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pioids could kill nearly half a million people across America over the next decade as the crisis of addiction and overdose accelerates.

Deaths from opioids have been rising sharply for years, and drug overdoses already kill more Americans under age 50 than anything else. STAT asked leading public health experts at 10 universities to forecast the arc of the epidemic over the next decade. The consensus: It will get worse before it gets better.

There are now nearly 100 deaths a day from opioids, a swath of destruction that runs from tony New England suburbs to the farm country of California, from the beach towns of Florida to the Appalachian foothills.

In the worst-case scenario put forth by STAT’s expert panel, that toll could spike to 250 deaths a day, if potent synthetic opioids like fentanyl and carfentanil continue to spread rapidly and the waits for treatment continue to stretch weeks in hard-hit states like West Virginia and New Hampshire.

If that prediction proves accurate, the death toll over the next decade could top 650,000. That’s almost as many Americans as will die from breast cancer and prostate cancer during that time period. Put another way, opioids could kill nearly as many Americans in a decade as HIV/AIDS has killed since that epidemic began in the early 1980s. The deep cuts to Medicaid now being debated in Congress could add to the desperation by leaving millions of low-income adults without insurance, according to the nonpartisan Congressional Budget Office.

Even the more middle-of-the-road forecasts suggest that by 2027, the annual U.S. death toll from opioids alone will likely surpass the worst year of gun deaths on record, and may top the worst year of AIDS deaths at the peak of that epidemic in the 1990s, when nearly 50,000 people were dying each year. The average toll across all 10 forecasts: nearly 500,000 deaths over the next decade.

Beyond the immeasurable pain to families, the overdoses will cost the U.S. economy hundreds of billions of dollars.

Opioid overdose deaths: 10 projected scenarios.

Natalia Bronshtein/STAT Sources: see below

In addition to the forecasts, provided by academics who specialize in epidemiology, clinical medicine, health economics, and pharmaceutical use, STAT conducted more than 40 interviews with politicians and patient advocates, providers and payers, doctors and drug makers. This analysis is also informed by a review of presentations from top Trump administration health officials, including Health and Human Services Secretary Tom Price, National Institutes of Health Director Francis Collins, and the acting chiefs of the Office of National Drug Control Policy, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention.

“It took us about 30 years to get into this mess,” Robert Valuck, professor at the University of Colorado-Denver’s School of Pharmacy and Pharmaceutical Sciences, told STAT. “I don’t think we’re going to get out of it in two or three.”

It’s already so bad that once unthinkable scenes of public overdose are now common: People are dying on public buses and inside fast-food restaurants. They’re collapsing unconscious on street corners and in libraries after overdosing on prescription pain pills, heroin, and fentanyl. A customer in Anchorage, Alaska, hit the floor of a Subway while trying to order a sandwich. A mom in Lawrence, Mass., sprawled in the toy aisle of a Family Dollar as her little girl screamed at her to wake up. A grandmother in East Liverpool, Ohio, slumped in the front seat of an idling car, turning blue, while a toddler in dinosaur pajamas sat in the back. 

There are so many deaths, some coroners are running out of room for bodies.

The most recent national statistics count more than 33,000 opioid-related deaths across the U.S. in 2015. Many victims are young, often in their 20s or 30s. Increasingly, many are white. But the plague touches all demographics: farmers and musicians, lawyers and construction workers, stay-at-home moms and the homeless.

Read next: 12 ways to slow the opioid epidemic

Most of the forecasts produced by STAT predict the annual death toll will increase by at least 35 percent between 2015 and 2027. Under the gravest scenarios, it could triple — to more than 93,000 deaths a year.

On this, all the experts agree: Fatal overdoses will not even begin to level off until sometime after 2020, because it will take time to see whether the federal government’s efforts to boost drug enforcement and push doctors to write fewer prescriptions for opioid pain pills are effective.

The worst-case scenario is built around the assumption doctors will continue to freely prescribe and that people addicted to opioids will continue to be exposed, perhaps unknowingly, to powerful synthetic compounds like carfentanil, an elephant tranquilizer capable of killing a human with just a couple of grains.

Opioid deaths: Worst case scenario

Opioid deaths: Worst case scenario
Scenario 1: The opioid deaths forecast for 2027 is 93,613. The forecasted change is 183% since 2015 when it was 33,091. This curve assumes total drug overdoses climb at the same rate they have for decades. It’s also based on the assumption opioid deaths keep making up roughly the same percentage of all drug deaths. Natalia Bronshtein/STAT

The best-case projection has fatal overdoses falling below 22,000 a year by 2027. But experts say reaching that level would require a major public investment in evidence-based treatment options and a concerted push among medical providers to control pain with non-narcotic therapies before trying prescription opioids. Right now the U.S. spends about $36 billion a year on addiction treatment — and just a fraction of those in need are getting care.

By contrast, federal officials estimate that opioid abuse drains nearly $80 billion a year from the American economy because of expenses tied to health care, criminal justice, and lost productivity.

President Trump, who has vowed to make opioids a priority, has appointed a commission led by New Jersey Gov. Chris Christie to explore solutions, but it hasn’t yet laid out its ideas — and in the meantime, the administration’s proposed budget would slash most domestic spending, which health advocates call profoundly counterproductive.

“Are we doing enough of what we think works — prescription drug monitoring programs, medication-assisted treatment, naloxone?” asked Dr. Donald Burke, dean of the University of Pittsburgh’s graduate school of public health. 

“And,” Burke said, “are we matching the societal costs with a like expenditure in prevention?”

Opioid deaths: Best case scenario

Opioid deaths: Best case scenario
Scenario 10: The opioid deaths forecast for 2027 is 21,300. The forecasted change is -36% since 2015 when it was 33,091. ‎‎This curve assumes doctors prescribe fewer opioids, states embrace prescription drug monitoring programs, and insurers enact reforms to increase treatment access. Natalia Bronshtein/STAT

Ignoring clear signs of danger

The STAT analysis projects many painful years ahead. The roots of the crisis, though, stretch back generations to the 1980s, when pharmaceutical firms first marketed prescription opioids like oxycodone and hydrocodone to treat pain — and claimed they carried minimal risk for addiction.

Over the years these companies pushed hard to get pills in patients’ hands with strategies that included paying middlemen to circumvent state regulations and allegedly bribing doctors to prescribe opioids.

The result are staggering: Opioid prescriptions nearly tripled between 1991 and 2011.

It has been abundantly clear in recent years that such prescriptions can be dangerous. From 2005 to 2014, the rate of opioid-related emergency department visits nearly doubled, according to a new report from the Agency for Healthcare Research and Quality. Yet as recently as 2015, doctors prescribed prescription painkillers to more than a third of American adults, despite limited upside for many patients.

Future of Opioids - Qt 1
Hyacinth Empinado/STAT

“It’s like cigarettes in the ’50s: We look back at the way people smoked and promoted cigarettes as laughably backwards — magazine ads with doctors saying, ‘Physicians prefer Camels,” Dr. Michael Barnett, assistant professor of health policy and management at Harvard University, said.

“We have the same thing now — Oxycontin ads in medical journals where doctors would say, ‘Opioids are good for treating pain. They don’t have addictive potential.’ It’s possible 20 years from now, we’re going to look back and say, ‘I cannot believe we promoted these dangerous, addictive medications that are only marginally more effective.’”

The state of Ohio, among a handful of governments currently suing drug makers, alleges that a “well-funded marketing scheme” led to its residents receiving 3.8 billion opioid pills from 2011 to 2015, fueling “human tragedy of epic proportion.” Fatal drug overdoses in Ohio have soared by 642 percent since the turn of the millennium.

Another statistic: The number of privately insured patients diagnosed with opioid dependence increased nearly sixfold in just five years, according to data compiled by Amino, a health care data analytics company.

In 2012, only 241,000 such patients had an opioid dependency diagnosis. By 2016, that number was 1.4 million. And those numbers don’t even account for the hundreds of thousands more battling addictions while on Medicaid or Medicare, or while uninsured.

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The surging death toll, affecting growing numbers of white Americans, sparked demand for action in ways unseen during past epidemics that disproportionately affected minority populations. Law enforcement officers started shutting down pain clinics, known as “pill mills,” where doctors accepted cash for painkiller prescriptions. But that only accelerated demand for heroin, as pill mill patients had trouble finding treatment to break free from their addictions.

Desperate to keep feeding their cravings and avoid the anguish of withdrawal, people from all walks of life — soccer moms in Vermont, C-suite execs in California, college-bound kids in West Virginia — began to shift from prescription pills to heroin, which was more potent and had become far cheaper, thanks to heightened drug trafficking into the U.S. by cartels. Two years ago, heroin deaths surpassed the toll from prescription opioids for first time this millennium, according to the Washington Post.

“Thirty years ago, the heroin dealers drove through Arkansas” on their way to more populous and lucrative markets, Dr. G. Richard Smith, professor of psychiatry, medicine, and public health at the University of Arkansas for Medical Sciences, told STAT. “That’s not the case now: People are switching from legal prescription meds, rightly or wrongly prescribed, to heroin.”

Future of Opioids - Qt 2
Hyacinth Empinado/STAT

A new threat rises 

Many of the experts STAT spoke with were even more concerned about the wave now crashing through communities: the synthetic opioids, such as fentanyl and carfentanil, that have flooded into the U.S. from China and Mexico. They can be cheaper and even deadlier than heroin — and can be made at home or ordered online. Between 2013 and 2015, deaths linked to these potent opioids tripled to more than 9,000.

The drugs can be so deadly, the U.S. Drug Enforcement Agency this month urged first responders to carry naloxone in case they accidentally overdose while trying to help a victim — as has already happened to officers in Ohio and Maryland. The DEA also recommended first responders wear protective equipment such as safety goggles and masks, and in some cases full hazmat suits.

Because they’re so strong, synthetic opioids have spawned strings of mass overdoses in cities throughout the eastern half of the U.S.

Last summer emergency workers in Cincinnati responded to an unprecedented 174 overdoses in six days; this past winter, paramedics in Louisville scrambled to get to 151 overdoses over four days. In the small city of Huntington, W. Va., reports of 28 overdoses in five hours last August forced 911 dispatchers to send out every available ambulance to revive drug users who had passed out inside homes and on highways.

And the most potent synthetic opioids haven’t even penetrated all the markets in the U.S. yet.

“We’ve not seen the worst yet,” said Tim Robinson, CEO of Addiction Recovery Care, a Louisa, Ky.-based company that runs several rehab programs. “As we transition from heroin toward fentanyl and carfentanil, when it hits the rural areas in Appalachia, we’re going to see a lot more devastation.”

Already, a long trend of declining death rates for young adults has been reversed: Death rates for people ages 25 to 44 increased from 2010 to 2015 in nearly every racial and ethnic group, in large part because of drug and alcohol abuse, the Washington Post found. The New York Times recently reached out to hundreds of state and county health officials to piece together an estimate of total drug overdose deaths last year. Its projection: More than 59,000 fatalities, most from opioids.

Future of Opioids - Qt 4
Hyacinth Empinado/STAT

In an interview with STAT at a national drug abuse summit earlier this year, Dr. Patrice Harris, then chair of the American Medical Association, said one key to bringing down the death toll is to spread the word that addiction is a chronic medical condition, not a personal failing.

Another key: getting more people access to medications that can reduce cravings, such as buprenorphine, methadone, and naltrexone — and convincing both patients and providers that such treatments don’t simply amount to trading one addiction for another.

“Any physician in this country can prescribe oxycodone in high doses, but they can’t prescribe buprenorphine unless they have special training,” said medical epidemiologist Jay Unick of the University of Maryland, Baltimore. “You just don’t have easy access to buprenorphine. And that’s crazy in a world flooded with opioids.”

The end result: waiting lists for treatment that can stretch for weeks or months.

In West Virginia, Marshall University student Taylor Wilson tried for 41 days to get treatment after nearly dying from an overdose. Her mother, Leigh Ann Wilson, finally got a call saying Taylor had cleared a buprenorphine waiting list. Her daughter had died four days earlier, from another overdose.

A landmark report last year from then-Surgeon General Vivek Murthy found only 10 percent of the estimated 2.2 million Americans with an opioid-use disorder have received addiction treatment.

“We know what works,” Murthy said this past April. “We’re just not doing enough of it.”

Read Next: 12 ways to slow the opioid epidemic

STAT reached out to dozens of public health experts, seeking thoughts on the arc of the opioid epidemic. Experts at 10 universities responded, spending weeks developing forecasts for the death toll over the next decade. Some created models that focused on the spread of fentanyl and trends in pain pill prescriptions; others looked more widely at trends in interventions, such as access to naloxone and medication-assisted treatment. Here’s a list of those contributing forecasts:
— University of Pittsburgh: Dr. Donald Burke, dean of the Graduate School of Public Health; Jeanine Buchanich, research associate professor
— University of Arkansas for Medical Sciences: Brad Martin, professor, division head of pharmaceutical evaluation and policy at the College of Pharmacy; Corey Hayes, Ph.D. student
— University of Virginia: Christopher Ruhm, professor of public policy and economics
— Ohio State University: Dr. William Miller, professor and chair of the division of epidemiology, College of Public Health
— Harvard University: Dr. Michael Barnett, assistant professor, department of health policy and management at the T.H. Chan School of Public Health
— Brown University: Brandon Marshall, professor of epidemiology at the School of Public Health
— University of Colorado, Denver: Robert Valuck, professor in the departments of clinical pharmacy, epidemiology, and family medicine at the Skaggs School of Pharmacy; Rebecca Helfand, evaluation manager, Colorado Department of Human Services
— University of California, San Francisco: Dr. Dan Ciccarone, professor of family and community medicine, principal investigator of the NIH-funded Heroin in Transition study
— University of Maryland, Baltimore: Jay Unick, medical epidemiologist, School of Social Work
— Johns Hopkins: ‎Caleb Alexander, associate professor of epidemiology and medicine, Bloomberg School of Public Health

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  • Pam is right. We should not throw the baby out with the bath water. Patients stable on medication and not at addiction risk should be allowed to continue and their physicians should not fear loss of license as long as they follow their state guidelines. Ideally, all patients should have a multidisciplinary approach to chronic pain, not just meds alone. In the 90’s we didn’t have good screening for addiction, nor did we have enough understanding of addiction as a brain disease, or good alternatives for rx of pain for those at risk of addiction. See a book “EVIDENCE BASED CHRONIC PAIN MANAGEMENT” for proven methods of Rx for various forms of pain. Belbuca and Butrans patches are both approved for treatment of pain, both forms of generic buprenorphine. Some insurances and state medicaids will cover, others want us to Rx opiates because they are a lot cheaper, a poor choice. Generic prices here as low as $1.15 and should be much lower. CDC is frightening Docs and swinging the pendulum too far backwards. Limits based on arbitrary #s, not good DNA tested metabolic rate science. Be patient, we get better at what we do in time. See a pain specialist. Talk to your Doc. We do care.

  • Pain is hard to bear but it’s preferable to tolerance, addiction or death. Even responsible opiate use comes with some serious side effects.

  • True many people abuse drugs however if your a chronic pain patient this is a death sentence, I have to live in pain and not function because people abuse drugs. Stats show tobacco and alcohol kill 120 more times than any medication where’s the outrage , none because bureaucrats go home at night and over indulge so that’s ok

    • That’s the truth Patty! I’d love to be a fly on the wall in all these corrupt politicians homes, I bet many indulge in alcohol nightly, I bet many are taking opiods to relieve pain or their loved ones, but they have private drs and pharmacies in their back pockets, I wonder how many are guilty of domestic violence that gets swept under the rug, I’d love to have all their skeletons exposed. None of them should have any right in our medical files, dictating what we can and can’t have for our debilitating incurable diseases that cause severe pain. I’m on hell thru no fault of my own. My dr abandoned me back in April after 5 years of being a model pt and following all the rules. His reason for abandoning me is that his license was more important and those are his exact words. I’m in NJ and asshole Christie put out even tighter restrictions, that’s when my dr dropped me. I told him those restrictions were for acute pain not intractable pain, but he could care less. This is INHUMANE!!

  • We already have such a medication, buprenorphine, but Docs won’t use it. The reasons why outlined in a recent nicely done article. Maybe there will be others eventually, but this one is here now and works well with little tolerance.

    • Very true however in order for insurance to pay for the medication the patients need to register as addicts which patients in pain don’t want to be labeled

    • Why should pain pts who were on stable doses for years, decades even, and having success on the SAME STABLE DOSE be abruptly cut off or having doses that worked lowered to ineffective doses that leave them in agony, only to be pushed into detox ctrs and suboxone pushed down thete throats, which btw is am addictive opiod, Killer Kolodny’s baby that he has pushed into every prison cell, and is pushing it onto pain pts. He finds it perfectly acceptable for addicts to be on suboxone for years, he calls it being dependent , but legitimate pain pts who are on LIFESAVING PAIN MEDICATION for years are labeled drug addicts. This whole opiod epidemic is nothing but a sham and a witchhunt. Seems to me the government and thier sidekicks the DEA, Cdc, FDA AND PROP are intentionally pushing pain pts to the streets for relief getting God knows what or SUICIDE! They are committing GENOCIDE thru out the pain community and not one word from the media. The war on drugs is a full blown attack on innocent law abiding chronically ill citizens and they are killing us off one by one

  • The solution is definitely NOT to just ignore the problem, or as one commenter suggested, simply stop responding to overdose calls. Rather, the government, big pharma and the medical community (all of whom contributed in part to this crisis in the first place) now need to step up to the plate and be responsible and humane (i.e.- they need to now make the safer alternatives available to all the people who are caught up in this opioid crisis). Although there are some exceptions, many of the people who are now dependent on opioids got this way as a result of being prescribed legal pain medication due to injuries or a chronic pain condition. The current knee jerk reaction to suddenly limit or cut off access to legal pain medication for long term chronic pain suffers is what is now help driving the increased use of heroin, fentanyl and carfentanil since these far more dangerous, illegal drugs are now becoming easier to obtain in many place than legal pain medication. Instead of cutting off the supply of legal pain medication the government, big pharma and the medical community need to make the safer alternatives readily available to everyone (and not just the rich and insured) and at the same time continue research into other safer, non-addictive pain relievers. Unfortunately, pain is part of human existence and as long as there is pain there will be a demand for pain relief. For those who judge the unfortunate souls trapped in the opioid crisis you better hope you never suffer severe injuries or severe pain.

  • What has happened in the Philippines since the recent policy of summary execution of dealers and suppliers? What would happen if responding for overdose was stopped? It seems the situation in America has deteriorated to the point where these extreme measures could be tried in a few states to see the effect it would have on the opioid problem,

  • Buprenorphine is safe, excellent for pain and you do NOT have to have a special license to rx for pain, only opiate addiction. Hospitals need to stock it IV for post op pain, and as sublingual. It doesn’t have respiratory depression of significance and tolerance is minimal. What are we waiting for?

    • Not true! As it’s only covered for treatment of addiction, what it was intended for, prescribing for pain is off label and not covered. Besides, why should pain pts on stable doses of pain medication that worked for them have to be denied their lifeline and put on suboxone/ buprenorphine when they were doing just fine on say oxycodone or whatever worked for them…oh wait it’s all about the $$$$ , and boy someones getting rich off the denial of lifesaving pain medication to those who require them to sustain a QUALITY OF LIFE! Compassion is no longer a part of the dr/pain pt relationship. It sickens me that we continue to be judged and labeled as drug addicts. There’s a huge difference between dependence/addiction. Also you state how well it works for pain, we’ll please keep in mind what works for one may not work for another

  • We know how to do this.
    Political will and leadership is what we lacking.
    Most commonly there is no treatment available for the uninsured,the poor on Medicaid,the elderly or disabled on Medicare.
    VA programs are now and historically have been a mess.
    Insurance companies of patients who have it limit benefits and require onerous prior authorization.
    By the way, all of American health care is delivered this way.
    In a fragmented,expensive,and discontinuous, unfriendly, inpatient centered way because we have completely been seduced by the “It’s socialized medicine” argument when implementing cost effective change is discussed.
    Single payer.

    • Ive been a buprenorphine prescriber for 14 years, that is, from the beginning. After I was ‘waivered’ I was excited to help a patient with opioid addiction, if s/he ever came to my internal medicine/primary care office. Now, in 2017, Ive treated over 500 opioid patients with medication assisted treatment. At the beginning of treatment, it was primarily about the medication (Mat). In a week treatment was more about ‘assisting’ (mAt), with weekly groups and self-help involvement. A year or so after initial encounters, most patients were thriving. I urge more people to obtain a waiver and seek to provide the highest quality treatment program possible. If you accept insurance, opioid treatment is affordable and sustainable!

  • Once in a lifetime, as they say, we went to see this ‘pride parade’ in SF, and it did freak me out, to say the truth. The last time I saw so many used syringes lying on the floor was back in Russia, during mid nineties, when the country was in rubble after the collapse of the Soviet Union. So many bums on the streets, alcoholics and absolutely insane people, on the Market street, that was not what I was expecting to see at all. WTF

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