A groundbreaking new study by RAND Corporation and the University of Southern California reveals that illicit opioid use—particularly of nonprescription fentanyl—is far more widespread in the United States than official estimates have indicated. In an online survey of 1,515 American adults conducted in June 2024, researchers found that 11 percent reported using illicit opioids in the past year, and 7.5 percent reported use of illicitly manufactured fentanyl. These figures dwarf the 0.3 percent fentanyl prevalence reported by the National Survey on Drug Use and Health (NSDUH) in 2022, underscoring a critical need for more accurate, near–real-time monitoring tools to guide the nation’s response to the ongoing opioid crisis.
A Crisis Evolving: From Prescription Pills to Fentanyl
The U.S. opioid epidemic has metamorphosed over the past two decades. Initially driven by overprescribing of opioid painkillers in the late 1990s and early 2000s, the crisis shifted to heroin use in the early 2010s. Within a few years, illicitly manufactured fentanyl—a synthetic opioid up to 50 times more potent than heroin—emerged as the deadliest threat, now implicated in the majority of opioid overdose deaths. As polysubstance use and multi-drug fatalities surge, understanding the true scale of illicit opioid consumption has taken on renewed urgency for public health officials and policymakers.
Study Methodology: An Innovative Online Survey Approach
To address gaps in existing surveillance, RAND senior economist David Powell and USC economist Mireille Jacobson led a cross-institutional team in designing and fielding a large, demographically representative online survey of American adults. The 1,515 respondents were drawn from a probability-based panel in June 2024 and queried about their nonprescription opioid use—heroin and illicitly produced fentanyl—within the prior 12 months. Crucially, the survey distinguished between intentional use (deliberate consumption) and unintentional exposure (for example, unaware ingestion of contaminated pills). Participants were asked:
- Whether they intentionally used nonprescription opioids in the past year
- Whether they intentionally or unintentionally used illicitly manufactured fentanyl
This nuanced questioning allowed researchers to capture both willful opioid consumption and the growing phenomenon of unsuspected fentanyl exposure.
Key Findings: A Far Larger Population at Risk
- Overall Illicit Opioid Use: 11 percent of respondents reported nonprescription opioid use in the past 12 months—equivalent to about 28 million American adults.
- Illicit Fentanyl Use: 7.5 percent reported illicitly manufactured fentanyl use—about 19 million adults. This represents more than 20 times the 0.3 percent rate from the NSDUH.
- Intentional vs. Unintentional Use:
- Intentional nonprescription opioid use: 7.7 percent
- Unintentional nonprescription opioid use: 3.2 percent
- Intentional fentanyl use: 4.9 percent
- Unintentional fentanyl exposure: 2.6 percent
- First Exposure to Opioids: Among users, 39 percent first used opioids via a prescription legitimately given to them; 36 percent first obtained pills not prescribed to them; and 25 percent began their opioid use with illicitly manufactured drugs.
These figures reveal not only the scale of deliberate opioid misuse but also the stealthy infiltration of illicit fentanyl into a wide cross-section of the population.
Comparison with Federal Estimates
The U.S. government’s long-standing benchmark for drug surveillance, the National Survey on Drug Use and Health, began asking about fentanyl only in 2022 and reported a lifetime adult usage rate of 0.3 percent that year. By contrast, the RAND/USC study’s 7.5 percent annual prevalence—capturing both intended and unintended fentanyl use—suggests that official counts may seriously understate the crisis. Powell observes:
“Our findings add to mounting evidence that government surveys may significantly underestimate illicit opioid use. New methods are urgently needed to track these trends in near real-time and guide effective policy responses.”
Why the Discrepancy? Survey Methods and Reporting Bias
Researchers speculate that differences in survey methodology likely contribute to the wide gap. The NSDUH conducts approximately half of its interviews in person, which can inhibit frank disclosure of illicit behaviors. Stigma, fear of legal repercussions, and social-desirability bias may all dampen self-reporting in face-to-face settings. The RAND/USC team’s online platform offered greater anonymity, potentially fostering more honest responses.
Despite its advantages, the online approach has limitations. The study’s authors acknowledge that voluntary panel participation could introduce unobserved sampling biases, and they plan to replicate their findings using alternative survey platforms designed to further mitigate bias.
Implications for Public Health Policy
If illicit opioid use is indeed as widespread as this study suggests, the ramifications are profound:
- Resource Allocation: Treatment programs, harm-reduction services, and overdose-response infrastructure may be underfunded relative to actual need.
- Early-Warning Systems: Public health agencies currently lack the tools for near‐real‐time monitoring of emerging hotspots. Rapid-cycle online surveys could supplement traditional data streams, enabling more agile intervention.
- Fentanyl Contamination: The high rate of unintentional fentanyl exposure underscores the urgency of widespread fentanyl-test-kit distribution and education on contamination risks, particularly in counterfeit pills.
- Prescription Policies: While prescription opioids remain a gateway for many users, the substantial share of first exposures occurring via illicit pills points to the necessity of robust law‐enforcement efforts against clandestine fentanyl production.
Expert Commentary
Mireille Jacobson, co-author and economist at USC, emphasises the policy potential of timely data:
“We need to know not just where we stand in this epidemic, but whether we’re making progress in reining it in. Near-real‐time information—gleaned at low cost via online surveys—could transform our ability to respond effectively.”
Public health experts also note that combining survey data with wastewater analysis, emergency department syndromic surveillance and law-enforcement seizure reports could yield a more comprehensive understanding of evolving drug trends.
Calls for Innovative Surveillance
The study’s authors advocate for routine, low-cost online monitoring as a complement to federal surveys, enabling quarterly or even monthly updates on illicit opioid prevalence. Such an approach could allow:
- Dynamic Resource Targeting: Redirecting naloxone distribution, treatment slots and mobile outreach units to emerging hotspots.
- Rapid Policy Evaluation: Assessing the impact of new regulations—such as fentanyl analog bans, expanded needle exchanges or altered prescribing guidelines—on actual use patterns.
- Public Awareness Campaigns: Tailoring educational efforts to the demographics and geographies showing spikes in unintentional exposure, thereby preventing fatal overdoses.
Funding and Collaborative Efforts
The research was supported by Arnold Ventures and the National Institutes of Health’s National Institute on Drug Abuse (NIDA) under grants R21DA06011 and 2P50DA046351-06A1. The study’s publication in JAMA Health Forum signals broad professional recognition of its importance. RAND Health Care and USC’s Schaeffer Center remain committed to refining methodologies and expanding collaborations with state health departments and community organizations.
Next Steps: Validation and Scale-Up
To bolster confidence in the findings, the research team plans several follow-on activities:
- Replication Studies: Conducting parallel surveys on alternative online panels and via text-message sampling to assess consistency.
- Longitudinal Tracking: Establishing cohorts for repeated measurement to discern individual trajectories and response to interventions.
- Integration with Administrative Data: Correlating self-reported use with hospital admissions, overdose fatality records and prescription monitoring programs to triangulate insights.
Conclusion
The RAND/USC study’s startling revelation—that illicit fentanyl use may be more than 20 times higher than federal estimates—serves as a clarion call for a paradigm shift in opioid surveillance. By harnessing modern survey technologies and AI-driven analytics, public health authorities can gain a clearer, more immediate view of the epidemic’s contours. With opioid fatalities continuing to exact a devastating toll, such innovations are not merely academic; they are essential to saving lives and restoring hope in communities across America.
