Background: Opioid overdose has accounted for 47,600 deaths in 2017 alone. The opioid crisis appears to be rapidly transforming into three different, and in some areas, overlapping epidemics: prescription opioids, heroin, and fentanyl.

Objective: To describe the current geographic landscape of the opioid epidemic and change from the past year across the United States using extant data and an expert driven consensus process.

Methods: A modified-Delphi process involving 10 experts in public health, harm reduction, illicit drug markets, and law enforcement was used to classify U.S. states based on dominant epidemic type (prescription opioid, heroin, and/or fentanyl).This was performed in three waves where experts anonymously classified states using an online interactive map in the first two waves. In the final wave, via an in-person meeting, consensus was reached at 75% agreement. National Vital Statistics System 2017 and state-based overdose death data were used to confirm expert categorization, and 2016 data informed estimates of change in epidemic type.

Results: Fentanyl overwhelmingly dominates the East Coast. Mixed epidemics of prescription opioids and fentanyl, as well as heroin and fentanyl, characterize the Midwest. Noncontiguous states west of the Mississippi River are primarily prescription opioid dominated with the exception of the Southwest and Pacific Northwest where opioid overdoses are defined by a mixture of prescription opioid and heroin deaths. Alaska and Hawaii remain prescription opioid dominated. From 2016 to 2017, 13 states and the District of Columbia (D.C.) transitioned to a more lethal epidemic with 11 states and D.C. overtaken by fentanyl or a fentanyl mixed epidemic.

Conclusion: This study confirms the proliferation of fentanyl across the U.S. as a major catalyst in the opioid epidemic. With nearly half of the country currently dominated by fentanyl, efforts to prevent the transition to fentanyl in states that have not yet transitioned are paramount to reduce the lethality of this crisis.