For years, the opioid crisis has been described as a three-wave disaster: prescription drugs, heroin, and fentanyl. This narrative is repeated by health authorities, journalists, politicians and prosecutors. In this frame, the first wave of death began prescription opioidsthe second with heroin around 2010, and the third with illegal fentanyl starting in 2013, some are now adding the fourth wave of fentanyl mixed with stimulants. Although the framework defines the changing categories of drugs associated with overdose, it is often mistaken for the whole truth. The story of three waves describes part of what happened, but not why it happened.
What the data shows
It was shown to the public in the 2000s graphs that opioid sales and prescription opioid deaths go hand-in-hand has reinforced the idea that prescription drugs were the sole driver of the crisis. But a longer view changes the story. Overall, drug overdose deaths increased before OxyContin, before the prescription peak, and before the expansion of the 1990s. A graph starting in the 1990s makes prescription opioids look like a unique spark, but a graph starting in the late 90s 1970s shows that accidental deaths from drug poisoning have increased over the decades. Something deeper was already burning.
What the data doesn’t show
This does not mean that prescription opioids were inappropriate. This means that they were just one class of drugs in the long-term drug overdose crisis, which was shaped by changing supply, increasing lethality and persistent social vulnerability. The metaphor of the wave suggests that one era has passed into another, but prescription opioids, transportable drugs, heroin, fentanyl, benzodiazepines, alcohol, cocaine, methamphetamine, and other drugs always coexist.
Drugs, death and drivers
The majority of overdose deaths have involved the use of more than one substance. Furthermore, a “prescription opioid death” does not necessarily mean that the deceased had a legal prescription. Legal and illegal markets have continuously interacted through diversification, informal exchanges, counterfeit drugs and street supply. The crisis did not break in three clean waves, but moved like a polluted river, carrying drugs, dangers and social conditions downstream.
Death certificates and toxicology reports may identify the substance involved, but may also include the source of the drug, whether prescribed or delivered, the contribution of other substances, and underlying medical and social conditions. Coding a death as opioid-related does not indicate whether the person was a pain patient, a recreational user, or a victim of untreated addiction, counterfeit drugs, or a police substance crisis.
Prescriptions fall, disappointment remains
Unfortunately, because policy was driven by the belief that the crisis was caused only by over-medication, the solution seemed obvious: fewer prescriptions. And so it happened. Prescriptions have decreased, surveillance has increased, guidelines have changed, and law enforcement has created fear around prescribing pain. Clinics have pushed back, pharmacies have limited supplies, and insurers have imposed barriers.
However, overdose deaths were not proportional. Instead, the crisis migrated to an increasingly deadly illegal market. Policymakers have succeeded in reducing prescriptions, but not in reducing hopelessness, active addiction, fentanyl exposure, social isolation, or unmanageable pain. By focusing on the supply chain rather than the roots of anxiety, policy interventions treated a symptom while not addressing the underlying disease.
Of course, supply issues and the potential for fentanyl have made the illegal supply of the drug far more deadly. But supply alone cannot explain the scale of American demand. This demand arises due to reduced economic opportunities, breakdown of social cohesion, lack of access to mental health treatment and trauma. When the availability of prescriptions without recourse to these drivers declined, the demand did not disappear; directed to it.
Major drug crisis
Fentanyl explains why drug use has become more deadly. It doesn’t explain why so many Americans turned to aid or escape in the first place. A more accurate framing is not that prescription opioids caused the first wave of the opioid epidemic, but that America experienced an overdose crisis. Medicines have changed, markets have changed, and mortality has changed, but the underlying vulnerability remains.
Prescription opioids have caused harm. Some prescriptions were excessive, some marketing was misleading, drugs were diverted, and patients were harmed. But acknowledging these facts does not require accepting the claim that prescription opioids started the crisis or that simply cutting them off can solve it.
A better story asks not just what drugs people use, but why so many are vulnerable, why the supply has become so deadly, and why our institutions have responded with fear, punishment, and abandonment rather than fear. Until we face this, the next supply of drugs will always find a market.
Written by Lynn Webster, MD
Lynn R. Webster, MD., is one of the world’s leading authorities on pain management, addiction medicine, and the complex interplay between public policy, misinformation, and human suffering. Board Certified in Anesthesiology, Pain Medicine, and Addiction and Past President of the American Academy of Pain Medicine (AAPM), author The Painful Truth: What Chronic Pain Really Is and Why It Matters to Each of Us and co-producer of the video documentary The Painful Truth, which aired on public broadcasting stations in the United States. His new book, co-written with Sarah Eichberg Dispelling toxic narratives: data, disparities, and a new path in the opioid crisis (May 28, 2026). Read more in lynnwebsterd.
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