In 2023, around 72,776 people in the United States died from a drug overdose that involved fentanyl. This was the second-highest number of fentanyl overdose deaths ever recorded in the United States, and a significant increase from the number of deaths reported in 2019. Fentanyl overdoses are now the driving force behind the opioid epidemic, accounting for the majority of overdose deaths in the United States. What is fentanyl? Fentanyl is an extremely potent synthetic opioid similar to morphine, but more powerful. It is a prescription drug but is also manufactured illegally and is sometimes mixed with other illicit drugs such as heroin and cocaine, often without the user’s knowledge. The potency of fentanyl makes it very addictive and puts users at a high risk for overdose. Illegally manufactured fentanyl has become more prevalent in the United States in recent years, leading to a huge increase in drug overdose deaths. In 2022, the rate of drug overdose death involving fentanyl was 22.7 per 100,000 population, compared to a rate of just one per 100,000 population in the year 2013. Fentanyl overdoses by gender and race/ethnicity As of 2022, the rate of drug overdose deaths involving fentanyl in the United States is over two times higher among men than women. Rates of overdose death involving fentanyl were low for both men and women until around the year 2014 when they began to quickly increase, especially for men. In 2022, there were around 19,880 drug overdose deaths among women that involved fentanyl compared to 53,958 such deaths among men. At that time, the rate of fentanyl overdose deaths was highest among non-Hispanic American Indian or Alaska Natives and lowest among non-Hispanic Asians. However, from the years 2014 to 2018, non-Hispanic whites had the highest fentanyl overdose death rates.
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The graph illustrates the number of deaths from fentanyl in the United States from 1999 to 2022. The x-axis represents the years, spanning from '99 to '22, while the y-axis displays the annual number of fentanyl-related fatalities. Over this 24-year period, deaths rise dramatically from 730 in 1999 to a peak of 73,838 in 2022. Notable milestones include an increase to 1,742 deaths in 2005, a significant jump to 9,580 in 2015, and a sharp escalation to 70,601 deaths by 2021. The data reveals a consistent and severe upward trend in fentanyl-related deaths, particularly accelerating in the mid-2010s. This information is presented in a line graph format, effectively highlighting the dramatic increase in fatalities due to fentanyl across the United States over the specified years.
From 1999 to 2022, the number of drug overdose deaths among U.S. females increased from ***** in 1999 to ****** in 2022. Globally, drug use is a general problem. As of 2021, there were an estimated *** million global drug consumers and **** million drug addicts. Opioid use in the United States Among many demographics, drug overdose deaths continue to rise in the United States. Opioids are the most commonly reported substance in drug-related deaths. The number of drug-related deaths in the U.S. due to opioids has dramatically increased since the early 2000s. In 2017, then-President Donald Trump declared a national emergency over the opioid crisis in the United States. Since then, there have been joint efforts among various governmental departments to address the opioid crisis through education and outreach. Substance use treatment Substance abuse treatment is vital in reducing the number of drug overdose deaths in the United States. As of 2020, the state of California had the largest number of substance abuse treatment facilities . However, many states in the U.S. have less than 100 substance abuse treatment facilities.
Data on drug overdose death rates, by drug type and selected population characteristics. Please refer to the PDF or Excel version of this table in the HUS 2019 Data Finder (https://www.cdc.gov/nchs/hus/contents2019.htm) for critical information about measures, definitions, and changes over time. SOURCE: NCHS, National Vital Statistics System, numerator data from annual public-use Mortality Files; denominator data from U.S. Census Bureau national population estimates; and Murphy SL, Xu JQ, Kochanek KD, Arias E, Tejada-Vera B. Deaths: Final data for 2018. National Vital Statistics Reports; vol 69 no 13. Hyattsville, MD: National Center for Health Statistics.2021. Available from: https://www.cdc.gov/nchs/products/nvsr.htm. For more information on the National Vital Statistics System, see the corresponding Appendix entry at https://www.cdc.gov/nchs/data/hus/hus19-appendix-508.pdf.
In 2022, around 81,806 people died from opioid overdoses in the United States. This statistic presents the number of opioid overdose deaths in the U.S. from 1999 to 2022.
In 2022, those aged between 35 and 44 years had the highest number of drug overdose deaths in the United States, with 27,583 deaths. Opioids are the main driver of overdose deaths in the United States. This statistic presents the number of drug overdose deaths in the U.S. from 2013 to 2022, by age group.
Data on drug overdose death rates, by drug type and selected population characteristics. Please refer to the PDF or Excel version of this table in the HUS 2019 Data Finder (https://www.cdc.gov/nchs/hus/contents2019.htm) for critical information about measures, definitions, and changes over time.
SOURCE: NCHS, National Vital Statistics System, numerator data from annual public-use Mortality Files; denominator data from U.S. Census Bureau national population estimates; and Murphy SL, Xu JQ, Kochanek KD, Arias E, Tejada-Vera B. Deaths: Final data for 2018. National Vital Statistics Reports; vol 69 no 13. Hyattsville, MD: National Center for Health Statistics.2021. Available from: https://www.cdc.gov/nchs/products/nvsr.htm. For more information on the National Vital Statistics System, see the corresponding Appendix entry at https://www.cdc.gov/nchs/data/hus/hus19-appendix-508.pdf.
In 2022, there were around ** overdose deaths involving fentanyl among non-Hispanic whites in the United States per 100,000 population. This statistic presents the rate of drug overdose deaths involving fentanyl in the U.S. from 1999 to 2022, by race/ethnicity.
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A. SUMMARY This dataset includes unintentional drug overdose death rates by race/ethnicity by year. This dataset is created using data from the California Electronic Death Registration System (CA-EDRS) via the Vital Records Business Intelligence System (VRBIS). Substance-related deaths are identified by reviewing the cause of death. Deaths caused by opioids, methamphetamine, and cocaine are included. Homicides and suicides are excluded. Ethnic and racial groups with fewer than 10 events are not tallied separately for privacy reasons but are included in the “all races” total.
Unintentional drug overdose death rates are calculated by dividing the total number of overdose deaths by race/ethnicity by the total population size for that demographic group and year and then multiplying by 100,000. The total population size is based on estimates from the US Census Bureau County Population Characteristics for San Francisco, 2022 Vintage by age, sex, race, and Hispanic origin.
These data differ from the data shared in the Preliminary Unintentional Drug Overdose Death by Year dataset since this dataset uses finalized counts of overdose deaths associated with cocaine, methamphetamine, and opioids only.
B. HOW THE DATASET IS CREATED This dataset is created by copying data from the Annual Substance Use Trends in San Francisco report from the San Francisco Department of Public Health Center on Substance Use and Health.
C. UPDATE PROCESS This dataset will be updated annually, typically at the end of the year.
D. HOW TO USE THIS DATASET N/A
E. RELATED DATASETS Overdose-Related 911 Responses by Emergency Medical Services Preliminary Unintentional Drug Overdose Deaths San Francisco Department of Public Health Substance Use Services
F. CHANGE LOG
This data presents provisional counts for drug overdose deaths based on a current flow of mortality data in the National Vital Statistics System. Counts for the most recent final annual data are provided for comparison. National provisional counts include deaths occurring within the 50 states and the District of Columbia as of the date specified and may not include all deaths that occurred during a given time period. Provisional counts are often incomplete and causes of death may be pending investigation resulting in an underestimate relative to final counts. To address this, methods were developed to adjust provisional counts for reporting delays by generating a set of predicted provisional counts. Several data quality metrics, including the percent completeness in overall death reporting, percentage of deaths with cause of death pending further investigation, and the percentage of drug overdose deaths with specific drugs or drug classes reported are included to aid in interpretation of provisional data as these measures are related to the accuracy of provisional counts. Reporting of the specific drugs and drug classes involved in drug overdose deaths varies by jurisdiction, and comparisons of death rates involving specific drugs across selected jurisdictions should not be made. Provisional data presented will be updated on a monthly basis as additional records are received. For more information please visit: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
In 2022, the death rate from opioid overdose was 25 per 100,000 population. Opioids are the main driver of overdose deaths in the United States. This statistic presents the death rate from opioid overdose in the U.S. from 1999 to 2022, per 100,000 population.
This data visualization presents county-level provisional counts for drug overdose deaths based on a current flow of mortality data in the National Vital Statistics System. County-level provisional counts include deaths occurring within the 50 states and the District of Columbia, as of the date specified and may not include all deaths that occurred during a given time period. Provisional counts are often incomplete and causes of death may be pending investigation resulting in an underestimate relative to final counts (see Technical Notes). The provisional data presented on the dashboard below include reported 12 month-ending provisional counts of death due to drug overdose by the decedent’s county of residence and the month in which death occurred. Percentages of deaths with a cause of death pending further investigation and a note on historical completeness (e.g. if the percent completeness was under 90% after 6 months) are included to aid in interpretation of provisional data as these measures are related to the accuracy of provisional counts (see Technical Notes). Counts between 1-9 are suppressed in accordance with NCHS confidentiality standards. Provisional data presented on this page will be updated on a quarterly basis as additional records are received. Technical Notes Nature and Sources of Data Provisional drug overdose death counts are based on death records received and processed by the National Center for Health Statistics (NCHS) as of a specified cutoff date. The cutoff date is generally the first Sunday of each month. National provisional estimates include deaths occurring within the 50 states and the District of Columbia. NCHS receives the death records from the state vital registration offices through the Vital Statistics Cooperative Program (VSCP). The timeliness of provisional mortality surveillance data in the National Vital Statistics System (NVSS) database varies by cause of death and jurisdiction in which the death occurred. The lag time (i.e., the time between when the death occurred and when the data are available for analysis) is longer for drug overdose deaths compared with other causes of death due to the time often needed to investigate these deaths (1). Thus, provisional estimates of drug overdose deaths are reported 6 months after the date of death. Provisional death counts presented in this data visualization are for “12 month-ending periods,” defined as the number of deaths occurring in the 12 month period ending in the month indicated. For example, the 12 month-ending period in June 2020 would include deaths occurring from July 1, 2019 through June 30, 2020. The 12 month-ending period counts include all seasons of the year and are insensitive to reporting variations by seasonality. These provisional counts of drug overdose deaths and related data quality metrics are provided for public health surveillance and monitoring of emerging trends. Provisional drug overdose death data are often incomplete, and the degree of completeness varies by jurisdiction and 12 month-ending period. Consequently, the numbers of drug overdose deaths are underestimated based on provisional data relative to final data and are subject to random variation. Cause of Death Classification and Definition of Drug Deaths Mortality statistics are compiled in accordance with the World Health Organizations (WHO) regulations specifying that WHO member nations classify and code causes of death with the current revision of the International Statistical Classification of Diseases and Related Health Problems (ICD). ICD provides the basic guidance used in virtually all countries to code and classify causes of death. It provides not only disease, injury, and poisoning categories but also the rules used to select the single underlying cause of death for tabulation from the several diagnoses that may be reported on a single death certificate, as well as definitions, tabulation lists, the format of the death certificate, and regul
This data presents counts of provisional drug overdose deaths by selected drugs and U.S. Department of Health and Human Services (HHS) public health regions, based on provisional mortality data from the National Vital Statistics System. This data is limited to drug overdose deaths with an underlying cause of death assigned to International Statistical Classification of Diseases, 10th Revision (ICD-10) code numbers X40-X44 (unintentional), X60-X64 (suicide), X85 (homicide), or Y10-Y14 (undetermined intent). Specific drugs were identified using methods for searching literal text from death certificates. The provisional data are based on a current flow of mortality data and include reported 12 month-ending provisional counts of drug overdose deaths by jurisdiction of occurrence and specified drug. Provisional drug overdose death counts presented on this page are for “12-month ending periods,” defined as the number of deaths occurring in the 12-month period ending in the month indicated. For example, the 12-month ending period in June 2022 would include deaths occurring from July 1, 2021, through June 30, 2022. Evaluation of trends over time should compare estimates from year to year (June 2021 and June 2022), rather than month to month, to avoid overlapping time periods. It is important to note that the data represent counts of deaths, and not mortality ratios or rates, which are the standard measure used to compare groups, and therefore should not be used to determine populations at disproportionate risk of drug overdose death.
This indicator includes unintentional overdoses, homicides, and suicides from drug overdose. Death rate has been age-adjusted to the 2000 U.S. standard population. ICD-10 codes used to identify drug overdose related deaths are X40-X44, X60-X64, X85, and Y10-Y14.Drug overdose deaths have increased dramatically in the US over the past two decades. The first wave of deaths in the 1990s largely involved prescription opioids and was a consequence of increased prescribing of these drugs by medical providers. In the second wave that began in 2010, there was a rapid increase in the number of deaths involving heroin and, in the current wave that started in 2013, there has been a rise in the number of overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, which can be found in combination with heroin, counterfeit pills, cocaine, and other drugs. In Los Angeles County in recent years, the vast majority of all drug overdose deaths have involved fentanyl. Important inequities have been noted by sociodemographic characteristics, with low-income and Black individuals found to have the highest overdose death rates. Cities and communities can take an active role in preventing overdose deaths by promoting primary prevention and supporting evidence-based harm reduction and treatment strategies.For more information about the Community Health Profiles Data Initiative, please see the initiative homepage.
In 2022, there were around 22.7 overdose deaths in the United States involving fentanyl per 100,000 population. The death rate involving fentanyl presented an exponential increase since 2014. This statistic presents the rate of drug overdose deaths involving fentanyl in the U.S. from 1999 to 2022.
This dataset describes drug poisoning deaths at the county level by selected demographic characteristics and includes age-adjusted death rates for drug poisoning from 1999 to 2015. Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug-poisoning deaths are defined as having ICD–10 underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Estimates are based on the National Vital Statistics System multiple cause-of-death mortality files (1). Age-adjusted death rates (deaths per 100,000 U.S. standard population for 2000) are calculated using the direct method. Populations used for computing death rates for 2011–2015 are postcensal estimates based on the 2010 U.S. census. Rates for census years are based on populations enumerated in the corresponding censuses. Rates for noncensus years before 2010 are revised using updated intercensal population estimates and may differ from rates previously published. Estimate does not meet standards of reliability or precision. Death rates are flagged as “Unreliable” in the chart when the rate is calculated with a numerator of 20 or less. Death rates for some states and years may be low due to a high number of unresolved pending cases or misclassification of ICD–10 codes for unintentional poisoning as R99, “Other ill-defined and unspecified causes of mortality” (2). For example, this issue is known to affect New Jersey in 2009 and West Virginia in 2005 and 2009 but also may affect other years and other states. Estimates should be interpreted with caution. Smoothed county age-adjusted death rates (deaths per 100,000 population) were obtained according to methods described elsewhere (3–5). Briefly, two-stage hierarchical models were used to generate empirical Bayes estimates of county age-adjusted death rates due to drug poisoning for each year during 1999–2015. These annual county-level estimates “borrow strength” across counties to generate stable estimates of death rates where data are sparse due to small population size (3,5). Estimates are unavailable for Broomfield County, Colo., and Denali County, Alaska, before 2003 (6,7). Additionally, Bedford City, Virginia was added to Bedford County in 2015 and no longer appears in the mortality file in 2015. County boundaries are consistent with the vintage 2005-2007 bridged-race population file geographies (6).
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The graph displays the number of drug overdose deaths in the U.S. from 2003 to 2023, with the x-axis representing the years and the y-axis showing the total overdose deaths each year. The data reveals a steady increase in deaths from 25,785 in 2003 to over 107,000 in 2022, highlighting the growing severity of the overdose crisis. The highest number of deaths occurred in 2022 (107,941), while 2023 saw a slight decrease to 105,007 deaths. A sharp rise is observed between 2015 and 2021, coinciding with the opioid epidemic and increased fentanyl-related overdoses. The data underscores the urgent need for stronger prevention and intervention efforts.
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Analysis of ‘💉 Opioid Overdose Deaths’ provided by Analyst-2 (analyst-2.ai), based on source dataset retrieved from https://www.kaggle.com/yamqwe/opioid-overdose-deathse on 13 February 2022.
--- Dataset description provided by original source is as follows ---
Opioid addiction and death rates in the U.S. and abroad have reached "epidemic" levels. The CDC's data reflects the incredible spike in overdoses caused by drugs containing opioids.
The United States is experiencing an epidemic of drug overdose (poisoning) deaths. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin). Source: CDC
In-the-News
:
- STAT: 26 overdoses in just hours: Inside a community on the front lines of the opioid epidemic
- NPR: Organ Donations Spike In The Wake Of The Opioid Epidemic, Deadly Opioid Overwhelms First Responders And Crime Labs in Ohio
- Scientific American: Wave of Overdoses with Little-Known Drug Raises Alarm Amid Opioid Crisis
- Washington Post: A 7-year-old told her bus driver she couldn’t wake her parents. Police found them dead at home.
- Wall Street Journal: For Small-Town Cops, Opioid Scourge Hits Close to Home
- Food & Drug Administration: FDA launches competition to spur innovative technologies to help reduce opioid overdose deaths
This data was compiled using the CDC's WONDER database. Opioid overdose deaths are defined as: deaths in which the underlying cause was drug overdose, and the ICD-10 code used was any of the following: T40.0 (Opium), T40.1 (Heroin), T40.2 (Other opioids), T40.3 (Methadone), T40.4 (Other synthetic narcotics), T40.6 (Other and unspecified narcotics).
Age-adjusted rate of drug overdose deaths and drug overdose deaths involving opioids
http://i.imgur.com/ObpzUKq.gif" alt="Opioid Death Rate" style="">
Source: CDCWhat are opioids?
Opioids are substances that act on opioid receptors to produce morphine-like effects. Opioids are most often used medically to relieve pain. Opioids include opiates, an older term that refers to such drugs derived from opium, including morphine itself. Other opioids are semi-synthetic and synthetic drugs such as hydrocodone, oxycodone and fentanyl; antagonist drugs such as naloxone and endogenous peptides such as the endorphins.[4] The terms opiate and narcotic are sometimes encountered as synonyms for opioid. Source: Wikipedia
contributors-wanted
See comment in DiscussionFootnotes
- The crude rate is per 100,000.
- Certain totals are hidden due to suppression constraints. More Information: http://wonder.cdc.gov/wonder/help/faq.html#Privacy.
- The population figures are briged-race estimates. The exceptions being years 2000 and 2010, in which Census counts are used.
- v1.1: Added Opioid Prescriptions Dispensed by US Retailers in that year (millions).
Citation: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Oct 19, 2016 2:06:38 PM.
Citation for Opioid Prescription Data: IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014. Accessed at NIDA article linked (Figure 1) on Oct 23, 2016.
Data Use Restrictions:
The Public Health Service Act (42 U.S.C. 242m(d)) provides that the data collected by the National Center for Health Statistics (NCHS) may be used only for the purpose for which they were obtained; any effort to determine the identity of any reported cases, or to use the information for any purpose other than for health statistical reporting and analysis, is against the law. Therefore users will:
Use these data for health statistical reporting and analysis only.
For sub-national geography, do not present or publish death counts of 9 or fewer or death rates based on counts of nine or fewer (in figures, graphs, maps, tables, etc.).
Make no attempt to learn the identity of any person or establishment included in these data.
Make no disclosure or other use of the identity of any person or establishment discovered inadvertently and advise the NCHS Confidentiality Officer of any such discovery.
Eve Powell-Griner, Confidentiality Officer
National Center for Health Statistics
3311 Toledo Road, Rm 7116
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Telephone 301-458-4257 Fax 301-458-4021This dataset was created by Health and contains around 800 samples along with Crude Rate, Crude Rate Lower 95% Confidence Interval, technical information and other features such as: - Year - Deaths - and more.
- Analyze Crude Rate Upper 95% Confidence Interval in relation to Prescriptions Dispensed By Us Retailers In That Year (millions)
- Study the influence of State on Crude Rate
- More datasets
If you use this dataset in your research, please credit Health
--- Original source retains full ownership of the source dataset ---
This dataset describes drug poisoning deaths at the U.S. and state level by selected demographic characteristics, and includes age-adjusted death rates for drug poisoning from 1999 to 2015. Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug-poisoning deaths are defined as having ICD–10 underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Estimates are based on the National Vital Statistics System multiple cause-of-death mortality files (1). Age-adjusted death rates (deaths per 100,000 U.S. standard population for 2000) are calculated using the direct method. Populations used for computing death rates for 2011–2015 are postcensal estimates based on the 2010 U.S. census. Rates for census years are based on populations enumerated in the corresponding censuses. Rates for noncensus years before 2010 are revised using updated intercensal population estimates and may differ from rates previously published. Estimate does not meet standards of reliability or precision. Death rates are flagged as “Unreliable” in the chart when the rate is calculated with a numerator of 20 or less. Death rates for some states and years may be low due to a high number of unresolved pending cases or misclassification of ICD–10 codes for unintentional poisoning as R99, “Other ill-defined and unspecified causes of mortality” (2). For example, this issue is known to affect New Jersey in 2009 and West Virginia in 2005 and 2009 but also may affect other years and other states. Estimates should be interpreted with caution. Smoothed county age-adjusted death rates (deaths per 100,000 population) were obtained according to methods described elsewhere (3–5). Briefly, two-stage hierarchical models were used to generate empirical Bayes estimates of county age-adjusted death rates due to drug poisoning for each year during 1999–2015. These annual county-level estimates “borrow strength” across counties to generate stable estimates of death rates where data are sparse due to small population size (3,5). Estimates are unavailable for Broomfield County, Colo., and Denali County, Alaska, before 2003 (6,7). Additionally, Bedford City, Virginia was added to Bedford County in 2015 and no longer appears in the mortality file in 2015. County boundaries are consistent with the vintage 2005-2007 bridged-race population file geographies (6).
Data come from Minnesota death certificates, with cause and manner of death information provided by a medical examiner or coroner. A drug overdose death is defined as having an underlying cause of death within the following range of ICD-10 codes: X40-X44, X60-X64, X85, Y10-Y14. Note that an opioid-involved death may also be counted as a cocaine-involved death if both drugs were listed on the death certificate as contributory causes. The seven non-exclusive categories of drug overdose deaths are defined as having a contributory cause of death: All opioid-involved deaths, Prescription opioids, Synthetic opioids, Heroin, Cocaine, Benzodiazepines, and Psychostimulants with abuse potential (includes methamphetamine).
In 2023, around 72,776 people in the United States died from a drug overdose that involved fentanyl. This was the second-highest number of fentanyl overdose deaths ever recorded in the United States, and a significant increase from the number of deaths reported in 2019. Fentanyl overdoses are now the driving force behind the opioid epidemic, accounting for the majority of overdose deaths in the United States. What is fentanyl? Fentanyl is an extremely potent synthetic opioid similar to morphine, but more powerful. It is a prescription drug but is also manufactured illegally and is sometimes mixed with other illicit drugs such as heroin and cocaine, often without the user’s knowledge. The potency of fentanyl makes it very addictive and puts users at a high risk for overdose. Illegally manufactured fentanyl has become more prevalent in the United States in recent years, leading to a huge increase in drug overdose deaths. In 2022, the rate of drug overdose death involving fentanyl was 22.7 per 100,000 population, compared to a rate of just one per 100,000 population in the year 2013. Fentanyl overdoses by gender and race/ethnicity As of 2022, the rate of drug overdose deaths involving fentanyl in the United States is over two times higher among men than women. Rates of overdose death involving fentanyl were low for both men and women until around the year 2014 when they began to quickly increase, especially for men. In 2022, there were around 19,880 drug overdose deaths among women that involved fentanyl compared to 53,958 such deaths among men. At that time, the rate of fentanyl overdose deaths was highest among non-Hispanic American Indian or Alaska Natives and lowest among non-Hispanic Asians. However, from the years 2014 to 2018, non-Hispanic whites had the highest fentanyl overdose death rates.