Fentanyl and the U.S. Opioid Epidemic – Council on Foreign Relations

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Fentanyl and other opioids are fueling the worst drug crisis in the history of the United States. More than 1,500 Americans per week die from taking some type of opioid, making the drug by far the leading cause of fatal overdoses in the country. In recent years, the crisis has become defined by illicit fentanyl, an extremely lethal synthetic opioid. Illegal fentanyl supplies are largely produced in China and Mexico and then smuggled into the United States.
Analysts say the opioid epidemic started with the overprescription of legal pain medications in the 1990s, but it has intensified in recent years due to influxes of cheap heroin, fentanyl, and other synthetic opioids supplied by foreign drug cartels. The crisis has become a scourge on the economy, a threat to national security, and a major foreign policy challenge.
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Opioids, a class of drugs derived from the opium poppy plant, can be divided into two broad categories: legally manufactured medications and illicit narcotics. Opioid medications, including oxycodone, hydrocodone, morphine, and fentanyl, are often prescribed to treat severe pain, while methadone is primarily used in addiction treatment centers. 
The opioid crisis has been characterized by three distinct waves. The 1990s saw growth in overdose deaths from opioid-based medications, such as Percocet and Oxycontin, as physicians increasingly prescribed them for chronic conditions despite concerns about their safety and effectiveness. This period was followed by the rise of illegal heroin that marked a brief second wave in the early 2010s. And most recently, synthetic opioids—fentanyl in particular—have been driving a dramatic spike in overdose deaths since around 2013. 
Fentanyl was legally manufactured and prescribed [PDF] as an intravenous anesthetic beginning in the 1960s. While it remains an important drug in health-care settings, its illegal manufacture and distribution has become an extraordinary threat to public health. In 2022, the head of the U.S. Drug Enforcement Administration (DEA), Anne Milgram, said that “fentanyl is the single deadliest drug threat our nation has ever encountered.”
New combinations of synthetic opioids continue to crop up as well, complicating the crisis. Xylazine, a powerful chemical used in horse tranquilizers, and other novel opioids are reported to have far higher potency than pure fentanyl.
Overdoses involving synthetic opioids, primarily fentanyl, are the leading cause of U.S. deaths in people ages eighteen to forty-five. In 2021, the overall death toll surged to 80,411, more than ten times the number of U.S. military service members killed in the post-9/11 wars in Iraq and Afghanistan. A study by researchers at the Mayo Clinic and Yale University found that deaths from fentanyl alone nearly tripled from 2016 to 2021.
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The COVID-19 pandemic worsened the opioid epidemic. Disruptions to supply chains forced people to turn to drugs they were less familiar with, and social-distancing measures led more people to take drugs alone, which brings a greater risk of overdosing, analysts say.
Along with the pandemic, the growing availability of illicit fentanyl, often disguised by drug cartels to appear as legal prescription opioids, has exacerbated the crisis. In 2022, the DEA seized more than fifty million fentanyl-laced, fake prescription pills, more than double the amount seized the prior year. Over half of these fake pills contained potentially lethal amounts of fentanyl, the DEA says.
Fentanyl’s extreme potency also makes the drug more addictive and more deadly, further fueling the crisis. A lethal dose requires just two milligrams of the drug—an amount roughly equivalent to ten to fifteen grains of table salt.
Fentanyl’s deadly toll affects a broad swath of the American public. Among U.S. drug overdose deaths in 2021, fentanyl was the top killer [PDF] for all regions of the country and all age, race, and ethnic groups. Still, it hit some harder than others—American Indian and Alaska Native people, Black people, younger adults, and men died from fentanyl-linked overdoses at higher rates.
Another concerning trend is the rise of fentanyl deaths in youths between ten and nineteen years old. Fatal fentanyl overdoses nearly doubled in teens between 2019 to 2021. Experts attribute some of this rise to the ease of purchasing counterfeit pills through social media.  
Research has also shown that other demographic groups, including military veterans, people with disabilities, those who have lost a spouse, renters, and those without health insurance, have been disproportionately harmed by opioids. 
The opioid epidemic is taking a heavy toll on the U.S. economy, according to many reports. One of the most staggering and widely cited estimates, by the U.S. Congress Joint Economic Committee (JEC), found that the opioid epidemic cost the United States nearly $1.5 trillion in 2020, or 7 percent of gross domestic product (GDP) that year, an increase of about one-third since the cost was last measured in 2017. The JEC projected this increase would continue given the rise in fatal overdoses. This massive sum includes the price of health care to treat overdoses, the costs of fighting fentanyl trafficking and pursuing criminal justice efforts, and lost productivity in the workforce, as well as the economic costs of human lives lost to overdose and the reduced value of life for overdose survivors.  
Most fentanyl in the United States is smuggled across the border with Mexico, U.S. officials say. Smugglers send it across in vehicles or with pedestrians, who can travel with small, easily concealable amounts of the drugs because of its high potency compared to other illicit narcotics. The median weight seized is just 1.2 kilograms (2.6 pounds), which contains more than fifty thousand lethal doses. By December 2023, at least 12,245 kilograms (27,000 pounds) had been intercepted at the southern U.S. border this year.
China was the dominant source of fentanyl coming into the United States, but the flow has significantly decreased since authorities banned production of all fentanyl variants in 2019. However, China is still the leading manufacturer of fentanyl ingredients, known as precursor chemicals. Most of the fentanyl smuggled into the United States from Mexico is made from chemicals from China.  
Mexican drug cartels are the leaders in fentanyl production. Two organizations, the Sinaloa Cartel, and the Jalisco New Generation Cartel, manage most of the production and distribution networks, often depending on American citizens to smuggle fentanyl across the border. Between 2017 and 2021, 86 percent of fentanyl traffickers were American citizens.  
In October 2023, the Sinaloa Cartel looked to publicly signal that it was moving away from fentanyl trafficking amid an intensifying crackdown on its operations by U.S. and Mexican authorities. As one of two major suppliers, this would be a significant shift, but it remains unclear how genuine or effective Sinaloa’s transition will be.  
 
For decades, the U.S. government has worked with several other countries, particularly Mexico, to restrict the flow of illegal narcotics entering the country. For instance, through the Mérida Initiative [PDF], the United States provided Mexico with some $3.5 billion in security and counternarcotics aid between 2008 and 2021, including for purchases of military aircraft and surveillance software. (Under Mexican President Andrés Manuel López Obrador, Mexico has broadly resisted cooperation with the United States on the issue, claiming that it does not produce fentanyl.) However, the sharp rise in fentanyl-related deaths in recent years has raised alarm in Washington, with lawmakers calling for a dramatic shift in U.S. drug policy.
President Joe Biden has made the fentanyl crisis a domestic and foreign policy priority, although the death toll from fentanyl overdoses has continued to climb during his time in office. In late 2021, he declared synthetic-opioid trafficking a national emergency and signed two executive orders allowing his administration to sanction individuals and entities associated with the production and dissemination of fentanyl. In late 2023, the U.S. government sanctioned twenty-five China-based firms and individuals it believed to be involved in producing fentanyl precursor chemicals. And Biden added China to the U.S. list of major illicit drug-producing and drug-transit countries, where it joins twenty-two others, including Colombia, India, and Mexico. 
Amid these efforts, the Biden administration has kept up pressure on Mexico to intercept precursors received from China and to crack down on clandestine labs in its own country. And in November 2023, on the sidelines of the Asia-Pacific Economic Cooperation summit, President Biden reached separate agreements with Chinese President Xi Jinping and Mexican President López Obrador to increase bilateral cooperation on the preventing manufacturing and distribution of illicit fentanyl.  
At the same time, the Biden administration is attempting to curb illicit opioid distribution domestically. Federal regulators have introduced new limits on opioid prescriptions and increased focus on seizing fentanyl and raising public awareness of the drug’s lethality. In 2022, the DEA seized double the amount of fentanyl compared to the prior year, and it released a public alert about fake prescription drugs laced with fentanyl—six out of ten fake pills contain a lethal dose of the drug.
To ameliorate the drug’s harm, in March 2023, the Food and Drug Administration (FDA) approved the naloxone nasal spray Narcan as the first over-the-counter drug to reverse fentanyl overdoses. Experts say the public sale of Narcan, which became available in many chain pharmacies beginning in September, marks a significant step forward in efforts to combat the epidemic, but it is not a panacea due to cost and accessibility challenges. 
To better respond to the current crisis, experts have suggested more research and development and applying alternative approaches, such as supervised consumption sites, improved disruption of illicit online transactions, intensified border inspection, and better overdose-prevention and employee-assistance programs.
For Think Global Health, CFR Senior Fellow David P. Fidler disentangles the foreign policy implications of stemming the flow of fentanyl into the United States. 
In a series of charts, CFR’s Mariel Ferragamo and Diana Roy visualize how fentanyl is a major U.S. foreign policy problem
On this episode of the Why It Matters podcast, CFR experts Thomas J. Bollyky and Zongyuan Zoe Liu explore China’s role in the U.S. fentanyl challenge
For Foreign Affairs, Brooking Institution’s Vanda Felbab-Brown looks at the geopolitics of synthetic opioids and why the United States is struggling to stop its epidemic
In Empire of Pain, writer Patrick Radden Keefe chronicles the Sackler dynasty’s role in the opioid crisis through Purdue Pharma’s marketing of OxyContin.
Antonio Barreras Lozano, Nathalie Bussemaker, and Alejandra Martinez contributed to this Backgrounder. Will Merrow helped create the graphic.
Corrections: A previous version of this article misnamed the Drug Enforcement Administration. 
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