Counterfeit Pills in Overdose Deaths More Than Doubled, 2019–2021, and Tripled in the West

U.S. drug overdose deaths are at historic highs — a preliminary 105,000+ in 2022. Counterfeit pills, made to look like real medicines (often oxycodone or alprazolam) but not made by drug companies, are complicating the illicit market. They often contain illicitly manufactured fentanyls (IMFs), illicit benzodiazepines such as bromazolam, etizolam and flualprazolam, or other drugs — exposing people to substances they never meant to take.

CDC reviewed death records, toxicology and medical examiner reports in its State Unintentional Drug Overdose Reporting System, flagging evidence of counterfeit pills such as pills identified as fake at the scene, pills testing positive for other drugs, "oxycodone" pills with no oxycodone in the body, unmarked pills, or witness reports of pill use when the drugs found aren't sold as legitimate pills.

Key findings

Overdose deaths with evidence of counterfeit pill use, by quarter and region, 30 jurisdictions. From CDC's MMWR.

In 2021, among 54,768 overdose deaths in 35 jurisdictions, 2,437 (4.4%) showed evidence of counterfeit pills. More than half involved counterfeit oxycodone — alone (55.2%) or with counterfeit alprazolam (3.9%).

How these deaths differed

What the findings suggest

• Fentanyl moving west: white-powder IMFs were historically rarer in western states, where it's hard to mix with the black tar heroin common there. Counterfeit oxycodone deaths clustered in the West, while nearly half of counterfeit-alprazolam-only deaths were in the South — so prevention materials that draw on local drug seizure data may work best.
• The pills likely caused the deaths: many counterfeit-pill deaths involved only IMFs. Adulterants differed from powder deaths, hinting at different sources, and nearly one in five counterfeit-alprazolam deaths involved illicit benzodiazepines of unpredictable potency.
• Younger victims: counterfeit pills have been marketed to young people, who may have lower tolerance, take more risks and use harm reduction services less. Outreach should be tailored to younger and Hispanic people, addressing language and other barriers.
• From prescriptions to the street: more prescription-misuse histories may reflect people switching from prescribed to illicit pills when access ends. Providers should screen for opioid misuse when prescriptions change and link patients to treatment, including medications for opioid use disorder.
• Smoking isn't safe: in the West, more than half of counterfeit-pill deaths involved smoking. Smoking can carry overdose risk similar to injecting because drugs are absorbed quickly.

Limits: results may not apply beyond the included jurisdictions; counterfeit pill use is likely undercounted; and pills found at a scene may not always have been used.

Prevention

Public health messaging should:

1. warn that pills obtained illegally or without a prescription may be counterfeit and contain potent drugs;
2. stress taking only pills prescribed to you;
3. encourage drug checking, with fentanyl test strips and drug-checking services, alongside having naloxone on hand and never using alone.

The Drug Enforcement Administration's One Pill Can Kill campaign offers materials for parents and caregivers, some in Spanish.

Sources

Based on O'Donnell J, Tanz LJ, Miller KD, et al., "Drug Overdose Deaths with Evidence of Counterfeit Pill Use — United States, July 2019–December 2021," Morbidity and Mortality Weekly Report 72(35), CDC; a work of the United States government in the public domain.