Key Takeaways
- The opioid crisis unfolded in three CDC-described waves: prescription painkillers in the 1990s, heroin around 2010, and illicit fentanyl driving most deaths since 2013 1.
- National overdose deaths fell nearly 14% in 2025 and opioid-involved deaths dropped for a third straight year, though some states and rural communities still saw sharp local spikes 2, 12.
- Only about one in six people with opioid use disorder receive medication treatment, with cost, distance, shame, and unstable housing — not willpower — blocking access to care 4, 21, 22.
- Evidence-based help combines FDA-approved medication, counseling, family support, and recovery scaffolding; getting naloxone in the house and leading with love are safe first steps for families 7, 10.
What the opioid crisis actually is, in plain language
The opioid crisis is the long, overlapping surge in addiction and overdose deaths tied to opioids — the family of drugs that includes prescription painkillers like oxycodone and hydrocodone, heroin, and illicit synthetic opioids like fentanyl. You may also hear it called the opioid epidemic. Both terms describe the same thing: a public-health emergency that has reshaped hospitals, families, and small towns across the country for more than two decades.
The CDC describes the crisis as unfolding in three waves — prescription opioids starting in the 1990s, heroin picking up around 2010, and illicit synthetic opioids, especially fentanyl, driving most deaths since about 2013.1 The drugs changed. The people caught in it changed less than you might think. A back injury on a ranch, a surgery that never fully healed, a shift-work routine built on painkillers — these are familiar starting points, not rare ones.
If you or someone you love is in this story right now, you are not a statistic and you are not alone. The pages ahead walk through how we got here, where things stand in 2025, who the crisis touches beyond the headlines, and what real help looks like — honestly, and without shame.
Three waves that reshaped medicine cabinets and small-town ERs
From prescription pads to heroin to fentanyl
You can picture the opioid crisis as one big story, but public-health researchers describe it as three overlapping waves — and each wave changed who was most at risk and what the drugs looked like.1
- The first wave started in the 1990s. Prescription opioids like oxycodone and hydrocodone were marketed aggressively for chronic pain, and well-meaning doctors wrote a lot of them. If you threw out your back loading hay, had a knee replaced, or came home from the ER with a bottle of pills after a car wreck, that bottle might have been your first encounter. Dependence often grew quietly, long before anyone called it a disorder.1
- The second wave took shape around 2010, when heroin use rose sharply. For some people, prescriptions dried up or became harder to get. Heroin was cheaper, easier to find, and already moving through the same networks. The story shifted from the pharmacy counter to the street, but many of the people involved were the same — a nurse who’d hurt her back, a welder who’d blown out a shoulder, a kid who’d been prescribed pills in high school.1
- The third wave began around 2013, when illicitly manufactured fentanyl and other synthetic opioids started showing up in the drug supply.1 Fentanyl is far more potent than heroin, cheap to produce, and now mixed into counterfeit pills, powders, and even stimulants. Many people who die of a fentanyl overdose did not knowingly buy fentanyl at all. That is the wave we are still inside.
Why the fentanyl wave hit working people the hardest
If you work with your body, you know pain is part of the job. Ranchers get thrown. Nurses and CNAs blow out their backs lifting patients. Line cooks stand on hard floors for twelve hours. Teachers and tradespeople push through injuries because somebody has to open the restaurant, finish the roof, or cover the shift. For a lot of folks, that first prescription after an injury or surgery was not a bad decision — it was a reasonable one. The trouble came later, quietly, when the pills kept working for the pain and also started working on everything else.
When the supply shifted to street drugs and then to fentanyl, the risk changed in ways you could not see or taste. A pill that looks like the one you used to get from a pharmacy might contain a dose of fentanyl that would stop your breathing. That is why so many of the people lost in this wave were not strangers to anyone. They were coworkers, veterans, church members, parents picking kids up from school.
None of that makes you weak or broken. The three-wave story matters because it shows the crisis grew out of ordinary life — a workplace injury, a surgery, a tough stretch — and then a drug supply that got more dangerous while nobody was looking. If opioids got their hooks in you this way, you are not the exception. You are the pattern. And a pattern can be met with the right kind of help.
Where the crisis stands in 2025: real progress, uneven ground
Here is the honest headline: the national overdose numbers are finally moving in the right direction, and that matters. The CDC estimates there were 69,973 drug-overdose deaths in the United States in 2025, nearly 14% fewer than the 81,313 estimated in 2024. Opioid-involved deaths dropped from 55,296 to 44,564 over the same stretch — the third straight year of national decline.2 If you have been bracing for worse news every month, let that one sink in for a second. It is real progress, and it reflects a lot of hard work by families, first responders, clinicians, and people in recovery.
Here is the second half of the story, and you deserve it too. Those 2025 figures are provisional. CDC updates them as more death records come in, and some states have already seen counts shift as investigations close.3 A few states still saw overdose deaths rise even as the national total fell.2 In other words, the trend line is pointed down, but the ground under your feet may not match the national average.
Fentanyl is still the main driver of opioid deaths, and the drug supply keeps shifting. Progress does not mean the crisis is over. It means something is finally working — wider naloxone access, more medication treatment, stronger community response — and it means the next step is making sure those gains reach the places and people still being left behind.
On the ground in Montana and the northern Rockies
If you live in Montana, Wyoming, Idaho, or the Dakotas, the national headline and your lived experience may not line up — and that is not your imagination. Montana’s opioid-overdose death rate was 8.4 per 100,000 residents in 2024, compared with a national rate of 16.3 per 100,000. About three in five unintentional overdose deaths in the state from 2020 through 2024 involved an opioid, usually fentanyl.12 By the raw numbers, Montana sits below the national average. That is a comfort worth noting, and it is nowhere near the whole picture.
Then came spring 2025. Montana reported 95 suspected opioid overdoses in March 2025, compared with an average of about 69 per month in 2024 — and suspected opioid-overdose EMS incidents rose roughly 35% year over year.12, 13 For the paramedics running those calls on long rural routes, for the sheriff’s deputy who arrives first, for the family that gets the phone call, the national decline felt very far away. Both things are true at the same time: a lower baseline rate, and a sharp local spike that moved fast.
Rural geography shapes everything that follows. Montana’s Substance Use Disorder Task Force Strategic Plan names opioid use as the main driver of drug-overdose deaths in the state and calls for expanding opioid treatment programs and medication access, especially in communities where the nearest clinic can be hours away.14 If you are on a ranch outside Lewistown or a shift job in Havre, driving 90 miles for care is not a scheduling problem — it is a reason people put off making the call. The state has responded with naloxone distribution, fentanyl test strips, and new wellness kiosks, and families are responding by learning what to do when someone they love is in trouble.13 The honest regional story is this: things are better than they were, worse than you want, and still very much worth acting on today.
The wider impact: families, children, workplaces, and dollars
What it does to families and the kids in the house
Opioid use rarely stays in one person’s lane. It moves into the kitchen, the truck cab, the pickup line at school. If you are the spouse, the parent, the sibling, or the grown kid watching it happen, you already know this. You are losing sleep, counting pills, checking a phone that stays dark too long. That weight is real, and it is part of the crisis too.
Children feel it first. Parental opioid misuse can shape how kids develop, how safe they feel at home, and who ends up tucking them in at night. When a parent can’t carry the load, grandparents often step in — sometimes overnight, sometimes for years. Researchers call these households grandfamilies, and the ones built in the wake of opioid use often take shape without warning, without legal paperwork, and without the retirement a grandparent had been planning on.19 If you are a grandmother in Great Falls raising a four-year-old you did not expect to raise, you are not alone, and you are not failing. You are holding a family together under conditions nobody prepared you for.
Siblings and spouses carry their own version. You cover shifts, lie to in-laws, hide car keys, and wonder if you are helping or enabling. Family-centered support — the kind that teaches boundaries and gives everyone a place to be honest — is not a luxury on top of treatment. It is part of how recovery holds.19
Pregnancy, rural distance, and shifting demographics
If you are pregnant and struggling with opioids, the shame can feel enormous. Please hear this: medication treatment for opioid use disorder during pregnancy is standard, evidence-based care, not a mark against you. A Tennessee cohort study of Medicaid-covered mother-infant pairs found that pregnant women with OUD living in rural areas were less likely to receive medication for OUD than urban patients, with an adjusted odds ratio of 0.66 — and that receiving medication was associated with lower rates of preterm and very preterm birth.18 That study was Tennessee, not Montana, but the rural access gap it describes will feel familiar to anyone two hours from a prenatal clinic.
The picture of who is affected has also shifted. Overdose harms have grown among American Indian and Alaska Native and Black populations, which complicates any old assumption that the opioid crisis is one community’s story.20 In Montana, that matters. Tribal communities, ranching towns, and small-city neighborhoods are each living their own version — and each deserves care that fits, not a template.
The economic weight: hospitals, workplaces, and lost lives
The dollars tell a quieter version of the same story. The Government Accountability Office cites Council of Economic Advisers estimates that the opioid crisis cost more than $700 billion in 2018 when the value of lives lost from opioid-related overdoses was included.16 Separate GAO work points to roughly $10.3 billion in hospitalization costs and $7.7 billion in criminal-justice costs tied to opioid misuse in the periods studied.15 Those are big numbers that sit on top of smaller, closer ones you may already know: the ER bill, the missed shifts, the truck that got repossessed, the ranch help that didn’t come back after lunch.
If you are an employer in Montana — a restaurant owner, a nursing supervisor, a shop foreman — you have felt this on the schedule. If you are the worker, you have felt it in your paycheck and your pride. The crisis is a health problem, a family problem, and an economic one at the same time. Treating it as all three is how communities start to get their footing back.
Why so few people get help, and what the evidence says works
The treatment gap, and why it is not about willpower
If you have ever wondered why someone you love hasn’t gotten help yet, or why you haven’t picked up the phone yourself, the answer is almost never willpower. It’s the gap between how many people need care and how much care they can actually reach.
SAMHSA’s 2025 National Survey on Drug Use and Health estimates that 4.0 million people aged 12 or older had past-year opioid use disorder, and about 15.7% of them received medication for OUD.4 That’s roughly one in six. The other five are not refusing help out of stubbornness. They are hitting walls that get in the way long before they ever meet a counselor.
Researchers who have asked people directly keep hearing the same list of barriers:
- Cost
- Availability
- Wait times
- Lack of diversity in the care they’d be walking into
- How far away the clinic is
- The shame that comes with being seen walking in21
A separate study of patients already trying to get OUD treatment added the structural layer underneath: unstable housing, a past arrest on your record, insurance that won’t cover what you need, and no reliable way to get to appointments.22 If any of that sounds like your week, it’s not a personal failing. It’s a system that has not caught up with the need.
What evidence-based care looks like today
Here is the part a lot of people never hear plainly: opioid use disorder has evidence-based treatments that work, and they do not require you to muscle through alone. The CDC is clear that medication treatment for OUD is associated with lower overdose and mortality risk, and recommends offering or arranging evidence-based care.5
There are three FDA-approved medications for OUD — methadone, buprenorphine, and naltrexone — and the national clinical practice guideline updated in 2024 recommends methadone and buprenorphine as first-line options, with the choice shaped by your situation, your history, and what you can realistically access.7, 8 These are medical tools, not substitutes for recovery. SAMHSA’s foundational protocol describes medication as one part of a bigger picture that also includes counseling, behavioral therapies, medical care, and recovery supports — the kind of day-to-day scaffolding that holds a new life together.7
Residential care is a different path within that bigger picture, for people who need to step out of their environment and work on the root causes — the pain, the grief, the shame, the family patterns — in a setting where someone is always available to talk. Rocky Mountain Treatment Center in Great Falls, Montana, is one example of that kind of residential, root-cause program. RMTC does not provide the medication-based treatments described above; instead, its 30-day inpatient stay, with the option to extend, focuses on tools rather than medication, with family programming, equine therapy, and individual and group counseling. The right path is the one that matches your life, your medical needs, and the people around you. There is more than one honest answer here, and that’s good news.
What has changed recently: naloxone, take-home rules, and funding
A lot has shifted in the last few years, and most of it is on your side.
In 2023, the FDA approved 4-milligram naloxone nasal spray for over-the-counter use — the first naloxone product cleared without a prescription.10 That means you can keep it in a glove box, a kitchen drawer, or a nurse’s bag without a doctor’s visit. If someone in your house is using, having naloxone within reach is one of the simplest, most loving things you can do.
SAMHSA’s 42 CFR Part 8 rule changes also made opioid treatment programs more workable for real lives. The updated rule allows take-home methadone doses to be considered from the first week of treatment under specified conditions, while keeping diversion-control safeguards in place.9 For a rancher two hours from the nearest clinic, that change can be the difference between staying in treatment and quitting because the drive broke the schedule.
On the funding side, HHS allocated more than $1.5 billion in FY2025 continuation grants — about $1.48 billion for states and nearly $63 million for Tribal communities — to support prevention, overdose reversal, medication treatment, and recovery.11 None of this fixes everything. It does mean the door is a little wider than it was, and worth walking through.
If someone you love is using opioids: a next step that is safe and simple
If you are reading this at 11 p.m. with the hallway light on, waiting to hear a car in the driveway, start here. You do not have to fix everything tonight. You just have to take the next right step.
Get naloxone in the house. The over-the-counter nasal spray does not require a prescription or a hard conversation at the pharmacy counter.10 Keep one in the kitchen drawer, one in your purse, one in the glove box. If you have ever learned CPR for a grandchild, you can learn this.
Then, when the moment is calm — not during a fight, not after a scare — tell the person you love what you see and that you are not going anywhere. Lead with love. Skip the words that sting: no “addict,” no “clean,” no ultimatums you cannot keep. Shame is one of the loudest reasons people put off asking for help, right alongside cost and distance.21 You do not have to add to it.
You also do not have to know which treatment is right before you make a call. Admissions teams at reputable programs will walk you through what fits — whether that is medication-based care through a local opioid treatment program, counseling, or a residential stay that steps someone out of their environment to work on root causes. Rocky Mountain Treatment Center in Great Falls, Montana, keeps an admissions line open 24/7 for exactly this kind of conversation — the kind where you are not sure what to ask yet, and nobody rushes you. Healing begins here, and it begins with one phone call. We’ve been there. We can help.
Frequently Asked Questions
What is the opioid crisis in simple terms?
The opioid crisis is the long rise in addiction and overdose deaths tied to opioids — prescription painkillers, heroin, and illicit synthetic opioids like fentanyl. The CDC describes it as three overlapping waves: prescription opioids in the 1990s, heroin starting around 2010, and fentanyl driving most deaths since about 2013.1
Is the opioid crisis getting better or worse in 2025?
Nationally, it is getting better. CDC’s provisional data show opioid-involved overdose deaths dropped for a third straight year in 2025.2 But the picture is uneven. Montana’s suspected opioid-overdose EMS calls jumped roughly 35% year over year in 2025, and the drug supply keeps shifting.12, 13 Progress is real, and local spikes still happen.
Why did fentanyl become such a big part of the problem?
Fentanyl is far more potent than heroin and cheap to produce, so it moved into the illicit supply fast starting around 2013.1 It now shows up mixed into counterfeit pills, powders, and even stimulants. Many people who overdose on fentanyl did not knowingly buy it. That hidden potency is why so many of the losses in this wave feel so sudden.
What does evidence-based treatment for opioid use disorder actually include?
Evidence-based care usually combines FDA-approved medication with counseling and recovery support. The three medications are methadone, buprenorphine, and naltrexone, with methadone and buprenorphine recommended as first-line options.7, 8 CDC notes that medication treatment lowers overdose and mortality risk, and that detox alone is not recommended for OUD because the risk of returning to use rises afterward.5, 6 Counseling, behavioral therapies, and day-to-day recovery supports fill out the plan.
How can I help a loved one who is using opioids without pushing them away?
Start by getting naloxone in the house — the over-the-counter nasal spray does not require a prescription.10 Pick a calm moment to say what you see and that you are not going anywhere. Use person-first words, not labels. Shame is one of the loudest reasons people delay getting help, right alongside cost and distance.21 You do not need to know the right program before you call one. You just need to open the door.
What does residential treatment at Rocky Mountain Treatment Center look like?
Rocky Mountain Treatment Center is a 26-bed residential program in Great Falls, Montana, that has been helping people since 1983. The 30-day inpatient stay, with the option to extend, includes individual and group counseling, CBT, motivational interviewing, family therapy, equine therapy, and optional Bible study or Wellbriety. More than 80% of staff are in personal recovery, admissions is available 24/7, and alumni stay connected through weekly Zoom aftercare. We’ve been there. We can help.
References
- Understanding the Opioid Overdose Epidemic. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
- U.S. Overdose Deaths Decrease for Third Consecutive Year in 2025. https://www.cdc.gov/nchs/pressroom/releases/20260513.html
- Provisional Drug Overdose Death Counts. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
- Key Substance Use and Mental Health Indicators in the United States: Results from the 2025 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/reports/rpt57150/2025-nsduh-annual-national-report.pdf
- Opioid Use Disorder: Treating. https://www.cdc.gov/overdose-prevention/hcp/clinical-care/opioid-use-disorder-treating.html
- CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022. https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
- TIP 63: Medications for Opioid Use Disorder – Full Document. https://www.samhsa.gov/resource/ebp/tip-63-medications-opioid-use-disorder
- Management of opioid use disorder: 2024 update to the national clinical practice guideline. https://pmc.ncbi.nlm.nih.gov/articles/PMC11573384/
- 42 CFR Part 8 Final Rule: Table of Changes. https://www.samhsa.gov/substance-use/treatment/opioid-treatment-program/42-cfr-part-8/changes
- FDA Approves First Over-the-Counter Naloxone Nasal Spray. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray
- HHS Provides More Than $1.5 Billion in State and Tribal Opioid Response Grants. https://www.hhs.gov/press-room/hhs-state-tribal-opioid-response-grants-2025.html
- Summary of Opioid Use in Montana. https://dphhs.mt.gov/assets/publichealth/EMSTS/Data/Opioid_Drug_Use_Summary.pdf
- State Health Officials Report Significant Increase in Overdoses. https://dphhs.mt.gov/news/2025/April/SignificantIncreaseinOverdoses
- Montana Substance Use Disorder Task Force Strategic Plan. https://dphhs.mt.gov/assets/publichealth/EMSTS/opioids/SUDsStrategicPlan2024.pdf
- HIGH-RISK: National Efforts to Prevent, Respond to, and Recover from Drug Misuse. https://www.gao.gov/assets/gao-20-474.pdf
- DRUG POLICY. https://www.gao.gov/assets/gao-22-106087.pdf
- NIH HEAL Initiative 2023 Annual Report: Research in Action. https://www.nih.gov/sites/default/files/2026-01/NIH%20HEAL-Annual-Report-2023_PDF.pdf
- Disparities in receipt of medications for opioid use disorder among pregnant women. https://pmc.ncbi.nlm.nih.gov/articles/PMC8875287/
- Grandfamilies and the Opioid Epidemic: A Systemic Perspective. https://pmc.ncbi.nlm.nih.gov/articles/PMC7829093/
- Bringing an Equity Lens to Address the Evolving Overdose Crisis: A Public Health of Consequence, April 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10003500/
- Addressing Stigmas That Hinder Addiction Treatment and Recovery. https://pmc.ncbi.nlm.nih.gov/articles/PMC11571192/
- Evaluating Barriers to Opioid Use Disorder Treatment From Patients’ Perspectives. https://pmc.ncbi.nlm.nih.gov/articles/PMC10887383/
