Illegal opioids such as fentanyl or nitazene can cause considerable damage to health – but how serious the effects are depends largely on the amount consumed. A new study by scientists from Carnegie Mellon University, the RAND Corporation and the University of Maryland now shows that the intensity of opioid consumption on the illegal market varies considerably and is much more complex than previously assumed.

Published in the American Journal of Drug and Alcohol Abuse, the study analyzes the extent to which the average daily amount of opioids consumed varies by region, target group and circumstances. Based on the analysis of 135 relevant articles, the researchers examined three groups of users – people who obtain opioids illegally, people with documented use at the start of treatment and patients with opioid use disorders who receive care via a medical system.

The results paint a drastic picture: While daily use outside structured programs is sometimes less than 100 morphine milligram equivalents (MME), it rises to around 600 MME with typical market access – and reaches up to 1,800 MME daily in programs with free access to therapeutic opioids, such as heroin-assisted treatment.

“We wanted to know whether heavy-consuming population groups consume similar amounts per day on average – or whether there are differences depending on context and region. The answer is clear: yes, there are huge variations,” explains study leader Prof. Jonathan P. Caulkins from Carnegie Mellon University.

According to this, people seeking treatment in particular report significantly higher consumption than people outside of medical systems. In addition, recent data – particularly from the era of illegal fentanyl – shows a trend towards even higher daily doses, while drug prices have fallen at the same time. This suggests that falling prices could lead to more intensive use in certain regions.

The strong variation in consumption levels has far-reaching consequences, as co-author Beau Kilmer from the RAND Corporation emphasizes: “Treatment strategies and prevention measures to avoid overdoses must be adapted to today’s sometimes significantly higher baseline consumption levels. Assumptions about longer-term health damage from opioids based on older – lower – consumption data may also need to be reconsidered.”

The researchers therefore call for an expansion and improvement of epidemiological monitoring systems, which should systematically record not only the prevalence – i.e. the number of users – but also the average intensity of use. The authors of the study suggest two approaches: regular surveys of users on their consumption behavior combined with quality data from law enforcement and drug control services or, alternatively, the collection of expenditure data, supplemented by price and purity information from the markets.

Despite progress in harm reduction and access to medical care, illicit opioid use remains a dynamic field that is difficult to control – especially as long as relevant parameters such as actual dose intake are not systematically recorded. This study is therefore an urgent call to policy-makers and researchers to take a closer look at the intensity of consumption in future.

DOI

10.1080/00952990.2025.2504147

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