access naloxone, according to the National Institute on Drug Abuse (NIDA). This means that many people who live far away from a pharmacy, those who lack health insurance, and those without access to community-distribution programs may not be able to access lifesaving emergency treatment during an opioid overdose.
Underfunded harm prevention services. Harm prevention services (social services designed to help rather than vilify or punish people who misuse drugs) such as syringe services programs are chronically underfunded — though the SAMHSA Harm Reduction Grant Program authorized by the 2021 American Rescue Plan is one step toward remedying national funding issues.

The Root Causes of the Opioid Epidemic

In the 1980s, the medical profession became increasingly interested in managing patient pain. Before the 1980s, physicians mainly prescribed opioids for short-term use for especially vulnerable patients, such as people with advanced cancer or people who had just undergone surgery.

Pharmaceutical companies, such as Purdue Pharma, began heavily promoting their extended-release opioids as treatments for chronic pain. In their advertisements and lobbying efforts, Purdue Pharma pushed the narrative that their prescription oxycodone drug, OxyContin, was safe, was efficient and had low potential for causing addiction. The company lied and paid $635 million in 2007 when it admitted it knew of OxyContin’s addictive effects and has been ordered in 2022 to pay another $6 billion for its causal role in the opioid epidemic.

The legacy of the War on Drugs campaign and its promotion of drug misuse as only being associated with certain races and classes of people provided fertile ground for the opioid epidemic. Purdue Pharma marketed its products to white suburban and rural communities — people who had not previously been associated with addiction and drug use by the media and the government the way that people of color had.

Today, prescription guidelines are stricter, but international drug cartels continue to feed the drug epidemic with cheap heroin and synthetic opioids — particularly fentanyl, which, according to the DEA, is much cheaper to produce than other opioids and is many times stronger than morphine.

Cities Facing Pervasive Drug Use

American Addiction Centers surveyed 51 U.S. cities in 2022 to understand how addiction affects the populations of major metropolitan areas. The survey did not study fentanyl specifically but did report on the use rates of several other addictive drugs that are often used together with fentanyl and are dangerous on their own.

In 2022, the top five cities with the most heroin use were:

Omaha, Nebraska, where 3.4% of the population has used heroin
Indianapolis, Indiana, where 3.4% of the population has used heroin
Columbus, Ohio, where 3.3% of the population has used heroin
Nashville, Tennessee, where 3.2% of the population has used heroin
Oklahoma City, Oklahoma, where 3.1% of the population has used heroin

In 2022, the top five cities with the most methamphetamine use were:

Phoenix, Arizona, where 15.1% of the population has used meth
Mesa, Arizona, where 14.1% of the population has used meth
Omaha, Nebraska, where 14.0% of the population has used meth
Oklahoma City, Oklahoma, where 13.8% of the population has used meth
Fresno, California, where 13.8% of the population has used meth

In 2022, the cities with the most overall drug use, based on “the rate of usage and the seriousness of the drug” were:

Wichita, Kansas
Tulsa, Oklahoma
Oklahoma City, Oklahoma
Mesa, Arizona

How the Pandemic Affected the Drug Epidemic

The social and economic instability caused by the global COVID-19 pandemic has exacerbated the drug epidemic. Social isolation, persistent fear and anxiety around contracting and spreading the virus, grief at the loss of loved ones, job upheavals including layoffs and undue burdens on front-line workers all contributed to a worsening mental health crisis in the U.S. since March 2020.

How Has the U.S. Government Responded to the Drug Epidemic?

In addition to using law enforcement measures to get illicitly manufactured fentanyl (IMF) off the streets, the U.S. government employs a coalition of public policy leaders across many different government agencies alongside community advocates, academic researchers and nonprofit workers to address the drug epidemic with a multifaceted approach.

One promising way the U.S. government has responded to the opioid epidemic specifically comes in the form of the 2021 American Rescue Plan. This legislation authorized SAMHSA to fund the Harm Reduction Grant Program, which provides $30 million to support community-based syringe services programs, overdose prevention programs and other empirically based harm reduction services.

Discover Public Health Approaches to Drug Epidemics

As the drug epidemic continues, the world needs public health leaders who understand how to apply the skills of evidence-based research and practice with an equity lens.

Discover how you can promote equitable, effective public health with a degree from USC’s online Master of Public Health (MPH) program. The USC online program is the only MPH delivered by a top-ranked medical school with a world-renowned faculty. Learn more about how earning an MPH from USC can springboard your career in public health today.