The opioid epidemic has been a defining public health crisis in the US for the past quarter century.
With more than 800,000 people dead from overdoses over nearly 25 years, it’s hard to find an event—outside of the Covid-19 pandemic—that has impacted the US healthcare system more. The economic cost of opioid use disorder and opioid overdoses in the US was estimated to be more than $1 trillion in 2017 alone, according to CDC data.
Today, the number of overdose deaths has finally started to decline. But experts warn impending changes to Medicaid could slow that progress.
Further, overdose deaths are still higher than they were pre-pandemic, Thuy Dieu Nguyen, an assistant professor of health management and policy at the University of Michigan School of Public Health, told Healthcare Brew.
“We still have an ongoing opioid crisis,” she said.
A brief history
The CDC breaks the opioid epidemic into three waves.
The first began in the 1990s, when doctors started prescribing more opioids for pain control, driven largely by Purdue Pharma’s OxyContin hitting the market in 1996. The second wave that began in 2010 saw an increase in heroin deaths, as the drug became cheaper and more available in the US. The third wave began in 2013 as synthetic opioids, primarily fentanyl-based drugs, rose in popularity.
The CDC first called the opioid crisis an “epidemic” in 2011, and in October 2017, President Donald Trump declared it a public health emergency.
As the crisis unfolded, national lawsuits targeted opioid manufacturers, pharmaceutical distributors, and pharmacies for allegedly “aggressively marketing” the drugs while “downplaying addiction and overdose risks.”. In 2019, Purdue Pharma, the maker of OxyContin, filed for bankruptcy. Though the company had profited $35+ billion from opioid sales, it was later forced to pay roughly $57 billion in legal settlements.
But what didn’t receive much legal attention—until recently—is the role of pharmacy benefit managers (PBMs), which negotiate with drug companies to create formularies for insurers.
A group of lawmakers asked the Department of Justice in December 2024 to investigate PBMs’ role in the opioid epidemic, saying in a letter that recent reports and a review of confidential files suggested the Big 3 PBMs—CVS Caremark, Express Scripts, and Optum Rx—“colluded and conspired to steer patients toward OxyContin in exchange for $400 million.”
The PBMs told the New York Times in December they offered payers the option to restrict opioid prescriptions.
Where we are now
After skyrocketing during the pandemic, the number of opioid-involved deaths started falling in 2023 for the first time since 2018, according to CDC data.
Between 2022 and 2023, the number of overdose deaths involving synthetic opioids fell by 2%, heroin by about 33%, and prescription opioids by almost 12%.
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Further, provisional CDC data shows total drug overdose deaths fell about 27% from 110,037 to 80,391 between 2023 and 2024.
Experts aren’t sure why, exactly, overdose deaths have started dropping so significantly, but Nguyen said there are a few potential explanations.
First, some experts think that because fentanyl overdoses have already killed so many people in recent years, the number of high-risk drug users is shrinking, she said.
Second, harm reduction measures, like increased access to naloxone, an opioid overdose reversal drug, may be working. In March 2023, the FDA approved over-the-counter Narcan (a brand-name naloxone), which can also be bought online.
“The interventions are now working,” Nguyen said. “People have easier access to naloxone, fentanyl testing strips, or certain things that have helped individuals to cope with deadly fentanyl products.”
Access to other opioid use disorder treatments, such as buprenorphine, has also been expanded significantly, Nguyen said. For instance, during the pandemic, the Drug Enforcement Agency and Substance Abuse Mental Health Services Administration allowed providers to prescribe buprenorphine after an audio-only telehealth call instead of requiring patients to go in person. That rule became permanent in January 2025.
And policies passed during the pandemic, including continuous Medicaid coverage that allowed beneficiaries to stay enrolled through the public health crisis, likely helped, she added. A KFF analysis shows that 47% of nonelderly adults with opioid use disorder are Medicaid beneficiaries.
Additionally, many states no longer require prior authorization for at least one type of buprenorphine, Heather Saunders, a senior research manager for KFF’s program on Medicaid and the uninsured, told us. That’s led to an increasing number of prescriptions for the treatment, she added.
Where we go from here
Potentially the biggest threats to this progress are the looming Medicaid cuts and work requirements, as Medicaid “finances the largest share of medication-assisted treatment,” Saunders told us.
President Trump’s One Big Beautiful Bill Act, which was signed into law on July 4, cuts Medicaid funding by about $1 trillion over the next 10 years and puts work requirements in place, which means beneficiaries must prove they spend 80 hours per month working, going to school, or doing other approved activities like community service.
The added paperwork burden that comes with work requirements may cause coverage gaps, which could raise the risk of overdose deaths, Saunders said.
Stopping opioid use disorder treatment is linked to a 6x higher mortality risk for the first four weeks after interrupting treatment, according to the KFF analysis, which Saunders co-authored.
“It’s anticipated that 10 million more people overall will become uninsured,” she said. “So, to the extent that includes people with opioid use disorder, that might have implications for them being able to access treatment continuously.”
This is one of the stories of our Quarter Century Project, which highlights the various ways industry has changed over the last 25 years. Check back each month for new pieces in this series and explore our timeline featuring the ongoing series.
