Introduction

In 2024, the amount of fentanyl seized by the U.S. Drug Enforcement Administration (DEA) was equivalent to 380 million lethal doses—enough to end the life of every man, woman, and child in the United States.^[1] Nearly 80,000 Americans died from drug overdoses in 2024, according to the U.S. Centers for Disease Control and Prevention (CDC).^[2] Synthetic opioids like fentanyl caused about 60% 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.

In a 2024 report, Iowa in the Context of America’s Fentanyl Epidemic, CSI explored the issue of fentanyl in Iowa within the broader context of America’s fentanyl epidemic. The report starts by describing the origin and evolution of the crisis over the previous decade. It maps the trend in drug overdose deaths across drug types, comparing Iowa with the United States. It found that overdose deaths caused by synthetic opioids (primarily fentanyl) rose by over 500% in Iowa between January 2015 and January 2024. The data show that while Iowa had the 3^rd lowest rate of fentanyl overdose deaths of all states in 2024, deaths from synthetic opioids were rising faster in Iowa than in the United States. The report also identified Iowa as one of just three states where methamphetamines claimed more lives than fentanyl. Finally, CSI’s analysis found fentanyl-related overdose deaths cost Iowa $3.5 billion in 2023, up from approximately $1.3 billion in 2018.

This year’s fentanyl report provides an update on the latest data presented in the 2024 report. It assumes the reader has read last year’s report or has a general knowledge of the fentanyl issue. While last year’s report explored the issue from a national level with a focus on Iowa, this year’s report tells the story in the context of the actions the state of Iowa has taken since 2017 to address the state’s fentanyl crisis. Like last year’s report, it ends with an update on the economic cost of fentanyl to the state of Iowa through the end of 2024.

Key Findings

• From 2019 to 2024, fentanyl overdose deaths in Iowa increased by 23% compared with 31% for the U.S.—making Iowa the 19^th lowest in the nation over this period.
• CSI estimates the fentanyl crisis has caused a total of $19.2 billion in economic damage to the state of Iowa from 2017 through 2024.
• Iowa reversed its uptrend in fentanyl overdose deaths 15 months sooner than the U.S. While fentanyl remains a problem, fatalities are trending back in the right direction.
  • Fentanyl overdose deaths in Iowa rose by 670% from January 2015 to their peak in March 2022. In the U.S., they did not peak until June 2023 and were up 1,250% at their high.
  • From their peak, Iowa’s fentanyl overdose deaths had fallen 46.3% by the end of 2024; in the U.S., they had fallen 38.4% from their peak.
  • From the start of 2015 to the end of 2024, fentanyl overdose deaths rose by a total of 313% in Iowa and 730% in the U.S.
• The data suggest Iowa’s 2018 opioid bill (HF 2377) helped the state temporarily reverse the growth in fentanyl deaths prior to the COVID-19 pandemic.
  • In the year immediately following passage of HF 2377, fentanyl overdose death rates in Iowa fell from 2.95 to 2.25 per 100,000 residents—a 24% decline. Overdose deaths continued to climb nationally during this time.
  • This led to a divergence from the national data, which allowed Iowa to lower its total growth in fentanyl overdose deaths over the last decade compared with the U.S.
  • The improvement lasted just 12 months. Iowa’s fentanyl overdose deaths began rising again with the rest of the U.S. starting in March 2019 and surged during the pandemic.
• In addition to HF 2377, CSI identified 4 other major pieces of legislation passed in Iowa between 2018 and 2025 that may have contributed most to the state faring better that the U.S. during the fentanyl crisis over the last decade: HF 391 (2021), HF 2573 (2022), HF 595 (2023), and HF 182 (2025).
• CSI identified a strong relationship between synthetic opioid deaths in Iowa, fentanyl seizures by U.S. Customs and Border Protection at the southern border, and southwest land border encounters by the U.S. Department of Homeland Security. This suggests Iowa’s decision to deploy state resources to the southern border in 2021 and 2023 may have contributed to the turnaround in the fentanyl epidemic since 2023.
• As of December 2024, Iowa ranked second lowest nationally for fentanyl overdose death rates.

The Fentanyl Epidemic Turned a Corner

In response to concerns over the abuse of prescription opioids in the United States, the U.S. Center for Disease Control and Prevention (CDC) issued new guidelines in 2016 on when and how to appropriately prescribe opioid painkillers.[3] By late 2016, over half of physicians surveyed reported reducing their opioid prescriptions; 1 in 10 had stopped prescribing opioids altogether.^[4] Explained with more context in CSI’s 2024 report on the fentanyl crisis, this change led many patients in chronic pain or with opioid dependency to look for alternatives. Many turned to synthetic opioids, especially fentanyl.

Figure 1 shows the number of drug overdose deaths over the 12 months preceding the specified month in the United States for three National Vital Statistics System (NVSS) classifications: natural and semi-synthetic opioids, synthetic opioids, and all opioids. The Appendix provides an explanation of overdose death classifications referenced in Figure 1 and throughout this report. The NVSS cause of death category labeled “Natural & semi synthetic opioids (T40.2)” captures prescription drugs like morphine, oxycodone, and hydrocodone. While the NVSS data does not single out fentanyl, most drugs under the classification “synthetic opioids excluding methadone (T40.4)” involve fentanyl.[5]

Figure 1. 

Source: U.S. Centers for Disease Control and Prevention (NVSS)

The data suggest the CDC’s new guidelines achieved their desired effect of reducing harm from prescription opioids nationally, but it was followed by a new crisis of synthetic opioid abuse. Prior to the guidance, more Americans fell victim to overdose death from prescription opioids than from synthetics like fentanyl, though fentanyl deaths were already on the rise. From the issuance of the CDC guidance through the end of 2024, prescription opioid deaths dropped 40%. Meanwhile, the total number of opioid-related overdose deaths has risen dramatically, driven by the rise in deaths from fentanyl and other synthetic opioids. Total opioid overdose deaths in the United States rose by 54% from the guidance through the end of 2024.

The subclassification of opioids called “synthetic opioids excluding methadone” (T40.4) accounted for most of these deaths. While the NVSS data does not single out fentanyl, most drugs under this classification involve fentanyl.[6] The death toll of these drugs increased by a staggering 1,247% nationally from January 2015 to the peak in the summer of 2023. Fortunately, deaths dropped sharply from mid-2023 through the end of 2024. In just 18 months, they fell 38.4% from their high, bringing the total increase since the start of 2015 to the end of 2024 to 730%. Synthetic opioid overdose deaths in Iowa have followed a similar pattern to the United States, as shown in Figure 2.

Figure 2.

Source: U.S. Centers for Disease Control and Prevention (NVSS)

While the benefit of hindsight reveals Iowa has fared better than the United States in the severity of the fentanyl crisis, the rate of increase in overdose deaths from synthetic opioids was already far outpacing that of any other drug in the state by 2017, raising alarm bells with state officials. In Iowa, the death toll of synthetic opioids like fentanyl increased by 670% from January 2015 to their peak. Iowa’s overdose deaths peaked in March 2022, 15 months sooner than they did for the U.S. From the peak to the end of 2024, they fell 46.3%, bringing the total increase since the start of 2015 to the end of 2024 to 313%.

Iowa’s Fight against Fentanyl

Recognizing the disturbing rise in opioid overdose deaths, the Iowa Department of Public Health (IDPH) presented to the Opioid Epidemic Evaluation Study Committee in October 2017, raising awareness of the issue with lawmakers.[7] By the time of their presentation, T40.2 deaths were still down 7% from 2015; T40.4 deaths had risen an alarming 180%. The presentation rightly noted the rate of increase in opioid overdose deaths as cause for concern. In its 2024 report looking back at overdose death data since 2015, CSI found Iowa has seen fewer overdose deaths than most other states. Nonetheless, the state has seen much larger rates of increase than the broader U.S. over several periods during the last decade.[8] Presenters from IDPH gave Iowa an “Opioids Report Card” that suggested policy changes to address opioid misuse, urging lawmakers “to be proactive instead of reactive.”[9] Lawmakers responded quickly in the following legislative session with House File (HF) 2377, the so-called “opioid bill.”[10]

Table 1. IDPH 2017 Policy Recommendations to Address the Opioid Crisis

Source: Iowa Department of Public Health

Early Success in Addressing the Fentanyl Crisis

The 2018 opioid bill adopted many of the recommendations made by IDPH in 2017. It required prescribers to use the state’s Prescription Monitoring Program and upload data to the system within 24 hours. It created a Good Samaritan Law, providing legal protections for low-level offenses when a good Samaritan seeks medical attention for someone experiencing an opioid overdose. It also required prescribers to receive training on the 2016 CDC prescribing guidelines. Though all these provisions did not go into effect immediately, these changes and education efforts by the state appear to have made a difference, at least initially.

Figure 3.

Source: U.S. Centers for Disease Control and Prevention (NVSS)

Based on the data in Figure 3, IDPH was correct to sound the alarm in 2017 over the rate of increase in overdose deaths from fentanyl and similar opioids. Fentanyl deaths had been rising persistently in Iowa and across the nation for several years by then. In the U.S., fentanyl overdose death rates continued to rise each month from 2015 until experiencing their first drop in April 2022. That reprieve lasted just two months and saw rates fall just 0.64%. In the year immediately following passage of the opioid bill, however, synthetic opioid overdose death rates in Iowa fell from 2.95 to 2.25 per 100,000 residents—a 24% decline. In a 2019 report, IDPH wrote, “Initial data show these efforts are making positive impacts in Iowa communities to prevent and reduce the negative consequences of opioid-related problems.”[11] Unfortunately, the decline in synthetic opioid overdoses in Iowa was short-lived.

Eyes on Fentanyl after the Pandemic

Fatalities began to rise more sharply than ever, leading up to and during the COVID-19 pandemic. Whatever Iowa policymakers were doing right to combat the crisis appears to have been overwhelmed by stronger counteracting forces driving the fentanyl crisis nationwide. As stated in CSI’s 2024 fentanyl report, the U.S. data support early research by Quest Diagnostics Health Trends, which suggested pandemic-related shutdowns were contributing to a surge in drug overdose use and deaths—especially from fentanyl—in 2020.[12] Notably, however, the return to rising fentanyl death rates in Iowa began in 2019, exactly one year after passage of HF 2377 and before all the bill’s provisions went into effect. Whatever the cause for the resurgence of fentanyl deaths in Iowa, by mid-2019 the state was on course to follow the broader U.S. headlong into a years-long fentanyl epidemic. With the passage of HF 2377, Iowa had only just begun to address it.

In 2020, with the nation shaken by a global pandemic, fentanyl received less attention despite the mounting number of lives it was destroying. As the nation came out of the pandemic, however, attention turned back to an ever-rising number of victims claimed by the deadly drug and how to stop it. Since 2021, the state has pursued multiple approaches to reducing the instances of death from fentanyl overdoses. The legislature passed a series of bills between 2021 and 2025, shown in Table 2.

Table 2.

Additional legislation promulgated in Iowa since the 2018 opioid bill has focused on conforming the state’s Uniform Controlled Substances Act with federal code, providing resources to help victims of fentanyl poisoning survive the episode, and cracking down on criminal activity that proliferates the deadly drug across the state. Other legislative efforts have stalled at the Capitol. In 2025, HF 699 aimed to make fentanyl test strips available in Iowa. Another bill, HF 792, would have made it first-degree murder to engage in certain activity that resulted in a fentanyl overdose death. But state action has not focused only on legislating.

Fentanyl is a Border Issue

As documented extensively in CSI Arizona’s 2022 report, Fentanyl, Crime, and Arizona’s Southern Border and discussed in more detail in CSI Iowa’s 2024 report, Iowa in the Context of America’s Fentanyl Epidemic, 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.^[13] In its National Drug Threat Assessment 2024, the DEA reported 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.”^[14] Fentanyl seizures by the U.S. Customs and Border Patrol (CBP) ballooned from about 2,650 pounds in 2019 to 21,200 pounds in 2024.[15] This corresponds closely with a surge in illegal border crossings, and unsurprisingly, the tragic rise in fentanyl overdose deaths in Iowa and across the U.S.

Figure 4. Iowa Synthetic Opioid Deaths and Southern Border Encounters and Fentanyl Seizures, 2015 to 2024

Source: Office of Homeland Security Statistics, U.S. Customs and Border Protection, U.S. Centers for Disease Control and Prevention (NVSS)

Recognizing the relationship between America’s border crisis and fentanyl crisis, Iowa deployed resources to America’s border with Mexico in 2021 and 2023 to help stop the flow of fentanyl into the United States—and ultimately into Iowa. As seen in Figure 4, as CBP encounters peaked and then fell last year, so did fentanyl seizures at the border. And as fentanyl flows across the border fell, so did fentanyl deaths in Iowa.

How Iowa Compares with other States

While now on the decline, Iowa’s synthetic opioid death rates have risen dramatically in recent years. Overdoses from synthetic opioids quadrupled from December 2016 to December 2024, rising by 398%. From January 2015 to its peak in March 2022, they rose 670% to a rate of 7.22 deaths per 100,000 residents. In the last 5 years from January 2019 through January 2024, the trailing 12-month rate of overdose deaths from synthetic opioids rose 23%. These figures put Iowa directly in the median of America’s fentanyl crisis, as shown in Figure 5.

Figure 5.

Source: U.S. Centers for Disease Control and Prevention (NVSS)

The percentage increase or decrease speaks to how much better or worse a state is becoming relative to where it was in the past. Oregon, Alaska, Washington, Oklahoma, and Nevada have seen the largest percent increases in overdose deaths from fentanyl over the past five years, but that does not mean they necessarily have the worst fentanyl overdose death rates. In 2019, Texas had the lowest fentanyl overdose death rate in the country. With an increase of 391% since then, it ranks in the top 10 states for rate of increase over the last five years. Yet, it still has the fifth-lowest rate of fentanyl deaths per 100,000 residents as of December 2024. Alaska and Oregon boasted some of the lowest rates of fentanyl overdose deaths in the nation before the pandemic. Today, after seeing the two largest increases over the last five years, they rank 45^th and 37^th, respectively. Conversely, West Virginia increased by only 1% over the last five years—less than the 31% median increase or the United States increase of 31%. Nonetheless, it has the second-highest fentanyl overdose rate of any state at 32.26 per 100,000, lagging only Alaska and Washington, D.C. Figure 6 compares the synthetic opioid overdose rates of all states, the District of Columbia, and the United States as a whole.

Figure 6.

Source: U.S. Centers for Disease Control and Prevention (NVSS)

On a percent change basis, Iowa has seen a similar growth trajectory to other states, but it has maintained its extraordinarily low overdose rates relative to the rest of the United States. In its 2025 Free Enterprise Report, CSI Iowa noted that Iowa ranks fifth lowest for drug overdose death rates nationally.[16] Figure 6 shows Iowa as the second lowest for synthetic opioid overdose death rates, but it does not include Nebraska due to a lack of data. Iowa likely ranks third. In January 2015 it had 0.96 deaths from synthetic opioids per 100,000 residents. In December 2024, it had 3.83—nearly a 4-fold increase. Alaska, the state with the highest fentanyl death rate, has 34.45 per 100,000 residents. Washington, D.C. lands on top at 43.57.

The Economic Cost of Fentanyl

Despite Iowa’s relatively low rates of fentanyl overdoses, the hundreds of deaths that occur each year come with a substantial cost. Common Sense Institute Iowa borrowed methodology from the CDC’s State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose – United States, 2017 paper to estimate the cost of an opioid overdose in Iowa.[17] The CDC estimated the cost of fatal opioid overdoses for thirty-eight states and DC in 2017. For Iowa, they found the total cost of all fatal opioid overdoses in 2017 to be over $2.37 billion. The CDC used a case count of 206 fatal opioid overdoses, a per-death cost of $11.5 million. Using this same approach, CSI estimated the cost per death and total costs from 2018 through 2024 by inflating the per-death costs in each category by the Personal Consumption Expenditure Price Index (excluding energy and food). This raises the cost per death from $11.5 million to $16.9 million. The total cost of any type of fatal opioid overdose in 2024 cost Iowa about $2.4 billion. Fentanyl alone accounted for 89.7% of all opioid overdose costs according to preliminary data, making the 2024 total cost of overdose deaths attributable to fentanyl $2.2 billion.

Table 3.

Bottom Line

The fentanyl epidemic has impacted countless lives across the United States over the past decade, and Iowa has seen its share of loss. Every state in the nation saw deaths from synthetic opioids rise after states and the federal government began to crack down on the abuse of prescription opioids around 2015 to 2016. In 2018, Iowa lawmakers responded with legislation to the state’s climbing death toll caused by synthetic opioid overdoses. The state subsequently bucked the national trend over the following year, seeing a decline in fentanyl overdose deaths into the start of 2019. Unfortunately, the problem grew worse during and after the pandemic—both in Iowa and nationally. Iowa continued to address the crisis with additional legislation and gubernatorial action. The data is evidence that it made a difference.

Ultimately, the state reversed the trend of rising fentanyl deaths more than a year before the broader U.S. Over the entire decade from the start of 2015 to the end of 2024, Iowa saw less than half the total increase in overdose deaths than the U.S. As of December 2024, Iowa ranked second-lowest nationally for fentanyl overdose death rates. Fentanyl has wrecked lives, but it also comes with an economic cost. Fentanyl cost Iowa alone nearly $20 billion in economic damage in just 8 years. The action state lawmakers took to combat the crisis helped Iowa fare better than the average state during this difficult period, reducing the economic cost of the crisis by billions for the state, and most importantly, saving precious lives.

Appendix

Fentanyl is a synthetic opioid used in medicine to treat chronic pain, like morphine, but around 100 times more potent. However, most fentanyl in the United States today is not a controlled prescription drug but rather an illicit synthetic opioid produced outside of the United States and trafficked into the country by criminal organizations such as Mexican drug cartels. Dealers regularly mix fentanyl with other drugs, often without the knowledge of the user. Because a mere two milligrams of fentanyl contain a lethal dose, the drug comes with a disquieting overdose mortality rate.

Note: Authentic (top) and counterfeit (bottom) oxycodone tablets. The counterfeit pills contain fentanyl.
Source: DEA

From a data perspective, the impact of the fentanyl epidemic shows up perhaps most clearly in overdose deaths and death rates. The U.S. Centers for Disease Control and Prevention tracks drug overdose deaths under the National Vital Statistics System (NVSS) and the State Unintentional Drug Overdose Reporting System (SUDORS). For the former, jurisdictions report cause of death data in accordance with the International Statistical Classification of Diseases and Related Health Problems (ICD).[18] For the latter, data comes through the Overdose Data to Action in States (ODEA-S) cooperative agreement administered by the CDC.[19] Each state reports overdose deaths to SUDORS at the CDC from death certificates and postmortem toxicology, coroner, and medical examiner reports. The SUDORS database includes more detailed information on overdose deaths than NVSS; however, the system was launched in 2016, and some data only goes back a few years.[20] The NVSS database classifies drugs into several broader categories:

• heroin (T40.1);
• natural opioid analgesics, including morphine and codeine, and semisynthetic opioids, including drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone (T40.2);
• methadone, a synthetic opioid (T40.3);
• synthetic opioid analgesics other than methadone, including drugs such as fentanyl and tramadol (T40.4);
• cocaine (T40.5); and psychostimulants with abuse potential, which includes methamphetamine (T43.6);
• opium (T40.0);
• heroin (T40.1);
• natural opioid analgesics (T40.2);
• methadone (T40.3);
• synthetic opioid analgesics other than methadone (T40.4); or
• other and unspecified narcotics (T40.6).[21]

Endnotes