Illicit Fentanyl Use Twice as Common as Medical Use
/By Pat Anson
Fentanyl has long played an essential role as a potent analgesic that can treat the most severe types of pain. But illicit versions of the synthetic opioid have been a scourge on the U.S. black market for over a decade, making it one of the leading causes of fatal overdoses.
The largest study to date has quantified how far those dual roles have gone, showing that illicit use of fentanyl is more than twice as common as medical use.
Analyzing urine drug tests for nearly 300,000 people who tested positive for fentanyl, researchers at The Ohio State University say 71.1% of them did not have a prescription for fentanyl, compared to 28.9% who had a legitimate medical reason for taking it.
“Fentanyl is a big problem, but we don’t actually know how serious illicit drug use is compared to medical use,” co-lead author Ping Zhang, PhD, a Professor in the College of Pharmacy at Ohio State said in a news release.
“Finding that illicit use has reached 70% among all fentanyl users is a surprise. And this is also a contribution of this paper. To make something that’s been a black hole visible to the healthcare system is significant.”
Zhang and his colleagues, who published their study in the journal eClinicalMedicine, also found that illicit fentanyl users were three times more likely to suffer an overdose than patients who were given fentanyl in a hospital or were prescribed the drug.
In 2023, over 105,000 people in the U.S. died from a drug overdose, with nearly 73,000 of those deaths involved synthetic opioids, primarily illicit fentanyl. That represents about 92% of all opioid-related deaths.
At one time, the CDC counted all fentanyl overdoses as prescription drug deaths, a mistake that significantly inflated the number of overdoses attributed to prescription opioids.
As a result of that misclassification, a 2017 public awareness campaign by CDC focused entirely on the abuse of prescription opioids, rather than the dangers posed by illicit fentanyl. When asked by PNN why it wasn’t warning people about fentanyl, a CDC spokesperson said the agency didn't want to risk “diluting” the primary message of its advertising campaign.
The Ohio State analysis found that illicit fentanyl users were younger, less likely to be married, had a higher concentration of fentanyl detected in their urine, and were more likely to have a mental health or substance use disorder.
Medical users of fentanyl were more likely to have a chronic health condition, such as cancer, cardiovascular disease, hypertension, and diabetes. They were also significantly less likely to overdose, abuse or become dependent on fentanyl compared to illicit users.
Geographically, Ohio had the highest proportion of illicit fentanyl users – 12.2% – followed by Massachusetts (10.5%) and California (8.8%).
The number of fatal overdoses involving synthetic opioids like fentanyl peaked in 2022 at nearly 74,000 deaths and have since declined significantly. By 2025, the number of fentanyl-related overdoses was estimated at 38,084 deaths.
