The number is large enough to have defined a public health emergency and shaped federal law enforcement priorities for more than a decade. It is also a number whose measurement depends on definitions that are contested and whose trends have changed substantially as the composition of the drug supply has shifted.
The Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health, the most comprehensive annual assessment of substance use patterns in the United States, estimated that approximately ten million Americans aged twelve or older misused prescription opioids in 2019, the last full survey year before the COVID-19 pandemic disrupted the survey methodology. The term misuse in the survey’s framework includes any use of prescription opioids in a manner other than as prescribed, including taking more than the prescribed dose, taking someone else’s prescription, or taking the medication for a purpose other than its therapeutic indication.
Opioid Use Disorder as a Distinct Category
Within the broader population of prescription opioid misusers, the NSDUH estimated that approximately one point six million Americans had an opioid use disorder related to prescription opioids in 2019, and that approximately eight hundred thousand had a heroin use disorder. The two populations overlap significantly, as heroin use disorder in the contemporary context often reflects a transition from prescription opioid dependence rather than a distinct initiating pattern.
Opioid use disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders, is a clinical diagnosis characterized by a problematic pattern of opioid use leading to clinically significant impairment or distress. It is a different condition from the physical dependence that may develop in any patient taking opioids at therapeutic doses for extended periods, and the distinction matters for the clinical management of patients who present to prescribing practitioners.
The Mortality Data as a Proxy for Magnitude
The overdose mortality data, maintained by the CDC’s National Center for Health Statistics, provides the most reliable quantitative measure of the opioid crisis’s severity, even though it measures deaths rather than the full population of persons with opioid misuse or dependence. In 2021, approximately eighty thousand of the one hundred seven thousand drug overdose deaths recorded in the United States involved opioids. That mortality figure, applied against standard epidemiological ratios of fatal to non-fatal overdose events, implies a population of active opioid users vastly larger than the mortality count alone suggests.
The mortality trend has not followed the prescription opioid prescribing trend. Despite the significant reduction in opioid prescribing that has occurred since the epidemic’s peak around 2012, overdose deaths have continued to rise. The fentanyl supply chain that has displaced pharmaceutical opioids in the illicit market is responsible for a mortality rate that exceeds what prescription opioid availability alone would predict.
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(212) 300-5196Geographic and Demographic Distribution
Opioid misuse and its consequences are not uniformly distributed across the population. The states with the highest rates of opioid use disorder and overdose deaths, concentrated in Appalachia and parts of New England, have per-capita rates two to three times the national average. Rural communities have been disproportionately affected relative to urban areas in some dimensions of the crisis, though urban communities have experienced the most severe fentanyl-related mortality in the current phase.
Demographically, the prescription opioid epidemic initially concentrated in white, working-class populations in states with high rates of physical labor employment and occupational injury. The heroin and fentanyl transitions expanded the affected demographic population while maintaining the geographic concentration in initially affected areas. The current fentanyl crisis affects a broader demographic range than either of its predecessor waves.
Why the Numbers Matter for Practitioners
The scale of opioid misuse and dependence in the United States is the context within which every controlled substance prescriber operates. It is also the context within which the DEA’s enforcement priorities were established and within which the PDMP data that triggers investigations is generated. A prescriber who serves a patient population with above-average rates of opioid use disorder is a prescriber whose prescribing data will appear more anomalous relative to a national peer comparison than relative to peers serving the same population.
Todd Spodek
Lead Attorney & Founder
Featured on Netflix's "Inventing Anna," Todd Spodek brings decades of high-stakes criminal defense experience. His aggressive approach has secured dismissals and acquittals in cases others deemed unwinnable.
Federal agents execute a search warrant at your medical practice, seizing patient records and prescription logs.
Can they take patient records without patient consent?
A valid federal search warrant overrides HIPAA privacy protections. However, the warrant must be properly scoped. An attorney can challenge overly broad warrants and move to suppress improperly seized evidence.
This is general information only. Contact us for advice specific to your situation.
The practitioner who prescribes opioids to a patient population with high rates of chronic pain, occupational injury, and limited access to specialty pain management is a practitioner whose prescribing data tells a story that the national peer comparison does not capture. The patients’ needs are real. The prescribing data is real. The challenge is building the clinical record that connects one to the other in a manner that withstands the scrutiny that the national data generates.
The Relationship Between Prevalence and Enforcement
The large estimated population of Americans who misuse opioids is the population from which the patients who appeared at pill mills, who doctor-shopped across the country, and whose demand drove the commercial prescribing operations that the DEA’s enforcement targeted were drawn. The prescriber who operated a legitimate pain management practice in a community with high rates of opioid use disorder served some patients who were using their prescriptions therapeutically and others who were not. The compliance infrastructure that identifies and manages the latter category, while preserving access for the former, is the infrastructure that distinguishes the legitimate practice from the commercial operation in the data that investigations generate.
