From its early days when it was considered a breakthrough of pharmaceutical science to its current role in the opioid crisis gripping the United States, fentanyl has drawn widespread attention. The drug was developed in the early 1960s by Belgian chemist Paul Janssen, and though it would take about 50 years for fentanyl to catch on as a street drug in the U.S., once the powerful painkiller arrived, it didn’t take long for it to become one of the chief contributors to drug overdose deaths in the United States.
The federal Centers for Disease Control and Prevention estimate that fentanyl and its derivatives contributed to almost half of all drug overdose deaths in 2018, which equates to thousands of lives taken by a drug that for decades was used to help cancer patients cope with agonizing post-surgical pain.
There are plenty of public faces of the fentanyl crisis, with the drug being blamed for the deaths of musicians Prince, Tom Petty and Mac Miller, but fentanyl remains an incredibly deadly drug for famous and everyday Americans alike, overtaking all other street drugs for the first time in 2016 in the number of deaths.
While every state in the U.S. is dealing with the opioid crisis, there’s no doubt that many states have been hit far harder than others. We wanted to examine which states have the highest rates of fentanyl-related drug overdose deaths as well as where in the U.S. fentanyl is being prescribed the most.
More than 70,000 people died from drug overdoses in 2017, which is higher than the number of people who died in traffic accidents or succumbed to influenza and pneumonia. Drug overdoses claimed almost as many lives in 2017 as diabetes, the nation’s seventh-leading cause of death. Deaths from drug overdoses have risen every year since 1999, climbing dramatically even in just the past few years, with a 49% increase recorded between 2014 and 2017.
There is a bright spot, though: According to preliminary CDC data for 2018, the number of drug overdose deaths fell by about 3%.
Due to the limitations of national death statistics, it’s not possible to know exactly how many drug overdose deaths were due to fentanyl, but the CDC estimates that fentanyl and illegally produced analogs were involved in about 46% of overdose deaths in 2018.
To understand how that equates to deaths on a state-by-state level, we applied the CDC’s formula for the share of U.S. drug deaths that are attributable to fentanyl to OD deaths in each state to estimate the rate of fentanyl-involved drug overdose deaths. According to our analysis, the fentanyl death rate is highest in West Virginia and lowest in Nebraska.
Using the CDC’s estimates of fentanyl involvement rates in drug overdoses from past years, we also looked at which states have seen the biggest increases in fentanyl-involved deaths. Over the past five years, every state has seen a huge increase in the rate of fentanyl-involved drug overdose deaths, led by an eye-popping 2,668% increase in North Dakota.
Even limiting our analysis to increases over a single year, 2016, shows that in almost every state, the fentanyl crisis is deepening. In fact, just one state — Wyoming — saw fentanyl-involved drug overdose deaths decrease, according to our analysis.
The only legally permitted use of fentanyl today is as a prescription pain reliever in the form of a patch or lozenge, and experts believe the vast majority of overdose deaths involve illegally manufactured fentanyl and fentanyl analogs, which are drugs that are similar in chemical structure but not 100% identical. These drugs can be used on their own but are also regularly mixed with heroin or cocaine — often without the user’s knowledge.
While most of the fentanyl that’s sold on the street is made illegally, there still is a huge demand for fentanyl that’s been diverted from legitimate uses, so understanding where in the country fentanyl is being prescribed most frequently may help predict future spikes in the street use of the drug in a state.
About 324,580 grams of fentanyl were legally purchased in the U.S. in 2017, the most recent year for which data is available, according to the DEA. Compare that to commonly prescribed painkillers like hydrocodone (27 million grams) and oxycodone (48 million grams).
From a sheer volume perspective, more fentanyl was legally purchased in California than any other state (more than 27,000 grams), with Florida, Texas, Pennsylvania and New York (about 17,000 grams), all high-population states, completing the top five. But after adjusting for population differences, California plummets down the list, and one of the big states — Pennsylvania — actually moves up.
In 2010, more than 529,000 grams of fentanyl were legally purchased in the United States, the high-water mark of the past decade-and-a-half. By 2017, retail volume had fallen by more than 38%.
Similarly, every state has seen the overall and population-adjusted retail distribution of fentanyl fall, though a few states have much more dramatically reduced fentanyl consumption than some others.
Where Is the Problem Worst?
We’ve seen where in the United States more people are dying from fentanyl, which is most often taken illegally, and which states lead the way in legal retail sales of the drug. So now that we understand the two ways that people come into contact with this potentially deadly drug, what conclusions can we draw about which states have it the worst when it comes to risk of death from a fentanyl overdose?
To draw correlations between the states, we compared the top 10 states in three categories — fentanyl-involved overdose death rates in 2017, the increase in that rate between 2013 and 2017 and the grams per 100,000 people sold in 2017. That gave us a total of 19 states, and we counted how many times each of the states appeared on any of the three top 10s.
States with highest risk levels
Only two states appeared on all three lists — Delaware and Pennsylvania. Here’s a look at how all 19 performed:
We should all take it as positive news that CDC data points to a decline, though a modest one, of the number of drug overdose deaths in the U.S. in 2018. But there’s no doubt that the proliferation of illegal fentanyl and analogs has already taken hold and done an enormous amount of damage. Accounting for almost half of all drug overdoses, this breakthrough painkiller is now changing lives for the worse instead of for the better.
Where practical, we’ve linked to the original sources of our data throughout this story. But here’s a summary of the two major sources of our analysis:
Drug overdose death rates: To calculate the rate of fentanyl-involved drug overdoses, we used the CDC’s WONDER tool, which allows users to make custom tables regarding the number and rate of all causes of death in the U.S., as well as on the state and local level. We limited our analysis to listed causes of death related to intentional and accidental drug overdose, which mirrors the methodology used by the CDC in a 2019 report on fentanyl-related deaths. In that report, the CDC estimates the number of drug overdoses involving fentanyl for every year since 2011. We used the CDC’s estimate to calculate the percentage of all drug overdose deaths in each year that involved fentanyl and applied those percentages to each state’s number of drug overdose deaths by year. We then calculated a crude rate per 100,000 people of fentanyl-involved drug overdose deaths.
Retail fentanyl sales: This information came from the DEA’s Automated Reports and Consolidating Ordering System (ARCOS), which requires manufacturers and drug distributors to report transactions involving controlled substances, such as fentanyl and other drugs. The DEA has posted these reports going back to 2016, and we used historical as well as current data.
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