Why Does America Have an Opioid Epidemic?

Published April 19, 2019 · Updated October 22, 2026

Medically reviewed by Danesh Alam MD, DFAPA, DFASAM

A doctor in a white coat and blue scrubs shows a folder to a woman seated on an exam table.

America's opioid epidemic grew in waves. The CDC traces it to a rise in opioid prescribing in the 1990s, a surge in heroin deaths starting in 2010, and illegally made fentanyl from 2013 on. Heavy marketing of prescription opioids helped start it. A very strong illegal fentanyl supply made it deadlier, and too few people got treatment.

Overdose deaths have fallen since 2023 but remain high. If someone cannot be woken or is not breathing normally, call 911 now and give naloxone if you have it.

What are the waves of the opioid epidemic?

The CDC describes three waves, each driven by a different kind of opioid. CDC: Understanding the opioid overdose epidemic

Prescription opioids, from the 1990s. The first wave "began with increased prescribing of opioids in the 1990s." Overdose deaths involving prescription opioids rose starting around 1999.
Heroin, from 2010. The second wave brought "rapid increases in overdose deaths involving heroin."
Illegally made fentanyl, from 2013. The third wave brought large increases in deaths involving synthetic opioids, mainly illegally made fentanyl and similar drugs.

Some researchers now describe a fourth wave: deaths involving methamphetamine and cocaine, often used with fentanyl or mixed with it. One review says this rise in stimulant deaths "appears entwined with the ongoing opioid epidemic." Curr Opin Psychiatry: The fourth wave of the opioid overdose crisis The CDC reports that in 2023, in the states and areas it tracked for this, nearly 47% of overdose deaths involved both opioids and stimulants. CDC: Understanding the opioid overdose epidemic

The overall toll is large. From 1999 to 2023, about 806,000 people in the U.S. died of an opioid overdose. In 2023, opioids were involved in about 76% of all overdose deaths.

How did prescribing and marketing start the epidemic?

The first wave grew out of a large rise in opioid prescribing for everyday pain, helped by aggressive drug marketing. Opioids work by attaching to opioid receptors on nerve cells, which relieves pain and can cause feelings of happiness and relaxation. They also affect the brain centers that control breathing, which is why an overdose can slow or stop a person's breathing. NIDA: Opioids

The amount of opioids prescribed per person in the U.S. rose more than fourfold from 1999 to its 2010 peak. Prescribing stayed near that peak through 2012, at about 81 prescriptions per 100 people. CDC MMWR: Changes in opioid prescribing, 2006 to 2015

OxyContin is the best-documented example of how marketing fed that rise. A 2009 analysis in the American Journal of Public Health found that OxyContin sales grew from $48 million in 1996 to almost $1.1 billion in 2000. Prescriptions for non-cancer pain rose from about 670,000 in 1997 to about 6.2 million in 2002. The maker, Purdue Pharma, roughly doubled its sales force over the late 1990s and trained representatives to say the risk of addiction was "less than one percent." It also offered coupons for free starter supplies. In 2007, a Purdue affiliate and three executives pleaded guilty to criminal charges of misbranding OxyContin. AJPH: The promotion and marketing of OxyContin

Prescribing has since come down. The CDC issued prescribing guidance in 2016 and a broader guideline in 2022. CDC: 2022 opioid prescribing guideline By 2024, pharmacies dispensed 35.4 opioid prescriptions per 100 people, down from 46.8 in 2019. CDC: Opioid dispensing rate maps But by then many people already had an opioid use disorder, and deaths had shifted to heroin and then fentanyl.

Why did fentanyl make the epidemic so much deadlier?

Fentanyl made the epidemic deadlier because it is extremely strong and is often mixed into other drugs without the buyer knowing. The CDC says fentanyl is "up to 50 times stronger than heroin and 100 times stronger than morphine." Illegally made fentanyl is commonly mixed into heroin, cocaine, and methamphetamine, and pressed into pills made to look like prescription opioids. You "wouldn't be able to see it, taste it, or smell it." CDC: Fentanyl facts

Most fentanyl harm comes from the illegal supply, not from prescriptions. Pharmaceutical fentanyl does not come in pill form, so a pill bought outside a pharmacy that contains fentanyl was made illegally. In 2023, synthetic opioids other than methadone were involved in about 69% of all U.S. overdose deaths. CDC: Fentanyl

Fake pills are part of that risk. In a CDC study, the share of overdose deaths with signs of counterfeit pill use more than doubled from mid-2019 to late 2021, and illegally made fentanyl was involved in 93% of those deaths. CDC MMWR: Overdose deaths with evidence of counterfeit pill use Federal survey researchers also warn that people may take fentanyl without knowing it, in products sold as heroin or as counterfeit prescription drugs. SAMHSA: 2025 NSDUH highlights

Why don't more people get treatment?

Most people with an opioid use disorder still do not get the medications proven to lower their risk of dying. In 2025, about 4.0 million Americans aged 12 or older had an opioid use disorder. Only 15.7% of them, about 623,000 people, received medication for opioid use disorder in the past year. SAMHSA: 2025 NSDUH annual national report

The gap is wider than medication. Among people who needed any substance use treatment in 2025, only about 1 in 6 received it. Among adults with a substance use disorder who went untreated, 94.5% did not seek treatment or think they needed it. SAMHSA: 2025 NSDUH highlights

Some barriers are built into how care is delivered. Methadone for opioid use disorder can be dispensed only through a certified opioid treatment program, which can mean frequent visits. SAMHSA: Methadone Access to buprenorphine has widened: since a 2023 federal law, any clinician with the right DEA registration can prescribe it for opioid use disorder, if state law allows. SAMHSA: Waiver elimination (MAT Act)

Are opioid overdose deaths going down?

Yes. Deaths have been falling since 2023, though they remain high. In CDC's most recent provisional count, about 66,478 people died of a drug overdose in the U.S. in the 12 months ending May 2026. That is CDC's predicted figure, which adjusts for reports still coming in. About 41,311 of those deaths involved opioids. CDC/NCHS: Provisional drug overdose death counts

In plain terms:

Down from a year earlier. The 12 months ending May 2025 had about 75,094 predicted overdose deaths, so the latest total is about 11% lower.
Down from the peak. The highest point was about 112,418 predicted deaths in the 12 months ending August 2023. The latest count is about 41% lower.
Still mostly opioids. About 6 in 10 overdose deaths in the latest period involved an opioid, and most of those involved fentanyl or similar synthetic opioids.

In Florida, the CDC counts about 4,001 predicted drug overdose deaths in the 12 months ending May 2026, down from 4,318 a year earlier. CDC: Provisional drug overdose death counts dataset

Treat these as early numbers. The CDC flags the newest months as likely undercounted, because some states are reporting deaths more slowly than usual, and counts can change when final data come in. The figures show that fewer people are dying. They do not, on their own, explain why.

What works to prevent opioid overdose deaths?

Naloxone, medication for opioid use disorder, and fentanyl test strips each lower the risk of dying.

Naloxone. Naloxone reverses an opioid overdose. In March 2023, the FDA approved Narcan nasal spray for sale without a prescription. FDA: First over-the-counter naloxone nasal spray It is now sold over the counter in all 50 states, at pharmacies, grocery stores, and gas stations. More than one dose may be needed when fentanyl is involved. Naloxone will not harm someone whose overdose is caused by something other than opioids. CDC: Lifesaving naloxone Our guide to Narcan and naloxone explains more.
Medication for opioid use disorder (MOUD). The FDA has approved three medicines for opioid use disorder: buprenorphine, methadone, and extended-release naltrexone. The FDA says all three "have been demonstrated to be safe and effective." FDA: Medications for opioid use disorder People treated with methadone or buprenorphine are less likely to die or to overdose than people who get no treatment. NIDA: Medications for opioid use disorder
Fentanyl test strips, where legal. The strips are inexpensive and usually give a result within 5 minutes. They might miss stronger fentanyl-like drugs such as carfentanil, so a negative result does not mean a drug is safe. CDC: Fentanyl facts In Florida, test products used only to check whether a drug contains fentanyl or xylazine are not considered drug paraphernalia. Florida Statutes 893.145 Laws differ by state.

Newer additives are also showing up in the supply. Our article on xylazine and nitazenes explains what Florida families should know about them.

What should you do if someone overdoses?

Call 911 and give naloxone right away. Signs of an opioid overdose include being unable to wake up; slow or shallow breathing, or choking sounds; discolored lips or nails; and tiny "pinpoint" pupils. CDC: Responding to an overdose

Call 911.
Give naloxone if you have it, following the package directions. If there is no response, a second dose may be needed.
Try to keep the person awake and breathing.
Lay them on their side to prevent choking.
Stay with them. After giving naloxone, the CDC advises staying until emergency help arrives or for at least four hours. CDC: Lifesaving naloxone

If someone in your home uses opioids, or any drug bought outside a pharmacy, keep naloxone where everyone can find it.

How can someone get help for opioid use?

Start with a medical assessment, and ask about medication for opioid use disorder. For free, confidential referrals at any hour, in English or Spanish, call SAMHSA's National Helpline at 1-800-662-4357. SAMHSA: National Helpline If you or someone you love is in crisis, call or text 988. 988 Suicide & Crisis Lifeline

At Ambrosia, care for opioid addiction and fentanyl addiction often starts with medical detox at Midwest Detox in West Palm Beach, which has 24/7 medical supervision by physicians and nurses. Medication-assisted treatment is provided through our detox center, and whether it fits is a clinical decision made with you. Detox is the first step, not the whole treatment. To plan what comes next, read what happens after detox.

Frequently asked questions

What caused the opioid epidemic?

The CDC traces the first wave to increased opioid prescribing in the 1990s, which aggressive marketing of drugs like OxyContin helped drive. Later waves came from heroin and then illegally made fentanyl, which is much stronger and often mixed into other drugs.

When did the opioid epidemic start?

The CDC dates the first wave to the 1990s, with prescription opioid overdose deaths rising from around 1999. Heroin deaths rose quickly from 2010, and fentanyl deaths from 2013.

What is the fourth wave of the opioid epidemic?

It is the term researchers use for rising deaths involving stimulants such as methamphetamine and cocaine, often together with fentanyl. In 2023, nearly half of overdose deaths in the areas the CDC tracked involved both opioids and stimulants.

Is the opioid epidemic getting better?

Overdose deaths are falling. CDC provisional data count about 66,478 overdose deaths in the 12 months ending May 2026, about 41% below the 2023 peak. That is still tens of thousands of deaths a year, most involving opioids.