The Substance Abuse and Mental Health Services Administration (SAMHSA) has released the 2024 edition of the National Survey on Drug Use and Health (NSDUH), the annual-ish report covering substance use, mental illness, treatment and recovery. The 2022 NDUHS was the first to include data on street-supply fentanyl, but for the third year in a row now SAMHSA has made some unconventional choices in how it organizes that data.
The 2024 NSDUH includes self-reported information from 70,241 respondents. Based on that data, the survey extrapolates that 73.6 million United States residents over age 12—about one in four—used unregulated drugs in 2024. This refers to any use of cocaine, hallucinogens, heroin, inhalants, marijuana, methamphetamine, and “misuse of prescription stimulants, tranquilizers or sedatives, or pain relievers.”
The category includes pharmaceutical fentanyl used in non-prescribed ways. But it does not reflect any use of street-supply fentanyl.
The survey separately indicates that “fentanyl misuse” has decreased somewhat, from a projected 991,000 people in 2022 down to 816,000 people in 2024. This particular category refers to both street-supply and pharmaceutical fentanyl, despite no real reason to group those together. Diverted prescription fentanyl isn’t shaping the landscape of drug use and health in the same way that street-supply fentanyl is. This category is also made more confusing by the fact that prescription fentanyl data get counted toward the overall numbers for unregulated drug use, but street-supply fentanyl data don’t. The decrease is attributed almost entirely to pharmaceutical fentanyl; street-supply accounted for an estimated 686,000 people using fentanyl in 2022, and still accounted for 668,000 in 2024.
Since it began including street-supply fentanyl with the 2022 survey, the NSDUH has always included lots of caveats about how those figures are almost certainly an undercount. But it has yet to take steps to adjust for that, or even make similar disclosures for how the missing data might skew other parts of the survey, too.
“Prescription pain relievers” is a new subcategory this year. Previous surveys had used the term “prescription opioids” and awkwardly shoehorned in non-opioid analgesics.
The report concludes that one of the overall trends to emerge over the past four years is that “opioid misuse” has decreased, dropping from 9.1 million people (3.2 percent of the population over age 12) in 2021 to 7.8 million (2.7 percent) in 2024. This category still does not include street-supply fentanyl—only heroin or pharmaceutical opioids, or both. The 2024 survey references supplementary data tables that do include street-supply fentanyl, but at publication time SAMHSA’s website still lists those tables as “coming soon.”
Almost 93 percent of data included in this category pertained only to “misusing” prescription opioids, without any heroin use—which implies those people had no interaction with street-supply opioids at all. But because of the very unhelpful way the data have been categorized, it’s difficult to draw any conclusions about that either.
Of the respondents who reported “prescription pain reliever misuse,” 43.7 percent said they got the medications from a health care provider, doctor’s office, clinic, hospital or pharmacy. Meanwhile, 49.9 percent reported getting them from a friend, relative, drug seller or stranger. (The remaining 6.4 percent sourced the medications “some other way.”)
Despite the sourcing methods getting their own subsection—and despite the Drug Enforcement Administration’s disproportionate focus on counterfeit pharmaceuticals—the NSDUH does not comment on the fact that, if we’re to take these categories at face value, about half the drugs represented as pharmaceuticals could conceivably have been street supply.
Street-supply fentanyl is commonly sold as pressed pills, especially on the West Coast. The single reference to this is a note that street-supply fentanyl “is sometimes present in products that are sold as heroin or in counterfeit prescription drugs that are made to look like commonly misused prescription opioids.”
The 2024 NDUHS also has the same foundational problem as in previous years, in terms of what skews its findings from representing drug use and mental illness in real life: It doesn’t reach the populations most heavily impacted by those things.
“NSDUH covers residents of households and people in noninstitutional group settings,” states the 2024 edition, the same as it has in previous years. “The survey excludes people with no fixed address.”
The new survey comes just days after President Donald Trump issued an executive order effectively criminalizing street-homelessness using the premise that substance use disorder and mental illness are the root causes.
Top image (cropped) via United States Sentencing Commission. Inset graphic via Substance Abuse Mental Health Services Administration.