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Author: Ben Murrey and Glenn Farley

Introduction

In 2023, the amount of fentanyl seized by the U.S. Drug Enforcement Administration (DEA) was equivalent to 381 million lethal doses—enough to end the life over every man, women, and child in the United States.[i] Over 100,000 Americans died from drug overdoses in 2023, according to the U.S. Centers for Disease Control and Prevention (CDC).[ii] Synthetic opioids like fentanyl caused about 70% of those deaths. Ten years prior, fewer than half the overdose deaths occurred, with only about 12% caused by synthetic opioids. Iowa has not dodged this crisis.

For medical patients under the care of a doctor, fentanyl is used as a powerful synthetic opioid used to treat severe pain after surgery. In recent years, its widespread availability and use outside of the hospital has made it the deadliest drug in America. One-hundred times more potent than morphine, just two milligrams can kill.[iii] Drug traffickers often mix illicit fentanyl with other drugs, in many cases without knowledge of the end user. Fake prescription pills intended to look like Xanax, Adderall, Percocet, and others have taken the lives of unsuspecting teenagers in Iowa and across the country.[iv] The Iowa Department of Public Safety (DPS) reported an “explosion” of these kinds of pill seized by state law enforcement in recent years. Sadly, far too many Iowa families and communities have felt the detrimental effects of this deadly substance.

This report explores America’s fentanyl epidemic and the struggles unique to Iowa. It evaluates overdose data to determine extent of the crisis in the state and its evolution over time, comparing Iowa with the rest of the nation. Finally, it estimates the cost of the fentanyl crisis on the state’s economy. 

Key Findings

  • Fentanyl-related overdose deaths cost Iowa $3.5 billion in 2023, up from approximately $1.3 billion in 2018.
  • Overdose deaths caused by synthetic opioids (primarily fentanyl) rose by over 500% in Iowa between Jan. 2015 and Jan. 2024.
  • Over the last five years (Jan. 2010 to Jan. 2024), overdose deaths from synthetic opioids rose at a faster pace in Iowa (140%) than in the United States (123%).
  • The 1-year increase in fentanyl overdose death rates peaked at 90% in July 2020.
  • Deaths from synthetic opioid (primarily fentanyl) overdoses have risen at a faster pace than for any other ICD drug category.
  • As of 2022, Iowa was one of only 3 states where methamphetamine claimed more lives than fentanyl alone, though overdose deaths often involve multiple narcotics.
  • Iowa has the 3rd lowest rate of drug overdose deaths in the nation and the 3rd lowest fentanyl overdose death rate.

America’s Opioid Crisis

While opioids – including heroin, morphine, and other compounds chemically isolated from the poppy plant – have been available for legitimate and illicit use in the United States since at least the 19th century, the development of synthetic and semi-synthetic opioids accelerated in the early 1900’s (beginning with the development of oxycodone in 1916).[v] In 1959, fentanyl was synthesized in pharmaceutical laboratories and quickly became popular for both its increased potency and low cost relative to other opioids.[vi]

Following the rise of illicit use and abuse of opioids (including heroin but also synthetic opioids and pharmaceutical drugs) the United States enacted a series of reforms intended to restrict their availability throughout the 1970’s and 1980’s, including with enactment of the Controlled Substances Act of 1970 – which standardized the categorization and regulation of drugs based on the balanced consideration of both harmfulness and potential medical use.  Fentanyl and other potent opioids are classified under Schedule II – drugs with an accepted medical use but high potential for abuse – and their prescription and distribution has been highly regulated.

By the 1990’s, attitudes had begun to shift. There was increasing belief in the medical community that pain was a distinct and undertreated condition,[vii] and that the development of addiction among otherwise healthy and drug-free patients from the temporary use of prescription opioids to manage pain was rare.[viii] This led to increased availability of prescription opioids in the American healthcare system.

In 1991, there were approximately 76 million prescriptions for opioids in the United States. By 1999, that had increased to 116 million (+53%)[ix]; at peak in 2012 there were over 250 million active opioid prescriptions in America – enough for every adult in the country at the time.

Unintended Consequences & The Fentanyl Crisis

In response to the perceived abuse of the nation’s prescription painkiller system by both providers and patients,[x] a national crackdown at both the state and federal levels by a variety of regulatory agencies began in the mid-2010’s. In 2016, the CDC issued new guidelines on when and how to appropriately prescribe opioid painkillers. Massachusetts became the first state to restrict initial opioid prescription painkiller supplies.[xi] Today 38 U.S. states, including Iowa, have policies limiting the availability of prescription opioids.[xii]

This led to pressure at all levels of the American healthcare system to reduce opioid prescriptions. Insurance companies, hospital systems, licensing boards, and non-profit professional associations all adopted new rules and structures around the dispensing of opioids by their providers. The pressure worked; a late-2016 survey of Sermo member physicians found over half had reduced opioid prescriptions, and 1 in 10 had stopped prescribing opioids altogether.[xiii] Today, the number of opioid prescriptions in the United States has fallen to just 132 million – about half its peak level. Because of the rapidity of the national change, patients in chronic-pain or with opioid dependency were desperate for alternatives. Many turned to synthetic opioids, especially fentanyl.

Figure 1.

In the 1980’s, overdose deaths related to illicit fentanyl use in the United States occurred only “sporadically”.[xiv] According to the CDC, in 2013 when opioid prescriptions peaked there were only about 1.0 deaths per 100,000 people in the United States from synthetic opioid use. By 2022, the rate had surged to 22.7 deaths per 100,000 people.[xv] An October 2020 study by Quest Diagnostics Health Trends found the lack of access to healthcare and substance abuse support during the pandemic shutdowns may have contributed to a surge in drug overdose use and deaths—especially from fentanyl—during the pandemic.[xvi]

Figure 2.

Drug Trafficking in the United States and Iowa

As demand for opioids in the United States increased and controlled prescription drugs (CPD) became less available, foreign drug producers, transnational criminal organizations, and domestic drug trafficking organizations ramped-up illegal supply. According to the U.S. Department of State, 70% of the worlds illicit fentanyl production in 2021 occurred in China.[xvii] The country has become a cheap and available illegal supply for American drug consumers following the loss of access to legal or semi-legal prescription painkillers. Beginning in the late-2010’s, opioid-related overdose deaths were surging despite (or perhaps more because of) the collapse in opioid prescriptions. Though cheap and available, illicit opioids – often principally or laced-with fentanyl – have proved far more dangerous than their prescription-market counterparts. These opioids have flooded the United States over the past decade, making their way into and throughout the United States.

Drug Trafficking Across the Southern Border

In 2018-2019, the U.S. Drug Enforcement Agency (DEA), Customs & Border Patrol (CBP), and other federal law-enforcement agencies began putting particular emphasis on combatting the illicit flow of grey- and black-market fentanyl into the United States from foreign countries (particularly China) via international trade. Also in 2019, China announced sweeping and novel domestic restrictions on the production and distribution of all types of fentanyl.[xviii] As a result, seizures of synthetic opioids (including fentanyl) in international U.S. mail fell from over 150 pounds in 2018 to an estimated just 10.5 pounds by 2020.[xix] [xx]

However, while data seems to support the thesis that direct shipments of fentanyl and equivalents from China to the United States appear to have declined, other evidence suggests that the flow of fentanyl has shifted rather than been stymied. Total seizures of the drug in the United States by the DEA have increased from approximately 6,800 pounds in 2019[xxi] to more than 29,200 pounds today[xxii] – a 320% increase.

As documented extensively in CSI Arizona’s 2022 report, Fentanyl, Crime, and Arizona’s Southern Border, stakeholders and experts report that the primary source of illicit fentanyl in the United States today is smuggling of the finished drug across the southern border with Mexico, and that production of it is enabled with chemicals and equipment sourced by Mexican drug manufacturers from the Chinese pharmaceutical industry.[xxiii] In its National Drug Threat Assessment 2024, the DEA again reports that: “Fentanyl manufactured by the Mexican cartels is the main driver behind the ongoing epidemic of drug poisoning deaths in the United States… China-based chemical suppliers are the main source of the chemicals used in the production of illicit fentanyl.”[xxiv]

Interstate Drug Trafficking in the Midwest

Figure 3:

Though Iowa lies far from America’s southern border, it faces its own unique challenges related to the illegal trafficking of fentanyl and other illicit drugs. In an interview with KWWL News last May, Waterloo Police Lieutenant and a leader of the Tri-County Drug Enforcement Task Force Rich Gehrke observed, “A lot of our stuff seems to be coming from south of the border, but it is available. If you want to get it, it is definitely here, and you can get it if you want it.”[xxv] Indeed, the Office of National Drug Control Policy under the Executive Office of the President of the United States has designated seven Iowa counties as part of the Midwest High Intensity Drug Trafficking Area (HIDTA): Blackhawk, Linn, Marshall, Muscatine, Polk, Pottawattamie, Scott, Woodbury. The designation is assigned to regions “that have critical drug trafficking problems that adversely impact the United States,” according to the Midwest HIDTA website.[xxvi] The 2023 Midwest HIDTA Threat Assessment report identified I-80, I-35, and I-29 as key transportation routes for drug trafficking, noting, “I-35 is particularly useful as a transportation route for Mexican DTOs” (drug trafficking organizations).[xxvii] It names the intersection of I-80 and I-35 in Des Moines in particular as a drug transportation hub.

Figure 4.

 

Of the 955 DTOs identified in the Midwest region, 132 were in Iowa and 19 of those were deemed “violent DTOs.” Methamphetamine made up 45% of drugs trafficked by DTOs in 2022, making it the number one drug trafficked. After so-called “polydrugs,” fentanyl was the second most trafficked drug with 11% of the total share.[xxviii] Poly drugs often include fentanyl.[xxix] For the first time since its inception in 1996, in the 2023 threat assessment report the Midwest HIDTA law enforcement partners consider fentanyl the greatest drug threat in the region.[xxx] Methamphetamine ranked number one in every prior year.[xxxi] Like the rest of the United States, the region’s fentanyl supply originates from China and Mexico and is primarily transported via private passenger vehicles or through the mail.[xxxii] This has led to an “explosion” of counterfeit opioid pills containing fentanyl being seized by state law enforcement, according to Iowa DPS’s 2024 Iowa Drug Control Strategy & Drug Use Profile report.[xxxiii] The Midwest HIDTA reported a 44 percent increase in fentanyl seizures between 2021 and 2022, from 439 kilograms to 633 kilograms.[xxxiv] The DEA noted a 105% increase in its seizure of fentanyl pills In Iowa from 2022 to 2023.[xxxv]

Figure 5.

Drug Overdose Deaths

Thanks to the opioid crisis, drug trafficking in and through the state, and its history with other illicit substances such as methamphetamine, Iowa has not evaded America’s fentanyl crisis. Drug abuse and addiction impacts lives and communities in countless ways, from overdose deaths to broken families, homelessness, and child neglect to name only a few of the most tragic. The rise of fentanyl use in the United States has only exacerbated these issues.

Fentanyl is a synthetic opioid used in medicine to treat chronic pain, like morphine but around 100 times more potent. However, most fentanyl in the United States today is not a controlled prescription drug but rather an illicit synthetic opioid produced outside of the United States and trafficked into the country by criminal organizations such as Mexican drug cartels. Dealers regularly mix fentanyl with other drugs, often without the knowledge of the user. Because a mere two milligrams of fentanyl contain a lethal dose, the drug comes with an alarming overdose mortality rate.

Drug Overdose Classifications

From a data perspective, the impact of the fentanyl epidemic shows up perhaps most clearly in overdose deaths and death rates. The U.S. Centers for Disease Control and Prevention tracks drug overdose deaths under the National Vital Statistics System (NVSS) and the State Unintentional Drug Overdose Reporting System (SUDORS). For the former, jurisdictions report cause of death data in accordance with the International Statistical Classification of Diseases and Related Health Problems (ICD).[xxxvi] For the later, data comes through the Overdose Data to Action in States (ODEA-S) cooperative agreement administered by the CDC.[xxxvii] Each state reports overdose deaths to SUDORS at the CDC from death certificates and postmortem toxicology, coroner, and medical examiner reports. The SUDORS database includes more detailed information on overdose deaths than NVSS; however, the system was launched in 2016 and some data only goes back a few years.[xxxviii] The NVSS database classifies drugs several broader categories:

  • heroin (T40.1);
  • natural opioid analgesics, including morphine and codeine, and semisynthetic opioids, including drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone (T40.2);
  • methadone, a synthetic opioid (T40.3);
  • synthetic opioid analgesics other than methadone, including drugs such as fentanyl and tramadol (T40.4);
  • cocaine (T40.5); and psychostimulants with abuse potential, which includes methamphetamine (T43.6);
  • opium (T40.0);
  • heroin (T40.1);
  • natural opioid analgesics (T40.2);
  • methadone (T40.3);
  • synthetic opioid analgesics other than methadone (T40.4); or
  • other and unspecified narcotics (T40.6).[xxxix]

Figure 6.

Figure 6 shows the number of drug overdose deaths in the United States for each NVSS drug classification and all drug-related deaths over the 12 months preceding the specified month. Drug overdose deaths have been on the rise over the past decade but began to rise precipitously during the COVID-19 pandemic. The U.S. data support the early research by Quest Diagnostics Health Trends, which suggested pandemic-related shutdowns were contributing to a surge in drug overdose use and deaths—especially from fentanyl—in 2020. The increase in opioid deaths drove the rise in the overall number of drug overdose deaths in the United States since 2015. The subclassification of opioids called “synthetic opioids excluding methadone” (T40.4) accounted for most of these deaths. While the NVSS data does single out fentanyl, most drugs under this classification involve fentanyl.[xl] Overdose deaths in Iowa have followed a similar pattern to the United States.

Figure 7.

Figure 7 shows the same data as figure 6 but for Iowa rather than the United States. Like the United States as a whole, Iowa saw a precipitous rise in total overdose deaths and from synthetic opioid deaths; however, it appears Iowa led the United States by about nine months in its initial surge and by about 16 months in its return to a downtrend. Whereas the United States saw a clear spike in overdose deaths when the first COVID-19 stay-at-home orders went into effect, Iowa’s spike began in the summer of 2019. Its pandemic lockdowns were relatively short-lived and had no discernable impact on the growth trajectory of fentanyl overdose deaths.[xli] Both in the United States and in Iowa, total drug overdose deaths and synthetic opioid deaths have trended down more recently. In March 2022, Iowa saw a peak followed by an apparent trend reversal; The U.S. saw the same occur over a year later in July 2023.

Fentanyl vs. Meth in Iowa

In Iowa, the deathrate for “Psychostimulants with abuse potential” (T43.6) kept pace with the synthetic opioids, whereas the gap between them widened significantly in the United State at large. See figures 6 and 7. The psychostimulants classification applies primarily to methamphetamine. Until recently, the annual Midwest HIDTA threat assessment deemed meth the largest drug threat across the region, as noted in the section of this report “Interstate Drug Trafficking in the Midwest.” Based on the data, meth continues to compete closely with fentanyl for the deadliest drug in Iowa.

Figure 8.

Figure 8 compares the increase in overdose deaths from psychostimulants with synthetic opioids. In January 2015, Iowa saw 46 overdose deaths from psychostimulants, primarily meth, and 30 from synthetic opioids, primarily fentanyl. That translates to a death rate per 100,000 residents of 1.47 and 0.97, respectively. By January 2024, deaths had risen to 223 and 185 with death rates of 6.95 and 5.77. With a small and short-lived exception at the end of 2017, the death rate from synthetic opioids didn’t exceed that of psychostimulants until 2021. Since then, overdose death rates from synthetic opioids have begun to fall while death rates for meth have climbed to a new all-time high. The SUDORS data on drug overdose deaths tells a similar story about Meth and Fentanyl in Iowa with more drug-specific data.

Table 1.

Number of States’ Leading Cause of Overdose Death each Year
  2020 2021 2022
Illegally-made Fentanyls with no other opioids or stimulants 25 21 22
Illegally-made Fentanyls and Cocaine 1 4 4
Methamphetamine with no other stimulants or opioids 6 7 3
Iowa’s Leading Cause of Overdose Death Meth Meth Meth
Source: Centers for Disease Control and Prevention, SUDORS Dashboard: Fatal Overdose Data

 

Every year from 2020 to 2022, methamphetamine led overdose deaths in Iowa, according to SUDORS data. See table 1. Of the states with available data in 2022, only Oklahoma and Utah joined it on that list. The rest had fentanyl or fentanyl with cocaine as the top cause of overdose deaths. Notably, the SUDORS database separates fentanyl deaths between those with fentanyl alone as the cause of death versus those involving fentanyl and another substance. When combined, fentanyl slightly exceeded meth as the leading cause of overdose deaths in 2022. The NVSS data shows a similar split in 2022, though it shows fentanyl rising back above meth in 2023 as seen in figure 8.

Table 2.

Iowa Drug Overdose Deaths (SUDORS vs. NVSS)
2020 2021 2022
All Drug Overdose Deaths (SUDORS) 341 400 384
All Drug Overdose Deaths (NVSS) 419 471 473
Deaths from all Opioids (SUDORS) 194 239 211
Deaths from all Opioids (NVSS) 213 258 237
Deaths from Illegally-Made-Fentanyl (SUDORS) 152 199 193
Deaths from Synthetic Opioids (NVSS) 162 213 203
Meth Deaths (SUDORS) 151 177 198
Psychostimulants Deaths (NVSS) 164 196 210
Drug Overdose Death Percents (SUDORS vs. NVSS)
2020 2021 2022
All Drug Overdose Deaths (SUDORS) 100.00% 100.00% 100.00%
All Drug Overdose Deaths (NVSS) 100.00% 100.00% 100.00%
Deaths from all Opioids (SUDORS) 56.89% 59.75% 54.95%
Deaths from all Opioids (NVSS) 50.84% 54.78% 50.11%
Illegally-Made-Fentanyl Deaths (SUDORS) 44.57% 49.75% 50.26%
Deaths from Synthetic Opioids (NVSS) 38.66% 45.22% 42.92%
Meth Deaths (SUDORS) 44.28% 44.25% 51.56%
Psychostimulants Deaths (NVSS) 39.14% 41.61% 44.40%
Source: Centers for Disease Control and Prevention, SUDORS Dashboard: Fatal Overdose Data

 

The data in table 2 clearly shows fentanyl and meth both present a serious threat to the health and welfare of Iowa communities. Both have become more pervasive over the last decade but especially over the last five years. Depending on the source, the data show that all or nearly all overdose deaths in Iowa involve either fentanyl or meth.[xlii] “Methamphetamine use in Iowa is high, rising, and increasing at a faster rate than in other states,” according to a 2021 report by the Iowa Department of Public Health.[xliii] The data bears that out. However, the surge in fentanyl use presents a newer and less familiar threat that must be taken seriously. According to Iowa DPS, of drug overdose deaths in Iowa in 2022 86% involved fentanyl.[xliv] Both meth and fentanyl remain a serious threat. State lawmakers, law enforcement, and the public must remain vigilant in combating these dangerous drugs.

How Iowa Compares on Fentanyl

Iowa has unquestionably seen an unprecedented increase in fentanyl use and overdose deaths over the last decade, but that shift has not happened in a vacuum. Every state has been impacted to a greater or lesser extent, depending on various factors. In 2022, CSI Arizona published an extensive report, Fentanyl, Crime, and Arizona’s Southern Border, on the fentanyl crisis and how it uniquely impacts the border state.[xlv] Common Sense Institute Colorado recently published a report on the economic cost of fentanyl in the Centennial State.[xlvi] Iowa faces its own challenges—discussed in part in the section of this report entitled “Interstate Drug Trafficking in the Midwest.”

Figure 9.

Figure 9 shows the seriousness of the fentanyl epidemic in Iowa. Throughout 2016 and 2017, synthetic opioid deaths rose continuously, reaching year-over-year increases of over 50% three times and over 75% once. Consequently, over the course of those two years the trailing 12-month death rate from synthetic opioid overdoses doubled, increasing from 1.5% in January 2016 to 3.05% in January 2017. The rate of growth in overdose deaths fell throughout 2018, leading to a year-over-year decline of as much as 26% in February 2019. By July 2020, the annual rate of increase in Iowa’s synthetic opioid deaths had climbed to an astounding 90.05%. While now on the decline, Iowa’s synthetic opioid death rates have risen dramatically in recent years.

Overdoses from synthetic opioids quintupled from January 2016 to January 2024, rising by 516.7%. From January 2015 to its peak in March 2022, they rose 670% to a rate of 7.22 deaths per 100,000 residents. In the last 5 years from January 2019 through January 2024, the trailing 12-month rate of overdose deaths from synthetic opioids rose 140%. These figures put Iowa directly in the median of America’s fentanyl crisis, as shown in figure 10.

Figure 10.

The percent increase or decrease speaks to how much better or worse a state is becoming relative to where it was in the past. Alaska, Oregon, Washington, Oklahoma, and Colorado have seen the largest percent increases in overdose deaths from fentanyl over the past five years, but that does not mean they necessarily have the worst fentanyl overdose death rates. In 2018, Hawaii had the lowest fentanyl overdose death rate in the country. With an increase of 550% since then, it ranks in the top 10 states for rate of increase over the last five years. Yet, it still has the fourth lowest rate of fentanyl deaths per 100,000 residents as of January 2024. Alaska and Oregon boasted some of the lowest rates of fentanyl overdose deaths in the nation before the pandemic. Today, after seeing the two largest increases over the last five years, they rank 44th and 36th. Conversely, West Virginia increased by only 97% over the last five years—less than the 138% median increase or the United States increase of 123%. Nonetheless, it has the highest fentanyl overdose rate of any state at 63.84 per 100,000, lagging only Washington, D.C. Figure 11 compares the synthetic opioid overdose rates of all states, the District of Columbia, and the United States as a whole.

Figure 11.

On a percent change basis, Iowa has seen a similar growth trajectory to other states, but it has maintained its extraordinarily low overdose rates relative to the rest of the United States. In a report last month, CSI Iowa noted that Iowa ranks third lowest for drug overdose death rates nationally behind South Dakota and Nebraska. Figure 10 shows Iowa as second lowest for synthetic opioid overdose death rates, but it does not include Nebraska due to a lack of data. Iowa likely ranks third. In January 2015 it had 0.96 deaths from synthetic opioids per 100,000 residents. In January 2024, it had 5.77—nearly a 6-fold increase. West Virginia, the state with the highest fentanyl death rate, has 63.84 per 100,000 residents. Washington, D.C. lands on top at 70.55.

The Economic Cost of Fentanyl

Despite Iowa’s relatively low rates of fentanyl overdoses, the hundreds of deaths that occur each year come with a substantial cost. Common Sense Institute Iowa borrowed methodology from the CDC’s State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose – United States, 2017 paper to estimate the cost of an opioid overdose in Iowa.[xlvii] The CDC estimated the cost of fatal opioid overdoses for thirty-eight states and DC in 2017. For Iowa, they found the total cost of all fatal opioid overdoses in 2017 to be over $2.37 billion. The CDC used a case count of 206 fatal opioid overdoses, a per death cost of $11.5 million. Using this same approach, CSI estimated the cost per death and total costs from 2018 through 2023 by inflating the per death costs in each category by the Personal Consumption Expenditure Price Index (excluding energy and food). This raises the cost per death from $11.5 million to $16.1 million. The total cost of any type of fatal opioid overdose in 2023 cost Iowa about $7.2 billion. Fentanyl alone accounted for 81.5% of all opioid overdose costs, making the 2023 total cost of overdose deaths attributable to fentanyl $3.13 billion.

Table 3.

Total Economic Cost of Opioid Overdose Deaths in Iowa
Number of Opioid Overdose Deaths Healthcare Cost per Death Lost Productivity per Death Value of Statistical Life Lost Total Cost per Death Total Cost for all Deaths Total Cost Attributable to Fentanyl
2017 206 $5,350 $1.44M $10.10M $11.50M $2.37B $1.86B
2018 138 $5,609 $1.51M $10.59M $12.10M $1.67B $1.31B
2019 157 $5,804 $1.56M $10.96M $12.52M $1.97B $1.54B
2020 213 $5,719 $1.54M $10.80M $12.33M $2.63B $2.06B
2021 258 $6,458 $1.74M $12.19M $13.93M $3.59B $2.99B
2022 237 $7,049 $1.90M $13.31M $15.21M $3.60B $3.30B
2023 238 $7,475 $2.01M $14.11M $16.12M $3.84B $3.51B

 

Iowa Fentanyl Laws

Iowa regulates the manufacture, delivery, and possession of fentanyl as a schedule I controlled substances with standard sentences and penalties under Iowa Code Title IV, Chapter 124.[xlviii] In 2023, the legislature amended several sections of Chapter 124 (Controlled Substances) to enhance penalties related to fentanyl. The code includes uniform sentencing and penalties for all schedule I controlled substances unless otherwise dictated. Prior to 2023, no peculiar sentencing requirements or penalties applied to fentanyl apart from those generally applicable to all schedule I controlled substances.[xlix] As such, the law forbade the manufacture, delivery, or possession of fentanyl and the involvement in such activities with others. Violation of the law constituted a class B or class C felony, depending on the amount of drugs present. Possession of 5 grams or less was classified as a class C felony punishable by no more than 10 years in prison and a fine of between $1,000 and $50,000 dollars. Possession of 5 grams to 5 kilograms was a class B felony with up to 25 years in prison and a fine of $5,000 to $100,000. Possession of 10 kilograms or greater was a class B felony with up to 50 years in prison and a fine of up to $1 million.[l] Notably, because fentanyl is often mixed with other drugs subject to stricter penalties, fentanyl dealers could be subject to more severe penalties in connection with other substances.

In 2023, House File 595 prescribed expressly defined and enhanced sentencing and penalty requirements for drug crimes involving fentanyl. Prior to its passage, Iowa law already included elevated penalties for other drugs including heroin, cocaine, and methamphetamine, amongst others.[li] The 2023 bill amended IA Code § 124.401, 124.401D, and 902.9 to include special penalties for drug crimes involved fentanyl. Those penalties are as follows:

 Table 4. Criminal Penalties Related to Fentanyl from HF 595 (2023)

Description Felony Penalty
The manufacture, delivery, or possession of a fentanyl-related substance containing more than 50 grams. Class B Confinement for no more than 50 years and a fine of not more than $1.0 million.
The manufacture, delivery, or possession of a fentanyl-related substance containing more than 5 grams but not more than 50 grams. Class B Confinement for no more than 25 years and a fine of not less than $5,000 nor more than $100,000.
The manufacture, delivery, or possession of a fentanyl-related substance containing 5 grams or less. Class C Confinement for no more than 10 years and a fine of not less than $1,000 nor more than $50,000.
An individual who causes the death of another person while participating in the manufacture, delivery, or possession of a controlled substance and who is not seeking medical assistance for a drug-related overdose. Three times the term otherwise imposed by law, and no such judgment, sentence, or part thereof may be deferred or suspended.
An individual who causes serious bodily injury to another person while participating in the manufacture, delivery, or possession of a controlled substance and who is not seeking medical assistance for a drug-related overdose. Two times the term otherwise imposed by law, and no such judgement, sentence, or part thereof may be deferred or suspended.
The delivery to a minor or possession with the intent to deliver to a minor a controlled substance, counterfeit substance, simulated controlled substance, or imitation controlled substance, including combining a controlled substance with a food or beverage product, marketing or packaging a controlled substance to appear similar to a food or beverage product, or modifying the flavor or color of a controlled substance to appear similar to a food or beverage product. Two times the term otherwise imposed by law, and no such judgement, sentence, or part thereof may be deferred or suspended.
Current law provides that a person who is 18 years of age or older who either directly or by extraction from natural substances, or independently by means of chemical processes, or both, unlawfully manufactures methamphetamine or its salts, isomers, or salts of its isomers in the presence of a minor will be sentenced up to an additional term of confinement of five years. The Bill adds any controlled substance listed in Iowa Code section 124.401(1)(a, b, and c) to this crime. The previous penalty of the felony was confinement for no more than 50 years and a fine of not more than $1.0 million. The Bill allows two times the term otherwise imposed by law, and no such judgement, sentence, or part thereof may be deferred or suspended. A second or subsequent violation is a Class A felony.
Current law states that it is unlawful for a person 18 years of age or older to act with, or enter into a common scheme or design with, or conspire with one or more persons to manufacture for delivery to a person under 18 years of age a material, compound, mixture, preparation, or substance that contains any detectable amount of amphetamine, its salts, its isomers, or salts of its isomers, or methamphetamine, its salts, its isomers, or salts of its isomers. The Bill adds any controlled substances listed in Iowa Code section 124.401(1)(a, b, and c) to this crime. The previous penalty of confinement for no more than 99 years is stricken, and the Bill provides that a person in violation will be sentenced to two times the term otherwise imposed by law, and no such judgement, sentence, or part thereof may be deferred or suspended. A second or subsequent violation is a Class A felony.

Source: Iowa General Assembly, Fiscal Note: HF 595, by Jennifer Acton, Legislative Services Agency (May 22, 2023), 1-2, https://www.legis.iowa.gov/docs/publications/FN/1374150.pdf.

Conclusion

The fentanyl epidemic that has plagued the United States did not spare Iowa. Originating largely from China, fentanyl typically makes its way across America’s southern border before traffickers bring it into and through Iowa on the state’s network of interstate highways. The fentanyl destined for Iowa is directly responsible for more than half of all overdose deaths in the state, according to CDC’s SUDORS database. Iowa DPS reports the illicit opioid plays a role in 86% of overdose deaths in the state.[lii] In addition to the immeasurable cost of losing precious human lives, those deaths come with an economic cost, estimated at over $3.5 billion in Iowa alone in 2023.

The rate of overdose deaths from synthetic opioids—primarily fentanyl—rose over 500% in Iowa between January 2015 and January 2024. But in Iowa, the increase in deaths from psychostimulants like methamphetamine kept pace with synthetic opioids. While synthetic opioids overtook meth as the leadings cause of overdose deaths in Iowa in 2021, meth once again became more deadly at the end of 2022 and remains so today. While Iowa has dropped from the state with the fifth lowest overdose death rate in January 2015 to the state with the third lowest

[i] United States Drug Enforcement Administration, https://www.dea.gov/.

[ii] “Provisional Drug Overdose Death Counts,” National Vital Statistics System, February 15, 2023, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

[iii] United States Drug Enforcement Administration, “Facts About Fentanyl,” https://www.dea.gov/resources/facts-about-fentanyl.

[iv] Daniel Perreault, “Special Report: How Fentanyl is Tearing Through Iowa Communities and Leaving Families in Grief,” KWWL, May 10, 2023, https://www.kwwl.com/news/top-stories/special-report-how-fentanyl-is-tearing-through-iowa-communities-and-leaving-families-in-grief/article_82da5b1c-eea2-11ed-aee0-23fb2686934b.html.

[v] Abu Shafi, Alex J. Berry, Harry Sumnall, David M. Wood, and Derek K. Tracy, “Synthetic Opioids: a Review and Clinical Update,” National Institutes of Health, December 20, 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9747888/.

[vi] Bryce Pardo et al., “Understanding America’s Surge in Fentanyl and Other Synthetic Opioids,” RAND, October 7, 2019, https://www.rand.org/pubs/research_briefs/RB10091.html.

[vii] Sonia Moghe, “Opioid History: From ‘Wonder Drug’ to Abuse Epidemic,” CNN, October 14, 2016, https://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html.

[viii] Jan Porter and Herschel Jick, “Addiction Rare in Patients Treated With Narcotics,” Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Accessed June 7, 2024, https://www.nejm.org/doi/pdf/10.1056/NEJM198001103020221.

[ix] Nora Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” Senate Caucus on International Narcotics Control, May 14, 2014, https://web.archive.org/web/20210211040532/https:/archives.drugabuse.gov/testimonies/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse.

[x] “Prescription Painkiller Abuse: Attitudes Among Adults in Massachusetts and the United States,” the Boston Globe, Harvard T.H. Chan School of Public Health, May 2015, https://www.hsph.harvard.edu/wp-content/uploads/sites/21/2015/05/Prescription-Painkiller-Poll-Report.pdf.

[xi] “Opioid Prescription Limits and Policies By State,” Ballotpedia, April 4, 2022, https://ballotpedia.org/Opioid_prescription_limits_and_policies_by_state#Arizona.

[xii] “Opioid Prescription Limits and Policies by State,” Ballotpedia.

[xiii] “U.S. Physicians Discuss Curtailing Opioid Prescriptions,” Sermo, January 9, 2017, https://www.sermo.com/blog/insights/rock-hard-place-u-s-physicians-curtailing-opioid-prescriptions/.

[xiv] Ying Han, Wei Yan, Yongbo Zheng, Muhammad Khan, Kai Yuan, and Lin Lu, “The Rising Crisis of Illicit Fentanyl Use, Overdose, and Potential Therapeutic Strategies,” Transl Psychiatry, November 11, 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848196/.

[xv] Merianne Spencer, Matthew Garnett, and Arialdi Minio, “Drug Overdose Deaths in the United States, 2002-2022,” U.S. Center for Disease Control, March 2024, https://www.cdc.gov/nchs/data/databriefs/db491.pdf.

[xvi] Justin K. Niles, Jeffrey Gudin, Jeff Radcliff, and Harvey W. Kaufman, “The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing in 2020,” Population Health Management, February 5, 2021, https://www.liebertpub.com/doi/full/10.1089/pop.2020.0230.

[xvii] Chao Wang, Nicholas Lassi, Xiaohan Zhang, and Vinay Sharma, “The Evolving Regulatory Landscape for Fentanyl: China, India, and Global Drug Governance,” Int J Environ Res Public Health, February 12, 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8871795/.

[xviii] Steven Lee Myers, “China Bans All Types of Fentanyl, Fulfilling Pledge to Trump,” The New York Times, April 1, 2019, https://www.nytimes.com/2019/04/01/world/asia/china-bans-fentanyl-trump.html.

[xix] “Oversight of Federal Efforts to Combat the Spread of Illicit Fentanyl,” U.S. House Energy and Commerce Committee, 2019, https://docs.house.gov/meetings/IF/IF02/20190716/109817/HHRG-116-IF02-Wstate-OverackerT-20190716-SD002.pdf.

[xx] Eric Katz, “Report: DHS, USPS, Failing in Their Requirements to Screen for Opioids in the Mail,” Government Executive, October 3, 2023, https://www.govexec.com/oversight/2023/10/dhs-usps-failing-their-requirements-screen-opioids-mail/390895/.

[xxi] Drug Enforcement Administration, “2020 National Drug Threat Assessment,” March 2021, https://www.dea.gov/sites/default/files/2021-02/DIR-008-21%202020%20National%20Drug%20Threat%20Assessment_WEB.pdf.

[xxii] Drug Enforcement Administration, “National Drug Threat Assessment 2024,”, 2024, https://www.dea.gov/sites/default/files/2024-05/5.23.2024%20NDTA-updated.pdf.

[xxiii] Glenn Farley, “Fentanyl, Crime, and Arizona’s Southern Border,” Common Sense Institute Arizona, August 2022, https://commonsenseinstituteaz.org/fentanyl-crime-and-arizonas-southern-border-august-2022/.

[xxiv] “National Drug Threat Assessment 2024,” https://www.dea.gov/sites/default/files/2024-05/5.23.2024%20NDTA-updated.pdf.

[xxv] Daniel Perreault, “Special Report: How Fentanyl,” https://www.kwwl.com/news/top-stories/special-report-how-fentanyl-is-tearing-through-iowa-communities-and-leaving-families-in-grief/article_82da5b1c-eea2-11ed-aee0-23fb2686934b.html.

[xxvi] “History,” Midwest High Intensity Drug Trafficking Area, https://midwesthidta.org/history.

[xxvii] “2023 Midwest HIDTA Threat Assessment,” Midwest HIDTA, June 2023, https://img1.wsimg.com/blobby/go/893a8d74-0308-463e-b5f2-5dc56ff67d71/downloads/2023%20Midwest%20HIDTA%20Threat%20Assessment.pdf?ver=1717009060086, 7.

[xxviii] “2023 Midwest HIDTA Threat Assessment,” 41.

[xxix] “Polysubstance Use Facts,” CDC, April 2, 2024, https://www.cdc.gov/stop-overdose/caring/polysubstance-use.html.

[xxx] “2023 Midwest HIDTA Threat Assessment,” https://img1.wsimg.com/blobby/go/893a8d74-0308-463e-b5f2-5dc56ff67d71/downloads/2023%20Midwest%20HIDTA%20Threat%20Assessment.pdf?ver=1717009060086, 10.

[xxxi] “2023 Midwest HIDTA Threat Assessment,” 15.

[xxxii] “2023 Midwest HIDTA Threat Assessment,” 14.

[xxxiii] “Iowa Drug Control Strategy & Drug Use Profile,” Iowa Department of Public Safety Office of Drug Control Policy, 2024, https://dps.iowa.gov/media/321/download?inline=, 5.

[xxxiv] “2023 Midwest HIDTA Threat Assessment,” https://img1.wsimg.com/blobby/go/893a8d74-0308-463e-b5f2-5dc56ff67d71/downloads/2023%20Midwest%20HIDTA%20Threat%20Assessment.pdf?ver=1717009060086, 10.

[xxxv] “DEA Omaha Division Notes Record Fentanyl Seizures in 2023,” Drug Enforcement Administration, January 17, 2024, https://www.dea.gov/press-releases/2024/01/17/dea-omaha-division-notes-record-fentanyl-seizures-2023.

[xxxvi] “Provisional Drug Overdose Death Counts,” https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

[xxxvii] “Overdose Data to Action in States,” CDC, May 2, 2024, https://www.cdc.gov/overdose-prevention/php/od2a/state.html.

[xxxviii] “Overdose Data to Action in States.”

[xxxix] “Provisional Drug Overdose Death Counts,” https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

[xl] “Medication and Drug Overdose in Graham County https://injuryfreenc.dph.ncdhhs.gov/DataSurveillance/StatewideOverdoseSurveillanceReports/CountyOverdoseDeathSlides/grahamcountyoverdosedeathslides.pdf, 2.

[xli] “Gov. Reynolds Signs New Proclamation Continuing the State Public Health Emergency Declaration,” Iowa Office of the Governor, June 10, 2020, https://governor.iowa.gov/press-release/2020-06-10/gov-reynolds-signs-new-proclamation-continuing-state-public-health.

[xlii] The sum of fentanyl and meth overdose deaths exceeds 100% in some years because the two drugs are often taken together or in close proximity, resulting in a count for each.

[xliii] 5, https://hhs.iowa.gov/media/9321/download?inline=.

[xliv] Iowa Drug Control Strategy & Drug Use Profile,” https://dps.iowa.gov/media/321/download?inline=, 5.

[xlv] Glenn Farley, “Fentanyl, Crime, and Arizona’s Southern Border,” https://commonsenseinstituteaz.org/fentanyl-crime-and-arizonas-southern-border-august-2022/.

[xlvi] Steven L. Byers, “Colorado’s Fentanyl Problem and the Economic Costs,” June 18, 2024, https://commonsenseinstituteco.org/colorados-fentanyl-problem-and-the-economic-costs/.

[xlvii] Li F. Luo and C. Florence, “State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose — United States, 2017,” MMWR Morb Mortal Wkly Rep 2021;70:541–546. DOI: http://dx.doi.org/10.15585/mmwr.mm7015a1.

[xlviii] IA Code § 124.401 (2024); IA Code § 124.204 (2024).

[xlix] IA Code § 124.401 (2023).

[l] IA Code § 124.401 (2023).

[li] IA Code § 124.401 (2024).

[lii] “State Unintentional Drug Overdose Reporting System (SUDORS),” CDC, https://www.cdc.gov/overdose-prevention/media/pdfs/2024/04/SUDORS-Fact-Sheet.pdf.