Detection of Illegally Manufactured Fentanyls and Carfentanil in Drug Overdose Deaths - United States, 2021-2024

Abstract

During 2023, approximately 72,000, or nearly seven in 10, drug overdose deaths in the United States were estimated to involve illegally manufactured fentanyls (IMFs). Carfentanil, a fentanyl analog 100 times more potent than fentanyl, has reemerged in the U.S. drug supply. Using CDC's State Unintentional Drug Overdose Reporting System data, this report describes trends in overdose deaths during January 2021-June 2024, overall and with IMFs detected, by U.S. Census Bureau region, and in deaths with carfentanil detected, in 45 states and the District of Columbia (DC). Numbers of deaths with carfentanil detected by state during January 2023-June 2024 in 49 states and DC are also reported. The number of overdose deaths with IMFs detected declined from 2022 to 2023 in the Northeast (3.2% decline), Midwest (7.8%), and South (2.8%) regions; deaths in the West increased 33.9%. The percentage of deaths with IMFs detected was steady at approximately 70%-80% in the Northeast, Midwest, and South. In contrast, the percentage of deaths with IMFs detected in the West increased from 48.5% during January-March 2021 to 66.5% during April-June 2024. Overdose deaths with carfentanil detected increased approximately sevenfold, from 29 during January-June 2023 to 238 during January-June 2024; during January 2023-June 2024, overdose deaths with carfentanil detected were reported in 37 states. Overdose prevention efforts that address the widespread presence of IMFs, including carfentanil, and can rapidly adapt to other potent opioids in the drug supply might result in lasting reductions in overdose deaths across the entire United States.

FIGURE 1

Number of drug overdose deaths overall* and number and percentage of overdose deaths with illegally manufactured fentanyls^† detected, by quarter of death^§ — State Unintentional Drug Overdose Reporting System, United States,^¶ January 2021–June 2024** Abbreviations: IMFs = illegally manufactured fentanyls; Q = quarter; SUDORS = State Unintentional Drug Overdose Reporting System. * A total of 251,089 overdose deaths occurred during January 2021–December 2023. Because not all overdose deaths that occurred during January–June 2024 have been entered into SUDORS, numbers of deaths overall and with IMFs detected during this time frame are underestimated and not presented. Percentages with IMFs detected during this time frame are restricted to deaths with toxicology information entered; these are expected to be accurate estimates of the percentages of overdose deaths with IMFs detected. ^† Fentanyl was classified as likely illegally manufactured using toxicology, scene, and witness evidence. For the 9.9% of deaths with fentanyl detected that had insufficient evidence for classification as illegal or prescription, fentanyl was classified as illegal because the majority of fentanyl overdose deaths involve illegal fentanyl. All fentanyl analogs except pharmaceutical analogs (i.e., alfentanil, remifentanil, and sufentanil) were included as IMFs. Among deaths with IMFs detected, 98.4% had IMFs listed as a cause of death. ^§ Q1: January–March; Q2: April–June; Q3: July–September; Q4: October–December. ^¶ Forty-six jurisdictions: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia. For inclusion, jurisdictions were required to report ≥75% of deaths in their jurisdiction in each 6-month period during January 2021–December 2023. ** Preliminary data were downloaded from SUDORS on November 26, 2024; 2024 data in this figure were restricted to deaths with toxicology information entered and represent approximately 55% of expected overdose deaths.

FIGURE 2

Number of drug overdose deaths overall*^,† and number and percentage of overdose deaths with illegally manufactured fentanyls^§ detected, by U.S. Census Bureau region^¶ and quarter of death** — State Unintentional Drug Overdose Reporting System, United States,^†† January 2021–June 2024^§§ Abbreviations: IMFs = illegally manufactured fentanyls; Q = quarter; SUDORS = State Unintentional Drug Overdose Reporting System. * A total of 251,089 drug overdose deaths occurred during January 2021–December 2023. Sample sizes provided in each panel represent the number of overdose deaths in that region during January 2021–December 2023. The number of deaths should not be compared across regions because population size varies by region, and not all jurisdictions in each region were included in the analysis. ^† Because not all overdose deaths that occurred during January–June 2024 have been entered into SUDORS, numbers of deaths overall and with IMFs detected during this time frame are underestimated and not presented. Percentages with IMFs detected during this time frame are restricted to deaths with toxicology information entered; these are expected to be accurate estimates of the percentages of overdose deaths with IMFs detected. ^§ Fentanyl was classified as likely illegally manufactured using toxicology, scene, and witness evidence. For the 9.9% of deaths with fentanyl detected that had insufficient evidence for classification as illegal or prescription, fentanyl was classified as illegal because the majority of fentanyl overdose deaths involve illegal fentanyl. All fentanyl analogs except pharmaceutical analogs (i.e., alfentanil, remifentanil, and sufentanil) were included as IMFs. Among deaths with IMFs detected, 98.4% had IMFs listed as a cause of death. ^¶ https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf ** Q1: January–March; Q2: April–June; Q3: July–September; Q4: October–December. ^†† Forty-six jurisdictions were included. Northeast Region: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest Region: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, and South Dakota. South Region: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Virginia, and West Virginia. West Region: Alaska, Arizona, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Washington. For inclusion, jurisdictions were required to report ≥75% of deaths in their jurisdiction in each 6-month period during January 2021–December 2023. ^§§ Preliminary data were downloaded from SUDORS on November 26, 2024; 2024 data in this figure were restricted to deaths with toxicology information entered and represent approximately 55% of expected overdose deaths.

FIGURE 3

Number of drug overdose deaths with carfentanil detected,* by 6-month period of death (A)^†,§ and jurisdiction (B)^¶ — State Unintentional Drug Overdose Reporting System, United States, January 2021–June 2024**^,†† Abbreviations: DC = District of Columbia; IMF = illegally manufactured fentanyl; SUDORS = State Unintentional Drug Overdose Reporting System. * IMF includes illegally manufactured fentanyl but does not include illegally manufactured fentanyl analogs. ^† For inclusion, jurisdictions were required to report ≥75% of overdose deaths in their jurisdiction in each 6-month period from January 2021 through December 2023. The percentage of overdose deaths reported for January–June 2024 was not calculated because data are preliminary and incomplete. ^§ Forty-six jurisdictions: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia. ^¶ Jurisdictions were included if they reported any drug overdose deaths to SUDORS during January 2023–June 2024. North Dakota was not included because it is not funded for SUDORS. For January–December 2023, all jurisdictions except one reported ≥90% of drug overdose deaths in their jurisdiction. For January–June 2024, the percentage of overdose deaths reported by jurisdiction was not calculated because data are preliminary and incomplete. Texas and Wyoming only include data on deaths during January–June 2024 per funding agreement. ** Data on drug overdose deaths that occurred in 2023 are final. Carfentanil was detected in overdose deaths in 25 states in 2023, totaling 210 deaths. Two states (Florida and West Virginia) reported ≥20 deaths, seven (Illinois, Indiana, Kentucky, Maryland, Michigan, New York, and Ohio) reported 10–19 deaths, and 16 (Alabama, California, Colorado, Connecticut, Georgia, Louisiana, Maine, Massachusetts, Minnesota, New Jersey, North Carolina, Pennsylvania, Tennessee, Virginia, Washington, and Wisconsin) reported one–nine deaths. ^†† Overdose deaths that occurred during January–June 2024 are preliminary and incomplete because not all deaths that occurred during this time frame were entered at the time of analysis; these data are required to be reported into SUDORS by January 24, 2025. Preliminary data were downloaded from SUDORS on November 26, 2024, and represent approximately 85% of expected overdose deaths.