• Posted May 12, 2025

U.S. Illicit Opioid Use Could Be 20 Times Higher Than Previously Estimated

MONDAY, May 12, 2025 (HealthDay News) — More Americans use illicit opioids like fentanyl than previously estimated, undercutting perceived progress in confronting the U.S. opioid crisis, a new study says.

More than 1 in 10 American adults (11%) reported illicit opioid use within the past 12 months, researchers reported May 9 in JAMA Health Forum.

Worse, nearly 8% said they’d used illicitly reported fentanyl, a highly dangerous opioid tied to increased overdose risk, researchers found.

Those rates are more than 20 times higher than estimates from a large federal survey that each year asks Americans about their illicit drug use, researchers noted.

The results indicate that government counts might significantly underestimate illicit drug use, researchers argue.

“Estimates of illicit opioid use are rare and typically are available only years after the information is collected, limiting our ability to monitor trends on a near-term basis,” lead researcher David Powell, a senior economist at the nonprofit research organization RAND, said in a news release.

“Our study offers a method to quickly and repeatedly monitor illicit opioid prevalence at low-cost,” Powell said.

The U.S. opioid crisis was initially driven by prescription opioids doled out as painkillers, then transitioned to heroin in the early 2010s as governments clamped down on those prescriptions, researchers said in background notes. 

The crisis then moved on to fentanyl and other synthetic opioids, which are cheaper and more readily available than heroin, researchers said.

The National Survey on Drug Use and Health is the main way that the U.S. has kept track of the opioid crisis, but it tends to lag current events, researchers said.

For example, the survey only started asking about illicit fentanyl in 2022, and reported that only 0.3% of adults used the drug that year.

For this study, researchers surveyed more than 1,500 Americans about their drug use in June 2024, using an online platform that creates high-quality nationally representative survey panels.

The survey asked people about their use of non-prescription opioids within the past 12 months, with heroin and fentanyl given as examples.

Nearly 8% reported that they’d intentionally used illicit opioids, and another 3% said they’d unintentionally used opioids.

The rate of intentional fentanyl use was about 5%, while unintentional use was just under 3%.

Exploring patterns of use, researchers found that about 3 out of 4 illicit users started with prescription opioids — 39% who first used opioids prescribed to them and 36% who used opioids prescribed to others.

Underestimates by the federal survey might be due to the way it is conducted, researchers said. About half the surveys are done in person, which might dissuade participants from being open about illicit drug use.

“Ultimately, the data presented here should be treated as a substantive data point for understanding and curtailing the ongoing opioid crisis,” senior researcher Mireille Jacobson, an economist at the University of Southern California, said in a news release. “More near real-time information is needed to evaluate not only where we are in the epidemic, but, more importantly, whether we are making progress in reining it in.”

In an accompanying editorial, experts said they “find the higher figure easier to reconcile with past estimates of the size of the heroin market, and with evidence that illicitly manufactured fentanyl has not only largely displaced heroin from its traditional markets but also expanded beyond, for example, into counterfeit pills.”

Based on the rate of fentanyl use found in this new study, it can be estimated that as many as 1 in every 250 illicit fentanyl users wind up dead from overdose, wrote the editorial team led by Jonathan Caulkins, a professor with Carnegie Mellon University.

“That is a startlingly large number, roughly the same as what literature reviews estimated for individuals dependent on opioids in the heroin era,” the editorial says. “It appears that fentanyl is so much more deadly than heroin that the annual overdose death risk for those reporting any past-year use of illicitly manufactured fentanyl is now comparable to the average for high-frequency heroin users in the past.”

More information

The U.S. Centers for Disease Control and Prevention has more on the opioid overdose epidemic.

SOURCES: RAND, news release, May 9, 2025; JAMA Health Forum, May 9, 2025