Tool Kit for Measuring Opioid Misuse Needs Expansion

The National Survey on Drug Use and Health (NSDUH) has been a key metric for measuring drug use across the United States since 1971. However, data published in JAMA Health Forum (2025 May 30. doi:10.1001/jama.2025.7760) indicate that this survey may be unable to capture the rapidly evolving opioid crisis. In response, researchers note the need to develop strategies for effective, long-term monitoring of illegal drug use that can deliver insight into helping people with opioid use disorder.

“The common perception is that a small set of people are using illicit opioids like heroin and fentanyl with high overdose and fatality rates,” explained study author David Powell, PhD, of the Rand Corp. in Arlington, Va. “However, we found that there are much higher rates of illicit opioid use than previously thought and that the mortality rate from using the drugs isn’t quite as high as previously believed to be. We might be in a very different opioid crisis than we thought we were.

“However, to get a really clear picture of where we are in the opioid crisis and what interventions would be most effective, we need longitudinal studies where we can compare trends year over year,” Powell continued.

Researchers polled a nationally representative sample of 1,515 Americans older than 18 years of age using an online survey from June 10-17, 2024. Among this sample, 166 participants (10.96%) reported nonprescription opioid use within the past 12 months, including 114 (7.52%) who reported illicitly manufactured fentanyl (IMF) use. This is in contrast to the 2022 NSDUH—the most recent year available to researchers during their analysis—in which less than 1% of adults said they had used fentanyl illegally in the past year. The reasons why rates of IMF use are starkly different between surveys remains unclear. However, researchers hypothesize that underreporting of drug use may reflect the in-person nature of the NSDUH. Furthermore, because it takes more than a year for NSDUH data to be compiled and released, the survey does not reflect more current behavior.

“Powell’s study illuminates some of the limits of the NSDUH. As the opioid crisis has unfolded, the government has not had a willingness to spend the money to invest in adequate new data collection efforts that reflect the challenges of tracking opioid use. People often do not want to report their illicit opioid use in person,” explained Jonathan Caulkins, PhD, a professor of public policy at Carnegie Mellon University, in Pittsburgh.

“Furthermore, the study illustrates the limits of traditional surveys in general. Even surveys done online can fail to capture people without internet access or who do not know what drugs they are using. The scope of the opioid crisis justifies investment new in new primary data collection,” Caulkins concluded. He noted that no single survey or study was likely to be effective at accurately capturing the opioid crisis. Instead, he suggested the need to triangulate data between studies like Powell’s and alternative approaches to monitoring drug use like wastewater testing and aggregating data from arrest and employment drug testing.

However, even before triangulated or year-over-year data are available, there are still two factors to be gleaned from Powell’s research with implications for clinicals.

First, among study participants reporting nonprescription opioid use within the past 12 months, 65 (39.16%) reported that their first use involved opioids prescribed to them, whereas 60 (36.14%) reported that their first use involved prescription opioids not prescribed to them. Only 41 (24.70%) answered that their first exposure involved illicit opioids. Powell pointed out that these data suggest recent efforts at opioid stewardship, which possibly explain a decrease in overdose deaths, do not necessarily translate to keeping people from using IMF. He emphasized that clinicians and researchers must remain aware of the fact that prescribing opioids puts patients and the general population at risk of starting to misuse IMF.

Second, 71 (4.69%) of all respondents reported that it was very likely that they would have an overdose due to opioid use. This rate increased to 33.33% among those who had used IMF within the past 12 months.

“People realize that what they’re doing is dangerous, and this suggests that maybe there is more demand for treatment than previously thought. Looking at people who think that their behavior with opioids is dangerous may be a novel way of measuring unmet demand for treatment. Our standard measures of treatment access, like number of beds, might not adequately capture all the barriers people face to getting treatment,” Powell explained.

However, to better determine the real rate of IMF use, demand for treatment and the impact of opioid stewardship programs, Powell reiterated the need for expanded longitudinal studies. His team is planning a second study that will engage with people who do not have internet access, ask participants whether they want treatment for opioid use disorder and compare year-over-year trends in opioid use.

—Myles Starr

Caulkins and Powell reported no relevant financial disclosures.