Opioid overdoses have become a devastating epidemic in the United States, claiming the lives of an average of 224 people per day in 2022. The rise in opioid-related deaths has been staggering, increasing tenfold over the past 25 years. In 2021, opioid addiction was the second most common reason people sought treatment at addiction recovery facilities, surpassed only by alcohol abuse. This crisis encompasses addiction to prescription opioids, heroin, and illegal fentanyl, a synthetic opioid that is 50 to 100 times more potent than heroin.

Since 2017, the U.S. government has taken significant steps to combat the opioid epidemic, with Congress allocating over $10.6 billion toward initiatives addressing the crisis. Additionally, lawsuits against opioid manufacturers, distributors, and pharmacies have resulted in nearly $50 billion in settlements awarded to state and local governments. The economic toll of the opioid epidemic is immense, with a report from the Joint Economic Committee estimating that it cost the U.S. economy approximately $1.5 trillion in 2020 alone.

Opioids, a class of drugs derived from the opium poppy plant, are primarily used to manage pain. These drugs are categorized into three groups: illegal drugs like heroin; legal synthetic opioids such as fentanyl, which is significantly more potent than heroin; and legal semi-synthetic opioids, including oxycodone, hydrocodone, and morphine. While the 2014 introduction of illicit fentanyl dramatically accelerated the opioid crisis, the roots of opioid addiction and overdose deaths extend back several decades.

The opioid crisis in the United States has unfolded in three distinct waves, each marked by a different dominant source of opioid use and overdose. Beginning in the 1990s, the crisis first stemmed from the widespread prescription of legal opioids like oxycodone and hydrocodone, before evolving into heroin use, and culminating in the current wave driven by synthetic opioids like fentanyl, which are responsible for the majority of opioid-related deaths today.

First Wave: Prescription Opioids

According to the Centers for Disease Control and Prevention (CDC), the first wave of the opioid crisis began in the 1990s when the prescription of opioid pain relievers increased dramatically. Prior to this period, opioids were prescribed cautiously due to their well-known risks of addiction. However, this began to change in 1996 with the introduction and patenting of OxyContin. This drug, marketed as a less addictive option for pain management, led to a sharp rise in opioid prescriptions.

The nonmedical use of prescription opioids also surged, as “pill mills” — clinics, pharmacies, and practitioners that irresponsibly dispensed opioids — proliferated across the country. These practices fueled an illegal market for prescription drugs. The impact was severe: between 1999 and 2009, deaths from prescription opioid overdoses nearly quadrupled, rising from 3,442 to 13,523. This first wave set the stage for the subsequent waves of the opioid epidemic, as the rise in opioid misuse quickly evolved beyond prescribed medications into more dangerous and illicit substances.

This overview of the first wave of the opioid epidemic underscores the need for ongoing attention to prescribing practices, as well as vigilance in monitoring how medical treatments can lead to broader public health crises.

Opioid prescription rates remained elevated throughout the 2000s, with the US average reaching a high of 81.3 prescriptions per 100 people in 2012 before dropping.

As of 2022, the national average was 39.5, but rates remain high in parts of the country, from 74.5 prescriptions per 100 people in Alabama to 24.3 per 100 people in Hawaii as of 2022.

By this point, the opioid epidemic had entered its second phase.

Second Wave: Heroin

The second wave of the opioid crisis emerged around 2010, marked by a sharp rise in heroin abuse. As opioid users began seeking alternatives to prescription painkillers, heroin became a common substitute due to its lower cost and increased availability. This surge in heroin use was fueled by heightened production across South Asia and Latin America, which led to a consistent and inexpensive supply flooding the U.S. market.

Between 2010 and 2017, heroin overdose deaths skyrocketed, increasing nearly fivefold. In 2010, there were 3,036 heroin-related deaths, a number that rose dramatically to 15,482 by 2017. This period saw heroin becoming a devastating force in the ongoing opioid epidemic, as users turned to this illicit drug, further escalating the public health crisis.

By the time heroin overdose deaths began dropping in 2018, the opioid epidemic had transitioned to its third and most deadly phase.

Third Wave: Fentanyl

Beginning in 2013 and continuing today, the third wave of the opioid epidemic saw the sharp rise of fentanyl overdoses, with 73,838 deaths in 2022 alone. Most fentanyl deaths result from illicit, non-pharmaceutical fentanyl, made with imported Chinese materials and manufactured primarily in Mexico. Fentanyl is often mixed with heroin, counterfeit pills, and cocaine, leading to unintentional overdoses when users unknowingly consume it.

Fentanyl overdose deaths have surged far beyond those caused by other opioids, with nearly four times the number of fatalities compared to prescription opioids and heroin. In 2022 alone, fentanyl was responsible for significantly more overdose deaths than prescription opioids, which accounted for 14,716 deaths, and heroin, with 5,871 deaths. This stark increase underscores fentanyl’s lethal potency and its dominant role in the current opioid epidemic.

Despite the escalating crisis, fewer people are seeking treatment for opioid addiction. In 2021, over 370,000 individuals received treatment for opioid use disorder, making it the second most common addiction treatment after alcohol, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). However, this number reflects a 45.4% decrease from the 2018 peak, when 670,000 people sought treatment. This decline in treatment engagement, coupled with the rise in fentanyl-related deaths, paints a concerning picture of the current state of the opioid crisis in the U.S.

According to a report by the National Institute on Drug Abuse, approximately 2.5 million adults aged 18 or older were estimated to have opioid use disorder in 2021. Despite this high number, only about one in five of these individuals received treatment for their addiction. The report also highlighted significant disparities in treatment access, noting that Black adults, women, unemployed individuals, and those living in rural areas were notably less likely to receive treatment for opioid addiction.

This data is drawn from multiple authoritative sources, including the CDC’s Overdose Prevention page and datasets from the National Center for Health Statistics. Additional insights come from the Congressional Research Service’s analysis of the opioid crisis, the Congressional Budget Office’s findings, and reports from the Substance Abuse and Mental Health Services Administration (SAMHSA). Together, these sources provide a comprehensive view of the opioid epidemic and its broader societal impact.