Illicit Opioid Use in America Far Higher Than Previously Thought

A new study has revealed that illicit opioid use in the United States is dramatically more widespread than official estimates suggest, with researchers finding rates more than 20 times higher than previously reported. The research, published May 9, 2025, in JAMA Health Forum, paints a troubling picture of America’s ongoing opioid crisis and raises urgent questions about how we track and address this public health emergency.

Shocking Numbers Challenge Official Statistics

The nationwide survey of 1,515 American adults found that nearly 11% reported using illicit opioids within the past year, including 7.5% who specifically reported using illicitly manufactured fentanyl (IMF) – the synthetic opioid responsible for the majority of overdose deaths in recent years.

These findings stand in stark contrast to the National Survey on Drug Use and Health (NSDUH), which reported that just 0.3% of adults used illicitly manufactured fentanyl in 2022. The enormous gap between these estimates suggests that traditional monitoring methods may be severely underestimating the true scale of the crisis.

“Estimates of illicit opioid use are rare and typically are available only years after the information is collected, limiting our ability to monitor trends on a near-term basis,” said David Powell, the study’s lead author and a senior economist at RAND, a nonprofit research organization. “Our study offers a method to quickly and repeatedly monitor illicit opioid prevalence at low-cost.”

Intentional vs. Unintentional Use

One of the study’s innovative aspects was distinguishing between intentional and unintentional use of illicit opioids, revealing that about 7.7% of participants reported intentional nonprescription opioid use, while another 3.2% reported unintentional use.

For fentanyl specifically, the researchers found:

• 4.9% of adults reported intentionally using illicitly manufactured fentanyl
• 2.6% reported unintentionally using illicitly manufactured fentanyl
• Over one-third of adults using illicit fentanyl reported it was “very likely” they would experience an overdose
• Most people using IMF recognized the heightened risk associated with its use

These distinctions highlight the complexity of the crisis, showing that a significant portion of fentanyl exposure happens without users’ knowledge – a finding with important implications for harm reduction strategies such as fentanyl test strips and naloxone distribution.

Prescription Opioids Still Play a Critical Role

Despite the crisis’s evolution toward synthetic opioids, the study found that prescription medications remain a significant pathway to illicit use. Among respondents reporting illicit opioid use in the past year:

39% reported their first opioid experience involved medication prescribed to them personally, while 36% said their first use was with prescription opioids obtained from someone else. Only 25% began directly with illicit opioids.

These findings suggest that despite the current dominance of fentanyl in overdose deaths, policies targeting prescription practices remain relevant in addressing the broader crisis.

Who Is Most Affected?

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

Age was an especially significant factor, with adults aged 18-34 reporting rates nearly 24 percentage points higher than those 55 and older. Those aged 35-54 showed rates 17.4 percentage points higher than the older group.

Perhaps surprisingly, the research did not find statistically significant geographic differences in illicit opioid use across regions, though the authors note the study may not have been sufficiently powered to detect such variations.

Why Such Different Results?

Why would this study find rates of illicit fentanyl use 25 times higher than federal estimates? The researchers suggest several possibilities, including differences in survey methodology and question wording.

“The reasons for the differences are unclear, but they may relate to the way the federal survey asks participants about illicit opioid use,” the researchers note, pointing out that about half of the federal surveys are conducted in person, which might discourage honest reporting of illicit drug use.

The online format of the new survey may have encouraged more candid responses about sensitive behaviors, though the authors acknowledge this approach has its own limitations.

Implications for Public Health Response

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

Using their estimates alongside CDC overdose data, the researchers calculated that approximately 0.32% of people using illicit fentanyl die from overdose annually – a sobering figure that highlights the lethal nature of the current crisis.

“Ultimately, the data presented here should be treated as a substantive data point for understanding and curtailing the ongoing opioid crisis,” said Mireille Jacobson, the study’s co-author and an economist at the University of Southern California. “More near real-time information is needed to evaluate not only where we are in the epidemic, but, more importantly, whether we are making progress in reining it in.”

This research provides a timely reminder that despite years of attention and action, America’s opioid crisis may be both more pervasive and more complex than we’ve recognized. As synthetic opioids continue to dominate the illicit drug landscape, developing more accurate and responsive monitoring systems appears increasingly crucial to effective public health response.

The researchers plan to conduct follow-up studies using more robust survey methods to further validate these concerning findings.