Illegal opioid use in the United States is much higher than previously thought

A new study shows that the use of illicit opioids in the United States is more extensive than official estimates suggest, and the researchers found that the rate is more than 20 times higher than previously reported. The study, published on May 9, 2025, depicts disturbing photos of the ongoing opioid crisis in the United States and raises urgent questions about how we can track and resolve this public health emergency.

Shocking digital challenge official statistics

A nationwide survey of 1,515 U.S. adults found that nearly 11% of people reported using illegal opioids over the past year, including 7.5% who specifically reported the use of illegally produced fentanyl (IMF) (a synthetic opioid that has resulted in most overdose deaths in recent years).

These findings are in stark contrast to the National Survey on Drug Use and Health (NSDUH), which reported that only 0.3% of adults used illegally made fentanyl in 2022. The huge gap between these estimates suggests that traditional monitoring methods may severely underestimate the true scale of the crisis.

“Estimates of illicit opioid use are rare, and we usually get our ability to monitor trends in the near future only a few years after information is collected,” said David Powell, a senior economist at the nonprofit research organization Rand, the study’s lead author. “Our study provides a way to quickly and repeatedly monitor low-cost illicit opioid prevalence.”

Intentional and unintentional use

One of the innovative aspects of the study was the distinction between intentional use of illicit opioids, indicating that about 7.7% of participants reported intentional over-the-counter opioid use, while another 3.2% reported unintentional use.

For fentanyl, the researchers found:

• 4.9% of adults intentionally use illegally made fentanyl
• 2.6% of people accidentally use illegally made fentanyl reports
• More than one-third of adults using illicit fentanyl report that they would have experienced an overdose
• Most people using the IMF recognize the increased risks associated with use

These differences highlight the complexity of the crisis, suggesting that a large portion of fentanyl exposure occurs without user knowledge – findings of hazard reduction strategies such as the distribution of fentanyl test strips and naloxone.

Prescription opioids still play a key role

Although the crisis is moving towards synthetic opioids, research has found that prescription drugs are still an important avenue for illegal use. Among the respondents who reported illegal opioid use in the past year:

39% reported their first opioid experience involved giving them the medication, while 36% said their first use was a prescription opioid obtained from others. Only 25% of illegal opioids start directly.

These findings suggest that although fentanyl currently dominates in overdose deaths, policies targeting prescription habits remain relevant to addressing the broader crisis.

Who is most affected?

The study identified several demographic patterns associated with higher illicit opioid use. Men reported interest rates 5.4 percentage points higher than women. Black respondents were 6.6 percentage points higher than other racial groups, while Hispanic participants were 5.5 percentage points higher.

Age is a particularly important factor, with the reporting rate of adults aged 18-34 years old is nearly 24 percentage points higher than that of adults aged 55 and above. People aged 35-54 were 17.4 percentage points higher than those in the elderly group.

Perhaps surprisingly, the study did not find statistically significant geographical differences in illicit opioid use in various regions, although the authors noted that the study may not have sufficient capacity to detect such changes.

Why are the results different?

Why did this study find that illicit fentanyl is used 25 times faster than federal estimates? The researchers raised several possibilities, including differences in survey methods and question wording.

The researchers noted that “the reasons for the differences are not clear, but they may be related to how the federal investigation asked participants about the use of illegal opioids.” Noting that about half of the federal investigations were conducted in person, which could prevent honest reporting of illegal drug use.

The online format of the new survey may encourage more candid responses to sensitive behaviors, although the authors acknowledge that this approach has its own limitations.

Impact on public health response

If these higher estimates are accurate, they suggest that the opioid crisis affects a much larger U.S. population than previously recognized. This has profound implications for how we allocate resources for prevention, treatment and damage reduction.

Using its estimates with CDC overdose data, the researchers calculated that about 0.32% of people who use illicit fentanyl each year die from overdose – a striking figure that highlights the deadly nature of the current crisis.

“Ultimately, the data presented here should be viewed as a substantial data point to understand and reduce the ongoing opioid crisis,” said Mireille Jacobson, co-author of the study. “Not only does we need to evaluate where we are in the pandemic, but more real-time information is needed, and more importantly, whether we are making progress in re-cultivating it.”

This study promptly reminds you that despite years of attention and action, the opioid crisis in the United States may be more common and complex than we recognize. As synthetic opioids continue to dominate the illicit drug landscape, developing more accurate and responsive monitoring systems seems crucial to effective public health responses.

The researchers plan to conduct follow-up studies using a stronger investigative approach to further validate these findings.