By Lauren Smith

Updated: 24 May 2023 & medically reviewed by Dr. Celeste Small

Nearly 70,000 Americans died of fentanyl-related overdoses in 2021, a four-fold increase from 2016, according to a new analysis from the CDC’s National Center for Health Statistics (NCHS).

Fentanyl Deaths Quadrupled Between 2016 And 2021

New study sifts fentanyl deaths from overdoses of other opioids

The new report is the first to nationally quantify how many lives have been lost specifically to fentanyl.[1]

Typically, overdose deaths are grouped by the class of drugs that caused them. For example, the National Vital Statistics System (NVSS) classes overdose deaths using the International Classification of Diseases (ICD-10) classification system, which doesn’t distinguish between overdoses of different synthetic opioids.[1]

This has meant that previous tallies of overdose fatalities haven’t made the distinction between fentanyl and, for example, oxycodone, an opioid one-hundredths as strong.

This has masked the prevalence of fentanyl and hobbled regulatory, medical, and law enforcement responses to the crisis. 

“We need to know exactly what people are dying from so we know what services they need to stay alive,” Caleb Banta-Green, a professor at the University of Washington School of Medicine’s Addictions, Drug & Alcohol Institute who was not involved in the report, told CNN.[2]

To address this information gap, the NCHS developed a method of searching the actual text of death certificates to identify mentions of specific substances by the medical examiner or coroner. It then tallied the number of overdose deaths attributed to five common substances—fentanyl, oxycodone, heroin, cocaine, and methamphetamine—and tracked their fluctuations across six years between 2016 and 2021 and across age cohorts, ethnicities, genders, and regions.

Fentanyl implicated in two out of three overdose deaths

The results were striking: of the record 108,000 overdose deaths recorded in 2021, around two-thirds involved fentanyl.[3]

In total across 2021, fentanyl was responsible for 21.6 deaths per 100,000 people. That’s nearly four times than rate of fentanyl deaths recorded in 2016 (5.7 per 100,000 people) and more than twice the rate of 2021 deaths caused by meth (9.6 per 100,000 people) and cocaine (7.9).[4]

The CDC’s findings about fentanyl’s deadly toll corroborated the anecdotal reports from emergency rooms, treatment facilities, and law enforcement, said Dr. Nora Volkow, director of the National Institute on Drug Abuse.[2] But having hard data about fentanyl deaths is “very, very useful,” she said.

“Understanding these differences [between drugs] is crucial because then you can target intervention to address the risk,” she added.[2]

Related: Identifying fentanyl

Deaths caused by other opioids declined

While fentanyl death rates have soared, those caused by other opioids have declined: heroin deaths were down from 4.9 per 100,000 Americans in 2016 to 2.9 in 2021, while oxycodone deaths fell from 1.9 to 1.5 per 100,000 Americans. This shift reflects the ease of access to fentanyl and its permeation of the opioid supply, experts say.

"The folks who were using heroin previously are the folks who are also using fentanyl now,” said Allison Lin, an addiction psychiatrist at the University of Michigan Medical School. “It's just that the supply of opioids and other drugs in our communities are primarily supplies that are predominantly fentanyl because of all the characteristics of it, how inexpensive it is, how easy it is to cut with other substances, other factors.”[4]

Fentanyl’s omnipresence in drug supplies is also obscuring the continued prevalence of crack cocaine and methamphetamine, she said, especially because these drugs are often contaminated or cut with fentanyl. 

“It doesn’t mean that we’ve ever addressed the crack epidemic, I would say, and we also have a rising meth epidemic in the country.” There is not just one single substance individuals are using anymore, she explained. “They’re really oftentimes combined with fentanyl.”

The pandemic fuelled fentanyl use and made treatment more difficult to access

The CDC’s report highlighted the explosive rise of fentanyl overdoses during the coronavirus crisis, with the death rate nearly doubling between 2019 (11.2 per 100,000 people) and 2021. 

Researchers have previously found that the pandemic’s social isolation, boredom, stress, economic worries, joblessness, and exacerbation of mental health conditions drove up the use of intoxicating substances from alcohol and cigarettes to opioids and psychedelics across societies.[5] 

People were also more likely to use substances alone, reducing the likelihood that a witness could administer naloxone or seek other emergency help if they overdosed. Harm reduction services, including those supplying naloxone, reduced their activities, and access to addiction treatment services was limited by lockdowns. 6]

Fentanyl—a tiny amount of which is highly potent, even deadly— also became more common in the drug supply as heroin and other opioids became more difficult and expensive to procure.[6]

Related: Fentanyl test strips

Fentanyl is now devastating Black and Indigenous communities hard

No groups of Americans were immune from the fentanyl epidemic. The substance was the most common drug implicated in fatal overdoses across all age cohorts, race and ethnicity groups, and genders. It even touched celebrity circles: The Wire actor Michael K. Williams died in March of that year after using heroin laced with fentanyl.[7]

However, the CDC’s analysis revealed growing racial disparities in drug use and deaths and undermined the popular perception that the opioid crisis exclusively affects white, rural communities. Instead, it exposed the path fentanyl has torn through communities of color over the last few years.

Among Black Americans, fentanyl deaths reached 31.3 per 100,000 people in 2021, 27% higher than the rate among whites (24.6) and more than double that among Hispanics (14.1), the CDC found.

Experts say that Black Americans struggle to access appropriate treatment for opioid abuse as a consequence of medical discrimination, the uneven geographic distribution of practitioners, inadequate doctor training, lack of insurance coverage, and the criminalization of drug use. In many cases, Black Americans aren’t even properly aren’t properly recognized as having opioid use disorder at all.

This disparity in access to treatment is particularly marked in the prescription of opioid replacement therapies like buprenorphine. In 2020, Black Americans who died of a drug overdose were half as likely as white causalities to have accessed medication substance abuse treatment.[8]

The rate of fentanyl deaths was even higher among American Indian and Alaska Native individuals (33.1 fentanyl-related deaths per 100,000 people), another group for whom access to treatment is difficult.

“The numbers tell us that we have a lot to do,” said Volkow.