Fentanyl shock: The changing geography of overdose in the United States
Abstract
Background Rapid increases in drug overdose deaths in the United States since 2014 have been highly regionally stratified, with the largest increases occurring in the eastern and northeastern states. By contrast, many western states saw overdose deaths plateau. This paper shows how the differential influx of fentanyl and fentanyl analogues in the drug supply has reshaped the geography and demography of the overdose crisis in the United States. Methods Using all state lab drug seizures obtained by Freedom of Information Act request, I analyze the regionally distinctive presence of fentanyl in the US drug supply with descriptive plots and statistical models. Main analyses explore state-year overdose trends using two-way fixed effects ordinary least squares (OLS) regression and two-stage least squares regression (2SLS) instrumenting for fentanyl exposure with state-longitude times a linear trend. Results First, fentanyl exposure is highly correlated with geography and only weakly explained by overdose rates prior to 2014. States in the east (higher degrees longitude) are much more heavily affected. Second, fentanyl exposure exhibits a statistically significant and important effect on overdose mortality, with model-predicted deaths broadly consistent with official death statistics. Third, fentanyl exposure explains most of the variation in increased overdose mortality between 2011 and 2017. Consequently, the epicenter of the overdose crisis shifted towards the eastern United Stat…
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The rapid spread of fentanyl in unregulated drug markets dramatically increases overdose mortality.
“Yet the rapid spread of fentanyl in unregulated drug markets dramatically increases overdose mortality,21,22 marking a “significant shift in the structural risk environment” for people who use illicit opioids.23(p108)”
From Drug Decriminalization, Fentanyl, and Fatal Overdoses in Oregon (2024) · cites this paper as [21]
Cites
Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., Xuan, Z., Bagley, S. M., Liebschutz, J. M., & Walley, A. Y. (2018) · Annals of Internal Medicine · doi:10.7326/m17-3107 · Cited by 1,076 · see citing works
Zoorob, M. J. (2018) · Pharmacoepidemiology and Drug Safety · doi:10.1002/pds.4417 · Cited by 17 · see citing works
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Shover, C. L., Falasinnu, T. O., Dwyer, C. L., Santos, N. B., Cunningham, N. J., Freedman, R. B., Vest, N. A., & Humphreys, K. (2020) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2020.108314 · Cited by 162 · see citing works
Park, J. N., Rashidi, E., Foti, K., Zoorob, M., Sherman, S., & Alexander, G. C. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2020.108416 · Cited by 128 · see citing works
Self-citationDrug Decriminalization, Fentanyl, and Fatal Overdoses in Oregon
Zoorob, M. J., Park, J. N., Kral, A. H., Lambdin, B. H., & del Pozo, B. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.31612 · Cited by 52 · see citing works
Self-citationPapsun, D. M., Krotulski, A. J., & Logan, B. K. (2022) · American Journal of Forensic Medicine & Pathology · doi:10.1097/paf.0000000000000787 · Cited by 51 · see citing works
Pitts, W. J., Heller, D., Smiley‐McDonald, H., Weimer, B., Grabenauer, M., Bollinger, K., Ropero‐Miller, J., & Pressley, D. (2023) · Journal of Forensic Sciences · doi:10.1111/1556-4029.15269 · Cited by 26 · see citing works
Hall, O. E., Trent Hall, O., Eadie, J. L., Teater, J., Gay, J., Kim, M., Cauchon, D., & Noonan, R. K. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2021.108637 · Cited by 21 · see citing works
Drug supply measures and drug overdose mortality in the era of fentanyl and stimulants
Cano, M., Timmons, P., Hooten, M., & Sweeney, K. (2023) · Drug and Alcohol Dependence Reports · doi:10.1016/j.dadr.2023.100197 · Cited by 17 · see citing works
Marland, V., Nisbet, L., & Nic Daéid, N. (2025) · Harm Reduction Journal · doi:10.1186/s12954-025-01287-9 · Cited by 15 · see citing works
“To date, opiate drug related deaths within the United Kingdom and Scotland, have not been as heavily impacted by the rise of synthetic opioids such as fentanyl and their analogues, as has been evidenced in other countries including the United States [2, 3].”
- Authors
- Zoorob, M.
- Affiliations
- Harvard University (US)
- Corresponding author
- Zoorob, Michael
- ORCID
- Zoorob, Michael
- Venue
- International Journal of Drug Policy
- Publisher
- Elsevier BV
- Published
- 2019-08
- Volume
- 70
- Pages
- 40-46
- ISSN
- 0955-3959 (ISSN-L)
- OpenAlex
- W2944311562
- Cited by
- 160
- References
- 2
- Citations by year
- 2026: 19 · 2025: 21 · 2024: 24 · 2023: 26 · 2022: 27 · 2021: 15 · 2020: 22 · 2019: 6
- FWCI
- 16.20
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Drug Policy (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Forensic Toxicology and Drug Analysis
- Keywords
- fentanyl, fentanyl analogs, drug overdose deaths, opioid epidemic, drug supply, regional variation, drug seizures, addiction policy, United States
- MeSH terms
- Analgesics, Opioid, Fentanyl, Humans, United States, Models, Statistical, Geography, Medical, Drug Overdose
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