On July 30, the Substance Use and Mental Health Services Administration released its annual survey on substance use, mental illness, treatment and recovery. The 2023 National Survey on Drug Use and Health (NSDUH) represents 67,679 people in the United States ages 12 and up, and for the second year running has given us a lot of data on the nation’s drug use that does not include unregulated fentanyl.
The 2022 NSDUH was the first to address any difference between prescribed fentanyl and “illegally manufactured fentanyl” (IMF) at all. But it didn’t ask respondents about it until the “Emerging Issues” section, by which time they had already answered most of the questions. So data represented in categories like “illicit drug use” and “opioid misuse,” as well those for substance use disorder (SUD) and opioid use disorder, only include pharmaceutical fentanyl.
A year later, the 2023 survey has done the same thing. (It’s actually only been eight and a half months since the 2022 NSDUH; for the past decade the annual survey has usually been released closer to the end of the year, but it’s always been kind of irregular.) SAMHSA told Filter that questions relating to “a newer population issue” generally remain at the end of the survey for a few years before being integrated more fully.
“NSDUH reports consistently state that the NSDUH estimates of IMF use are likely underestimates because people who use IMF are often not aware that they are using it,” the agency stated to Filter. “SAMHSA continues to prioritize treatment and recovery support for people with opioid use disorder, including those who use IMF, due to IMF’s role in a majority of drug overdose deaths each year.”
The 2022 survey noted that the omission of unregulated fentanyl data didn’t impact the results, due to relatively low numbers of people who reporting using it. It’s conceivable that some of the street supply fentanyl got reported as pharmaceutical fentanyl, and likely that the survey just wasn’t accessible to a lot of the people impacted.
The 2023 survey was well underway before it reached the question below, which is the first reference to fentanyl of any kind and seems pretty ambiguous. It’s meant to refer to only pharmaceutical fentanyl.
Much later on in the survey, respondents would read that what they’d answered earlier was about whether they “had used prescription fentanyl, also known as Duragesic or Fentora,” and that they would now be asked about “illegally made fentanyl, which is fentanyl that people can’t get from a doctor or pharmacy.”
“To date, we are not aware of any concerns regarding these questions, [which] undergo multiple rounds of review by subject matter experts and are cognitively tested prior to being included,” SAMHSA stated to Filter. “In addition, questions pertaining to pharmaceutical drugs display images of the drug(s) to minimize respondent confusion between pharmaceutical and illicit substances.”
A representative told Filter that the subject matter experts included people with lived experience. But with unregulated drug use in particular, an emphasis on academic experience tends to result in questions—and answers—that give the impression of having been mistranslated.
Substance “misuse” at one point had some function related to prescription drug use—separating the kind that’s okay from the kind that’s not okay—but federal agencies collectively lost the plot with this some time ago. “Opioid misuse” includes heroin and pharmaceutical fentanyl, but not unregulated fentanyl. The NSDUH suggests methadone and buprenorphine as prescription pain relievers you might have misused, and also as medications you might have taken to avoid using drugs. But neither are suggested in the question about things you might have taken to “get over or avoid having heroin withdrawal symptoms.” (The options are “Heroin,” “Prescription pain relievers” or “Something else.”)
Meanwhile, you can use pharmaceutical opioids exclusively as prescribed and still be diagnosed with SUD. And because of the way it’s still organizing the fentanyl data, the survey ends up asking people about needing treatment related to pharmaceutical pain relievers, but not unregulated opioids. “Any use of opioids” still doesn’t include unregulated fentanyl. But does include pharmaceutical analgesics like tramadol, or Tylenol with codeine.
Even the big takeaways don’t tell us much. One finding highlighted was that out of all substances that people in the US started using in 2023, the most common was vaped nicotine. The report estimated that 5.9 million people initiated use (tried it at least once), about half of them between ages 12 and 26.
The estimated number of people who currently smoke cigarettes has dropped since the 2022 NSDUH, from 41.1 million to 38.7 million. During that time, the number of people vaping nicotine has increased from 23.5 million to 26.6 million.
A survey tracking shifting behaviors around substance use would have been a convenient place to ask whether the people who stopped smoking cigarettes had migrated to the less-harmful alternative. The 2023 NSDUH did ask whether respondents had ever—“even once”—vaped e-liquids without nicotine, but not whether they’d ever vaped as an alternative to cigarettes, and the report doesn’t mention whether or how the two are related.
As a “household survey,” each NSDUH already skips over the populations disproportionately vulnerable to harm from drug use and mental illness, and by treatment services too. The survey isn’t offered in any institutional settings—like prisons, psychiatric institutions or residential drug treatment centers—or to anyone sleeping outside. Instead it’s offered to communities that tend to be more accessible to SAMHSA, and less impacted by the things SAMHSA’s asking about.
“Populations that may have higher risk of IMF use (e.g., populations experiencing homelessness not in shelters or incarcerated populations) are not included,” SAMHSA stated to Filter. “Multiple data sources must be considered to fully characterize this complex issue.”
Top image via City of Miami Springs. Inset graphics of 2023 National Survey on Drug Use and Health via Substance Abuse and Mental Health Services Administration.