America’s overdose epidemics: A short history with a long shadow

Editor’s note: This article is Part 2 of a series on the overdose epidemic.   

For all the attention on today’s fentanyl crisis, the United States has been here before. Overdose epidemics are not new. What is new is the scale. Understanding earlier waves helps explain how the country reached this moment and why the current crisis remains so difficult to contain.  

South Carolina reflects this national history. After years of increases, overdose deaths have now begun to decline statewide, but the Charleston area has experienced the same long progression seen across the country, from prescription opioids to heroin and now fentanyl. That evolution continues to shape the risks facing Lowcountry families. 

First wave: Post-Civil War opioid dependence 

The nation’s first opioid epidemic began after the Civil War. Military surgeons relied heavily on opium, laudanum, and morphine, and the new hypodermic syringe made morphine especially potent. Thousands of soldiers returned home dependent on opioids, and by the 1870s medical journals described a widespread “morphine habit,” later referred to as “soldier’s disease.” This doctor-driven epidemic eventually pushed Congress toward the Harrison Narcotics Act of 1914, the first major federal drug law. 

Heroin era of the ’60s and ’70s 

A century later, heroin fueled another overdose wave. In the late 1960s and 1970s, heroin use surged in many cities and among Vietnam veterans. Overdose deaths climbed, and heroin became a national political issue. The federal response, including the creation of the Drug Enforcement Administration in 1973, treated heroin as both a public health and public safety threat. 

The prescription opioid boom 

The modern crisis began in the doctor’s office and in corporate boardrooms. In the 1990s and 2000s, pharmaceutical companies aggressively marketed new opioid painkillers as safe and non-addictive. These claims were false, but they reshaped American medicine. Prescriptions soared. Millions of Americans were exposed to long-term opioid therapy, and overdose deaths involving prescription opioids quadrupled. 

Courts later found that manufacturers, distributors, and retail pharmacies had misled doctors, failed to monitor suspicious orders, and flooded communities with pills. The result was the largest public health litigation in U.S. history. The national opioid settlements, now exceeding $50 billion, require that most funds be used for treatment, prevention, and recovery, an unprecedented acknowledgment of corporate responsibility for a public health disaster. 

The shift to heroin 

As prescribing tightened, heroin filled the gap. Around 2010, many people who had developed opioid use disorder turned to heroin, which was cheaper and easier to find. Overdose deaths rose again. But this phase was short-lived, because a far more dangerous synthetic opioid was already entering the supply. 

The fentanyl era 

Then came fentanyl, and everything changed. Beginning around 2013, illicit fentanyl began appearing in heroin, then in counterfeit pills, then in cocaine and methamphetamine. Today it is found in nearly every illicit drug category and drives more than 70 percent of overdose deaths nationwide. The crisis is defined by unpredictable mixtures, counterfeit pills, and a drug supply more lethal than anything the country has seen. 

In the Lowcountry, fentanyl’s arrival was just as disruptive. Charleston, Berkeley, and Dorchester counties have seen a surge in counterfeit pills made to look legitimate, often taken by young people who believe they are using a real prescription medication. Officials now find fentanyl not only in heroin but also in cocaine, methamphetamine, and pills sold as oxycodone, Xanax, or Adderall. The result is a drug supply that is fast- moving, unpredictable, and far deadlier than anything South Carolina faced a decade ago. 

A dual response 

Public health and public safety now operate side by side and in closer coordination, sharing intelligence and aligning strategies, an acknowledgment that neither treatment nor enforcement alone can contain a crisis driven by both addiction and an extraordinarily dangerous drug supply. Public health agencies expand naloxone access, treatment, and education, while law enforcement targets fentanyl trafficking and counterfeit pill operations. In the Charleston area, these efforts increasingly align to protect local communities. 

The long shadow 

Across 150 years, the pattern repeats: a potent drug becomes widely available, its risks are underestimated, and social vulnerability magnifies the damage. The fentanyl era is the culmination of all of it, supercharged by synthetic chemistry, globalized supply chains, and a drug market that evolves faster than public health systems can respond. This is not the first overdose epidemic in American history. It is simply the deadliest. 

Doug Treasurer is a longtime Daniel Island resident and an analyst with the Atlanta-Carolinas High Intensity Drug Trafficking Areas or HIDTA. Treasurer also served a full career as a special agent with the Drug Enforcement Administration.