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This report analyses the introduction of synthetic opioids into the US drug market and the proceeding toxic unregulated drug crisis. The report aims to provide decision makers, researchers, media outlets, and the public with insights intended to improve their understanding of the toxic drug crisis and how to respond to it. The authors contend that: "supplier decisions, not user demand, drive the transition to fentanyl"; " synthetic opioids drive up deaths rather than the number of users" and "problems with synthetic opioids are likely to worsen before they improve".