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Research Questions

  1. In what parts of the United States are synthetic opioids most concentrated, and to what extent is the problem diffusing?
  2. Are synthetic opioids replacing heroin in some drug markets?
  3. What share of the rising numbers of cocaine overdose deaths also involve synthetic opioids?

The synthetic opioid surge in the United States is a public health emergency. Synthetic opioids, principally fentanyl, were reported in more than 31,000 fatal overdoses, or two-thirds of all opioid-involved deaths, in 2018. In less than six years, the number of fatal overdoses involving synthetic opioids in the United States has risen tenfold, surpassing drug overdoses for heroin or prescription opioids by a factor of two. Perhaps even more troubling is the possible diffusion of synthetic opioids into non-opioid markets.

In this report, the authors examine mortality data at the state level across several drug classes to better understand the evolution and concentration of overdose fatalities in the United States. They also analyze drug seizures of fentanyl and fentanyl analogs across states and over time to determine the overlap between supply-side indicators and state-level mortality data.

The authors report three main findings. First, overdose deaths involving synthetic opioids and certain supply-side indicators of synthetic opioids have increased over time but remain concentrated in certain states. Second, there have been sharp increases in the share of heroin or cocaine overdoses that involve synthetic opioids; furthermore, there appears to have been an absolute decline in fatal overdoses involving heroin without synthetic opioids in a few states. Third, a substantial share of cocaine overdoses also mention synthetic opioids, suggesting that people who use cocaine are increasingly exposed to these drugs. The authors conclude that drug policy needs to account for how rapidly these potent opioids are upending the old order.

Key Findings

  • Through 2017, seizures of fentanyl and overdose deaths involving synthetic opioids were geographically concentrated, with parts of Appalachia and New England most severely affected. Given the concentration of exposure, there is a worrying possibility that fentanyl and other synthetic opioids will become entrenched in other drug markets, especially in the western United States.
  • Although synthetic opioid overdoses are rising in Ohio and New Hampshire, there has been a simultaneous decline in these states in the absolute number of fatal overdoses and seizures involving heroin, possibly suggesting that fentanyl and other synthetic opioids are replacing and not just adulterating heroin. In states that have been exposed to fentanyl and synthetic opioids the longest, there is a continued upward trend in the number of fatal synthetic opioid overdoses that do not include heroin or cocaine.
  • Nationally, half of cocaine overdose deaths also include mention of synthetic opioids. The reasons behind this relationship are unclear, but people who use cocaine are increasingly at risk of fatal overdose because of increasing contact with synthetic opioids. There is also a rising trend in psychostimulant (specifically methamphetamine) overdoses that also involve synthetic opioids.


  • A transitioning of opioid markets from heroin to more-potent synthetic opioids could have broad effects on public health and public safety and require new approaches, given the specific challenges posed by these chemicals. For example, their potency may require additional administrations of naloxone to reverse overdoses. Also, their shorter duration of action may increase the number of times the drugs are injected per day, potentially exacerbating the spread of blood-borne diseases and the degree to which opioid use disorders disrupt daily life functioning.
  • The data show that cocaine-related overdoses increasingly mention synthetic opioids. The near tripling since 2013 in overdose deaths involving cocaine is driven in large part by deaths that also involve synthetic opioids. This vulnerability suggests the need for interventions aimed specifically at reducing the risk of overdose in these populations. Such interventions might include public alerts or education about this risk, investment in the development of better fentanyl testing technology, and distribution of naloxone beyond traditional opioid-using groups, including to people who do not intend to use opioids.

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