Fentanyl was a legitimate surgical drug for decades before it became a crisis. The turning point came in 2013, when deaths involving illegally manufactured fentanyl began climbing steeply across the eastern United States. Within a few years, it had reshaped the entire landscape of drug overdose in America.
From Operating Room to Street Supply
Fentanyl was first developed in 1959 by a Belgian chemist and introduced in the 1960s as an intravenous anesthetic. For most of its history, it stayed in clinical settings: hospitals, surgical suites, and later as prescription patches and lozenges for severe chronic pain. It is roughly 50 to 100 times more potent than morphine, which made it valuable in medicine but catastrophic once it entered the illegal drug supply.
The key distinction in understanding the crisis is the difference between pharmaceutical fentanyl, prescribed by doctors, and illegally manufactured fentanyl (often called IMF). Prescription rates barely changed during the years when fentanyl deaths exploded. In Ohio, fentanyl prescribing actually declined 7% between 2013 and 2014, even as fentanyl deaths in the state surged by 526%. The crisis was never really about prescriptions. It was about a new, cheap, extraordinarily potent product flooding the illegal market.
The Three Waves of the Opioid Crisis
The CDC describes the broader opioid epidemic in three waves. The first began in the late 1990s with a rise in overdose deaths tied to prescription painkillers like oxycodone and hydrocodone. The second wave started around 2010 as heroin use surged, partly among people who had first become dependent on prescription pills. The third wave, driven by illegally manufactured fentanyl, began in 2013 and quickly dwarfed the first two.
Several forces converged to trigger that third wave. Fentanyl is far cheaper to produce per dose than heroin because it’s made entirely from chemical precursors rather than opium poppies. More efficient methods of synthesizing it spread through the internet, and regulatory gaps in source countries, particularly China, allowed precursor chemicals to flow with little oversight. Some researchers argue fentanyl filled a gap during periods of relative heroin shortage, giving traffickers a financial incentive to switch. Whatever the precise mix of causes, the result was a supply-driven event: fentanyl entered the market not because users demanded it, but because it was profitable to produce and distribute.
How It Spread Across the Country
The earliest surges hit states in the Northeast and Midwest. Florida and Ohio were among the hardest hit in the initial years. Between 2013 and 2014, law enforcement submissions of drugs testing positive for fentanyl jumped 494% in Florida and over 1,000% in Ohio. Deaths followed in lockstep. In those early years, illegally manufactured fentanyl was primarily mixed into or sold as heroin, meaning many people who died had no idea they were taking it.
The crisis then spread unevenly from east to west. Some states experienced their steepest increases before the COVID-19 pandemic, while others, particularly in the West, saw fentanyl saturate their drug supplies later. By the time the pandemic hit in 2020, fentanyl had reached virtually every corner of the country.
Counterfeit Pills Changed the Risk
The second major shift came when fentanyl moved beyond the heroin supply and into counterfeit prescription pills. Dealers began pressing fentanyl into tablets designed to look like oxycodone, Xanax, Adderall, and other common medications. This expanded the population at risk far beyond people who used heroin. Someone buying what they believed was a legitimate painkiller or anti-anxiety pill from an informal source could unknowingly take a fatal dose.
The scale grew rapidly. The number of counterfeit pills containing fentanyl seized by the DEA jumped nearly 430% from 2019 onward. Testing revealed that four out of every ten fentanyl-laced counterfeit pills contained a potentially lethal dose. As little as 2 milligrams of fentanyl, roughly the size of a few grains of salt, can kill. The margin between a dose that produces a high and one that stops someone’s breathing is vanishingly small, and the uneven mixing of fentanyl into pills or powder makes every use a gamble.
Adulterants Made the Supply More Dangerous
Starting around 2019, an animal tranquilizer called xylazine began showing up mixed into the fentanyl supply. Xylazine is not an opioid, which means the overdose-reversal drug naloxone doesn’t counteract its effects. Among 21 jurisdictions tracked by the CDC, the percentage of fentanyl-involved deaths where xylazine was also detected rose 276% between January 2019 and June 2022. The monthly count of such deaths climbed from 12 to 188 over that same period. Xylazine’s presence made overdoses harder to reverse and introduced new medical complications, including severe skin wounds at injection sites.
Some researchers now describe a “fourth wave” of the overdose crisis defined by the combination of fentanyl with stimulants like methamphetamine and cocaine. People using stimulants may not realize their supply contains fentanyl, or they may use both intentionally. Either way, the mixing of drug classes has broadened the overdose crisis well beyond what anyone would traditionally call an “opioid” problem.
The Regulatory Response
One challenge for law enforcement was that underground chemists could tweak fentanyl’s molecular structure slightly to create analogs that weren’t technically illegal. In February 2018, the DEA used emergency authority to temporarily place all fentanyl-related substances into Schedule I, the most restrictive category under federal law. That order was originally set for two years and has been repeatedly extended, though the broader debate about making it permanent continues.
Where Things Stand Now
After years of relentless increases, fentanyl-related deaths dropped significantly in 2024. The death rate from synthetic opioids other than methadone (a category dominated by fentanyl) fell 35.6% from 2023 to 2024, dropping from 22.2 to 14.3 deaths per 100,000 people. In raw numbers, about 47,735 people died from synthetic opioids in 2024. That’s a meaningful decline, but the toll remains enormous, still far higher than during the earlier waves of the opioid crisis.
The short answer to “when did fentanyl become a problem” is 2013 to 2014, when illegally manufactured fentanyl flooded heroin markets in the eastern United States and deaths began climbing at a pace no one had seen before. But the crisis didn’t stay in one place or one form. It moved westward, jumped into counterfeit pills, absorbed new adulterants, and merged with the stimulant supply, reshaping American drug overdose deaths for more than a decade.