People get opioids through several distinct channels: legitimate prescriptions from doctors, pills shared by friends or family, counterfeit pills sold on the street, and illegal online pharmacies. About half of all people who misuse prescription opioids got them free from a friend or relative, according to federal survey data from SAMHSA. Understanding each pathway helps explain why opioid misuse remains so widespread.
Prescriptions From a Doctor
The most straightforward way people obtain opioids is through a prescription. Doctors prescribe them for acute pain lasting less than a month (post-surgical recovery, dental procedures, broken bones, kidney stones), subacute pain lasting one to three months, and chronic pain lasting longer than three months. The CDC’s 2022 prescribing guideline recommends that clinicians try non-opioid treatments first for many common conditions, since over-the-counter pain relievers and other therapies work just as well for things like low back pain, sprains, strains, simple dental extractions, and migraines.
When a doctor does prescribe opioids, they’re expected to discuss the realistic benefits and risks with the patient, set goals for pain relief and daily function, and plan how to taper off. For chronic pain, those conversations become more involved because the risks of long-term use are higher. About 22 percent of people who misuse prescription opioids say they got them from a single doctor’s prescription, and another 3 percent obtained them from more than one doctor.
Friends, Family, and the Medicine Cabinet
This is the single largest source of misused opioids. SAMHSA data shows that 50.5 percent of people who misused prescription pain relievers got them from a friend or relative for free. Another 4.4 percent took them from someone without asking. That pattern holds across age groups and genders.
The reason this channel is so common comes down to leftover pills. A survey of over 300 post-surgical patients found that roughly 87 percent stored their opioids in an unlocked location, most often in the bathroom (45 percent), kitchen (23 percent), or on a bedroom nightstand (19 percent). Between 28 and 34 percent of patients said they planned to simply keep their unused pills rather than dispose of them. Those unlocked, easily accessible bottles are what friends, family members, or visitors end up reaching into.
Counterfeit Pills on the Street
Since around 2020, the illegal opioid market has shifted dramatically toward counterfeit pills. These are tablets pressed in clandestine labs to look identical to legitimate pharmaceuticals, most commonly 30 mg oxycodone pills. On the street, they go by names like “blues,” “dirty oxys,” or “fentanyl pills.” They’re stamped with the same numbers and markings as the real thing, making them nearly impossible to distinguish by appearance alone.
What’s inside these pills is a different story. They typically contain illicitly manufactured fentanyl rather than oxycodone, and the dosing is wildly inconsistent from one pill to the next. The precursor chemicals used to make fentanyl originate primarily in China, which the U.S. intelligence community identifies as the primary source country for these raw materials and even pill-pressing equipment. Those precursors are shipped to Mexico, where transnational criminal organizations synthesize the fentanyl and press it into pill form before trafficking it into the United States. Since China tightened controls on finished fentanyl in 2019, almost no completed fentanyl enters the U.S. directly from China. The production has simply moved to Mexico.
In cities like Phoenix, these counterfeit pills have become ubiquitous. As one person described in a research study on counterfeit pill use: “They say it’s fentanyl, but they honestly look like Perc 30s because when I was doing Perc 30s they looked exactly the same.” Sellers prefer pills over raw powder partly because the dosing appears more controlled, which keeps buyers alive and coming back.
Illegal Online Pharmacies
Rogue online pharmacies sell prescription opioids without requiring a valid prescription. These sites often look professional, featuring photos of doctors and medical staff to create the impression of legitimacy. Some even have a cooperating physician who will “prescribe” medications without ever examining or even speaking to the patient.
People turn to these sites for several reasons: lower prices than legitimate pharmacies, convenience, the ability to bypass a doctor who refused to prescribe, or the desire to self-medicate without involving the healthcare system at all. The pills shipped from these sites may be legitimate medications diverted from real supply chains, but they can also be counterfeit, contaminated, or contain entirely different substances than advertised. Social media platforms have added another layer, with individual sellers and marketing accounts directing buyers to online vendors, though this activity remains relatively small-scale compared to in-person sales.
Veterinary Prescriptions
A less well-known pathway involves opioids prescribed for animals. Veterinarians routinely use fentanyl, tramadol, and buprenorphine for surgical pain in pets. Some pet owners exploit this by “vet-shopping,” visiting multiple veterinarians to get controlled substances prescribed for their animals, then taking the drugs themselves. Warning signs include requesting higher doses than the animal needs, suggesting specific controlled drugs by name, or repeatedly claiming the medication isn’t working.
Unlike human medicine, veterinary prescribing is not consistently tracked through monitoring databases. The absence of a universal veterinary prescription monitoring program makes this form of diversion harder to detect and prevent.
How the System Tries to Limit Diversion
Every U.S. state now operates a Prescription Drug Monitoring Program, or PDMP. These are electronic databases that track when and where controlled substances are dispensed. Before writing an opioid prescription, clinicians can check the PDMP to see whether a patient is already receiving opioids from other providers or taking combinations of drugs that raise overdose risk, such as opioids and benzodiazepines together. This is the primary tool for catching “doctor shopping,” where a person visits multiple providers to stockpile prescriptions.
PDMPs have real limitations, though. Interstate data sharing is incomplete, veterinary prescriptions are often excluded, and the databases can only flag patterns after prescriptions have already been filled. They do nothing to address the counterfeit pill supply, street-level sales, or pills passed between friends and family. The monitoring system was designed for a prescription-driven crisis, and the landscape has shifted heavily toward illicitly manufactured fentanyl that never touches a pharmacy at all.