Research: U.S. Illicit Opioid Use Is 20 Times Higher Than Previous Estimates

More than one in 10 American adults (11 percent) reported illicit opioid use within the past 12 months, and 7.5 percent reported the use of illicitly produced fentanyl during the same period—rates that are more than 20 times higher than estimates from a large annual federal study.

The federal National Survey on Drug Use and Health reported that only 3.1 percent of people in the United States aged 12 or older misused opioids in 2023—primarily misusing prescription pain relievers. This estimate does not include illegally made fentanyl (IMF). For IMF in particular, the survey tabulated that only 0.3 percent of people in the United States—or 828,000 people—misused fentanyl in 2023 (the latest numbers available). IMF can sometimes be added to counterfeit prescription drugs, though, making it more difficult to track.

The survey cautioned that, “Because people who used IMF may have been unaware that they used it, caution must be taken in interpreting estimates of IMF use; these estimates are almost certainly an underestimate of true IMF use.”

The new RAND study—published in the JAMA Health Forum journal—found that this undercount is likely more complicated than looking just at unwitting IMF use. The researchers noted that the way the federal survey is conducted may skew results. About half of the federal surveys are done in person, which could inhibit participants from reporting illicit drug use.

The researchers from RAND and the University of Southern California used a representative online panel of 1,515 American adults to ask about nonprescription opioid use, including heroin and IMF. The survey also asked if participants intentionally or unintentionally used illicit opioids or IMF—7.7 percent reported intentional nonprescription opioid use, and 3.2 percent reported unintentional use. Most people who used nonprescription opioids also reported illicit fentanyl use.

“Among respondents reporting nonprescription opioid use within the past 12 months, 39 percent reported their first use of opioids involved medication prescribed to them, while 36 percent reported their first use involved prescription opioids not prescribed to them,” RAND reported. “The remaining 25 percent answered that their first exposure to opioids involved illicitly manufactured opioids.”

The pathway to illicit opioid use is a murky one. Information on initial opioid use is scant, the RAND study said, and “attention to the role of prescription opioids has waned, even though overdose deaths from prescription opioids remain high and prescription opioids may operate as critical pathways to illicit opioid use.”

The study called out the need for more timely information and resources about the opioid and fentanyl crisis, including online surveys that leverage demographic quotas to match the national population. These time-sensitive surveys can focus more on usage rates, rather than outcomes like overdoses and infectious diseases.

“Understanding the current size of the illicit opioid market is critical for forecasting treatment need and assessing the value of regulatory and policy decisions such as making naloxone available over the counter or distributing fentanyl test strips,” the report said. “Furthermore, such information is needed to gauge the harms associated with illicit opioid use and the extent to which use is pervasive, risky, or both.”

There are still limitations to online surveys and other speedier methods of data collection. RAND noted that the survey sample required Internet access—which eliminates a number of potential respondents. Additionally, a larger percentage of survey respondents said they had achieved a higher education level compared to the current population percentage, potentially biasing the findings.

“Despite the importance of and widespread interest in understanding the prevalence of illicit opioid use in the US, efforts to assess this information in a timely manner are limited,” the report concluded. “This study fielded a survey that could be part of a national toolkit to quickly and repeatedly monitor illicit opioid prevalence at low cost. The findings of this study suggest that illicit opioid use may be more common than previously reported. Although there are trade-offs in how information has been collected in prior surveys relative to this study, our results are consistent with reports indicating substantial underreporting of illicit opioid use in ongoing national surveys.”