Executive summary
Four decades of unabated growth in drug-related fatalities in the United States shows an escalating public health crisis, though drug use prevalence has not shown much increase since 2002. The national overdose growth rate, remarkably constant over the period and roughly doubling every eight years, is apparently impervious to shifts in policy interventions. Even the emergence and decline of specific drugs has little effect; deadly as fentanyl is, statistically, it looks merely like an extension of what was even in 2015 a 35-year trend.
Fentanyl has saturated many U.S. drug markets as a cheaper and more potent replacement for heroin, and entered others where heroin was rare or absent. Fentanyl now also shows up primarily in fatal overdoses that also involve cocaine and methamphetamine; it is not just a substitute opioid. Cocaine use in the United States has declined substantially perhaps as a result of the falling price of methamphetamine. The significant decline in cocaine use is demand-driven since cocaine production has expanded substantially in the Andes over the last decade. Methamphetamine now is cheaper and more potent than the product that existed in the previous wave of the early 1990s. Fentanyl and methamphetamine have supplanted heroin and cocaine as the dominant drugs of policy concern.