America’s fentanyl epidemic, explained in six charts

SOMETIMES A TREND does not need to be new to be shocking. Fentanyl, a synthetic opioid up to 50 times more potent than heroin, has long been used as a powerful painkiller in hospitals. But in 2014 America’s Drug Enforcement Administration (DEA) raised the alarm about the spread of illicit supplies of the drug. A decade later fentanyl is responsible for 70% of annual overdose deaths. Every 14 months more Americans die from taking the drug than were killed in all of the country’s wars combined since 1945. Our six charts below show why this is the most lethal phase yet of an opioid epidemic that stretches back to the late 1990s.


image: The Economist

Purdue Pharma first released OxyContin, an opioid painkiller, in 1996. Other drugmakers followed, and scores of Americans got hooked on the highly addictive pills. In 2010 Purdue reformulated OxyContin to make it harder to crush and then snort or inject. That, plus stricter guidelines for prescribing opioids, reduced supply and increased the price. Addicts in withdrawal turned to heroin instead. Later, many moved on to fentanyl because they craved a more powerful high. Not everyone who dies of a fentanyl overdose takes the drug knowingly: fentanyl powder is often mixed with other substances and counterfeit fentanyl pills are passed off as less dangerous drugs. The DEA says that it is so powerful that “one pill can kill”.

The covid-19 pandemic also contributed to fentanyl’s rising death toll. People were more isolated and cut off from support systems and treatment options. More recently deaths seem to have plateaued at a very high level. Authorities see that as a victory—revealing how intractable the problem has become.


image: The Economist

Fentanyl is a trafficker’s perfect drug. In the past, drug running was resource-intensive. Drug gangs needed vast swathes of land on which to grow marijuana or coca, the plant used to make cocaine. Law-enforcement officers could disrupt supply by burning fields of the stuff or dropping pesticides on coca farms. Fentanyl is different. Synthetic drugs can be manufactured by one person in a basement or a tiny flat. That makes finding and destroying such makeshift labs difficult. The drug’s small size and potency also make it much easier to transport. Carfentanyl and nitazenes, another class of synthetic opioid, can be more powerful still.


image: The Economist

Fentanyl-trafficking networks are mutable. The precursor chemicals used to make the drugs come largely from China, which has a massive pharmaceutical industry. India is also an emerging source of the stuff; its chemicals industry is less regulated. Drug gangs in Mexico import the precursors and then “cook” fentanyl in makeshift labs, before sending the finished product north across the  border. Most fentanyl is carried through legal ports of entry by Americans.

Seizures of fentanyl roughly doubled in 2023, though it is unclear whether that means more drugs are coming across the border or whether authorities have just got better at finding them. (The acting commissioner of America’s Customs and Border Protection (CBP) told The Economist that he reckons it is a bit of both.) The DEA maintains that two gangs, Sinaloa and Jalisco New Generation, are responsible for most of the fentanyl that comes into America. But production has atomised across different sources.


image: The Economist

The pain and suffering wrought by America’s opioid epidemic has spread to every corner of the country, although regional differences in drug use still abound. In 2013, just as fentanyl was taking off, high death rates were confined to places where heroin use had also been rampant: in the north-east, Appalachia and certain parts of the south-west. Fentanyl was slow to infiltrate other western states. Black tar heroin was more popular than the white stuff west of the Mississippi river, and it is harder to mix with fentanyl. Westerners tend to smoke powdered fentanyl rather than inject it. Xylazine or “tranq”, an animal tranquilliser that strengthens the effects of fentanyl and can cause rotting wounds, is more commonly found in the east and south.


image: The Economist

Early on in the epidemic, white and Native American people were dying at a much higher rate than other racial groups. But as fentanyl spread, the victims have become more diverse. The rate of fatal overdoses for black Americans was relatively low during the prescription phase of the epidemic. That changed as fentanyl was mixed with other illicit substances that African-American drug users took more often, such as heroin. By 2020 black and white Americans were overdosing at roughly the same rate—although it is older black users and younger white ones who are dying most often.


image: The Economist

Federal funding for drug control has more than doubled since 2008. But in many ways policymakers have been much too slow to respond to the carnage. Some 6m Americans are addicted to opioids, and around four in ten say they know someone who has died of a drug overdose. President Joe Biden is taking a slightly different tack than his predecessors. In 2021, for the first time, the government spent more on treatment and prevention than on trying to reduce the supply of drugs. Mr Biden’s administration has also sought to make it easier to access proven treatments for opioid-use disorder—such as methadone and buprenorphine—and naloxone, a life-saving drug that can reverse an opioid overdose.

Much more could be done. Methadone is still impossible for many people to access, especially in rural areas. The state of Wyoming, for example, has no treatment providers. Strips that people can use to test their drugs for fentanyl are illegal in some states because they are classified as drug paraphernalia. CBP says it doesn’t have enough funds to install more x-ray machines that can discover drugs hidden in cars and lorries. All the while, the epidemic rages on. 

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