From Pills to Powder: How a Generation's Pain Prescriptions Became a Fentanyl Crisis

Addiction & Public Health
Written By Vital Biomedical News Staff

Illustration & Quote from a 2018 Goldman Sachs biotech report.

By Vital Biomedical News Staff

Last updated October 6, 2026. Overdose figures reflect CDC provisional data through March 2026.

An entire generation went to the doctor for pain and left with a prescription. Fifteen years later, many of them were buying fentanyl on the street. The research now shows how one step led to the next.

It started with a sore back

Chris Marshall was a 22-year-old auto mechanic in Northeast Philadelphia when he hurt his back on the job. His first Percocet came from his grandmother, who gave him ten more in case it happened again. She had no idea what she was handing him.

A few years later, Marshall had back surgery. His doctors prescribed what he asked for, including OxyContin. By the time he realized he was dependent, he checked himself into a weeklong detox. There, he later said, he heard constantly about heroin, a drug he had never touched. It became the next step.

What followed reads like a map of the American overdose crisis. Heroin led to injecting cocaine and smoking crack. Then he sought out fentanyl. He stole from his mother and his son, lost his family, and ended up homeless. His story was documented by the Science History Institute.

Marshall's path was not unusual. It was the path of a generation. Researchers now describe the crisis in four waves: prescription pills, then heroin, then fentanyl, then fentanyl mixed with stimulants like cocaine and methamphetamine. Each wave grew out of the one before it. This is how that happened, what the evidence says, and where the country stands in 2026.

Wave one: the prescription years

The first wave began in good faith. In the early 1990s, doctors were criticized for undertreating pain, especially chronic pain and cancer pain (Jones et al., Pain & Therapy, 2018). Pressure grew to prescribe more, and drug makers were ready to supply it.

Purdue Pharma marketed OxyContin as a safer, longer-lasting painkiller. Reporting by the Los Angeles Times later showed the company promised 12 hours of relief that, for many patients, wore off sooner. That gap left patients in withdrawal between doses (Ryan et al., Los Angeles Times). Doctors also had financial ties to the industry. Thousands received payments from opioid manufacturers in 2014 and 2015 alone (Hadland et al., AJPH, 2017).

Prescribing climbed for two decades. It peaked in 2012 at 255 million opioid prescriptions, a rate of 81.3 for every 100 Americans (CDC via PolicyMap).

Most people who received those prescriptions took them as directed and stopped. But at that volume, even a small share adds up to millions. Today's research gives a sense of the scale. About 6% of surgical patients who had never taken opioids keep filling opioid prescriptions months after recovery, a pattern called new persistent opioid use (Anesthesiology and Perioperative Science, 2025). Researchers consider it one of the most common complications after surgery.

The risk is not limited to major operations. Matt Ward of Michigan was prescribed opioids after a tooth extraction in high school. His family says that is where his addiction began. He died of an apparent fentanyl poisoning in 2019, at 21 (Michigan Association of Health Plans).

Tennessee families tell the same story. In a collection gathered by the state, a Shelby County woman describes how her mother's addiction began with surgery. Repeated operations kept her supplied with morphine and Percocet for nearly 15 years (Tennessee Faces of Opioids).

Wave two: August 2010 and the turn to heroin

In August 2010, Purdue replaced OxyContin with a version that was hard to crush, snort or inject. The goal was to stop misuse. For many patients already dependent on the drug, it closed the easiest door, and heroin was the cheaper one next to it.

This moment matters because it lets researchers test cause and effect. Economists at Notre Dame and Boston University found that opioid pill use stopped rising in August 2010. Heroin overdose deaths began climbing the following month. The increase was largest in places with more OxyContin misuse and better access to heroin (Evans, Lieber and Power, Review of Economics and Statistics, 2019). Over the next four years, heroin death rates quadrupled.

The lead author described the result as a one-for-one trade: pill deaths fell, and heroin deaths took their place (University of Notre Dame). A separate study concluded the reformulation explains most, if not all, of the rise in heroin overdoses from 2010 to 2013 (Alpert, Powell and Pacula, NBER).

Surveys of people with heroin addiction show the same shift. Among those who began using opioids in the 1960s, more than 80% started with heroin. Among those who began in the 2000s, 75% said their first opioid was a prescription drug (Cicero et al., JAMA Psychiatry, 2014). People who misused pain relievers were 19 times more likely to start heroin.

When researchers asked people why they switched, most gave practical reasons: heroin was easier to find and cost less (Cicero et al., NEJM, 2015). One study of people who moved from pills to injecting heroin borrowed its title from a participant: "Every 'never' I ever said came true" (Mars et al., International Journal of Drug Policy, 2014).

The evidence is strong but not unanimous. One later analysis argues earlier studies overlooked generic oxycodone, and that the reformulation was a major cause rather than the only one (working paper, 2021). Either way, the direction is the same: cutting off pills without treating addiction pushed people toward the street.

Wave three: fentanyl takes over the supply

Around 2013, a third wave began. Illicitly manufactured fentanyl started showing up in the heroin supply. It is far stronger than heroin and much cheaper to produce, which made it attractive to traffickers.

The people buying heroin mostly did not ask for it. In interviews, people who use drugs have consistently said they did not want fentanyl. Researchers conclude its spread was driven by suppliers, not by demand (study of people who use stimulants, 2021). Physician-researcher Daniel Ciccarone's team was studying heroin markets when the change happened. They documented fentanyl being sold as "heroin," and users disliking it at first (Ciccarone, Journal of Medical Toxicology, 2025).

Over time, many people lost the option to choose. One drug-testing lab saw heroin-positive tests fall 80% from 2016 to 2022, while fentanyl positives rose. Its conclusion: fentanyl has replaced heroin on the street (Pesce et al., Annals of Clinical & Laboratory Science, 2023).

This is how a person who first took a pill after surgery could die from a drug they never knowingly bought.

Wave four: fentanyl meets cocaine and meth

The fourth wave is fentanyl combined with stimulants. Deaths involving both fentanyl and a stimulant rose more than 50-fold after 2010. By 2021 they made up 32% of all U.S. overdose deaths (Friedman et al., Addiction, 2023). That year, a stimulant was the drug most often found alongside fentanyl in every state.

The mix depends on geography. In the Northeast, fentanyl is most often paired with cocaine. In the South and West, it is more often paired with methamphetamine (EurekAlert). These deaths fall hardest on Black and Native American communities.

There are two routes into this wave, and both are real.

Contamination. Fentanyl gets into cocaine and other stimulants in the supply chain. Someone who only uses cocaine has no opioid tolerance, so a trace of fentanyl can stop their breathing. Studies estimate 6% to 15% of street stimulant samples contain fentanyl (Frontiers in Psychiatry, 2026).

Deliberate co-use. Many people who use fentanyl now add meth on purpose. As clean heroin and pills disappeared, people began using stimulants to fight fentanyl's heavy sedation and to ease withdrawal (pharmacology study, 2022). In interviews in Dayton, Ohio, people described learning from friends that meth could take the edge off opioid withdrawal (Substance Use & Misuse, 2021).

This is where the debate sits. Writing for VICE in 2023, drug journalist Max Daly argued that accidental fentanyl-laced cocaine is not the main driver of these deaths, pointing to intentional use of both drugs instead (VICE). The research suggests the answer varies by place and by person. What both sides agree on is that the mixed drug supply is more dangerous than ever, and that naloxone reverses only the opioid part of an overdose.

Where things stand in 2026

There is real progress. Overdose deaths have fallen for three straight years. The CDC's latest provisional data predicts 67,798 deaths in the 12 months ending March 2026, down 12.3% from a year earlier (CDC). Deaths in 2025 fell 14% and reached their lowest level since 2019 (AJMC). Still, that is more than 180 Americans a day.

Prescribing has been reined in. The national opioid dispensing rate fell from 46.8 prescriptions per 100 people in 2019 to 35.4 in 2024. The CDC now says prescription opioids are no longer the main driver of overdose deaths, though they still contribute (CDC). Tennessee's neighbors in the South still prescribe the most, led by Arkansas at 68.8 and Alabama at 68.5.

Careful prescribing works. Since 2013, both the size of post-surgery prescriptions and the rate of new persistent opioid use have dropped nationwide (Annals of Surgery, 2025). Prescribing less led to fewer long-term users, which supports the case that prescribing helped create the problem. A 2025 review of 27 studies found the patients most at risk are those on Medicaid, those already taking benzodiazepines, and those with depression or anxiety (Pain Medicine, 2025).

Most people still don't get treatment. Only about 25% of people with opioid use disorder receive medication for it, even though methadone and buprenorphine are proven to reduce deaths (Penn LDI). Access depends on where you live. In 2024, West Virginia pharmacies dispensed 24.9 buprenorphine prescriptions per 100 people, while Texas dispensed 1.4 (CDC).

Coverage is at risk. Medicaid covers nearly half of U.S. adults with a substance use disorder. One estimate projects that 1.6 million Medicaid enrollees in addiction treatment could lose coverage under the 2025 federal budget law (CHERISH). Researchers warn that losing coverage interrupts treatment, and interrupted treatment costs lives.

Tennessee is expanding access. TennCare doubled the maximum daily dose of oral buprenorphine from 16 mg to 32 mg and removed a six-month limit on treatment (Stateside). Removing the time limit lets patients stay on treatment as long as they need it.

Purdue is gone. On May 1, 2026, Purdue Pharma dissolved as its $7.4 billion settlement with the Sackler family took effect. Its manufacturing moved to a new company, Knoa Pharma, run by a board with no ties to Purdue (Michigan Attorney General). Payments to states will fund treatment, prevention and recovery over the coming years. Individual victims are still waiting for theirs.

A crisis that changed shape, not direction

Chris Marshall's story began with a back injury and a few pills from someone who loved him. For a generation of Americans, the path ran the same way: a legitimate need for pain relief, then dependence, then a cheaper drug, then a deadlier one.

Each wave grew out of the last. Heavy prescribing created dependence. Cutting off pills without offering treatment sent people to heroin. Fentanyl replaced heroin because it was cheaper to make. Stimulants followed, sometimes by accident and sometimes on purpose.

The lesson for 2026 is that supply-side fixes alone have never ended this crisis. They moved it. What reduces deaths is what the falling numbers now reflect: careful prescribing, wide access to naloxone, and medication treatment people can actually reach and afford. Whether that progress holds depends on keeping the door to treatment open.

If you or someone you know is struggling with substance use, call or text the SAMHSA National Helpline at 1-800-662-4357, or visit FindTreatment.gov. In an emergency, call 911.

Sources

About the author: Vital Biomedical News reports on medicine, public health, and biomedical research with a commitment to accuracy and independence. Every story links to its primary sources, including peer-reviewed studies, government data, and published reporting, so readers can check the evidence for themselves.

Vital Biomedical News Staff

Vital Biomedical News reports on medicine, public health, and biomedical research with a commitment to accuracy and independence. Every story links to its primary sources, including peer-reviewed studies, government data, and published reporting, so readers can check the evidence for themselves.

https://www.vitalbiomedicalnews.com/about
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