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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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  • You speak as if you know so much and yet you know so little. Properly prescribed opioids taken responsibly give people quality of life they couldnt have w/o them. Anyone can abuse a substance to get high. Such as inhalants…but chronic pain suffers take what they need to live somewhat productivly we arent high at all. All this talk is causing a horrible burden on people like myself who am able to work pay my taxes support my family and pay for insurance! Without it I couldnt work and in fact would probably have died by choice rather than suffer so horrendously. Until you actually deal with chronic pain or speak to those who do you really dont knoe ehat your tslking about. Opioids arent being freely prescribed where i live every other avenue was tried and failed after a point. Medication had given me back some normalcy but even then i dare not ask for an increase should i need it for fear of being precieved an addict. You are creating monsters out of hurting people. We treat animals more humanely.

  • Please stop adding drama to the “opiate myth,” the current research is flawed, and corrupt with special interests. Please note that these drugs are definitely not originating from legitimate chronic pain patients and well trained pain management physicians, yet they are assuming the bulk of the burden, and are being harmed as a result, for a flawed DEA oversight plan of drugs being fueled from countries like China. Max, I recommend you consider writing your next article on the level of corruption associated with this hyped up opioid crisis, who stands to benefit and follow the money! Example #1 http://www.nbcnews.com/storyline/americas-heroin-epidemic/fentanyl-crisis-deadly-drug-easily-available-online-purchase-n791311 Example #2

    • Thank you D, this is exactly right. The prescribing is down but the fake pills of fentanyl carfentanil are flooding into the US and Canada from China. Pain patients are being blamed for something they have no control of. I think follow the money is right. It sounds as if the powers that be want every pain patient on Suboxone, Buphrenorphine or in rehab. Since last year I have been trying to find out what is really going on.
      I agree with you, something is happening that doesn’t make sense. I read a report from Maryland that death from prescriptions is down by 70% yet fentanyl deaths are up 116%

    • A great point in support of the legalization and/or at least the decriminalization of ALL substances. Why does using one substance make you a criminal when you can use alcohol (the number one killer compared to all other drugs combined!) with no repercussions…in fact, as a culture we condone the use of alcohol at pretty much every event and social gathering despite the known consequences that it has on so many people in our communities.

  • Tatyana, you didn’t mention suboxone. Get him into a treatment program that uses medication assistance, suboxone is the safest. Combine with a psychosocial program like NA. That is the best hope for success. You go to Naranon and learn how to best help him in the process. Dr. Rust

  • My son started this drug road when he was 15 and now he’s 25. I never had even 1 normal day since. It’s hard to explain what family going through the only what I can say we all have no life. For years him and lot of his friends were getting pills from Icant call him doctor and he would prescribe hundreds of hiest dose of oxycodone few tomes a month. And all this years we all left alone cause those 1 month rehabs not working and the others who can afford. He’s trying again and the only hope for us God and people who had same problems. If nothing going to be done we have no future TO MANY DYING

  • “required” needs to ID him/herself. Pseudoaddiction should be in DMS-6. Easy to identify and happens a lot. Generally post is correct. Why not a trial on buprenorphine for these patients whose docs are forcing them to reduce? Works great and will keep CDC happy.

  • When the coroner determines cause of death as some type of drug overdose and those types of deaths dramatically rise, you question if they are addicts?

  • From what I can tell this study looked solely at the diagnosis of “opioid use disorder”, which is from DSM 5. DSM 5 came into use in May of 2013. This study shows that the use of this diagnosis increased dramatically from 2012 (early adopters of the dx) to present time, as would be expected from a new nomenclature. SAMHSA data does not support a sudden increase in “addiction” in the culture. At Duke we are currently trying to find out why people are dying, before making assumptions that the death rate comes from the disease of addiction.

    • Dr Prakken, yours seems to be a voice of reason in a debate which often lacks that dimension. If you can possibly free up time to read and occasionally write, I’d like to invite you into an Opioid Policy Correspondents List, of which I am corresponding secretary. If you have any interest, feel free to send me a note at lawhern@hotmail.com

    • You folks really need to start looking in the opposite direction. Most are so concerned with over medicating, you fail to even consider that the drastic reduction in prescribing may have negatively affected those on the therapy…AND IT HAS. In the long game, if the threshold of the individuals tolerance is not met, they might as well not take anything, and will be suffering more than they originally would. The fear of tolerance is counterproductive for someone who is chronically ill, and is the corner stone of our medical systems misunderstanding. The ideology of prescribing the minimum effective dose, 9 times out of ten is resulting in an undermedicated patient. The patient is then trapped in a cycle of fabricated crisis, that is later diagnosed as something completely different than what it truely is. Pseudo addiction is running rampant yet doctors see this as outdated information. The idea that there are very few patients capable of seeing positive results on high dose opioids, is an absolute lie (and is almost entirely a result of poorly/biasedly collected data). The current ideology of safety surrounding opioids needs to be almost completely scrapped, as it is completely out of touch with reality. It is leading a formidable treatment option, down a very self destructive path, when there are not many to choose from. This epidemic has been inadvertantly fabricated by fear and the unknown, approached through a liberal mindset. The patient, will more often than not try to hide their uncontrolled pain, in fear that they will lose everything if they bring up the topic. PAIN CONTROL IS A RIGHT NOT A PRILEDGE , AND IS AS NECESSARY AS WATER OR AIR. It is far too common, for there to be no safe place to talk about opioids for the people who need them, there is only the reluctant prescribing of doctors who would rather not; and the looming understanding that one should consider themselves LUCKY to get ANY treatment at all. This atmosphere has resulted in HORRIBLY inaccurate polling and statistic, which are then used to regulate the situation further in the wrong direction. The medical and regulatory institutions are doing the exact opposite of what needs to be done and this includes the abandonment of pain as a vital sign. The idea that pain medications simply make the experience more bearable mentally is false…and in most cases until a patients pain IS managed, there can be no progress made on the remaining fronts. The uncontrolled pain makes the management or even simply monitoring of the patients levels, even more difficult. The reason we are seeing these deaths are because of the very large numbers of people in pain, who have been channeled into addiction treatment or denied management period. Without their pain managed it is only a matter of time before their bodies completely shut down , and become largely unresponsive to any form of therapy. Aside from the obstacles already encountered as a result of their condition, patients are being made to suffer an added social/moral/political hell on earth, by people so narrow minded they ignoring the valuable information only the experienced could provide. Reading/studying chronic pain, barely scrapes the surface of the information collected/navigated daily by the patient…and their experience MUST be taken into account/not seen as a further complication. The medical comunity seems to barely be able to grasp simply daily nuances life with chronic pain, which the patient actually understands like the back of their hand. The answers lie in the minds of the suffering, not the minds of the assuming. It is terrifying to see how horribly wrong the establishment is dealing with opioids, because as far as most can see, many more are going to die as a result of these arrogant policies. Its not difficult to see (that is for someone who isn’t completely devoid of humanity/compassion for human life), that we are making the situation worse with our current efforts. We have created a world that treats humans as the machines we worship: the difference is that we DO/NEED to experience pain, as well as be able to manage it when it becomes out of control. Having to wait for permission to manage pain that is at times very unpredictable is counter productive, and the obsession with controlling peoples every move/decision must stop, if we are to move forward.

    • The very term “opioid use disorder” is stigmatizing and crass. There are many that hold that putting the patient first means treating each one as an individual. That means addiction with chemical receptor disease is very different than physiologic dependence. Let’s keep our quest for patient engagement open in the realm of addiction medicine.

      In any discussion on chronic pain, lack of opioids, and deaths from overdose, we need to not be afraid to talk about patients killing themselves or their doctor, due to raw, untreated pain. We find it sad there was a need for hashtag #SuicideDue2Pain, coined by Kimmee K. Miller in response to the “opioid crisis” that is due to underground heroin and fentanyl drug pushers, not doctors offices. Perhaps unintended, the consequence of patient suicide and physician homicide (sometimes both on the same day) due to even pereceived patient abandonment is the elephant in the room. Patients have a right to be relieved of pain, and Hippocrates said, “Divine is the task to relieve pain.”

      So let’s not give up on the patient.

    • Please don’t confuse science with an agenda. The agenda is to keep illegal opiates profitable, and to force people from safe regulated pain killers to the more profitable blackmarket . We saw this in the 80s with crack cocaine. The CIA was funding itself with the profits. Lookup mena Arkansas – turns out George Bush was a big time Drug Lord. Who was the govenor of Arkansas at the time ? Bill Clinton. That’s why the whole war on drugs is a farce and a scam !!

    • The prescribing is down but the fake pills of fentanyl carfentanil are flooding into the US and Canada from China. Pain patients are being blamed for something they have no control of. I think follow the money is right. It sounds as if the powers that be want every pain patient on Suboxone, Buphrenorphine or in rehab. Since last year I have been trying to find out what is really going on. After 12 years of being on a long term pain medication my husband is being tapered much too quickly and his doctor is taking him from 100 mg to nothing, inducting him to suboxone. Everything I read said he has to be below 30 mg before transferring him to suboxone.
      Something is happening that doesn’t make sense. I read a report from Maryland that death from prescriptions is down by 70% yet fentanyl deaths are up 116%

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