AbstractThis study reviewed and compared fentanyl's potential impact on public health in India and China, two nations linked to its production and distribution. A comparison of China and India's governance structures, historical experiences with opioids, ideologies, and drug policies on the potential for domestic fentanyl use showed that fentanyl will likely become a more significant threat to Indian society. India's relatively weak governance, historical acceptance of opium, and permissive drug culture facilitate an environment conducive to the production and use of fentanyl. In contrast, China's strong central government, the Opium Wars, the historical effects of opium addiction, and adherence to conservative Confucian ethics will likely contribute to opposition to fentanyl use. Understanding these disparities is paramount for policymakers and public health officials in both nations to develop and customise strategies to confront the challenges posed by fentanyl.