The Opioid Crisis Is Shifting: What's Replacing Prescription Pain Medications

Prescription opioids are no longer driving America's addiction crisis. A major analysis of nearly 1.7 million urine samples from patients with substance use disorder (SUD) reveals that illicit use of prescription pain medications has collapsed over the past decade, dropping from 80% in 2016 to just 4.9% by 2025. This dramatic decline suggests the nation's drug problem is evolving in unexpected ways—and pain patients themselves may be feeling the consequences.

How Dramatically Has Prescription Opioid Misuse Declined?

The shift is striking. In 2016, up to 80% of patients who tested positive for illicit fentanyl also tested positive for a prescription opioid that wasn't prescribed to them. By 2025, that number had plummeted to 4.9%. The decline reflects two major trends: stricter opioid prescribing practices over the past decade and the fact that legitimate pain patients now struggle to access these medications legally.

"Within the population using fentanyl, we've seen a continued drop in the detection of prescription opioids. In 2025 the positivity rate for prescription opioids—I'm talking about hydrocodone, hydromorphone, oxycodone, oxymorphone, tramadol as a group—are at all-time lows in our database. It's about 5 percent," said Eric Dawson, PharmD, Vice President of Clinical Affairs at Millennium Health, the drug testing company that conducted the analysis.

However, the decline isn't uniform across the country. Regional differences are significant:

• Southern States: 9.1% of SUD patients tested positive for both fentanyl and prescription opioids
• Western States: Only 4.1% tested positive for both substances
• National Average: 4.9% of patients showed evidence of both drugs

What's Replacing Prescription Opioids in the Illicit Drug Supply?

As prescription opioids have become scarcer in the illegal drug market, users are turning to other substances. The most concerning trend is the rise of stimulants like methamphetamine and cocaine. Even as fentanyl use has leveled off and declined in recent years, stimulant use has risen steadily among people with substance use disorders.

"I continue to hear it everywhere I travel. Stimulants, methamphetamine and cocaine, are just incredibly plentiful in so many communities, and extremely inexpensive. And so, if you present a drug in front of a population that tends to use drugs and it's cheap or free and potent, they tend to gravitate toward that," Dawson explained.

Beyond illicit drugs, another unexpected player is emerging: kratom, a herbal supplement derived from a Southeast Asian tree. Kratom use among addiction treatment patients has grown significantly. In 2016, less than 1.5% of SUD patients tested positive for kratom alkaloids (the active compounds in the plant). By 2025, that had grown to about 3%, with even higher levels in the South.

Why Is Kratom Use Growing Among People With Addiction?

Kratom's rise reflects increased awareness that the herbal supplement can be used to treat pain, anxiety, and other health conditions. The federal government estimates that 1.7 million Americans used kratom in 2021, though the American Kratom Association, an advocacy group, puts the number much higher at 10 to 16 million Americans.

The growing awareness has spread to addiction treatment providers themselves. In 2016, only about one-third of Millennium Health's urine drug tests included a request to test for kratom. By 2025, over 77% of urine drug tests included analysis for kratom alkaloids. This shift suggests that addiction specialists are increasingly monitoring for kratom use among their patients.

The data paints a picture of a drug crisis in transition. While the opioid epidemic that dominated headlines for two decades is waning—at least in terms of prescription medication diversion—the underlying problem of addiction and substance use disorder remains. The substances people turn to are simply changing, driven by availability, cost, and potency rather than by any reduction in the desire to use drugs.

For chronic pain patients, the silver lining is complicated. The dramatic reduction in prescription opioid diversion means fewer of these medications are being diverted to the black market. But it also reflects the reality that legitimate pain patients face: stricter prescribing guidelines have made it harder for them to access opioids, even when medically appropriate. Understanding these broader trends helps explain why pain management has become such a challenging landscape for both patients and healthcare providers.