Illicitly manufactured fentanyl (IMF) abuse has spread across the United States, with fatal overdoses rising sharply in the southern and western states. The CDC reported on trends in IMF-related deaths in a recent Morbidity and Mortality Weekly Report (MMWR).

Between May 2020 and April 2021, the estimated number of fatal overdoses exceeded 100,000 for the first time. Most of those deaths can be linked to IMFs, including both fentanyl and illicit fentanyl analogs. Fatal overdoses spiked during the pandemic: between July 2019 and December 2020, IMF-related deaths increased by 64.7% in the south and 93.9% in the west.

During the same period, more IMF-related deaths co-involved stimulants rather than additional opioids. Cocaine with heroin was the most common combination in the midwest, south, and eastern US. In the west, methamphetamine with prescription opioids was the most common combination. Co-involvement can complicate substance use disorder treatment as well as increase overdose risk.

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Injection was the most frequently reported route of administration across all regions except for the west (22.7 – 30.6%). Snorting, smoking, and swallowing were reported in the west in over half (57.1%) of deaths in the western US.

The report also noted over half (56%) of the individuals who died from IMF overdose had no pulse when first responders arrived, which points to a need for more timely response, the report states.

This study had some limitations. The jurisdictions that reported overdose results do not represent the US as a whole. In addition, death investigation differs among states and counties, which may have affected the data. A lack of standard toxicology testing is another study limitation.

“Urgent action is needed to slow and reverse rapid increases in drug overdose deaths involving IMFs and other drugs, including enhancing access to substance use disorder treatment (eg, medications for opioid use disorder) and expanding harm reduction approaches that address risk factors associated with IMFs,” the report states.

“Innovative approaches are needed to address the endemic nature of IMF-involved overdoses, noninjection routes of IMF use, and frequent polysubstance use; in particular, the rising use of opioids and stimulants.”


O’Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends in and characteristics of drug overdose deaths involving illicitly manufactured fentanyls – United States, 2019-2020. MMWR Morb Mortal Wkly Rep. 2021;70(50):1740-1746. doi:10.15585/mmwr.mm7050e3