Drug Overdose Deaths with Evidence of Counterfeit Pill Use

United States, July 2019-December 2021

Julie O'Donnell, PhD; Lauren J. Tanz, ScD; Kimberly D. Miller, MPH; Amanda T. Dinwiddie, MPH; Jessica Wolff, MPH; Sasha Mital, PhD; Rochelle Obiekwe, MPH; Christine L. Mattson, PhD


Morbidity and Mortality Weekly Report. 2023;72(35):949-956. 

In This Article

Abstract and Introduction


Using data from CDC's State Unintentional Drug Overdose Reporting System, this report describes trends in overdose deaths with evidence of counterfeit pill use during July 2019–December 2021 in 29 states and the District of Columbia (DC) and characteristics of deaths with and without evidence of counterfeit pill use during 2021 in 34 states and DC. The quarterly percentage of deaths with evidence of counterfeit pill use more than doubled from 2.0% during July–September 2019 to 4.7% during October–December 2021, and more than tripled in western jurisdictions (from 4.7% to 14.7%). Illicitly manufactured fentanyls were the only drugs involved (i.e., caused death) in 41.4% of deaths with evidence of counterfeit pill use and 19.5% of deaths without evidence. Decedents with evidence of counterfeit pill use, compared with those without evidence, were younger (57.1% versus 28.1% were aged <35 years), more often Hispanic or Latino (18.7% versus 9.4%), and more frequently had a history of prescription drug misuse (27.0% versus 9.4%). Smoking was the most common noningestion drug use route among deaths with evidence of counterfeit pill use (39.5%). Overdose prevention messaging that highlights the dangers of pills obtained illicitly or without a prescription (because they might be counterfeit), encourages drug product testing by persons using drugs, and is tailored to persons most at risk (e.g., younger persons) could help prevent overdose deaths.


Drug overdose deaths are at historically high levels in the United States, with a preliminary estimate of more than 105,000 deaths in 2022.[1] The proliferation of counterfeit pills, which are not manufactured by pharmaceutical companies, but are typically made to look like legitimate pharmaceutical pills (frequently oxycodone or alprazolam), is complicating the illicit drug market and potentially contributing to these deaths*.[2] Counterfeit pills often contain illicitly manufactured fentanyls (IMFs), illicit benzodiazepines (e.g., bromazolam, etizolam, and flualprazolam), or other illicit drugs, and can increase overdose risk because the pills might expose persons to drugs they did not intend to use.