Introduction

In 2023, the amount of fentanyl seized by the U.S. Drug Enforcement Administration (DEA) was equivalent to 381 million lethal doses—enough to end the life over every man, women, and child in the United States.[i] Over 100,000 Americans died from drug overdoses in 2023, according to the U.S. Centers for Disease Control and Prevention (CDC).[ii] Synthetic opioids like fentanyl caused about 70% of those deaths. Ten years prior, fewer than half the overdose deaths occurred, with only about 12% caused by synthetic opioids. Iowa has not dodged this crisis. For medical patients under the care of a doctor, fentanyl is used as a powerful synthetic opioid used to treat severe pain after surgery. In recent years, its widespread availability and use outside of the hospital has made it the deadliest drug in America. One-hundred times more potent than morphine, just two milligrams can kill.[iii] Drug traffickers often mix illicit fentanyl with other drugs, in many cases without knowledge of the end user. Fake prescription pills intended to look like Xanax, Adderall, Percocet, and others have taken the lives of unsuspecting teenagers in Iowa and across the country.[iv] The Iowa Department of Public Safety (DPS) reported an “explosion” of these kinds of pill seized by state law enforcement in recent years. Sadly, far too many Iowa families and communities have felt the detrimental effects of this deadly substance. This report explores America’s fentanyl epidemic and the struggles unique to Iowa. It evaluates overdose data to determine extent of the crisis in the state and its evolution over time, comparing Iowa with the rest of the nation. Finally, it estimates the cost of the fentanyl crisis on the state’s economy.

Key Findings

Fentanyl-related overdose deaths cost Iowa $3.5 billion in 2023, up from approximately $1.3 billion in 2018.
Overdose deaths caused by synthetic opioids (primarily fentanyl) rose by over 500% in Iowa between Jan. 2015 and Jan. 2024.
Over the last five years (Jan. 2010 to Jan. 2024), overdose deaths from synthetic opioids rose at a faster pace in Iowa (140%) than in the United States (123%).
The 1-year increase in fentanyl overdose death rates peaked at 90% in July 2020.
Deaths from synthetic opioid (primarily fentanyl) overdoses have risen at a faster pace than for any other ICD drug category.
As of 2022, Iowa was one of only 3 states where methamphetamine claimed more lives than fentanyl alone, though overdose deaths often involve multiple narcotics.
Iowa has the 3^rd lowest rate of drug overdose deaths in the nation and the 3^rd lowest fentanyl overdose death rate.

America’s Opioid Crisis

While opioids – including heroin, morphine, and other compounds chemically isolated from the poppy plant – have been available for legitimate and illicit use in the United States since at least the 19^th century, the development of synthetic and semi-synthetic opioids accelerated in the early 1900’s (beginning with the development of oxycodone in 1916).^[v] In 1959, fentanyl was synthesized in pharmaceutical laboratories and quickly became popular for both its increased potency and low cost relative to other opioids.^[vi] Following the rise of illicit use and abuse of opioids (including heroin but also synthetic opioids and pharmaceutical drugs) the United States enacted a series of reforms intended to restrict their availability throughout the 1970’s and 1980’s, including with enactment of the Controlled Substances Act of 1970 – which standardized the categorization and regulation of drugs based on the balanced consideration of both harmfulness and potential medical use. Fentanyl and other potent opioids are classified under Schedule II – drugs with an accepted medical use but high potential for abuse – and their prescription and distribution has been highly regulated. By the 1990’s, attitudes had begun to shift. There was increasing belief in the medical community that pain was a distinct and undertreated condition,^[vii] and that the development of addiction among otherwise healthy and drug-free patients from the temporary use of prescription opioids to manage pain was rare.^[viii] This led to increased availability of prescription opioids in the American healthcare system. In 1991, there were approximately 76 million prescriptions for opioids in the United States. By 1999, that had increased to 116 million (+53%)^[ix]; at peak in 2012 there were over 250 million active opioid prescriptions in America – enough for every adult in the country at the time.

Unintended Consequences & The Fentanyl Crisis

In response to the perceived abuse of the nation’s prescription painkiller system by both providers and patients,^[x] a national crackdown at both the state and federal levels by a variety of regulatory agencies began in the mid-2010’s. In 2016, the CDC issued new guidelines on when and how to appropriately prescribe opioid painkillers. Massachusetts became the first state to restrict initial opioid prescription painkiller supplies.^[xi] Today 38 U.S. states, including Iowa, have policies limiting the availability of prescription opioids.^[xii] This led to pressure at all levels of the American healthcare system to reduce opioid prescriptions. Insurance companies, hospital systems, licensing boards, and non-profit professional associations all adopted new rules and structures around the dispensing of opioids by their providers. The pressure worked; a late-2016 survey of Sermo member physicians found over half had reduced opioid prescriptions, and 1 in 10 had stopped prescribing opioids altogether.^[xiii] Today, the number of opioid prescriptions in the United States has fallen to just 132 million – about half its peak level. Because of the rapidity of the national change, patients in chronic-pain or with opioid dependency were desperate for alternatives. Many turned to synthetic opioids, especially fentanyl.

Figure 1.

In the 1980’s, overdose deaths related to illicit fentanyl use in the United States occurred only “sporadically”.^[xiv] According to the CDC, in 2013 when opioid prescriptions peaked there were only about 1.0 deaths per 100,000 people in the United States from synthetic opioid use. By 2022, the rate had surged to 22.7 deaths per 100,000 people.^[xv] An October 2020 study by Quest Diagnostics Health Trends found the lack of access to healthcare and substance abuse support during the pandemic shutdowns may have contributed to a surge in drug overdose use and deaths—especially from fentanyl—during the pandemic.[xvi]

Figure 2.

Drug Trafficking in the United States and Iowa

As demand for opioids in the United States increased and controlled prescription drugs (CPD) became less available, foreign drug producers, transnational criminal organizations, and domestic drug trafficking organizations ramped-up illegal supply. According to the U.S. Department of State, 70% of the worlds illicit fentanyl production in 2021 occurred in China.^[xvii] The country has become a cheap and available illegal supply for American drug consumers following the loss of access to legal or semi-legal prescription painkillers. Beginning in the late-2010’s, opioid-related overdose deaths were surging despite (or perhaps more because of) the collapse in opioid prescriptions. Though cheap and available, illicit opioids – often principally or laced-with fentanyl – have proved far more dangerous than their prescription-market counterparts. These opioids have flooded the United States over the past decade, making their way into and throughout the United States.

Drug Trafficking Across the Southern Border

In 2018-2019, the U.S. Drug Enforcement Agency (DEA), Customs & Border Patrol (CBP), and other federal law-enforcement agencies began putting particular emphasis on combatting the illicit flow of grey- and black-market fentanyl into the United States from foreign countries (particularly China) via international trade. Also in 2019, China announced sweeping and novel domestic restrictions on the production and distribution of all types of fentanyl.^[xviii] As a result, seizures of synthetic opioids (including fentanyl) in international U.S. mail fell from over 150 pounds in 2018 to an estimated just 10.5 pounds by 2020.^[xix] ^[xx] However, while data seems to support the thesis that direct shipments of fentanyl and equivalents from China to the United States appear to have declined, other evidence suggests that the flow of fentanyl has shifted rather than been stymied. Total seizures of the drug in the United States by the DEA have increased from approximately 6,800 pounds in 2019^[xxi] to more than 29,200 pounds today^[xxii] – a 320% increase. As documented extensively in CSI Arizona’s 2022 report, Fentanyl, Crime, and Arizona’s Southern Border, stakeholders and experts report that the primary source of illicit fentanyl in the United States today is smuggling of the finished drug across the southern border with Mexico, and that production of it is enabled with chemicals and equipment sourced by Mexican drug manufacturers from the Chinese pharmaceutical industry.^[xxiii] In its National Drug Threat Assessment 2024, the DEA again reports that: “Fentanyl manufactured by the Mexican cartels is the main driver behind the ongoing epidemic of drug poisoning deaths in the United States… China-based chemical suppliers are the main source of the chemicals used in the production of illicit fentanyl.”^[xxiv]

Iowa in the Context of America's Fentanyl Epidemic