Gov. Greg Abbott says fentanyl is the leading cause of death for Americans 18 to 45. Is that true?

The day before holding a "One Pill Kills" summit in Austin on the dangers of fentanyl, a synthetic opioid that has led to a surge in overdose deaths, Texas Gov. Greg Abbott pointed out how deadly the drug has been. 

"Fentanyl is the leading cause of death for Americans 18-45," Abbott tweeted April 5. 

The governor has made combatting the crisis one of his seven emergency items for the Texas Legislature to address during this year’s session. The Legislature has several priority bills working through the Capitol, including decriminalizing fentanyl testing strips and increasing the criminal penalty for fentanyl distribution. 

Is fentanyl the No. 1 killer of a large swath of American adults, overtaking suicides, heart disease, cancer and other causes? 

Abbott’s office sent us four sources for their claim: A Washington Post analysis on fentanyl deaths from ages 18 to 49; a Fox News article saying fentanyl has become the leading cause of death for 18 to 45; a Snopes fact-check about fentanyl deaths; and an analysis from Families Against Fentanyl, a nonprofit started by Jim Rauh, who lost his son to a fentanyl overdose. 

The Centers for Disease Control and Prevention is in charge of collecting data to reveal the leading causes of death across the nation. The CDC doesn’t keep tabs on which drugs or narcotics cause the most fatalities nationwide. 

Instead, fentanyl deaths fall under the broader category of "other synthetic narcotics," said Brian Tsai, a spokesperson with the CDC’s National Center for Health Statistics Public Affairs Office. Fentanyl compromises about 90% of the deaths in that category, the spokesperson said. 

For the 18-to-45 age group, Tsai said, the leading cause of death was "Accidents (unintentional injuries)." Within the several subcategories under "unintentional injuries," "unintentional drug overdoses," is the largest proportion, and "synthetic narcotics," is the No. 1 category. 

"If one were to break out the unintentional injuries category to make the drug categories rankable, the leading cause for those 18-to-45 would be unintentional drug overdose due to other synthetic narcotics," Tsai said. 

The second-leading cause of deaths for that age group was suicide in 2020 and COVID-19 in 2021. The data for 2022 will not be available until later this year, he said.  

"If one assumes that the other synthetic narcotics category for those 18 to 45 is 90% fentanyl, then one can argue that unintentional fentanyl overdose is likely the leading cause in that age group," Tsai said. 

Dr. Tildabeth Doscher, the University of Buffalo’s fellowship director for addiction medicine, said one challenge is medical examiners across the country sometimes don’t test for drugs when determining causes of death. 

"It’s very tricky because medical examiners around the country have very different ways of looking, of testing," Doscher said. "So, we really cannot say." 

Brandon Marshall, a Brown University professor of epidemiology, said the lack of specific statistics from the CDC makes it difficult to completely verify Abbott’s claim. 

"I think the statement is likely true, but we just can’t necessarily say with certainty because of those data limitations," Marshall said. 

Late last year, The Washington Post published a seven-part investigative series on fentanyl and how the synthetic opioid has wreaked havoc in communities across the country. As part of its effort, the Post’s team of reporters sought to parse the CDC’s data to see how lethal the drug is.

Steven Rich, data editor with the the Post’s investigative team and a two-time Pulitzer Prize winner, combed through the CDC’s data and thousands of reports from medical examiners’ offices across the country to create a new data set. 

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The Post’s analysis found that in 2021 fentanyl was the leading cause of death for Americans 18-to-49. The second-leading cause of death for that age range was COVID-19. Fentanyl was No. 1 by several thousand deaths. 

"It’s not particularly close," Rich said. 

Rich said the Post did not reach out to the CDC after conducting the analysis to get a response from them. He did touch base with experts throughout the project to ensure he was doing work correctly. Pulling data from medical examiners’ offices allowed them to not rely on guesswork, he said. 

The Post also sought to verify whether fentanyl made up 90% of the "other synthetic narcotics'' subcategory. They discovered that the percentage of synthetic narcotics that were, in fact, fentanyl was around 97% or 98%. They didn’t have a percentage below 95%. 

"One of the things that I want to emphasize here is that the CDC collects good data, it’s just that their data is limited by this international code system, which is good," Rich said. "That is a very good thing for data because it makes data comparable to other countries. But it also makes it so that the CDC doesn’t collect, specifically, fentanyl deaths." 

The CDC had no comment on the Post’s analysis, Tsai said. 

Abbott said fentanyl deaths are the leading cause of death for Americans 18 to 45, and a range of sources point to that statement being accurate. 

The CDC said it is "likely" true because, according to its data, the leading cause of death for that age range is unintentional drug overdoses due to other synthetic narcotics. Fentanyl comprises about 90% of synthetic narcotic deaths, the CDC said. 

Medical experts also said it is likely true but could not be sure because of the lack of CDC data. 

The Washington Post conducted its own analysis for a similar age range, 18 to 49, and found that fentanyl was the leading cause of death for that group in 2021 by several thousands. 

Abbott’s statement is accurate but needs clarification or additional information. That’s our definition for Mostly True.