The Opioid Crisis in the United States: A Brief History

The Opioid Crisis in the United States: A Brief History

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December 1, 2022
The Opioid Crisis in the United States: A Brief History
Opioids act on receptors in the brain that are important in
of heroin-involved deaths increased from 1 to 4.9 per
regulating pain and emotion. For centuries, opioids have
100,000. In 2015, heroin surpassed prescription
been used as medicines to manage or treat pain. Natural
medications as the leading opioid involved in overdose
opioids (sometimes referred to as opiates), such as
deaths. The rise in heroin-involved deaths has been referred
morphine, are derived from the opium poppy plant, while
to as the second wave of the opioid crisis in the United
synthetic opioids like methadone and fentanyl are made
States.
entirely in a laboratory. Semi-synthetic opioids, which
include heroin and many prescription pain medications such
Figure 2. Opioid-Involved Overdose Deaths in the
as oxycodone and hydrocodone, are synthesized from
United States, by Opioid Type, 1999-2020
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
Source: CRS analysis using data from CDC WONDER.
that prescription opioid sales in the United States
Notes: Overdose deaths may involve more than one opioid and
quadrupled from 1999 to 2010. At the same time, opioid
should not be summed. Natural and semi-synthetic opioids includes
misuse and opioid-involved overdose deaths increased
prescription opioid medications other than methadone. Synthetic
(Figure 1). Between 1999 and 2010, the rate of opioid-
opioids consists primarily of fentanyl and fentanyl analogues. Heroin
involved overdose deaths in the United States doubled from
and methadone are classified separately in CDC mortality data.
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
Fentanyl
the recent opioid crisis.
In 2016, synthetic opioids—led by fentanyl—surpassed
Figure 1. Drug-Related Overdose Deaths in the
heroin and prescription drugs as the leading type of opioids
United States, by Opioid Involvement, 1999-2020
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
Source: CRS analysis using data from CDC WONDER.
consumer’s knowledge. From 2015 to 2020, the rate of
opioid-involved overdose deaths—driven by fentanyl—
Heroin
once again doubled, from 10.4 to 21.4 per 100,000. The rise
Around the time that the opioid crisis’s first wave was
in fentanyl-involved overdose deaths is often referred to as
unfolding, retail prices for heroin—an illegal opioid in the
the third wave of the U.S. opioid crisis (Figure 2).
United States—began to decline. Around 2010, the
predominant source of heroin in the United States shifted
U.S. Efforts to Address the Crisis
from South America to Mexico. Increases in Mexican
Between 1999 and 2020, 565,000 Americans died of
production ensured a reliable supply of low-cost heroin. As
opioid-involved overdoses. In turn, federal, state, and local
prices declined and availability increased, heroin-related
governments responded with various legal and policy
overdose deaths began to rise. From 2010 to 2016, the rate
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The Opioid Crisis in the United States: A Brief History
efforts to curb opioid misuse and drug-related overdose
opioid misuse. The Department of Justice (DOJ) and
deaths.
Department of Homeland Security (DHS) aim to reduce the
diversion of prescription opioids and the use,
Major Federal Legislation
manufacturing, and trafficking of illicit opioids. DOJ—via
Recent Congresses have enacted several laws addressing
the Drug Enforcement Administration (DEA)—regulates
the opioid crisis, such as the Comprehensive Addiction and
opioid manufacturers, distributors, and dispensers; it also
Recovery Act of 2016 (CARA, P.L. 114-198); the 21st
controls the opioid supply through enforcement of
Century Cures Act (P.L. 114-255); the Substance Use-
regulatory requirements. DEA has initiated enforcement
Disorder Prevention that Promotes Opioid Recovery and
proceedings against various entities and individuals in the
Treatment for Patients and Communities Act (SUPPORT
drug supply chain for violations of the Controlled
Act, P.L. 115-271); the Fentanyl Sanctions Act (Title
Substances Act (CSA). The agency also combats drug
LXXII of P.L. 116-92); and the Blocking Deadly Fentanyl
trafficking to and within the United States. DOJ provides
Imports Act (P.L. 117-81, §6610). These laws addressed
grants to state and local agencies to support oversight of
overprescribing and misuse of opioids, expanded substance
opioid-prescribing practices through prescription drug
use disorder prevention and treatment capacities, bolstered
monitoring programs (PDMPs), drug courts redirecting
drug diversion capabilities, and enhanced international drug
individuals from the criminal justice system to substance
interdiction, counternarcotics cooperation, and sanctions
use treatment, and law enforcement efforts to disrupt
efforts. Congress also directed additional funds to many of
domestic drug trafficking, among other initiatives. DHS, via
these initiatives through appropriations.
Customs and Border Protection and the U.S. Coast Guard,
conducts counterdrug operations at U.S. borders.
Substance Use Prevention and Treatment
Certain federal efforts have focused on increasing the
Congress has considered how to regulate fentanyl-related
availability of substance use prevention, treatment, and
substances. While fentanyl and multiple fentanyl analogues
recovery services nationwide. Over the past decade,
are controlled substances subject to the CSA, other
Congress increased federal funding for evidence-based
chemicals related to fentanyl are not currently expressly
initiatives for opioid use, such as medication-assisted
scheduled but may be regulated as controlled substance
treatment (MAT) and peer recovery networks. For instance,
analogues. Such scheduling may allow for less effective
Congress has provided more than $1 billion annually since
control than if the substances were expressly scheduled
FY2018 to the Substance Abuse and Mental Health
under the CSA. In 2018, DEA placed a class of over 3,000
Services Administration for a new State Opioid Response
fentanyl-related substances under temporary CSA control.
grant program. Additional funding has also been provided
Since that time, Congress has extended the temporary
to CDC for opioid surveillance activities and to the Health
control via legislation while it further considers the issue.
Resources and Services Administration to enhance the
behavioral health workforce.
Foreign Supply Reduction
The United States has taken a multipronged foreign policy
Congress has supported certain harm reduction strategies
approach to addressing foreign flows of illicit opioids. To
that emphasize prevention of adverse events associated with
date, this approach has included multilateral diplomacy,
substance use, such as overdose and disease transmission.
bilateral efforts, and unilateral action involving several
For example, Congress provided funding in the American
federal departments and agencies. Multilaterally, the State
Rescue Plan Act of 2021 (ARPA; P.L. 117-2) for syringe
Department (DOS) has led efforts at the United Nations to
services programs (often known as needle exchange
control synthetic opioids and precursors. DOS also provides
programs) and other harm reduction initiatives. Federal and
bilateral assistance to countries, including Mexico, to
state harm reduction strategies have frequently involved the
combat illicit production and trafficking of opioids. This
distribution of naloxone (e.g., Narcan)—a medication used
assistance includes provisions of synthetic opioid detection
to reverse an opioid overdose—and test strips used to detect
equipment, clandestine laboratory dismantlement and
fentanyl in drug samples. Some states and localities have
disposal capabilities support, and justice sector and
explored the use of supervised consumption sites, though
investigatory capacity building. The Department of Defense
these facilities have yet to be endorsed by the federal
supports bilateral and regional counterdrug activities and
government and their legal status under federal law is
leads in monitoring and detecting air and maritime illicit
unclear.
drug flows into the United States. Federal law enforcement
agencies, such as DEA, maintain a robust global presence
In addition to receiving federal funds, state, local, and tribal
through attaché offices and specialized units for joint
governments have sought to support their prevention and
investigations with foreign counterparts. The U.S.
treatment efforts by pursuing a substantial number of civil
Department of the Treasury administers counternarcotics
lawsuits against entities along the prescription opioid
sanctions programs aimed at international drug traffickers,
supply chain. These cases have begun to result in
their associates, and affiliated financial structures.
substantial settlements that require portions of the
settlement fund to be used for abatement strategies, such as
Johnathan H. Duff, Analyst in Health Policy
increasing access to MAT and naloxone.
Wen W. Shen, Legislative Attorney
Reducing Domestic Diversion and Illicit Trafficking
Liana W. Rosen, Specialist in International Crime and
Narcotics
The federal government has also partnered with state and
local authorities to reduce opioid trafficking and curb
Joanna R. Lampe, Legislative Attorney
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The Opioid Crisis in the United States: A Brief History

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