Synthetic Opioids Driving a Worsening Crisis of Overdose Deaths

These interactive graphics allow users to explore how the crisis of overdose deaths involving opioid use has not only grown in magnitude since 2000, but has also changed in character.

As the number of opioid overdose deaths grew more than eight-fold between 2000 and 2018 – reaching 49,047 deaths in 2019 – the minutes between deaths fell correspondingly. By 2019, one person was dying of an opioid overdose every 10.7 minutes.

Over this period, the crisis evolved in three well-documented waves. Initially, overdose deaths were predominantly linked to common prescription opioids, such as oxycodone and hydrocodone. By 2011, however, heroin was increasingly involved in overdose deaths, and beginning in 2014, there was an explosion in the number of deaths involving synthetic opioids such as fentanyl. Despite a decline in deaths involving prescription opioids and heroin in the since 2016, deaths involving synthetic opioids have continued to rise exponentially. Because a single death may involve multiple types of opioids, summing across the three categories in any year will overstate the total number of deaths in that year.

Although final death statistics are currently available from the CDC only through 2019, provisional data also compiled by the CDC show a sharp rise in opioid deaths just at the time when COVID-19 lockdowns began in March 2020. The rise is particularly notable for deaths involving synthetic opioids, but there were also upticks in deaths involving commonly prescribed opioids and heroin – both of which had been declining in recent years. Anxiety and despair over the pandemic situation may have contributed to greater drug use. Additionally, lockdowns made it challenging for people to receive in-person treatment for existing substance abuse problems, and social isolation made it more likely that people would be using these substances alone, with less chance of a rescue in case of an accidental overdose.

The three waves of the opioid crisis are also apparent when looking at temporal changes in the share of opioid deaths in a given year that involved each substance. At the beginning of the period, 65 percent of all opioid overdose deaths involved common prescription pain killers, but this figure had declined to 29 percent by 2019. Deaths involving heroin began playing a larger role in overdose deaths around 2011, before beginning to tail off after 2015, only to be supplanted by the very significant rise in the involvement of synthetic opioids. By 2019, 74 percent of all opioid deaths involved a synthetic product. Again, since multiple substances may be involved in a single death, the percentages reflecting the share of total deaths involving each substance will sum to more than 100 percent in a given year.

In the panel above, we present unduplicated counts of the number of deaths involving specific combinations of prescription opioids, heroin and synthetic opioids. It is apparent that a growing share of opioid deaths involve two or even all three of these substances, particularly in recent years.

For example, in the second tab, focusing on common prescription opioids, we see a leveling off and then a decline in the number of deaths attributable solely to this type of opioid (the dark blue segments), as well as the increasing involvement of heroin and/or synthetic opioids used in combination with prescription drugs. The majority of polysubstance deaths involve synthetic opioids.

In the third tab, we see deaths involving only heroin began to rise in 2011 and deaths involving both heroin and synthetic opioids increased rapidly from 2014 onward.

Finally, data presented in the fourth tab show not only the rising importance of synthetics as the sole cause of opioid overdoses, but also how common it has become for overdose deaths to involve synthetic products in combination with heroin and/or prescription opioids.

Coincident with the rise of heroin and synthetic opioids, both of which have much less predictable potency and purity than prescription pain killers, there has been a rapid increase in the number and share of opioid deaths ruled accidental. By 2019, 91 percent of all opioid overdose deaths were deemed to be accidental compared to 77 percent in 2000.

The burden of opioid deaths is spread unevenly across the U.S., particularly for deaths involving heroin and synthetic opioids. Synthetic opioid death rates are higher in the eastern portion of the U.S., as are deaths involving heroin. This phenomenon has been attributed to the fact that powdered heroin is typically used in this area of the country, and is more easily mixed with synthetic opioids, making for a potent and deadly combination. In contrast, the heroin used in the western portion of the country is a tar-like substance that does not mix easily with synthetic opioids, providing a small measure of protection against unintended heroin overdoses. For prescription opioids, while there are some state hot spots with elevated death rates, strong geographic patterns are harder to detect.

The opioid crisis has always touched all age groups, but in the early years when opioid abuse was primarily associated with prescription pain medications, the crisis was initially felt most acutely by adults in their 40s. Beginning around 2007 overdose deaths began to affect all age groups more equally. By the end of the period, when synthetic opioids had come to dominate the crisis, younger adults aged 25 to 40 were the hardest hit by overdose deaths.