Fentanyl deaths peaked in 2022. There were several overlapping reasons: COVID-19 accelerated the fentanyl crisis. During 2020–22, social isolation, disruption of treatment, changes in drug markets, and increased use of fentanyl mixed with cocaine and methamphetamine pushed overdose mortality sharply higher. Fentanyl had largely replaced heroin and prescription opioids. Fentanyl is extraordinarily potent, cheap, and increasingly appeared in counterfeit pills and other drugs. This produced a huge increase in the probability that an illicit-drug user would encounter fentanyl. By 2022, the fentanyl market was approaching “saturation.” This is an important—and somewhat counterintuitive—point. Once fentanyl had replaced most of the heroin/illicit-opioid supply, there were fewer new people to transition from less-potent opioids to fentanyl. Researchers describe this as fentanyl saturation. The population at risk was beginning to shrink. Prescription-opioid exposure had been declining for years, and estimates of people misusing opioids also declined. That means fewer people were entering the pool of people at risk, although the risk to someone who continued using illicit opioids remained extremely high. Harm-reduction measures improved. Naloxone became much more widely available, and more people learned how to recognize and reverse overdoses. Other changes included treatment expansion and changes in how people consumed fentanyl. These probably contributed to the decline, although researchers don’t think they explain all of it. The illicit drug supply itself began changing. Fentanyl’s share of drug seizures stopped increasing and subsequently declined. One recent analysis found that fentanyl’s representation in illicit-drug seizures fell from 28.8% to 23.2% from summer 2023 to fall 2024, coinciding with a very large decline in opioid mortality.
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