Conflict is reshaping the global trade map, and the collapse of Afghanistan’s opium production could, paradoxically, be pushing the world even faster toward more dangerous synthetics. Meanwhile, governments continue to prioritise punishment over care for people caught up in the cycle of drug use.

Nearly half a million people died from drug use in 2023, driven by infectious disease, untreated addiction and the spread of synthetic drugs more potent than anything markets have seen before, according to the new report by the UN Office on Drugs and Crime (UNODC).

“The consequences are lethal,” Monica Juma, UNODC’s executive director, wrote in the World Drug Report 2026. “These deaths are a reminder that the world drug problem remains, at its nucleus, a human challenge that affects lives, families and communities.”

An estimated 331 million people worldwide used illicit drugs in 2024, the highest number ever recorded and a 34% increase over the past decade that has well outpaced population growth.

Part, but not all, of the recorded rise reflects “the availability of new and more accurate data,” per the report, meaning better tracking of use that was already there.

“As drug use increases, more people are exposed to health and social risks,” Juma wrote. “Yet as healthcare needs continue to grow, access to treatment remains unequal. In many parts of the world, services are scarce or unavailable, leaving millions, especially women and vulnerable groups, without access to recovery and support.”

The report describes a drug trade in the middle of a historic transformation, away from crops like coca, opium poppy and cannabis that need land, seasons and favourable climates to grow, and toward chemicals that can be synthesised in laboratories anywhere in the world and sold to customers close by.

But synthetics are also leading more and more people into uncharted waters, with wide variations in toxicity and often lethal or unknown impacts on health. A record 755 new psychoactive substances were detected in circulation in 2024. Five times more unique drug types, primarily synthetic, now appear in seizures than before 2000.

“We have seen an unprecedented spike in new types of drugs on the market, and worryingly, some are more potent or dangerous than before,” Juma said.

The global drug market, she told the report’s launch in Vienna, is “rapidly evolving, expanding, and in some cases outrunning the very systems designed to stop it.”

More than overdoses: hepatitis C and HIV are the biggest killers

Of the 492,000 deaths attributed to drug use in 2023, just 172,500 were direct deaths such as fatal poisonings. Most of the rest were killed slowly, by infections passed through needles years or decades earlier.

“Opioids continue to account for the largest part of the global burden of disease attributed to drug use, while hepatitis C remains a key driver of drug use-related deaths,” the report finds. Opioids are “the most lethal group of drugs, accounting for nearly three quarters of the estimated total number of deaths directly related to drugs.”

Cirrhosis and liver disease caused by hepatitis C were the leading cause of death attributed to drug use, responsible for 46% of the total, some 224,528 lives in 2023.

HIV/AIDS claimed another 15%, with opioid overdoses and dependence, the largest source of direct deaths, accounting for 26%. That toll lands as the global HIV response reels from the biggest funding crisis in its history, with services for people who inject drugs, long among the populations left furthest behind, squeezed by the donor retreat.

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An estimated 14.3 million people injected drugs in 2024. Nearly half of them, 7 million people, were living with hepatitis C, and almost one in eight with HIV. The risk of acquiring HIV is 14 times higher for people who inject drugs than for the general population.

Drug deaths remain a fraction of the toll from legal substances, which sit outside UNODC’s treaty mandate. Tobacco kills around 8 million people a year and alcohol some 2.6 million. But illicit drugs strike earlier in life. Use is concentrated between the ages of 15 and 34, and the report counts 29 million years of healthy life lost to drugs in 2023.

“Young people, in particular, are often more exposed to high-risk patterns of drug-use and drug-related violence,” Juma wrote.

One in 12 people get treatment, only one in 23 women

Of the 63 million people living with drug use disorders, only one in 12 received any form of treatment in 2024.

Coverage is thinnest in Africa and Asia, where the epidemic is youngest: a third of people in treatment in Africa are under 25, rising to nearly half in South America. The report lists the high cost of treatment, chronic shortages of funding and staff, long waiting lists, missing medications and “stigma and sometimes criminalization faced by patients” among the barriers.

Just one in 23 women with a drug use disorder receives treatment, against one in nine men, even though women progress faster from first use to dependence, a phenomenon researchers call the “telescoping effect.”

“Women use drugs less than men, but when they do, the impact on their lives is greater,” the report states.

Women who inject drugs are 20% more likely than men to be living with HIV. Women more often begin using drugs to self-medicate pain, depression or anxiety, and face what the report calls “double, triple or multiple stigma,” judged both for their drug use and for failing gender role expectations, “which is aggravated if they have children.”

Heightened stigma, a lack of services for women’s needs, “a lack of childcare and the fear of losing custody of their children while in treatment” keep women out of care, the report finds.

“When they enter drug treatment, women exhibit similar or, in some cases, better treatment outcomes in relation to drug use disorders than men,” it notes.

The pain divide and the opioid crisis

In 2021, 73.5 million people worldwide experienced what the Lancet Commission on Palliative Care defines as serious health-related suffering: pain and distress so severe it cannot be relieved without medical intervention. Nearly 80% of them lived in low- and middle-income countries.

Those same countries received 14% of the world’s pharmaceutical opioids.

Adjusted for population, opioid availability for pain relief and palliative care in poorer countries was 96% lower than in rich ones. In 2024, 87.5% of humanity lived in countries with below-average access. West and Central Africa, the worst-served subregion, had 25 standard daily doses per million people. High-income countries had nearly 18,000.

The reasons include weak supply chains, untrained health workers and entrenched fear of addiction. “Manufacturers in many countries may also avoid producing low-cost options such as morphine, if they are seen as unprofitable,” the report notes.

Prescription opioids, fentanyl in North America and beyond

The synthetic drugs at the heart of the report’s warnings have already produced one catastrophe, a fentanyl crisis that has defined a generation of American politics and law, filled bestseller lists and television dramas, and now kills more Americans in a single year than the entire Vietnam War. The United States, home to about 4% of the world’s population, recorded roughly 110,000 overdose deaths at the epidemic’s 2023 peak, according to US health authorities, accounting for roughly 25% of global drug deaths.

Nearly a million people died in North America’s opioid epidemic in the first two decades of this century, triggered by easy access to OxyContin, a prescription painkiller derived from the opium poppy and manufactured by Purdue Pharma.

Members of the Sackler family, whose company Purdue Pharma made OxyContin, never faced criminal charges. Liability suits brought by thousands of people who said they had been wrongfully addicted were settled in civil court for billions of dollars.

“The opioid crisis in North America, which has been linked to the aggressive marketing and overprescription of pharmaceutical opioids for reasons other than cancer treatment, surgery and palliative care, has also likely raised concerns about the misuse of pharmaceutical opioids in other countries,” the report finds.

Just as awareness of OxyContin abuse grew into a national enforcement and litigation issue, fentanyl was being introduced into the supply of heroin sold on the streets, “with users initially unaware of its presence,” the report recounts.

The synthetic opioid is roughly 50 times stronger than heroin and “significantly cheaper both for producers and for consumers,” the report notes, describing the transformation as evidence that opioid markets “can permanently change.”

Opioid overdose deaths involving fentanyls fell 17% in Canada and by more than a third in the United States in 2024, the first decline in a decade, credited to shrinking supply, wider access to the overdose antidote naloxone and expanded treatment.

If fentanyl were to break out of North America at scale, the economics favour it. A shift to such alternatives, the report warns, would elevate “levels of harm for those using illegally sourced opioids.”

After fentanyl, something even stronger: nitazenes

Fentanyl’s successors are already circulating, the report finds, and some are even stronger. Nitazenes, a class of synthetic opioids that can exceed fentanyl’s potency, have been identified in 37 countries since 2019, “making them far more geographically widespread than fentanyls ever have been.”

Some nitazene metabolites “may even exceed the potency of the parent compound,” causing respiratory depression so severe it can require repeated doses of naloxone to reverse.

In the United Kingdom, nitazenes were linked to roughly 750 overdose deaths between June 2023 and August 2025, about three times the toll of fentanyl there. In West Africa, nitazenes have turned up in “kush,” a cheap smoked mixture spreading among adolescents; in Guinea, nearly 1% of school students surveyed in 2024 reported using it. A newer class still, the orphines, has surfaced in at least 14 countries.

“We see a lot of nitazenes now,” Chloé Carpentier, the UNODC research chief who coordinated the report, told UN News. “The worry is really that synthetic opioids might replace heroin and lead to much more harm.”

Synthetics: a market that cannot be stopped

The synthetic takeover is, for now, a threat still largely looming in the future. Plant-based drugs continue to dominate the global trade.

With 256 million users worldwide, cannabis remains by far the most used drug. Production of cocaine, a derivative of the coca plant native to the Andes, meanwhile hit an all-time record of 4,100 tons in 2024, more than four times the level of a decade ago.

Overall, synthetics “are well placed to supplant plant-based drugs; however, to date this seems to be far from the case in practice,” the report finds.

Synthetic drugs need no land, no harvest and no particular climate, and can be made next to their consumers, slashing the risk of interception. The only real constraints, the report finds, are chemical expertise and precursor supplies, “barriers which are too easily overcome in a globalized, digitalized world characterized by the free flow of information and plentiful channels for international trade.”

Since 2014, the international control system has scheduled 92 new psychoactive substances. In 2024 alone, 118 new ones appeared.

The precursor economy has meanwhile pulled drug policy into superpower politics. US intelligence names China and India as the primary sources of fentanyl precursor chemicals, and Washington has designated illicit fentanyl and its core precursors as weapons of mass destruction.

Fentanyl became the formal legal basis of American tariffs on China in 2025, before the Supreme Court struck them down this February, and Beijing has tightened chemical controls in trade-deal instalments after each summit with Washington.

Most precursors in use today are “designer” chemicals not scheduled anywhere, redesigned faster than either government can ban them.

Dictators, insurgents and the drug supply

Two political earthquakes, more than any enforcement strategy, are redrawing the world’s drug map. Criminal groups, Juma wrote, “rapidly adjust to changing circumstances.”

The first came from Kabul. The Taliban spent two decades taxing the opium trade to fund their insurgency, then banned it upon taking power. Afghan production, once 80% of the world’s illicit opium, has collapsed 95%, from 6,200 tons in 2022 to an estimated 296 tons in 2025. Heroin prices in 12 major destination markets doubled in two years, to nearly $500 per pure gram, and UNODC estimates Afghan stockpiles could run dry by the end of 2026.

No other producer is filling the gap. Myanmar is now the world’s largest source of opium, but its rise reflects its own civil war, not Afghan shortfalls. Rebuilding poppy fields and smuggling networks is unlikely, the report concludes, and traffickers turning to fentanyls, nitazenes and orphines would be “essentially reshaping global illicit opioid markets.”

History’s most effective supply-side intervention, delivered by an insurgency the drug war was never designed to produce, may end up pushing the world toward far deadlier drugs.

The second earthquake was the fall of Bashar al-Assad in late 2024, which dismantled what had effectively become a narco-state. Syria’s captagon industry, an amphetamine trade researchers valued in the billions of dollars annually, dwarfing the country’s legal exports, grew under regime protection and serviced markets across the Gulf. “The stimulant was used on the battlefield but also found a market in the wider region,” the report notes.

Since December 2024, Syria’s new authorities have dismantled 16 mostly industrial-scale laboratories, and panicked operators dumping stockpiles drove a surge in seizures. The price of a captagon tablet in Lebanon more than doubled, from $2–3 to $5–7.

Methamphetamine is moving into the space captagon left behind. In Saudi Arabia it has taken root among former captagon users and now ranks among the country’s three most used drugs; in Iraq and Türkiye it has become the leading drug of concern in treatment. The two drugs share a precursor chemical, and in 2024 Iraqi authorities dismantled a laboratory in Sulaymaniyah province producing both.

The numbers nobody is counting

The report’s data has major gaps. It is built on what governments report to Vienna, and much of the world reports little.

The toxicology data behind direct-death estimates come from 66 countries, roughly a third of UN member states, and mostly wealthy ones with functioning death registries. The estimate that one in four people who inject drugs is a woman rests on data from 23 countries.

For amphetamines, one of the world’s most used drug classes, the report concedes the global trend “cannot be calculated” for lack of data. In Africa and Asia, home to billions, data scarcity “prevents a clear understanding” of cocaine use and makes adolescent trends impossible to assess.

The undercounting cuts both ways in time: if some of the decade’s recorded rise in use is simply better counting, the past was darker than the old numbers showed, and the half-million death toll is likely a floor.

“A global map, no matter how detailed, will never fully capture the texture of local realities on the ground,” Juma said at the launch.

Punishment over care

Some 5.9 million people came into formal contact with police for drug offences in 2024, 63% of them for possession or personal use. Of 2.2 million people convicted worldwide, more than half were convicted for using drugs or possessing them.

The link between drugs and crime “is best understood as probabilistic rather than deterministic,” the report finds. “Many intoxicated people do not display violent behaviour.”

Civil society groups seized on those numbers at the report’s launch, telling member states that people who use drugs should be “supported and not punished.” Amnesty International used the same week to demand that UN drug control bodies act against the death penalty for drug offences, which it says continues to be applied unlawfully in a string of countries.

Poverty, homelessness and poor mental health, not drug use itself, are the strongest predictors of violence and insecurity, the report’s security chapter concludes, and “the worst security and safety outcomes are avoided when there is sufficient availability of health and social care interventions, including evidence-based drug treatment.”

Its prescription is treatment where there is none, pain relief where it is absent, prevention aimed at the young, and responses “grounded in evidence, centred on people and tailored to local contexts.”

“Only by combining public health, justice and security approaches can we reduce harm, save lives and build safer, healthier and more resilient societies,” Juma wrote.

Image Credits: Fatima Shahid.