*Purpose: The impact of the current opioid epidemic has been felt throughout the nation, and has seen significant geographic variation in the impact on decease organ donation, which continues to evolve.

*Methods: We analyzed OPTN deceased donors recovered between 2010 and 2017 to compare trends in donors with drug intoxication as a mechanism of death. Donor conversion, discard, and acceptance rates, stratified by OPTN region were examined to address the impact, variance, and evolution of the opioid epidemic across the U.S.

*Results: The proportion of drug intoxicated (DI) donors has increased nationally from 4.3% in 2010 to 13.4% in 2017. While every region saw an increase in DI donors, the increase in the proportion recovered ranged from 10% in the South Western U.S. to over 500% in the Mid-Atlantic region. In 2017, kidney acceptance rates for DI donors was 24.1% compared 19.1% for all other donors. Liver acceptance rates for DI donors was 22% compared to 24.1% for all other donors. DI donor kidney acceptance rates ranged from 20.6% to 31.8% across regions, compared to a range of 12.9% to 36.2% for liver. The conversion rate of DI donors between 2010 and 2017 was 82.9 per 100 donors compared to 71.3 for all other donors. The overall DI donor conversion rate in 2017 was 78.8, varying across OPTN region from 75.5 to 83.9. Discard rates for DI kidney donors were lower than non-DI donors but this trend was not observed in liver discard rates. Regional variance was pronounced, with DI donor kidney and liver discard rates in 2017 ranging from 8.1% to 17.7% and 2.5% to 12.45%, respectively. Nationally, organs transplanted per donor was higher in DI donors compared to non-DI donors over the entire period (3.12 vs 3.06, respectively).

*Conclusions: The opioid epidemic and its effect on deceased donation, first observed in small pockets across the U.S., has evolved to impact all regions. Utilization of DI donors is greater than non-DI donors perhaps reflecting clinical and demographic differences. Shared learning of best practices across regions may improve variation in recovery and acceptance practices as well as discard rates.

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