The Opioid Crisis in the United States: A Brief History
Opioids act on receptors in the brain that are important in regulating pain and emotion. For centuries, opioids have been used as medicines to manage or treat pain. Natural opioids (sometimes referred to as opiates), such as morphine, are derived from the opium poppy plant, while synthetic opioids like methadone and fentanyl are made entirely in a laboratory. Semi-synthetic opioids, which include heroin and many prescription pain medications such as oxycodone and hydrocodone, are synthesized from naturally occurring opium products, such as morphine and codeine. Opioids—particularly those with higher potencies—can pose significant dangers, such as dependence and overdose resulting in death.
The Opioid Crisis in the United States
In the 1990s, the intensified marketing of newly reformulated prescription opioid medications (e.g., OxyContin) and an influential pain advocacy campaign that encouraged greater pain management led to a precipitous rise in opioid use in the United States. Research from the Centers for Disease Control and Prevention (CDC) shows that prescription opioid sales in the United States quadrupled from 1999 to 2010. At the same time, opioid misuse and opioid-involved overdose deaths increased (Figure 1). Between 1999 and 2010, the rate of opioid-involved overdose deaths in the United States doubled from 2.9 to 6.8 deaths per 100,000 people. This initial rise in opioid-related deaths is often referred to as the first wave of the recent opioid crisis.
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Figure 1. Drug-Related Overdose Deaths in the United States, by Opioid Involvement, 1999-2020 |
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Source: CRS analysis using data from CDC WONDER. |
Heroin
Around the time that the opioid crisis's first wave was unfolding, retail prices for heroin—an illegal opioid in the United States—began to decline. Around 2010, the predominant source of heroin in the United States shifted from South America to Mexico. Increases in Mexican production ensured a reliable supply of low-cost heroin. As prices declined and availability increased, heroin-related overdose deaths began to rise. From 2010 to 2016, the rate of heroin-involved deaths increased from 1 to 4.9 per 100,000. In 2015, heroin surpassed prescription medications as the leading opioid involved in overdose deaths. The rise in heroin-involved deaths has been referred to as the second wave of the opioid crisis in the United States.
Fentanyl
In 2016, synthetic opioids—led by fentanyl—surpassed heroin and prescription drugs as the leading type of opioids involved in U.S. overdose deaths. Fentanyl is a synthetic opioid and is up to 50 times stronger than heroin. Pharmaceutical fentanyl is used to treat severe pain. Illicit, non-pharmaceutical fentanyl and similar chemical formulations, known as analogues, are used illegally as recreational drugs. While some pharmaceutical fentanyl is diverted for recreational use, most fentanyl-related overdoses involve illicit, non-pharmaceutical fentanyl. This form is manufactured primarily in Mexico with chemical inputs, or precursors, from China and smuggled across the southwest border. Illicit fentanyl is used by itself, mixed with other drugs (e.g., heroin or cocaine), or pressed into counterfeit prescription pills, sometimes without the consumer's knowledge. From 2015 to 2020, the rate of opioid-involved overdose deaths—driven by fentanyl—once again doubled, from 10.4 to 21.4 per 100,000. The rise in fentanyl-involved overdose deaths is often referred to as the third wave of the U.S. opioid crisis (Figure 2).
U.S. Efforts to Address the Crisis
Between 1999 and 2020, 565,000 Americans died of opioid-involved overdoses. In turn, federal, state, and local governments responded with various legal and policy efforts to curb opioid misuse and drug-related overdose deaths.
Major Federal Legislation
Recent Congresses have enacted several laws addressing the opioid crisis, such as the Comprehensive Addiction and Recovery Act of 2016 (CARA, P.L. 114-198); the 21st Century Cures Act (P.L. 114-255); the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act, P.L. 115-271); the Fentanyl Sanctions Act (Title LXXII of P.L. 116-92); and the Blocking Deadly Fentanyl Imports Act (P.L. 117-81, §6610). These laws addressed overprescribing and misuse of opioids, expanded substance use disorder prevention and treatment capacities, bolstered drug diversion capabilities, and enhanced international drug interdiction, counternarcotics cooperation, and sanctions efforts. Congress also directed additional funds to many of these initiatives through appropriations.
Substance Use Prevention and Treatment
Certain federal efforts have focused on increasing the availability of substance use prevention, treatment, and recovery services nationwide. Over the past decade, Congress increased federal funding for evidence-based initiatives for opioid use, such as medication-assisted treatment (MAT) and peer recovery networks. For instance, Congress has provided more than $1 billion annually since FY2018 to the Substance Abuse and Mental Health Services Administration for a new State Opioid Response grant program. Additional funding has also been provided to CDC for opioid surveillance activities and to the Health Resources and Services Administration to enhance the behavioral health workforce.
Congress has supported certain harm reduction strategies that emphasize prevention of adverse events associated with substance use, such as overdose and disease transmission. For example, Congress provided funding in the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) for syringe services programs (often known as needle exchange programs) and other harm reduction initiatives. Federal and state harm reduction strategies have frequently involved the distribution of naloxone (e.g., Narcan)—a medication used to reverse an opioid overdose—and test strips used to detect fentanyl in drug samples. Some states and localities have explored the use of supervised consumption sites, though these facilities have yet to be endorsed by the federal government and their legal status under federal law is unclear.
In addition to receiving federal funds, state, local, and tribal governments have sought to support their prevention and treatment efforts by pursuing a substantial number of civil lawsuits against entities along the prescription opioid supply chain. These cases have begun to result in substantial settlements that require portions of the settlement fund to be used for abatement strategies, such as increasing access to MAT and naloxone.
Reducing Domestic Diversion and Illicit Trafficking
The federal government has also partnered with state and local authorities to reduce opioid trafficking and curb opioid misuse. The Department of Justice (DOJ) and Department of Homeland Security (DHS) aim to reduce the diversion of prescription opioids and the use, manufacturing, and trafficking of illicit opioids. DOJ—via the Drug Enforcement Administration (DEA)—regulates opioid manufacturers, distributors, and dispensers; it also controls the opioid supply through enforcement of regulatory requirements. DEA has initiated enforcement proceedings against various entities and individuals in the drug supply chain for violations of the Controlled Substances Act (CSA). The agency also combats drug trafficking to and within the United States. DOJ provides grants to state and local agencies to support oversight of opioid-prescribing practices through prescription drug monitoring programs (PDMPs), drug courts redirecting individuals from the criminal justice system to substance use treatment, and law enforcement efforts to disrupt domestic drug trafficking, among other initiatives. DHS, via Customs and Border Protection and the U.S. Coast Guard, conducts counterdrug operations at U.S. borders.
Congress has considered how to regulate fentanyl-related substances. While fentanyl and multiple fentanyl analogues are controlled substances subject to the CSA, other chemicals related to fentanyl are not currently expressly scheduled but may be regulated as controlled substance analogues. Such scheduling may allow for less effective control than if the substances were expressly scheduled under the CSA. In 2018, DEA placed a class of over 3,000 fentanyl-related substances under temporary CSA control. Since that time, Congress has extended the temporary control via legislation while it further considers the issue.
Foreign Supply Reduction
The United States has taken a multipronged foreign policy approach to addressing foreign flows of illicit opioids. To date, this approach has included multilateral diplomacy, bilateral efforts, and unilateral action involving several federal departments and agencies. Multilaterally, the State Department (DOS) has led efforts at the United Nations to control synthetic opioids and precursors. DOS also provides bilateral assistance to countries, including Mexico, to combat illicit production and trafficking of opioids. This assistance includes provisions of synthetic opioid detection equipment, clandestine laboratory dismantlement and disposal capabilities support, and justice sector and investigatory capacity building. The Department of Defense supports bilateral and regional counterdrug activities and leads in monitoring and detecting air and maritime illicit drug flows into the United States. Federal law enforcement agencies, such as DEA, maintain a robust global presence through attaché offices and specialized units for joint investigations with foreign counterparts. The U.S. Department of the Treasury administers counternarcotics sanctions programs aimed at international drug traffickers, their associates, and affiliated financial structures.